STUDY DESIGN:Retrospective cohort study. OBJECTIVE:To investigate the association between preoperative body mass index (BMI) and 30-day mortality following metastatic spinal tumor surgery (MSTS), with particular emphasis on underweight status as a predictor of early postoperative mortality. SUMMARY OF BACKGROUND DATA:Surgical intervention for spinal metastases carries substantial perioperative risk. BMI has emerged as a potential prognostic biomarker given its accessibility and relationship to nutritional status and physiological reserve. However, evidence regarding its predictive value remains conflicting. Moreover, the prognostic implications of low BMI are underexplored despite the high prevalence of cancer-related cachexia in this population. METHODS:Data from the American College of Surgeons National Surgical Quality Improvement Program (2018-2023) were analyzed. Patients with disseminated cancer managed with MSTS were included. Underweight status was defined as BMI < 18.5 kg/m2. The primary endpoint was 30-day all-cause mortality. Univariable and multivariable logistic regression analyses were performed, with covariates selected a priori based on clinical relevance and established predictors of perioperative mortality. RESULTS:Among 2,098 patients (Mean age: 63 years; 60% male population), mean BMI was 27.3 kg/m2, with 4% (n = 90) patients classified as being underweight. The 30-day mortality rate was 8% (n = 164). On multivariable analysis, preoperative BMI as a continuous variable was independently associated with 30-day mortality (OR 0.96 [95% CI 0.93 to 0.99]; p = 0.016). Underweight status was also independently associated with nearly two-fold increased odds of 30-day mortality (OR 1.95 [95% CI 1.03 to 3.71]; p = 0.04). CONCLUSION:Lower preoperative BMI is independently associated with increased 30-day mortality following MSTS, with underweight patients facing nearly twice the odds of early postoperative death. Low BMI may serve as a simple, readily available marker of heightened physiologic vulnerability, warranting comprehensive preoperative evaluation of nutritional and functional status in this high-risk population.

Abstract Introduction Poor nutrition status has been associated with poor outcomes in the treatment of oncologic disease, however, there are no defined nutritional indicators for patients with metastatic spine disease (MSD). Hypoalbuminemia has been shown to be a potential biomarker for poor nutritional status in other populations, but the role it plays in the treatment of MSD remains unclear. Methods A scoping review of the literature up to December 2022 was conducted using PubMed/ Medline, EMBASE, and Web Science databases. Studies that included patients with MSD, collected albumin levels and reported associated clinical outcomes were included. Baseline health and clinical outcomes data including serum albumin levels, treatments for MSD, ambulatory status, readmission rate, mortality, and complications were collected. Results Thirty-eight studies comprising 21,401 patients were analyzed. The majority of studies defined hypoalbuminemia as a binary variable with a level <3.5 g/dL. Twenty-seven (71%) studies evaluated mortality as a primary outcome and 20 of these studies (74%) demonstrated a significant association between albumin levels and survival. A total of 13 studies (34%) included post-treatment complications, 54% of which reported a significant association between hypoalbuminemia and increased risk of complication. Notably only two studies evaluated hypoalbuminemia with regard to discharge disposition, but both studies found a significant association between albumin level and non-routine discharge. Conclusion The evidence from this scoping review suggests a threshold of 3.5g/dL is an appropriate definition for hypoalbuminemia in patients with MSD. Many studies demonstrated a correlation between hypoalbuminemia and both operative and non-operative outcomes in patients with MSD.

To examine implementation approaches and effectiveness of preoperative cognitive behavioral therapy (CBT) on patient-reported outcomes following lumbar fusion. We systematically searched PubMed/Medline, Cochrane Database of Systematic Reviews, and Epistemonikos (inception to December 15, 2024) for studies investigating preoperative CBT in patients scheduled for lumbar fusion. Primary and secondary outcomes were postoperative disability (Oswestry Disability Index, ODI) and health-related quality of life (EQ-5D), respectively, at 3 and 6 months. Meta-analysis employed Inverse Variance Random Effects Standardized Mean Difference models to compare the change from baseline. From a total of 182 studies, three RCTs comprising 307 patients (mean age: 50 years; 58

Instrumentation failure (IF) is a major complication after lumbar spondylectomy for spinal tumors, yet risk factors remain poorly defined. The present study aimed to determine the prevalence of IF and identify variables associated with IF and revision surgery using pooled individual patient data. A systematic review and individual patient data analysis were performed per PRISMA guidelines. PubMed, CDSR, and Epistemonikos were searched through January 2025, and additional patient-level data were obtained from prior series. Studies were included if they reported outcomes after lumbar spondylectomy for primary or metastatic tumors. Demographic, tumor, surgical, and (neo)adjuvant therapy variables were extracted. Statistical analyses included chi-square tests, t-tests, and Firth’s penalized logistic regression. Variables with p < 0.1 on univariable analysis and considered clinically relevant were entered into a penalized multivariable model, with a sensitivity analysis incorporating estimated blood loss as a surrogate of operative burden. A total of 169 patients (mean age 40.7 ± 17.6 years) were included after screening. IF occurred in 14

OBJECTIVE:Workload equity is a factor critical in maintaining resident well-being but remains inadequately addressed via duty-hour restrictions alone. We evaluated a Resident Call Points (RCP) System's effectiveness in promoting equity in residency training by reducing disparities in workload variance and improving duty hour compliance. METHODS:A single-site retrospective analysis of the call burden of 94 junior neurosurgical residents over 22 years was conducted. The RCP system is a weighted call-allocation framework used to measure and balance resident call burden quantitatively by assigned shifts a specific point value. Equity of workload distribution and overall call burden were the primary outcomes. Equity was measured using the variance (statistical spread) of RCPs while call burden was measured with the median RCP. Two groups: G1; pre-RCP period (2003-2011), and G2; post-RCP period (2012-2025) were analyzed and compared based on median RCP, RCP variance, and accredited survey-reported duty-hour compliance. RESULTS:After implementation of the RCP system, overall variance significantly decreased in G2 compared to G1, indicating greater equity in workload distribution. RCP median was significantly increased between G2 and G1 for PGY-3 only, indicating an increased workload for that specific training year. Sub-analysis did not reveal differences in workload between PGY-2 and PGY-3 in G2. Reported duty-hour violations decreased from 34% (18/53) to 11.1% (10/90) post-implementation (p < 0.001). CONCLUSION:The RCP system likely promotes equity in the call schedule by significantly reducing workload variance and is associated with improved resident compliance with duty-hours. By promoting fairness and addressing workload equity, the RCP system may provide a reproducible framework for improving duty-hour compliance in graduate medical education.

Background/Objectives: Adult spinal deformity (ASD) management often requires pelvic fixation, with S2 alar-iliac (S2AI) screws emerging as an alternative to traditional iliac screws. Despite multiple meta-analyses comparing these techniques, the methodological quality of these syntheses and technical heterogeneity across primary studies significantly impact their conclusions and subsequent clinical decision-making. This systematic review evaluates the evidence quality of meta-analyses comparing S2AI with traditional iliac screws for ASD management, focusing on methodological rigor, primary study overlap, and clinical heterogeneity. Methods: PubMed, Cochrane, and Epistemonikos were searched for meta-analyses comparing S2AI with iliac screws for patients with ASD. The Quality of Reporting of Meta-analyses (QUOROM) checklist and the revised Assessment of Multiple Systematic Reviews (AMSTAR 2) tool were adopted to assess the methodological quality. Primary study overlap was evaluated using the Corrected Covered Area (CCA) method. Clinical heterogeneity was assessed by examining characteristics of studies included in ≥67% of meta-analyses. Results: From a total of 29 publications, six meta-analyses met the inclusion criteria (4807 patients; mean age: 59 years; 33% female). All included meta-analyses exhibited critically low methodological quality per AMSTAR-2, with common flaws including failure to provide lists of excluded studies and lack of a priori protocols. Very high primary study overlap was observed (CCA: 31%), with only 11% (2 of 19) primary studies included in all meta-analyses, whereas 42% (8 of 19) primary studies were included by only a single meta-analysis. Substantial clinical heterogeneity existed regarding patient characteristics, surgical techniques, and outcome definitions. Conclusions: This systematic review of meta-analyses identified critically low methodological quality, high primary study overlap, and substantial clinical heterogeneity in the existing evidence comparing pelvic fixation techniques for ASD. While published meta-analyses generally favor S2AI screws, these significant limitations prevent drawing definitive conclusions about superiority. Future research should prioritize high-quality prospective studies with standardized reporting to generate more reliable evidence for improving surgical outcomes in ASD management.

Abstract Accurate preoperative risk stratification remains challenging in patients undergoing metastatic spinal tumor surgery (MSTS). While albumin-based indices have demonstrated prognostic utility across various surgical specialties, their performance following MSTSremains unexplored. The purpose of this study was to evaluate and compare the predictive utility of preoperative albumin level, albumin-bilirubin index (ALBI) score, and albumin-hemoglobin index (AHI) in for 30-day outcomes following MSTS. This retrospective analysis utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2018 – 2023) to identify patients with disseminated cancer undergoing MSTS. The primary endpoint was 30-day mortality and the secondary endpoint was 30-day major complications (Clavien-Dindo Grade III or IV). Univariable and multivariable logistic regression analyses assessed associations between biomarkers and outcomes. Receiver operating characteristic (ROC) curves were generated to evaluate discriminative ability, with area under the curve (AUROC) values compared using DeLong’s test. Among 2,097 patients (mean age 63 years, 60% male), 30-day mortality and major complication rates were 8% and 20%, respectively. In multivariable analysis, only preoperative albumin maintained independent predictive value for 30-day mortality (OR 0.53 [95% CI 0.28 to 0.99]; p = 0.048) and major complications (OR 0.58 [95% CI 0.35 to 0.95]; p = 0.031). None of the biomarkers achieved good discrimination (AUROC ≥ 0.7), with albumin demonstrating the strongest performance for mortality (AUROC 0.68) and complications (AUROC 0.61). Pairwise comparisons showed albumin significantly outperformed both composite indices for 30-day major complications. Preoperative albumin level demonstrated superior discriminative ability compared to ALBI and AHI indices for predicting 30-day outcomes in spine metastases surgery, though overall predictive performance remained modest. These findings support continued use of simple albumin measurement while highlighting the need for more sophisticated risk stratification approaches incorporating cancer-specific variables in this complex patient population.

Abstract Surgery for metastatic spine disease carries significant morbidity risk, but comprehensive analysis of complication patterns across different surgical approaches remains limited. Contemporary literature shows varying complication rates, potentially reflecting differences in patient selection, surgical techniques, and reporting standards. This systematic review aimed to comprehensively analyze perioperative complications following metastatic spine tumor surgery (MSTS) across different surgical approaches, providing evidence-based benchmarks for clinical decision-making. A systematic literature search across PubMed, Cochrane database, and Epistemonikos was conducted on February 8, 2025 for studies published between 2015-2025 reporting perioperative complications following MSTS. Data extraction encompassed patient demographics, tumor characteristics, surgical approaches (open, minimally invasive surgery, hybrid), and detailed complication profiles. Studies were stratified by surgical approach for comparative analysis. Statistical analysis included descriptive statistics and meta-analysis of complication rates. From 692 initial articles, 133 studies met inclusion criteria, encompassing 77,338 patients with mean age 61 years and 41% female representation. The overall complication rate was 42.56% (Mean: 29.97 ± 20.27%) (Range: 0 – 91.87%). Among surgical approaches, open procedures showed rates ranging 1 – 92%, hybrid approaches 9 – 92%, while minimally invasive procedures ranged 0 – 75%. Major complications included mortality 10.79% (0 – 18.29%), vascular and hemorrhagic events 27.49% (0 – 77.39%), respiratory and cardiac complications 23.43% (0 – 41.39%), as well as reoperation 2.53% (0 – 32.35%). Non-routine discharge occurred in 38.71% (0.51 – 67.97%) patients and readmission rate was 29.11% (2.14 – 37.46%). Major infectious complications occurred in 3.29% (0 – 18.18%). Minor cement complications occurred in 20.45% (1.45 – 51.35%) and minor neurological complications occurred in 19.42% (2.04 – 48.98%). This comprehensive systematic review demonstrates substantial perioperative complication burden following MSTS, with significant variation across surgical approaches. The wide statistical ranges emphasize heterogeneity in patient populations and surgical techniques. These evidence-based benchmarks shall support informed surgical planning and targeted quality improvement initiatives in this vulnerable patient population.

An in-silico study of the biomechanical behavior of the reconstructed spine after separation surgery at the cervicothoracic junction. To biomechanically compare different reconstruction techniques of the cervicothoracic junction after performing the separation surgery at the T1 level. Separation surgery in spinal oncology refers to a technique where circumferential decompression and stabilization of the spinal cord are performed to provide enough space for safe delivery of higher doses of radiation. Separation at the cervicothoracic junction poses unique biomechanical challenges for reconstruction, given the transitional anatomy and high stress of this area. As such, the optimal reconstruction technique remains unclear. A cervical thoracic finite element model (C4–T3) was developed to test the biomechanical behavior of instrumented spine under 5 Nm moment. The separation surgery was simulated at T1, with instrumentation ranging up to two levels above and two levels below. Six unique constructs were tested to evaluate the effect of type of screw [pedicle screw (PS) versus lateral mass screw (LMS)] and levels of fixation. Range of motion was not affected by the screw type. Longer fixation with LMS or PS resulted in greater resistance to motion and a stiffer spine. Screw stress was much higher than rod stress, and concentrated at construct end-points. Increasing length of thoracic endpoints did not reduce bony stress, while more than one level of cervical fixation suggested a protective effect on bone stress. PS fixation resulted in an additional protective effect on bone stress (30%) compared with LMS. The highest resistance to motion was observed in the two-above and two-below construct, irrespective of the type of screw. The use of PS suggested the greatest protective effect on bone stress. Selection of screw type and endpoint should be made with additional clinical considerations and requires future clinical verification.

To systematically review the published literature on minimally invasive spine surgery (MISS) approaches for intramedullary spinal cord tumor (IMSCT) resection and summarize surgical techniques, perioperative outcomes, neurological results, and complications. A PRISMA-guided search of PubMed, CINAHL, Cochrane Trials, and Scopus was performed from inception through November 19, 2025. Studies reporting MISS techniques for IMSCT resection with operative details and perioperative outcomes were included. Out of a total of 482 studies identified, 11 were included that reported on a total of 222 patients (Age range: 11-72; 52.9

Background: Chordoma is a rare bone cancer with limited treatment options. Clinical trials are crucial for developing effective therapies, but their success depends on including diverse patient populations. The objective of this study was to systematically evaluate the reporting of racial, ethnic, and socioeconomic diversity in United States clinical trials exploring treatment for chordoma. Methods: A literature search was conducted through PubMed/Medline, Cochrane, Epistemonikos, and ClinicalTrials.gov databases for published US chordoma trials up until 19 August 2024. The data collected included trial characteristics and racial and ethnic data, as well as socioeconomic indicators when available. Methodological Index for Non-Randomized Studies (MINORS) and Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB2) analyses were adopted to assess the methodological quality. The N-1 Chi-squared (χ2) test was implemented to compare the reported racial and ethnic data with the most recent US Census Bureau data. Results: Five trials involving 111 patients (median age: 63 years; 34% female) were included. Four studies (80%) were single-arm non-randomized studies with one study (25%) having a high methodological quality and three (75%) having a moderate quality based on the MINORS analysis. Most patients (91%, n = 82) were White/Caucasian, representing a proportion which was significantly higher than the reported 75% in the US population (p = 0.0005). Black/African American patients (2%, n = 2) were significantly underrepresented compared to the 14% in the US population (p = 0.0015). Regarding ethnicity, Hispanic/Latino patients (7%, n = 6) were significantly underrepresented compared to the 20% in the US population (p = 0.0021). No measures of socioeconomic status were reported. Conclusions: This systematic review highlighted the need for improved racial and ethnic diversity in chordoma trials and the better reporting of socioeconomic data. The underrepresentation of minority groups may obscure potential disparities in disease incidence, treatment access, and clinical outcomes.

Background: Performance status is often cited as an independent predictor of survival after metastatic spine tumor surgery (MSTS), but its standalone predictive value for short-term outcomes remains unclear. We aimed to evaluate how well Karnofsky (KPS) and Eastern Cooperative Oncology Group performance status (ECOG-PS) predict 90-day survival, a common surgical candidacy threshold, in patients managed with MSTS. Methods: We conducted a retrospective study of 175 adult patients who underwent MSTS at a single institution (2012–2025). All patients had documented preoperative KPS and ECOG-PS scores. Univariable logistic regression was used to assess associations with 90-day survival. Predictive performance was assessed by discrimination (AUC), diagnostic accuracy, calibration (Brier score), and clinical utility (decision curve analysis). Results: The crude 90-day survival rate was 73%. Both KPS (OR 1.02 [95% CI 1.01 to 1.05]; p = 0.001) and ECOG-PS (OR 0.51 [95% CI 0.36 to 0.73]; p < 0.001) were statistically associated with survival. However, discrimination was modest (AUC 0.65 for KPS, 0.68 for ECOG-PS), with the most balanced diagnostic accuracy achieved at KPS ≥ 70 (sensitivity 0.66, specificity 0.62) and ECOG-PS ≤ 2 (sensitivity 0.76, specificity 0.5). Calibration was fair (Brier scores 0.185 and 0.182, respectively). Decision curve analysis showed minimal net benefit across most threshold probabilities, with ECOG-PS performing slightly better at intermediate thresholds (30–60%), the zone of greatest clinical uncertainty. Conclusions: Despite being widely cited as an independent predictor of postoperative survival in patients with metastatic spine disease, performance status assessed via the KPS and ECOG-PS demonstrated only modest overall discriminatory ability, diagnostic accuracy, calibration, and clinical utility when used alone to predict 90-day survival after MSTS. While both scores retained meaningful value at the extremes (i.e., patients with very poor or very good performance status had more predictable outcomes), caution is warranted in intermediate cases, where performance status alone may be insufficient to guide treatment decisions. These findings highlight the critical difference between statistical association and the real-world clinical utility of a single metric to predict outcome in this patient population.

To develop an algorithmic approach for predicting surgical site infections (SSIs) in patients undergoing lumbar laminectomy and discectomy for adult degenerative spinal disease (DSD) by incorporating ensembled stacking into state-of-the-art (SOTA) automated machine learning (aML). The study utilized a comprehensive dataset from a prospective multicenter surveillance study on SSIs following lumbar laminectomy and discectomy to manage adult DSD. The Google Colab environment was adopted to load the dataset using Python programming language. Nine algorithms, including eXtreme Gradient Boosting (XGBoost), Light Gradient Boosting Machine (LGBM), Neural Network (NN), Categorical Boosting (CatBoost), and Random Forest (RF), were adopted with hyperparameter tuning using the current SOTA for aML. Ensembling of the developed algorithmic models was carried out, followed by stacking and ensembled stacking. Five-fold stratified, shuffled cross-validation was implemented. The macro-weighted average Area Under the Receiver Operating Curve (mWA-AUROC) analysis was used to evaluate the discriminating classification ability of the developed models along with other evaluation metrics. A stacked ensemble algorithmic model, comprising a stacked XGBoost model and an ensemble of XGBoost, NN, CatBoost, LGBM, and RF algorithmic models, achieved an mWA-AUROC of 0.994, an accuracy of 98.7

Background: Tranexamic acid (TXA) has shown efficacy in reducing blood loss in various surgical specialties without increasing thromboembolic risks, but its role in metastatic spinal tumor surgery (MSTS) remains unclear. This systematic review synthesized evidence on the safety and efficacy of TXA in MSTS. Methods: PubMed, Cochrane, and Epistemonikos were searched from inception to February 1, 2025 for studies reporting on TXA use in MSTS. Study quality was assessed using the Methodological index for non-randomized studies (MINORS) tool for non-randomized studies and the the Revised Cochrane risk-of-bias tool for randomized trials (RoB2) for randomized controlled trial (RCT). The impact of TXA on perioperative complications, blood loss, transfusion requirements, and operating time were evaluated. Meta-analysis feasibility was explored based on methodological and patient population uniformity. Results: Out of a total of nine studies, 6 studies reporting on 566 patients (mean age 59 years; 45% female) met the inclusion criteria. The 5 nonrandomized studies exhibited moderate methodological quality on MINORS analysis, while the RCT demonstrated low risk of bias on RoB2 analysis. A meta-analysis was precluded due to high participant and protocol heterogeneity. TXA was not associated with increased perioperative complications, including thromboembolic events. Blood loss impact varied, with 2 studies reporting contrasting results and others finding no significant effect. Transfusion requirements showed inconsistent results across studies. TXA consistently showed no impact on operative time. Conclusion: There is limited evidence to draw definitive conclusions regarding the safety and efficacy of TXA in metastatic spine tumor surgery. The best available evidence suggests that the complication rate is not higher in cases involving TXA use. The benefit in decreasing blood loss was variable. High-quality research is imperative to clarify the role of TXA in this complex patient population, as well as for the establishment of refined treatment protocols.

Background/Objectives: Anterior cervical discectomy and fusion (ACDF) is a common procedure for treating cervical spondylotic myelopathy. Limited research exists on the predictors of subsidence following ACDF. Subsidence can compromise surgical outcomes, alter alignment, and predispose patients to further complications, making it essential to prevent and understand it. This study aims to identify key risk factors for clinically significant subsidence and evaluate its impact on cervical alignment parameters in a large, diverse patient population. Methods: We conducted a retrospective review of patients who underwent ACDF between 2013 and 2022 at a single institution. Subsidence was calculated as the mean change in anterior and posterior disc height, with clinically significant subsidence being defined as three millimeters or more. Univariate analysis was followed by regression modeling to identify subsidence predictors and analyze patterns. Subgroup analyses stratified patients by implant type, number of levels fused, and cage material. Results: A total of 96 patients with 141 levels of ACDF met the inclusion criteria. Patients with significant subsidence were younger on average (52.44 vs. 55.94 years; p = 0.074). Those with less postoperative lordosis were more likely to experience significant subsidence (79.5% vs. 90.2%; p = 0.088). Patients with significant subsidence were more likely to have standalone implants (38.5% vs. 16.7%; p < 0.01), taller cages (6.62 mm vs. 6.18 mm; p < 0.05), and greater loss of segmental lordosis (7.33 degrees vs. 3.31 degrees; p < 0.01). Multivariate analysis confirmed that standalone implants were a significant independent predictor of subsidence (OR 2.679; p < 0.05), and greater subsidence was positively associated with loss of segmental lordosis (OR 1.089; p < 0.01). Subgroup analysis revealed that multi-level procedures had a higher incidence of subsidence (35.7% vs. 28.1%; p = 0.156), and PEEK cages demonstrated similar subsidence rates compared to titanium constructs (28.1% vs. 29.4%; p = 0.897). Conclusions: Standalone implants are the strongest independent predictor of significant subsidence, and those that experience subsidence also show greater loss of segmental lordosis, although not overall lordosis. These findings have implications for surgical planning, particularly in patients with borderline bone quality or requiring multi-level fusions. The results support the use of plated constructs in high-risk patients and emphasize the importance of individualized surgical planning based on patient-specific factors. Further research is needed to explore these findings and determine how they can be applied to improve ACDF outcomes.

Background:Frailty assessment is becoming increasingly important for risk stratification in metastatic spine disease (MSD) management. However, the optimal frailty assessment tool for this population remains undefined. The aim of this systematic review was to critically evaluate frailty indices utilized in surgical and radiotherapeutic management of MSD by appraising their components and predictive performance. Methods:We systematically searched PubMed, Cochrane, and Epistemonikos from inception until November 13, 2024 for studies exploring frailty indices in MSD management. Methodological quality assessment was undertaken using the Methodological index for nonrandomized studies (MINORS) and Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tools. We evaluated indices for comprehensiveness by assessing if they included measures across 8 dimensions (comorbidity burden, mobility, cognition, mood, social vulnerability, nutrition, energy, and function). We also assessed their predictive utility for mortality and complications. Results:Out of a total of 42 studies, 15 studies reporting on 61,663 patients (Mean age: 63 years; 44% female) met the inclusion criteria. All studies were of moderate quality based on MINORS analysis. Six frailty indices were identified, with all including comorbidities while none incorporating energy measures. The Hospital Frailty Risk Score was the most comprehensive (75% of frailty spectrum). Predictive performance varied considerably across studies, with inconsistent associations with complications and mortality after both: surgical and radiotherapeutic interventions. Conclusions:Contemporary frailty indices showed substantial heterogeneity in both composition and predictive performance for MSD outcomes. The inconsistent performance and incomplete capture of frailty dimensions underscored the need for developing a novel frailty index that incorporates oncologic factors and balances comprehensive evaluation with clinical feasibility to help guide treatment decisions between surgery and radiotherapy for patients with MSD.

Background/Objectives: Failure to rescue (FTR), defined as the occurrence of a major complication plus death within 30 days, is a key measure of surgical safety. Hypoalbuminemia is a known risk factor for poor outcome in metastatic spinal tumor surgery, yet its association with FTR has not been explored. The purpose of this study is to evaluate serum albumin level as predictor of FTR after surgery for spinal metastases. Methods: A total of 1749 patients with disseminated cancer who underwent oncologic surgery for spinal metastases (identified by CPT codes) and met our inclusion criteria were identified in the ACS-NSQIP database (2018-2023). The primary endpoint was FTR, defined as a major complication plus death occurring within 30 days of surgery. Serum albumin was analyzed both as a continuous and categorical variable (hypoalbuminemia < 3.5 g/dL, normal albumin > 3.5 g/dL). Univariable and multivariable logistic regression was performed, adjusting for demographic and operative variables. Results: The mean preoperative serum albumin level was 3.63 g/dL (standard deviation = 0.642) and the FTR rate was 4% (71 of 1749). After adjusting for potential confounders such as modified Frailty Index 5, ASA class, functional status, emergent case, and reoperation, higher preoperative albumin levels (OR 0.39 [95% CI 0.26-0.61]; p < 0.001) were independently associated with decreased odds of FTR. Conclusions: The findings of this study suggest an association between preoperative serum albumin level and FTR in oncologic surgery for spinal metastases. This highlights the importance of albumin assessment for perioperative prognosis, but the findings require further validation.