Short-Term Outcomes in Planned Versus Unplanned Surgery for Spinal Metastases

Background/Objectives: Metastatic spine disease (MSD) affects a significant proportion of patients with advanced malignancies and often necessitates surgical intervention to preserve neurological function, alleviate pain, and maintain spinal stability. While oncologic spine surgery is ideally performed in a planned, semi-elective setting, a substantial number of patients require unplanned (urgent or emergent) surgery due to acute deterioration. The impact of surgical planning status on postoperative outcomes following metastatic spine tumor surgery remains underexplored. This study aimed to compare the patient characteristics and short-term outcomes of those undergoing planned versus unplanned surgery for spinal metastases. Methods: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2018 to 2023. Patients with disseminated cancer undergoing tumor surgery were identified. Case types were grouped into planned (elective) and unplanned (urgent or emergent). The primary endpoint was failure to rescue (FTR); secondary endpoints included 30-day major complications, 30-day mortality, and length of hospital stay. Univariable and multivariable regression analyses were performed. Results: A total of 2147 patients met our inclusion criteria, out of whom 60% (n = 1284) underwent planned and 40% (n = 863) underwent unplanned surgery. Patients in the unplanned surgery group had a significantly higher prevalence of severe hypoalbuminemia, severe anemia, and ASA class IV status (p ≤ 0.001 for all). For our primary endpoint, a multivariable analysis showed a significant association between unplanned surgery and FTR (OR 2.11 [95% CI 1.24 to 3.56]; p = 0.005). Significant associations were also found with 30-day mortality (OR 1.84 [95% CI 1.25 to 2.72]; p = 0.002) and length of hospital stay (β 2.7 [95% CI 1.97 to 3.43]; p < 0.001). However, unplanned surgery could not independently predict 30-day major complications (OR 1.21 [95% CI 0.97 to 1.51]; p = 0.08). Conclusions: Our study found that unplanned surgery for spinal metastases was associated with significantly higher rates of FTR, 30-day mortality, and extended hospital stay, independent of other covariates. These findings highlight the importance of the timely identification of patients requiring surgery and the potential benefits of semi-elective care.