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Measuring the paraspinal muscles as an important tool for predicting the overall survival period after spine surgery in lung cancer patients with spine metastasis

BMC Musculoskeletal Disorders volume 26, Article number: 414 (2025) Cite this article

Abstract

Study design

Retrospective cohort study

Background

Metastatic lung cancer in the spine is difficult to determine whether to perform an additional surgical intervention, as patients at the end stage of lung cancer often have low performance status with significant muscle atrophy. This study aimed to demonstrate whether sarcopenia affects the prognosis after spine surgery in lung cancer patients by measuring the paraspinal muscles.

Methods

A total of 65 lung cancer patients who underwent spine surgery were reviewed. Patients were divided into two groups based on the survival period after surgery (≤ 6 months; n = 33 and > 6 months; n = 32). Based on magnetic resonance imaging, the quantity and quality of the paraspinal muscles (psoas major, quadratus lumborum, erector spinae, and multifidus) were analyzed by an Image J program. Patient- and surgery-related factors were compared between the two groups.

Results

The quantity of the erector spinae muscle was higher in the > 6 months group (11.5 ± 2.8 cm2/m2) than in the ≤ 6 months group (10.0 ± 2.3 cm2/m2, p = 0.013). The logistic regression analysis showed that the muscle quantity of the erector spinae (p = 0.026, odds ratio 1.343) and the number of vertebrae involved in metastasis (p = 0.016, odds ratio 0.199) were the main prognostic factors for the survival period after spine surgery.

Conclusions

Lung cancer patients with a low quantity of the erector spinae muscles are at a high risk of poor prognosis after spine surgery. Therefore, measuring the erector spinae muscle could be an important tool for distinguishing patients appropriate for palliative treatments and surgical interventions.

Peer Review reports

Introduction

Lung cancer is one of the most common cancers in the world [1]. Overall, lung cancer mortality and trends are similar to those of incidence because of the low survival rate of lung cancer patients. Furthermore, lung cancer is generally diagnosed in the progressive stage causing the treatment to be difficult, with a poor prognosis [1].

Among various organs, spine metastases are particularly common in lung cancer [2]. Patients with spinal metastasis typically have pain, spinal instability, and nerve dysfunction, all of which can affect the quality of life [3]. For the treatment strategies for spinal metastasis, a multidisciplinary approach, including surgery, radiation therapy, bone cement, bisphosphonates, and chemotherapy, is currently recommended [4]. Surgery remains a standard treatment for spine metastasis patients with progressive spinal cord compression or at high risk of spinal instability [4]. However, it can cause some complications, such as considerable muscle injury, blood loss, and postoperative infections [5]. Furthermore, late-stage lung cancer patients generally have sarcopenia, which increases the mortality rate after spine surgery [6]. Since patients at the end stage of lung cancer often have low performance status with a significant decrease in muscle volume and quality, it is difficult to determine whether to perform additional surgical intervention for these frail patients. In addition, other prognostic factors related to prognosis after the surgery of metastatic spine lung cancer have not been well understood.

Therefore, the aim of this study was to demonstrate whether sarcopenia affects the patient’s prognosis after spine surgery and to find other important predictors to help determine the direction of surgical treatment.

Methods

Patient selection

We retrospectively reviewed all 331 metastatic spine cancer patients who underwent spine surgery between January 2014 and December 2020. In patients with lung cancer and spine metastasis, surgery is primarily indicated for cases with severe neurological deficits, spinal instability, or intractable pain unmanageable by other treatments [7, 8]. Patients in whom preoperative magnetic resonance imaging (MRI) scans were not available by the time of the analysis were excluded (n = 75) due to the inability to obtain the intended measurements. Finally, 65 patients whose primary region of metastatic cancer was the lung were included. Of the 65 patients, 39 were diagnosed with small-cell lung cancer (SCLC), and 26 with non-small-cell lung cancer (NSCLC). All patients presented with spinal metastases; the SCLC cases were classified as extensive stage, while the NSCLC cases were categorized as Stage 4 [9]. Previous research on survival outcomes in patients with spinal metastases from lung cancer often considers an overall survival of less than 6 months as poor prognosis [10, 11]. In our study, we also used a 6-month post-surgery survival period to divide the groups, ensuring an appropriate distribution of cases for analysis. This study was performed after obtaining institutional review board (IRB) approval from our institution (IRB number: 2022–1144). All procedures were carried out in compliance with the Helsinki Declaration.

Variables

Data on the age, sex, past medical history, smoking status, body mass index, operating time, length of hospital stay, follow-up period, ambulatory status, survival period, quality and quantity of paraspinal muscles, the spinal instability neoplastic score (SINS), and the Karnofsky performance scale were evaluated. In addition, the survival period, the number of vertebrae involved in metastasis, preoperative intervention (embolization and radiotherapy), and surgery-related factors, including the type of surgery, operative time, and amount of blood loss and transfusion, were analyzed [12].

Analysis of the paraspinal muscles

All patients underwent an MRI examination. The MRI system was a 1.5 Tesla Imaging System (GE Health care Milwaukee, WI, USA). Lumbar paraspinal muscles of interest in this study were the quadratus lumborum, erector spinae, multifidus, and psoas major. Skeletal muscle mass was measured from cross-sectional MRI images taken at the middle point of the L3 vertebral body within 3 months before surgery [13]. When identifying paraspinal muscles, the boundary of each muscle was defined by its attachment to the bone. For areas not in contact with bone, the borders were manually drawn by smoothly connecting the regions where the muscle signal was clearly visible on the T2-weighted MRI, thereby establishing distinct boundaries between each paraspinal muscle (Fig 1).  Image J software (U.S. National Institutes of Health, Bethesda, MD) was used to outline the cross-sectional area (CSA) of each paraspinal muscle. To normalize the CSA of each patient, the measured CSA was divided by height2 and defined as a muscle quantity [14, 15]. The quality of muscle represented by fat infiltration rate was examined using the following steps on T2 weighted image. The scale pixel was first set, and each image was quantified using a threshold technique and converted to a grayscale 8-bit image using the tool of the Image J software [16] (Fig. 2). Two spine surgeons with more than 5 years of work experience completed the assessment, and the average value was used.

Fig. 1
figure 1

The region of interest sites of the paraspinal muscles on magnetic resonance imaging. A A patient (≥ 6-month survival period) with relatively normal paraspinal muscles B A patient (< 6-month survival period) with a low quantity of the erector spinae muscle (10.2 cm2/m2) with muscular atrophy and fat infiltration.P, psoas muscle; Q, quadratus lumborum; E, erector spinae; M, multifidus

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Fig. 2
figure 2

Threshold technology of Image J tool to analyze the quality of paraspinal muscles. The patient is a 62-year-old lung cancer patient. A A high signal of the erector spinae muscle surrounded by the yellow line is colored white on T2 weighted image. B When using the threshold technique of Image J, the white color in the yellow line changed to red, representing the quality of the muscle

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Statistical analysis

Parametric statistical analyses were performed for normally distributed variables of the two groups; otherwise, nonparametric statistical analyses were performed. Comparisons between each group of continuous variables were made using independent sample t-tests. For nominal variables, the Fisher’s exact or chi-square test was used. Interobserver agreements were assessed using an intraclass correlation coefficient (ICC). The logistic regression analysis was performed to find important preoperative factors to help determine the direction of surgical treatment. Additionally, we analyzed the direct association between the paraspinal muscle and survival period using propensity score matching to reduce the effect of confounding factors. Propensity score matching and logistic regression were performed using Python. Threshold values for paraspinal muscles in predicting survival period were obtained using receiver operating characteristic (ROC) curve analysis in MedCalc version 11.1.1.0 for Windows (MedCalc Software, Mariakerke, Belgium). Other statistical analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). A p-value of < 0.05 was considered to indicate statistical significance.

Results

The mean survival period of the > 6 months and ≤ 6 months groups were 22.6 ± 16.0 and 2.7 ± 1.7 months (p < 0.001). There was no significance in age, sex, past medical history, smoking status, body mass index, operating time, SINS, Karnofsky performance scale, and muscle quality between the two groups. However, the proportion of patients who could ambulate preoperatively was significantly higher in the survival > 6 months group (26/32, 81.3%) than in the ≤ 6 months group (17/33, 51.5%; p = 0.011). Furthermore, there were more patients with multiple sites of vertebral metastasis (< 6 months group: 27/33, 81.8%; ≥ 6 months group: 18/32, 56.3%, p = 0.026) and vertebral collapse ([collapse rate more than 50%: < 6 months group: 15/33, 45.5%; ≥ 6 months group: 11/32, 34.4%], [collapse rate under 50%: < 6 months group: 15/33, 45.5%, ≥ 6 months group: 9/32, 28.1%], and [no collapse, < 6 months group: 3/33, 9.1%; ≥ 6 months group: 12/32, 37.5%], p = 0.023) in the survival < 6 months group. The rates of cord compression and other organ metastasis were not significantly different between both the groups. Patient characteristics are summarized in Table 1.

Table 1 Patient characteristics
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Quantity and quality of the paraspinal muscles

The ICCs for the paraspinal muscles were 0.914 (quadratus lumborum), 0.963 (erector spinae), 0.932 (multifidus), and 0.932 (psoas major). The quantity of the erector spinae muscle (ESM) was significantly higher in the > 6 months group (11.5 ± 2.8 cm2/m2) than in the ≤ 6 months group (10.0 ± 2.3 cm2/m2, p = 0.013). However, the quality of muscles was not significantly different between the two groups. Other muscles, including the quadratus lumborum, psoas major, and multifidus, did not show significant intergroup differences regarding the quantity and quality of muscles (Table 2). The ROC curve for the quantity of the ESM is shown in Fig. 3 (cut-off value = 10.486, sensitivity = 65.5, specificity = 66.7).

Table 2 Comparison of quantity and quality of the paraspinal muscles
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Fig. 3
figure 3

Receiver operating characteristic curve for cross-sectional area/height2 of the erector spinae muscle (cut-off value = 10.486, sensitivity = 65.5, specificity = 66.7). ROC, receiver operating characteristic; AUC, area under the curve; P, p-value

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Surgery-related factors

The estimated blood loss (p = 0.042) and amount of transfusion (p = 0.021) during surgery was significantly higher in the ≤ 6 months group (blood loss = 978.2 ± 1,958.5 mL, transfusion = 748.5 ± 1,103.0 mL) than in the > 6 months group (362.8 ± 348.4 mL, 298.4 ± 546.9 mL). However, the number of laminectomy levels, preoperative interventions, such as embolization or radiation, type of surgery, including posterior fixation, decompression, or corpectomy, and operation time did not show significant intergroup differences (Table 3).

Table 3 Surgery-related factors
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Logistic regression analysis

Logistic regression analysis was performed using preoperative variables with a p-value < 0.05, such as ambulation status, the number of vertebral segments involved in metastasis, the amount of vertebral collapse, and muscle quantity of the ESM, from the univariate analysis. The results showed that the muscle quantity of the ESM (p = 0.026, odds ratio 1.343) and the number of vertebral segments involved in metastasis (p = 0.016, odds ratio 0.199) were the most important preoperative factors for predicting the survival period after the surgery (Table 4).

Table 4 Result of 6-month survival rate-related preoperative risk factors from logistic regression analysis
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To assess the correlation of ESM with survival while controlling for potential confounders, propensity score matching was performed using preoperative ambulation status, number of metastases in the vertebral body, amount of vertebral body collapse, estimated blood loss, and amount of transfusion as confounding variables. To create a balanced dataset, nearest neighbor matching was conducted with a 1:1 ratio, using a caliper width of 0.2 to minimize differences in propensity scores between matched pairs. A logistic regression model was then applied to the matched dataset, with the quantity of ESM as the primary independent variable predicting survival. The analysis demonstrated a statistically significant association between ESM and survival, with an odds ratio of 1.519 (95% CI: 1.060–2.180, p = 0.024). This suggests that ESM may play a meaningful role in influencing survival outcomes, independent of the confounding effects.

Discussion

Lung cancer patients with bone metastasis have a low life expectancy [17]. Furthermore, in patients with spinal metastasis, surgical treatment can burden the patient's overall condition. Therefore, the performance status, such as the Karnofsky scale or Eastern Cooperative Oncology Group performance status, is preoperatively considered in determining whether to perform the surgical treatment [18]. The degree of performance status is known to be closely related to the paraspinal muscles [19, 20]. In this study, the authors first analyzed the correlation between the paraspinal muscles and prognosis after spine surgery in lung cancer patients. The results of our study highlight the importance of measuring the ESM preoperatively because the low quantity of the ESM was related to short survival periods.

Lung cancer patients at the advanced stage are prone to a sedentary or bedridden state [17, 21]. This inactivity aggravates muscle shortening and weakness, causing sarcopenia [22]. Previous studies have demonstrated that during bed rest, antigravity muscle groups, including the erector spinae, frequently decrease in size, and up to 40% of themuscle strength can be lost within the 1st week of bed rest [23,24,25]. Sarcopenia could be aggravated, as patients at advanced cancer stage are vulnerable to sarcopenia because systemic inflammation caused by cancers induces the reduction of muscle quantity by proteolysis and appetite suppression [26]. This overall condition is known to be associated with higher mortality in cancer patients [21, 27].

In this study, the poor prognosis group showed relative sarcopenia with a small quantity of the ESM and ambulation disorder. As the paraspinal muscles function as the antigravity muscles in posture maintenance, these muscles are important for better quality of physical activity [28]. Among the paraspinal muscles, the ESM functions mainly during ambulation, [29, 30] and it has been found to correlate with survival and physiologic function in several diseases [31,32,33]. This study also showed that patients with a low quantity of the ESM and walking disorder had shorter survival than the other group. Therefore, the quantity of the ESM and the preoperative ambulation status are very important preoperative criteria for deciding whether to perform surgery.

Imagama et al. [20] proved that the paraspinal muscle strength significantly affects quality of life. Furthermore, poor physical performance, disability, and fear-induced inactivity are associated with a decrease in the muscle strength [19, 34]. In such frail patients, preserving the paraspinal muscle is essential for maintaining daily living and continuing supportive treatments. Therefore, if the patients could not ambulate or if the quantity of the ESM is less than 10.486 cm2/m2, based on the cut-off value from the ROC curve, it would be desirable to preserve and strengthen the ESM without damaging it through surgery. The result of a previous animal study showed that the reversal of muscle wasting increased the survival period in a cancer cachexia model [35]. Therefore, instead of surgical interventions, nutritional support with paraspinal muscle exercise would be more appropriate for such frail lung cancer patients.

Previous studies showed that the distribution of fat composition within a muscle increases sarcopenia, causing muscle disability [36, 37]. However, this study showed that the quality of the paraspinal muscles did not have a significant effect on the postoperative survival period. It is possible that muscle quality did not have a significant correlation with patient prognosis because the base characteristics of the two groups, divided based on survival after surgery, were not completely identical. There are several studies demonstrating the adverse effect of poor muscle quality on the mortality of patients [37, 38]. In the future, analyzing sarcopenia with a greater focus on ensuring that the demographic characteristics of patients are as similar as possible would be more helpful in understanding how muscle quality affects patient prognosis after surgery. In addition, this study used Image J for measuring fat distribution. Considering that there are other various tools for measuring muscle quality, it is difficult to reach a single drawn conclusion using one modality [16].

According to the existing SINS criteria, if there is a high degree of vertebral collapse, surgical treatment is preferred [18]. However, univariate analysis showed that vertebral collapse could act as a cause of poor prognosis after the surgery. Therefore, patients’ needs and performance status as well as the structural instability should be considered in determining the treatment plan for spine metastasis.

The results of logistic regression analysis revealed that the number of metastatic vertebral bodies and the ESM were important preoperative factors for determining the prognosis after surgery. The number of metastatic vertebral bodies is one of the criteria in the Tokuhashi scoring system, designed to yield an estimated patient survival time based on preoperative evaluation. Multiple metastases indicate the progression of cancer, and it is difficult to expect a favorable prognosis after the surgery. Therefore, a therapeutic plan should be determined after sufficient explanation to patients as active surgical treatment does not guarantee a good prognosis.

Finally, when surgery is decided, various efforts are needed to reduce intraoperative bleeding, since a large amount of bleeding and blood transfusion are greatly associated with the patient's poor prognosis. Especially in cases where patients with metastasis to multiple vertebrae or low quantity of erector spinae muscles undergo surgery unavoidably, reducing bleeding during surgery could be helpful for the patient's prognosis. Preoperative embolization could be one of these efforts to decrease intraoperative bleeding [39, 40]. However, our study showed that preoperative embolization did not affect the survival period, probably because lung cancer is not as rich in blood vessels as thyroid and kidney cancer [41, 42]. Therefore, other proven methods, such as controlling hypotension during surgery or discontinuing antiplatelet drugs prior to surgery, would be recommended before spine surgery in lung cancer patients (Fig. 4) [43].

Fig. 4
figure 4

Flow chart for determining surgical treatment in lung cancer patients with spine metastasis

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In this study, considering that the average survival time of patients who died within six months postoperatively was 2.7 months, it could be interpreted that the burden of surgery itself may have contributed to the shortened survival period. Extensive intraoperative blood loss and high transfusion volumes, rather than paraspinal muscle sarcopenia alone, were likely associated with postoperative survival. However, even when controlling for potential confounding factors related to preoperative and intraoperative variables associated with survival through propensity score matching, ESM remained a significant factor influencing survival. Therefore, preoperative assessment of ESM should be regarded as an important consideration in surgical decision-making.The present study had several limitations. First, it was a retrospective study conducted at a single center with a relatively small sample size. A prospective study with more patients is desirable in the future. Second, although the cut-off value was presented on the ROC curve, it would be recommendable to use it as an indicator showing survival prognosis after the surgery rather than an absolute contraindication of surgery because the measurement value would vary slightly from person-to-person. In this study, although differences in measurements were noted between the two spine surgeons, the overall interobserver agreement was strong, with an ICC of 0.9 or higher. Thirdly, the study did not analyze patient prognosis in detail based on the type of chemotherapy. Over time, better chemotherapy strategies may have been developed, which could have had an impact on patient prognosis. Finally, this study used the term “sarcopenia” as a lack of the ESM or ambulation disorder. Even though there is no unified definition of sarcopenia, it has recently been defined more specifically in terms of muscle mass, muscle strength, and physical performance [44, 45]. Therefore, future studies are needed based on a prospective study design with a clear definition of sarcopenia.

Conclusions

Several perioperative factors could help predict prognosis after spine surgery in lung cancer patients. Among them, evaluation of the paraspinal muscle, especially the erector spinae, is important for determining the surgical strategy for spine metastasis. Furthermore, patients with a low quantity of the ESM and multiple spine metastasis are at high risk of poor prognosis after the surgery. Therefore, instead of surgery, palliative treatments should be considered first, as surgical interventions could not guarantee a favorable prognosis after the surgery.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Seoul Seonam Hospital, Seoul, Republic of Korea

    Sung Tan Cho

  2. Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43, Olymipic-Ro, Songpa-Gu, Seoul, Republic of Korea

    Jae Hwan Cho, Dong-Ho Lee, Chang Ju Hwang & Sehan Park

  3. Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170, Juhwa-Ro, Ilsangeo-Gu, Goyang-Si, Gyeonggi-Do, Republic of Korea

    Jin Hwan Kim & Se Hwan Um

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  1. Sung Tan Cho
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  2. Jae Hwan Cho
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  3. Jin Hwan Kim
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  4. Se Hwan Um
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  7. Sehan Park
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Contributions

(I) Concept and design: J.H.C, S.P, S.T.C; (II) Administrative support: D.H.L, J.H.C; (III) Provision of study materials or patients: S.P, S.T.C; (IV) Collection and assembly of data: S.T.C; (V) Data analysis and interpretation: S.T.C, J.H.K; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Corresponding author

Correspondence to Jae Hwan Cho.

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Ethics approval and consent to participate

This retrospective study was approved by the Institutional Review Board of Asan Medical Center (IRB number: 2022–1144). This study was performed in line with the principles of the Declaration of Helsinki.

Due to the study's retrospective design and the use of anonymized clinical data for analysis, the requirement for informed consent was exempted. Additionally, the Asan Medical Center's Institutional Review Board granted approval for this exemption (IRB number: 2022–1144).

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Not applicable.

Competing interests

The authors declare no competing interests.

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Cho, S.T., Cho, J.H., Kim, J.H. et al. Measuring the paraspinal muscles as an important tool for predicting the overall survival period after spine surgery in lung cancer patients with spine metastasis. BMC Musculoskelet Disord 26, 414 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08483-5

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08483-5

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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