Clinical outcomes of the LORDS strategy for thoracolumbar spinal metastases: a retrospective cohort study

To compare surgical outcomes between patients with spinal metastases who received surgical treatment concordant with the LORDS (life expectancy, operability, responsible segment, decompression, and stabilization) strategy and those who did not.

The Neurologic, Oncologic, Mechanical, and Systemic (NOMS) framework is widely used to guide decision-making in spinal metastases. With advances in targeted therapy, immunotherapy, and surgical techniques, more patients are now candidates for anterior column resection. However, a balanced surgical strategy that is compatible with NOMS framework and surgery remains lacking.

We included 238 adult patients (≥18 years) with spinal metastases who underwent surgery between January 2018 and December 2022. Patients were categorized into the LORDS-concordant group (n = 129) and the non-concordant group (n = 109). The non-concordant group was further subdivided based on decompression extent into de-escalated (n = 37) and escalated (n = 72) subgroups. Surgical outcomes included blood loss, duration of surgery, change in Frankel grade, postoperative systemic therapy (chemotherapy, targeted therapy, immunotherapy, bone-modifying agents), radiotherapy, length of hospitalization, reoperation, complications, overall survival (OS), and local progression-free survival (LPFS).

Patients who underwent surgery in accordance with the LORDS strategy exhibited a higher proportion of both radioresistant and radiosensitive individuals, while the proportion of patients with undefined radiosensitivity was lower (p = 0.030). However, this baseline difference did not reach statistical significance in subgroup analysis (p = 0.102). Furthermore, the LORDS-concordant group experienced a shorter length of hospitalization compared to the non-concordant group (p = 0.004), with subgroup analysis confirming consistent results (p < 0.001). Regarding survival outcomes, patients in the LORDS-concordant group demonstrated significantly improved OS (802.00 [95% CI: 544.00; 1332.00] days) and LPFS (530.00 [95% CI: 364.00; 980.00] days) compared to the non-concordant group (OS: 590.00 [95% CI: 283.00; 844.00] days, LPFS: 376.00 [95% CI: 234.00; 711.00] days) (p < 0.001 for OS and p = 0.008 for LPFS). Subgroup analysis further revealed longer OS and LPFS in the LORDS-concordant group compared to both the de-escalated (OS: 590.00 [95% CI: 303.00; 1179.00] days, LPFS: 280.00 [95% CI: 185.00; 759.00] days) and escalated groups (OS: 587.50 [95% CI: 275.50; 817.75] days, LPFS: 423.50 [95% CI: 240.00; 710.25] days) (p < 0.001 for OS and p = 0.008 for LPFS).

The LORDS strategy represents an exploratory surgical framework that integrates key clinical considerations while remaining compatible with the NOMS framework. It may offer a balanced and individualized approach to surgical decision-making in spinal metastases, with the potential to optimize outcomes without increasing operative risks. Further prospective validation of the LORDS strategy and refinement of its life-expectancy assessment are warranted.