Comparing the Effectiveness of Surgical versus Medical Approaches in Managing Patients with Indeterminate Spinal Instability Neoplastic Scores

Background. Treating indeterminate cases of spinal metastases (those with spinal instability neoplastic score [SINS] of 7–12) remains a clinical dilemma, as there are currently no well-defined recommendations for this category. This study aimed to identify the most appropriate approach for patients with indeterminate SINS by reviewing and analyzing published evidence. Objective. To determine the effectiveness of surgical and medical approaches in managing spinal metastasis with indeterminate SINS. Methodology. A comparative effectiveness study was conducted using systematic review and meta-analysis. A systematic search was performed in the following databases: PubMed, Embase, Cochrane Library, and Google Scholar. Studies were selected based on inclusion and exclusion criteria comparing surgical and medical approaches for indeterminate SINS. The outcomes analyzed were patients’ functional status, complications, and conversion to surgery/revision surgery. Quantitative data were analyzed using Review Manager version 5.3 software, and results were reported using a forest plot. Results. Eight studies were included in the qualitative review, and six were included for quantitative synthesis, involving 1,312 patients. In patients with spinal metastasis with indeterminate SINS, surgery resulted in less functional decline than medical management, with a pooled odds ratio (OR) of 0.50 (95% CI: 0.31, 0.81). However, significantly more complications were associated with surgery (OR of 2.6; 95% CI: 1.66, 4.08). The authors reported a pooled result of 21.19% conversion to surgery among those initially managed with a medical approach. In the initial surgery group, there was a significant reduction in conversion to surgery or revision surgery, with an OR of 0.19 (95% CI: 0.10, 0.34). Conclusion. This study addresses the dilemma of treating spinal metastasis with indeterminate instability, advocating for surgery as the primary intervention due to its potential to improve functional outcomes and provide a satisfactory quality of life, which may, in turn, influence overall survival. This topic can be explored further including identifying a specific SINS threshold that could serve as a criterion for recommending surgery.