Preoperative assessment and surgical indications: Separation surgery | Revista Española de Cirugía Ortopédica y Traumatología

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Fuentes Caparrós, F. Rodríguez de Tembleque Aguilar, M.Á. Marín Luján, J.A. Gutiérrez Castro" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Fuentes Caparrós" "email" => array:1 [ 0 => "sfuentesc@telefonica.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Rodríguez de Tembleque Aguilar" ] 2 => array:2 [ "nombre" => "M.Á." "apellidos" => "Marín Luján" ] 3 => array:2 [ "nombre" => "J.A." "apellidos" => "Gutiérrez Castro" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Valoración e indicaciones quirúrgicas: cirugía de separación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 2192 "Ancho" => 2508 "Tamanyo" => 420683 ] ] "descripcion" => array:1 [ "en" => "Indication for vertebral body replacement." ] ] ] "textoCompleto" => "IntroductionIn 2018 figures from the USA, 1.7 million new cancer diagnoses are made per year, of which 40%–70% will develop vertebral metastases (mx), the most frequent to develop being breast (40%), lung (15%), prostate (10%) and renal (10%) cancers. Among these, around 20% will progress to spinal cord compression. In a not insignificant number of them, the presence of clinical symptoms, manifested as pain or neurological symptoms, will involve surgical treatment. Not so long ago Patchell et al.<a class="elsevierStyleCrossRef" href="#bib0190">1</a> demonstrated surgery's superiority over radiotherapy alone, in terms of improved neurological results, better quality of life and lower economic and social cost.Since then, the change in the approach to the treatment of these patients has progressed beyond a single vision; the approach must be made by evaluating multiple parameters: quality of life, neurological status, primary tumour, extension, stability, etc., in order to adapt the treatment to the clinical characteristics of each patient. In this regard, we would like to highlight three now classic studies that have enabled a multidisciplinary consensus categorisation to be made, and thus achieve a better treatment adaptation: the revised scale of Tokuhashi et al., 2005<a class="elsevierStyleCrossRef" href="#bib0195">2</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), for the assessment of tumour disease and its metastatic burden, the Spinal Instability Neoplastic Score (SINS) 2010 for biomechanical assessment<a class="elsevierStyleCrossRef" href="#bib0200">3</a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and the Epidural Spinal Cord Compression (ESCC) scale of Bilsky et al., 2010<a class="elsevierStyleCrossRef" href="#bib0205">4</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) for the assessment of the possibility of spinal cord risk in radiotherapeutic treatment. The integration of these concepts has given rise to the current approach to the treatment of metastatic pathology, the NOMS algorithm (Neurologic, Oncologic, Mechanical, Systemic framework),<a class="elsevierStyleCrossRef" href="#bib0210">5</a> which is the basis for the work of the current commissions on spinal metastases.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Surgical indication: changes in patient assessmentToday we consider a survival expectancy of less than 3 or 6 months as the threshold for offering invasive treatment, but how can we refuse treatment to patients when we cannot be sure of this life expectancy? Or how can we refuse treatment to patients with disabling pain or progressive neurological impairments because their life expectancy is less than 3 months?This vision, established on knowledge and evidence that dates back to the first decade of this century, is also changing with the development of new oncological treatments based on genetic and molecular therapy (the most widely used scales, Tomita or Tokuhashi, do not include this consideration); changes in radiotherapy algorithms based on single major targeted doses (Stereotactic Body RadioTherapy [SBRT]; extracranial stereotactic radiosurgery) or with protons that achieve high percentages (70%–90%) of local control independently of the primary<a class="elsevierStyleCrossRef" href="#bib0215">6</a> tumour or, in surgery, the change from the concept of “excisional” surgery to “separation” surgery associated with radiosurgery (SBRT), the former being mainly indicated in the treatment of radioresistant tumours. All of these are giving patients a better life expectancy, and oncologists and surgeons new therapeutic weapons.In this sense of focusing surgical treatment on the patient's expectations and quality of life, it is worth evaluating the results of the study by Dea et al.<a class="elsevierStyleCrossRef" href="#bib0220">7</a> in which they evaluated an international cohort of 466 patients, from countries of different cultures, with a survival prognosis of less than 3 months. Their results showed that 76.9% of patients were satisfied with their treatment at 6 weeks and none reported not recommending it. However, as expected, they found a greater number of adverse effects in the group of patients with lower life expectancy compared to those with higher life expectancy, effects which, when analysed, did not occur during intraoperative management (they were not associated with the “surgical burden” measured in duration of surgery or blood loss), but in the postoperative period.For all these reasons, they conclude, and we agree, that the preoperative baseline clinical condition should be the main determinant of surgical indication rather than the expected survival. These indications should also take into account the concept of outcome effectiveness, with recommendation of the least aggressive possible.Predictive scales reviewThis improvement in the survival of tumour patients with metastatic disease has been achieved thanks to a better understanding and treatment of the biology of metastasis (RANKL-RANK association mechanism and the development of drugs such as denosumab that block it by preventing the osteolysis process); the progress of new knowledge in immunogenetics which has made treatments with target drugs directed against tumour cells a reality, allowing better survival rates in classically more aggressive tumours such as lung, melanoma or ovarian tumours, and the improved knowledge of spinal biomechanics in the context of metastatic tumours in these patients. In recent years these factors have given rise to numerous studies reviewing predictive scales based on the analysis of success according to the area under the curve (AUC) technique. These studies show good predictive results (discrimination “c-statistic: patients who survive/death with the best result being “1” and a result equal to chance “.5”).In this regard, the analysis of the predictive results of the Tokuhashi scale carried out by Zoccali et al.<a class="elsevierStyleCrossRef" href="#bib0225">8</a> in which the reliability of the scale's survival prognosis from 2007 to 2013 is analysed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) may be highlighted. In this meta-analysis of the results of 10 studies involving 1, 686 patients, prediction is analysed according to the 3 groups defined by the Tokuhashi scale (group 1: survival <6 months, group 2: survival 6–12 months and group 3: survival >12 months), finding that if the overall predictive accuracy of the scale was 63%, it was very different depending on the group, being higher for the group with the longest survival (group 3: 77.21%), decreasing for group 1 (64.10%) and no higher than chance for group 2 (55.12%). The decrease in prediction has increased from the appearance of the scale in 2005 to the present day, reflecting the lack of sensitivity of the parameters in the groups with the poorest prognosis, which are those that have benefited most from the development of the most up-to-date treatments.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>New scales and parameters are proposed to improve the reliability of predictions in higher risk groups, a first example of which is the one made by the group of Katagiri et al.<a class="elsevierStyleCrossRef" href="#bib0230">9</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). For the first time this establishes prognostic differences depending on sensitivity to hormone-dependent treatment in the case of breast or prostate or with specific target drugs in lung cancer, and biochemical parameters are also included in the assessment. The scale, with a score between 0 and 10, in our view improves the prognostic results (>.75, <.25) for the high and low survival groups, as well as in the 6-month survival of patients classified as intermediate. Thus, the recommendations for patients with score 0–3, whose life expectancy is greater than one year in 91%, treatment with radiosurgery or combined with separation surgery would be indicated. However, for patients with a score between 7 and 10, with a 6-month survival expectancy of 27% and only a one-year expectancy of 6%, the most indicated option would be conventional radiotherapy combined with internal fixation in case of instability or neurological progression.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>However, although the predictive capacity of these scales has improved to reach a statistic c=.78 for prediction at one year, their predictive capacity for the most severe patients has improved to the same extent. Thus, in order to improve the reliability of survival prediction, new, especially biochemical parameters have been proposed for inclusion. As a useful and simple example, Karhade et al.<a class="elsevierStyleCrossRef" href="#bib0235">10</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) proposed serum alkaline phosphatase levels under 100 (c=.75) as an independent prognostic factor for survival longer than 6 months and/or metastatic tumour burden.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>FA is a metalloenzyme that is expressed on the surface of osteoblasts and whose level indicates increased activity. In osteolytic lesions it is produced secondarily in an attempt to compensate for destruction and in osteoblastic lesions by direct stimulation. FA is also a marker of intrahepatic bile duct obstruction due to liver metastases.Regarding tumour metastatic burden, levels >100UI/l are associated with statistically significant differences (p<.001) for the presence of multiple spine metastases (102UI/l), presence of extra-spinal bone mx (105UI/l) or presence of visceral mx (105UI/l).Finally, the prognostic role of FA in patients treated only with RT, CT or palliative measures has not been studied and neither have the changes in FA in patients treated with antiresorptive drugs before or after surgery.New scales based on algorithmsOutstanding in this attempt to ensure survival prediction is the work of the Paulino et al.<a class="elsevierStyleCrossRefs" href="#bib0240">11,12</a> group from the Massachusetts General Hospital. It described a first algorithm, the “SORG normogram”, based on multiple parameters to reach a prediction of .70 at 30, 90 and 365 days.Since the publication of the “SORG normogram” staging, work has continued on more complete decision algorithms based on the capabilities of artificial intelligence (“machine learning”). Led by Karhade's group at Harvard Medical School, and joined by Sciubba's group at Johns Hopkins University School of Medicine,<a class="elsevierStyleCrossRefs" href="#bib0250">13,14</a> they created the survival prediction algorithm “SORG Machine-Learning” (SORG-ML), an algorithm based on 15 clinical and biochemical parameters which, entered into a computerised database, provide an automated prediction. This algorithm, externally validated,<a class="elsevierStyleCrossRef" href="#bib0260">15</a> improves results in discrimination (c-statistic .75–.81 for 90 days and .77–.78 for one year), calibration, Brier score (mean squared difference between model predicted and observed) and decision curve.This study is based on the detection methodology described above, and on the study of a sample of 781 patients and 15 variables, both qualitative (primary tumour, ECOG or Charlson morbidity scale<a class="elsevierStyleCrossRefs" href="#bib0265">16,17</a>) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) and quantitative (Alk. P levels, haemogram, etc.), creating a computerised algorithm with free access that assesses survival at 90 and 365 days on 15 parameters of different characteristics (<a href="https://sorg-apps.shinyapps.io/spinemetssurvival/">https://sorg-apps.shinyapps.io/spinemetssurvival/</a>) (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Regarding mortality at 90 days, the prediction of the algorithm obtained a c=.83 with the most predictive variables being the primary tumour, preoperative albumin and ECOG grade. Regarding mortality at one year, it reached a statistic of c=.85.External validation of the SORG-ML algorithm was made compared with 9 prognostic scales (Tokuhashi, revised Tokuhashi, Tomita, Bauer, revised Bauer, Katagiri, van der Linden, SORG classic and Sorg normogram) concluding that it presents a better prediction in mortality at 90 days (AUC=.75–.81) and similar for one year (AUC=.77–.78).Our indications according to the NOMS conceptIn 2015, the Metastatic Spine Disease Multidisciplinary Working Group, a group that includes radiation oncologists, interventional radiologists and surgeons, proposed consensus treatment guidelines based on 5 clinical groups,<a class="elsevierStyleCrossRef" href="#bib0275">18</a> corrected in 2019<a class="elsevierStyleCrossRef" href="#bib0280">19</a> (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>), in accordance with this multidisciplinary concept in the approach to the treatment of metastatic patients. Following this idea and the updated literature, in which the patient's general condition and stability are the first factors to be evaluated when it comes to the indication, rather than the symptomatology itself, we have proposed the following treatment groups:<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Low aggressiveness treatment<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a.Palliative radiotherapy: only indicated in patients with a poor systemic status, ECOG 3–4 and/or neurological involvement ASIA A of over 48h evolution.</li><li class="elsevierStyleListItem" id="lsti0010">b.SBRT (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5a–d</a>): our indication for single high-dose stereotactic radiosurgery is established in patients with good clinical status ECOG 1–2, stable with SINS <6 and with epidural compression <2. Preferably life expectancy >6 months and with single metastasis.<a class="elsevierStyleCrossRef" href="#bib0285">20</a> It is important to take into account the determination of spinal stability prior to the indication of SBRT as a single treatment even in patients without epidural compression. In a study of patients<a class="elsevierStyleCrossRef" href="#bib0290">21</a> with vertebral mx without epidural compression, prior RT or surgery undergoing SBRT they found that patients with SINS≥11 were associated with a higher number of adverse effects in the radiated area (vertebral fractures, admission for pain, emergency or scheduled surgery, new neurological symptoms and/or epidural compression). A higher frequency of adverse effects is also observed when comparing SBRT versus conventional multifraction Minimally aggressive techniques (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6, a–h</a>): the combination of RT with percutaneous techniques such as ablation or cementation is a useful option for fragile patients. Our indication is the same in patients up to ECOG 2, with slow growing tumours and multiple metastases or metastases which progress despite satisfactory control of the systemic disease, particularly in areas of thoracolumbar hinge zones with SINS up to 9 (according to the considerations indicated by Lam et al.<a class="elsevierStyleCrossRef" href="#bib0290">21</a>) and preferably with low degrees of spinal cord compression (Bilsky 1C).<elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li></ul>Some considerations in the application of this technique must be taken into account in order to avoid the complications described with its application (up to 20%). Contraindications for the use of cementation are the involvement of the posterior wall or the presence of a neurological lesion. Regarding ablation, a minimum of 5mm must be established between the ablation area and the spinal cord in order to avoid lesion and to assess the cementation in order to avoid the development of a fracture.Preventive treatment: SINS 7–12In the evaluation of the mechanical stability of patients assessed by the SINS scale, the guidelines for action are clear for the “stable” (0–6) and “unstable” (13–18) groups. However, for the “potentially unstable” category (7–12), which accounts for 75% of the patients consulted,<a class="elsevierStyleCrossRef" href="#bib0280">19</a> there is no consensus agreement on the parameters for deciding whether or not to stabilise.In this sense, Pennigtong et al.<a class="elsevierStyleCrossRef" href="#bib0295">22</a> carried out a review of the therapeutic decisions indicated in a series of patients classified in this group, and of their clinical characteristics. They present a series of patients with a median SINS of 9 (IQR: 7–10 and mode 10) with a Tokuhashi of 8 (IQR: 7–11) and 75% of unstable lesions.Their conclusions were that 79% of patients with SINS 10-12 were operated on, compared with only 11% with SINS 7–9. The reasons for operating on patients with SINS 7–9 was an epidural compression ESCC 2–3, while patients with high SINS with low survival probability (ECOG 3 and multiple lesions) were not operated on. The operated patients, irrespective of their SINS, were significantly younger, had a higher Tokuhashi, thus associated with longer survival and also a higher Karnofsky. A sub-analysis in these patients also found a higher lytic lesion involvement and pain. This finding is similar to that given by Versteeg et al.,<a class="elsevierStyleCrossRef" href="#bib0300">23</a> who also give cut-offs of 10.7 vs. 7.2 (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<elsevierMultimedia ident="fig0035"></elsevierMultimedia>In keeping with this, our unit is particularly interventionist in patients with SINS 9–12, especially in patients with multiple sites or who have undergone previous radiotherapy. The main limiting factor for us is the general status of the patient and secondly the neurological condition. Estimated survival is much less important with our main aim being to ensure quality of life and neurological status during survival (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8a–f</a>).<elsevierMultimedia ident="fig0040"></elsevierMultimedia>Separation surgeryFor many groups, including ours, during the last decade of the last century and the first decade of the present century, the indicated surgical treatment for patients with single metastasis was en bloc vertebrectomy described by Roy-Camille et al. and popularised by Tomita et al.<a class="elsevierStyleCrossRefs" href="#bib0305">24,25</a> whose aim was to perform surgery “as compartmental as possible”, transferring the excisional concept of oncological surgery of the extremities to the spine. The objections to this treatment lie, firstly, in the characteristics of the metastatic disease itself and the presence of “skip metastases” metastases not detectable at the time of indication and the extension of the tumour into the epidural space (layer D in the classification of Weinstein et al.,<a class="elsevierStyleCrossRef" href="#bib0315">26</a>) which implies that this compartmental resection is impossible except in patients with Tomita's type 1 intraosseous involvement.<a class="elsevierStyleCrossRef" href="#bib0320">27</a>This concept changed radically in the second decade of this century with the appearance of stereotactic radiosurgery (SRS or SBRT) which allows the total application of the dose in single fractions, minimising the exposure of the tissues at risk, especially the spinal cord. This achieves a direct cytotoxic effect and local control of up to 98% at 2 years, changing the objectives of radiotherapy from traditional pain relief to ablative radiotherapeutic treatment of vertebral metastasis<a class="elsevierStyleCrossRef" href="#bib0325">28</a> and, therefore, from surgical indications based on the need for vertebral tumour reduction or excision (corporectomies or vertebrectomies).However, these high doses with a tumour-killing effect need a safety margin, estimated to be about 2mm, to be delivered, which is why the concept of “hybrid therapy” is defined, in which surgery aims to create this margin to allow safe treatment with radiosurgery in a second phase.In their article Barzilai et al.<a class="elsevierStyleCrossRef" href="#bib0330">29</a> give a detailed description of the technique, which is based on a first step of instrumented stabilisation, at least 2 levels above and below the lesion in order to restore a mechanical instability present or secondary to the removal of bone from the posterior elements. A second step of decompression that must take into account the use of technical gestures that avoid putting pressure on the compression, using drills as much as possible (areas free of tumour involvement) and being careful in the intracanal manipulation of the Kerrison heel. This posterior part should end with the achievement of an access corridor to the anterior component that allows the resection of 20% of the vertebral body, the separation of the thecal sac from the posterior common vertebral ligament and the depression of the tumour component in order to obtain a circumferential separation of the dura. Excision of the remaining vertebral tumour within the body or in paraspinal tissues is not necessary as they fall within the treatment field of radiosurgery. Anterior support is only needed in case of a vertebral body resection of more than 50% (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9a–c</a>). In our unit, protocolised preoperative tumour embolisation is almost routinely performed, especially in patients with hypervascular tumours.<elsevierMultimedia ident="fig0045"></elsevierMultimedia>In recent years, various technological innovations have improved the separation technique. From the surgical point of view, the development of implants made of carbon fibres reinforced with PEEK® (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10a–g</a>) has led to an improvement in the quality of the planning and application of radiotherapy by avoiding the scattering effect induced by titanium implants on ionising radiation and particles without reducing the safety offered by the implants in mechanical terms,<a class="elsevierStyleCrossRef" href="#bib0335">30</a> as well as improving the quality of postoperative use of MRI.<a class="elsevierStyleCrossRef" href="#bib0340">31</a><elsevierMultimedia ident="fig0050"></elsevierMultimedia>In our unit the technique of choice in the treatment of single metastasis is SBRT radiosurgery when spinal cord compression is Bilsky <2 and the hybrid protocol described for separation surgery with carbon instrumentation combined with early SBRT (2 weeks) in Bilsky ≥2 compression cases. According to the literature, the indication for the hybrid technique does not depend on the type of tumour or age of the patient, but above all on the patient's functional status, the degree of spinal cord injury and the prognosis according to the NOMS.Spinal cord compression associated with neurological impairmentIn this section on “preventive” treatment, we also wanted to include the indications, especially in terms of time, of spinal cord compression with neurological impairment. In this regard, we should highlight the work of Patchel et al.<a class="elsevierStyleCrossRefs" href="#bib0190">1,32</a> and Cole et al.<a class="elsevierStyleCrossRef" href="#bib0345">32</a> in which they report a 62% recovery of ambulatory capacity after decompression surgery plus stabilisation and radiotherapy performed before 48h in patients with incomplete or progressive lesions, or that of Fan et al.,<a class="elsevierStyleCrossRef" href="#bib0350">33</a> the latter performed on a group of 43 patients with complete paraplegia (34 Frankel A and 9 Frankel B) in which they observed that those Frankel B patients operated on in a period of less than 48h also improved by at least 2 grades on the scale. None of the Frankel A patients regained ambulation postoperatively. This recommendation is set at 24h, the treatment recommendations given by the NICE guideline.<a class="elsevierStyleCrossRef" href="#bib0355">34</a>Regarding other predictors, Laufer<a class="elsevierStyleCrossRef" href="#bib0360">35</a> established as a poor predictor of functional recovery the established vesicle dysfunction and, in contrast, presented a muscle balance of 3. No relationship has been found between functional recovery with other types of variables such as age, sex and type (aggressiveness) of the tumour. No statistically significant relationship was found with an increase in complications, infections or hospital stay either, compared with preoperative neurological involvement.<a class="elsevierStyleCrossRef" href="#bib0365">36</a>In this sense, our approach is the same as studies that have been commented upon,<a class="elsevierStyleCrossRefs" href="#bib0190">1,32–34</a> indicating, firstly, that general medical treatment (analgesia, thromboprophylaxis) be used, specifically with large doses of dexametasone in 16mg/24h doses, neurological status control and surgery in ECOG 0–2 patients who present with a neurological status up to ASIA B of under 48h evolution, regardless of the type of tumour and above all if this is associated with the impossibility of radiosurgery (Bilsky≥2) and/or the presence of oligometastasis. Early decompression may prevent the cascade of vascular changes which trigger ischaemia and spinal infarction,<a class="elsevierStyleCrossRef" href="#bib0370">37</a> and thereby the ability of reversibility of the neurological involvement, facilitating a particularly significant qualitative neurological improvement (<a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11a–e</a>).<elsevierMultimedia ident="fig0055"></elsevierMultimedia>Level of evidenceLevel of evidence I.FundingNo funding was received for this article.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2103684" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1792792" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2103685" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1792791" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Surgical indication: changes in patient assessment" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Predictive scales review" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "New scales based on algorithms" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Our indications according to the NOMS concept" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Low aggressiveness treatment" ] ] ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Preventive treatment: SINS 7–12" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Separation surgery" ] 11 => array:2 [ "identificador" => "sec0045" "titulo" => "Spinal cord compression associated with neurological impairment" ] 12 => array:2 [ "identificador" => "sec0050" "titulo" => "Level of evidence" ] 13 => array:2 [ "identificador" => "sec0055" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interests" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-01-27" "fechaAceptado" => "2023-04-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1792792" "palabras" => array:3 [ 0 => "Metastasis" 1 => "Rachis" 2 => "Separation surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1792791" "palabras" => array:3 [ 0 => "Metástasis" 1 => "Raquis" 2 => "Cirugía de separación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Neurological compression occurs in 10%–20% of patients who develop spinal metastases. In the last decade, the evolution of oncological diagnostic and medical techniques, the change from conventional external radiation to radiosurgery and the new surgical instruments have meant that the treatment of these patients must be indicated in a personalized manner and by consensus, multidisciplinary way, in specific commissions.Today, the biological state of the patient, the presence of mechanical instability, the neurological assessment and degree of epidural compression, as well as the best prognostic categorization of the tumor, are established as decision factors prior to the indication of surgical treatment, treatment that has passed from a cytoreductive concept to that of a spinal cord release from tumor in order to ensure safe radiosurgery." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La compresión neurológica se presenta entre el 10-20% de los pacientes que desarrollan una metástasis vertebral. En la última década, la evolución de las técnicas diagnósticas y médicas oncológicas, el cambio de la radiación convencional externa a la radiocirugía y los nuevos instrumentales quirúrgicos, han hecho que el tratamiento de estos pacientes deba de ser indicado de forma personalizada y en consenso, de forma multidisciplinar, en comisiones específicas.Hoy, el estado biológico del paciente, la presencia de inestabilidad mecánica, la valoración neurológica y el grado de compresión epidural, así como la mejor categorización pronóstica del tumor, se establecen como los factores de decisión previa a la indicación del tratamiento quirúrgico, tratamiento que ha pasado de un concepto «citorreductor» al de «separador» o «preparador» de la médula para asegurar una radiocirugía segura." ] ] "multimedia" => array:16 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3407 "Ancho" => 2508 "Tamanyo" => 703617 ] ] "descripcion" => array:1 [ "en" => "Epidural spinal cord compression." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2428 "Ancho" => 2508 "Tamanyo" => 304435 ] ] "descripcion" => array:1 [ "en" => "Variation in the capacity for prediction of the Tokuhashi scale." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2821 "Ancho" => 2508 "Tamanyo" => 335219 ] ] "descripcion" => array:1 [ "en" => "Prognosis according to alkaline phosphatase levels.<a class="elsevierStyleCrossRef" href="#bib0230">9</a>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 4033 "Ancho" => 3175 "Tamanyo" => 546034 ] ] "descripcion" => array:1 [ "en" => "SORG-ML interface and parameters to be included." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2884 "Ancho" => 2508 "Tamanyo" => 500590 ] ] "descripcion" => array:1 [ "en" => "SBRT clinical case." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 4349 "Ancho" => 2835 "Tamanyo" => 862347 ] ] "descripcion" => array:1 [ "en" => "Minimally invasive techniques clinical case." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1325 "Ancho" => 1627 "Tamanyo" => 112375 ] ] "descripcion" => array:1 [ "en" => "Need for stabilisation in intermediate area (SINS 7–12)." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 4341 "Ancho" => 2398 "Tamanyo" => 708379 ] ] "descripcion" => array:1 [ "en" => "SINS 7–12 clinical case." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 2192 "Ancho" => 2508 "Tamanyo" => 420683 ] ] "descripcion" => array:1 [ "en" => "Indication for vertebral body replacement." ] ] 9 => 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=> array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Revised evaluation scale for the prognosis of spine metastases</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. General status (functional status):</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poor (EF 10%–40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate (EF 50%–70%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Good (EF 80%–100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Number of extraspinal osseous mx:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Number of extraspinal osseous mx:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Metastases in major internal organs:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unresecable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resecable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Primary tumour:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lung, osteosarcoma, oesophagus, stomach, bladder, pancreas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver, unidentified \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Kidney, uterus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rectum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroid, breast, prostate, carcinoid tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Paralysis:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complete (Frankel A, B) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Incomplete (Frankel C, D) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No paralysis (Frankel E) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prognostic criteria according to score:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–8 <6 months survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9–11 ≥6 months survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12–15 ≥1 year survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480367.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Prognostic Tokuhashi (revised 2005) scale." ] ] 12 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spinal instability neoplastic score (SINS)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Site:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transitional (Occ-C2, C7-T2, T11-L1, L5-S1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flexible spine (C3-C6, L2-L4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Semi-rigid spine (T3-T10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rigid spine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Pain:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Occasional but not mechanical pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lesion with no pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Bone lesion:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lytic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mixed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blastic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Al Radiographic spine alignment:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subluxation/movement present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">de novo deformity (Cyphosis/escoliosis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal alignment. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Vertebral body collaps:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>50% collaps \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><50% collapse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No collapse with >50% of the body affected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of the above \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6. Involvement of posterolateral elements:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None of the above \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prognostic criteria according to score:</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–6: stable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–12: indeterminate or imminent instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13–18: unstable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SINS 7–18: ensure interconsultation to surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480368.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Spinal instability neoplastic score." ] ] 13 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation scale for prognosis of spine metastases</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Primary tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. Slow growing: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Breast and hormone dependent prostate, thyroid, myeloma, lymphoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B. Moderate growing: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Lung with capacity for targeted molecular treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Non hormone dependent breast and prostate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Renal, endometric, ovarian, sarcomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C: Fast growing: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Lung without capacity for targeted molecular treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Colorectal, stomach, pancreas, oesophagus, hepatocellular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Head and neck, spleen, unknown origin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Visceral metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. Nodular or cerebral metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B. Disseminated metastases: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Pleurals, peritoneals, leptomeningeal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Lab data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A. Abnormal: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- CRP>.4mg/dl, LDH>250IU/dl, albumin<3.5g/dl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">B. Critical: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Platelets<100,000, Ca>10.3g/dl, bilirrubina >1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. ECOG 3-4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Previous chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Multiple vertebral metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480369.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prognostic criteria according to score (95%)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 months \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 months \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 months \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0–3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.981 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.914 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.778 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4–6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.740 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.493 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.276 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.269 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.060 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480371.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Katagiri<a class="elsevierStyleCrossRef" href="#bib0225">8</a> prognostic scale." ] ] 14 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HIV: human immunodeficiency virus." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Charlson comorbidity index</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Myocardial infarction or congestive mycardiopathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Peripheral vascular disease or aortic aneurism >6cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Cerebrovascular accident, dementia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Chronic obstructive pulmonary disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Connective tissue disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Peptic ulcer disease or liver disease (without portal hypertension) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Diabetes without organ involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Hemiplegia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Moderate to severe kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Diabetes with organ involvement (retinopathy, neuropathy, etc.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Non metastic tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Leukaemia, lymphoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Moderate to severe liver disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Metastatic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Defined aids (not only HIV positive) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">For each decade above 40 years of age add 1 point to the total. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480370.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Charlson comorbidity index." ] ] 15 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "MSDMWG: Metastatic Spine Disease Multidisciplinary Working Group." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MSDMWG clinical groups \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Asymptomatic spine metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Uncomplicated spine metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Unstable spine metastasis with fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Stable spine metastasis with fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. Spine metastasis with neurological compression \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3480372.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical groups of the Metastatic Spine Disease Multidisciplinary Working Group." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0190" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.A. Patchell" 1 => "P.A. Tibbs" 2 => "W.F. Regine" 3 => "R. Payne" 4 => "S. Saris" 5 => "R.J. Kryscio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(05)66954-1" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2005" "volumen" => "366" "paginaInicial" => "643" "paginaFinal" => "648" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16112300" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0195" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y. Tokuhashi" 1 => "H. Matsuzaki" 2 => "H. Oda" 3 => "M. Oshima" 4 => "J. Ryu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.brs.0000180401.06919.a5" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "2005" "volumen" => "30" "paginaInicial" => "2186" "paginaFinal" => "2221" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16205345" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0200" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from Spine Oncology Study Group" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.G. Fisher" 1 => "C. DiPaola" 2 => "T.C. Ryken" 3 => "M.H. Bilsky" 4 => "C.I. Shaffrey" 5 => "S.H. Berven" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BRS.0b013e3181e16ae2" "Revista" => array:6 [ "tituloSerie" => "Spine" "fecha" => "2010" "volumen" => "35" "paginaInicial" => "e1221" "paginaFinal" => "e1229" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20562730" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0205" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reliability analysis of the epidural spinal cord compression scale" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.H. Bilsky" 1 => "I. Laufer" 2 => "D.R. Fourney" 3 => "M. Groff" 4 => "M.H. Schmidt" 5 => "P.P. Varga" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2010.3.SPINE09459" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg Spine" "fecha" => "2010" "volumen" => "13" "paginaInicial" => "324" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20809724" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0210" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The NOMS framework: approach to the treatment of spinal metastatic tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Laufer" 1 => "D.G. Rubin" 2 => "E. Lis" 3 => "B.W. Cox" 4 => "M.D. Stubblefield" 5 => "Y. Yamada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1634/theoncologist.2012-0293" "Revista" => array:6 [ "tituloSerie" => "Oncologist" "fecha" => "2013" "volumen" => "18" "paginaInicial" => "744" "paginaFinal" => "751" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23709750" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0215" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcomes and toxicity for hypofractionated and single fraction image-guided stereotactic radiosurgery for sarcomas metastasizing to the spine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.R. Folkert" 1 => "M.H. Bilsky" 2 => "A.K. Tom" 3 => "J.H. Oh" 4 => "K.M. Alektiar" 5 => "I. Laufer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijrobp.2013.12.042" "Revista" => array:6 [ "tituloSerie" => "Int J Radiat Oncol Biol Phys" "fecha" => "2014" "volumen" => "88" "paginaInicial" => "1085" "paginaFinal" => "1091" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24661662" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0220" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastatic spine disease: should patients with short life expectancy be denied surgical care? An International Retrospective Cohort Study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Dea" 1 => "A.L. Versteeg" 2 => "A. Sahgal" 3 => "J.J. Verlaan" 4 => "R. Charest-Morin" 5 => "L.D. Rhines" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/00006123-197805000-00025" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2020" "volumen" => "2" "paginaInicial" => "303" "paginaFinal" => "311" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/732986" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0225" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Tokuhashi score: effectiveness and pitfalls" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Zoccali" 1 => "J. Skoch" 2 => "M. Walter" 3 => "M. Torabi" 4 => "M. Borgstrom" 5 => "A.A. Baaj" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00586-015-4339-6" "Revista" => array:6 [ "tituloSerie" => "Eur Spine J" "fecha" => "2016" "volumen" => "25" "paginaInicial" => "673" "paginaFinal" => "678" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26626082" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0230" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New prognostic factors and scoring system for patients with skeletal metastasis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Katagiri" 1 => "R. Okada" 2 => "T. Takagi" 3 => "M. Takahashi" 4 => "H. Murata" 5 => "H. Harada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Cancer Med" "fecha" => "2014" "volumen" => "3" "paginaInicial" => "1359" "paginaFinal" => "1367" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0235" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic value of serum alkaline phosphatase in spinal metastatic disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.V. Karhade" 1 => "C.B.S. Quirina" 2 => "M. Kuverji" 3 => "P.T. Ogink" 4 => "M.L. Ferrone" 5 => "J.H. Schwabb" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/s41416-019-0407-8" "Revista" => array:6 [ "tituloSerie" => "Br J Cancer" "fecha" => "2019" "volumen" => "120" "paginaInicial" => "640" "paginaFinal" => "646" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30792532" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0240" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of a pronostical survival algorithm for patients with metastatic spine disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.R. Paulino Pereira" 1 => "S.J. Janssen" 2 => "E. Van Dijk" 3 => "M.B. Harris" 4 => "F.J. Hornicek" 5 => "M.L. Ferrone" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2106/JBJS.15.00975" "Revista" => array:6 [ "tituloSerie" => "J Bone Joint Surg Am" "fecha" => "2016" "volumen" => "98" "paginaInicial" => "1767" "paginaFinal" => "1776" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27807108" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0245" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The SORG nomogram accurately predicts 3–12 months survival for operable spine metastatic disease: external validation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.R. Paulino Pereira" 1 => "L. Mc Laughlin" 2 => "S.J. Janssen" 3 => "E. Van Dijk" 4 => "J.A.M. Bramer" 5 => "I. Laufer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/jso.24620" "Revista" => array:6 [ "tituloSerie" => "J Surg Oncol" "fecha" => "2017" "volumen" => "115" "paginaInicial" => "1019" "paginaFinal" => "1027" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28346699" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0250" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of machine learning algorithms for prediction of 30-day mortality after surgery for spinal metastasis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.V. Karhade" 1 => "C.B.S. Quirina" 2 => "P.T. Ogink" 3 => "A.A. Shah" 4 => "C.M. Bono" 5 => "P.J. Saylor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/neuros/nyy469" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2019" "volumen" => "85" "paginaInicial" => "E83" "paginaFinal" => "E91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30476188" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0255" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicting 90-Day and 1-year mortality in spinal metastatic disease: development and internal validation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.V. Karhade" 1 => "C.B.S. Quirina" 2 => "P.T. Ogink" 3 => "C.M. Bono" 4 => "M.L. Ferrone" 5 => "K.S. Oh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/neuros/nyz070" "Revista" => array:6 [ "tituloSerie" => "Neurosurgery" "fecha" => "2019" "volumen" => "85" "paginaInicial" => "E671" "paginaFinal" => "E681" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30869143" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0260" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "External validation of the SORG 90-day and 1 year machine learning algorithms for survival in spinal metastatic disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.V. Karhade" 1 => "A.K. Ahmed" 2 => "Z. Pennington" 3 => "A. Chara" 4 => "A. Schilling" 5 => "C.B.S. Quirina" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.spinee.2019.09.003" "Revista" => array:6 [ "tituloSerie" => "Spine J" "fecha" => "2020" "volumen" => "20" "paginaInicial" => "14" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31505303" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0265" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A new method of classifying prognostic comorbidity in longitudinal studies: development and validation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. Charlson" 1 => "P. Pompei" 2 => "K.L. Ales" 3 => "C.R. MacKenzie" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Chronic" "fecha" => "1987" "volumen" => "40" "paginaInicial" => "373" "paginaFinal" => "383" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0270" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.E. Charlson" 1 => "R.E. Charlson" 2 => "J.C. Peterson" 3 => "S.S. Marinopoulos" 4 => "W.M. Briggs" 5 => "J.P. Hollenber" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Clin Epid" "fecha" => "2008" "volumen" => "61" "paginaInicial" => "1234" "paginaFinal" => "1240" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0275" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The metastatic Spine Disease Multidisciplinary Study Working Group Algorithms" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.N. Wallace" 1 => "C.G. Robinson" 2 => "J. Meyer" 3 => "N.D. Tran" 4 => "A. Gangi" 5 => "M.R. Callstrom" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1634/theoncologist.2015-0085" "Revista" => array:6 [ "tituloSerie" => "Oncologist" "fecha" => "2015" "volumen" => "20" "paginaInicial" => "1205" "paginaFinal" => "1215" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26354526" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0280" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The metastatic Spine Disease Multidisciplinary Study Working Group Algorithms" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.N. Wallace" 1 => "C.G. Robinson" 2 => "J. Meyer" 3 => "N.D. Tran" 4 => "A. Gangi" 5 => "M.R. Callstrom" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Oncologist" "fecha" => "2019" "volumen" => "24" "paginaInicial" => "424" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0285" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consensus guidelines for postoperative stereotactic body radiation therapy for spinal metastases: results of an international survey" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.J. Redmon" 1 => "S.L. Simons" 2 => "S.G. Soltys" 3 => "Y. Yamada" 4 => "I.J. Barani" 5 => "P.D. Brown" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2016.8.SPINE16121" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg Spine" "fecha" => "2017" "volumen" => "26" "paginaInicial" => "299" "paginaFinal" => "306" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27834628" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0290" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse outcomes after palliative radiation therapy for uncomplicated spine metastasis: role of spinal instability and single-fraction radiation therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.C. Lam" 1 => "H. Uno" 2 => "M. Krisham" 3 => "S. Lutz" 4 => "M. Groff" 5 => "M. Cheney" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Radiat Oncol Biol Phys" "fecha" => "2015" "volumen" => "93" "paginaInicial" => "373" "paginaFinal" => "381" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0295" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "SINS score and stability: evaluating the need for stabilization within the uncertain category" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Z. Pennington" 1 => "A.K. Ahmed" 2 => "E.M. Westbroek" 3 => "E. Cottrill" 4 => "D. Lubelski" 5 => "M.L. Goodwin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "World Neurosurg" "fecha" => "2019" "volumen" => "127" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0300" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effect of introducing the Spinal Instability Neoplastic Score in routine clinical practice for patients with spinal metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.L. Versteeg" 1 => "J.M. Van der Velden" 2 => "H.M. Verkooijen" 3 => "M. Van Vulpen" 4 => "F.C. Oner" 5 => "C.G. Fisher" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1634/theoncologist.2015-0266" "Revista" => array:6 [ "tituloSerie" => "Oncologist" "fecha" => "2016" "volumen" => "21" "paginaInicial" => "95" "paginaFinal" => "101" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26668252" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0305" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Total excision of thoracic vertebrae (author's transl)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Roy-Camille" 1 => "G. Saillant" 2 => "M. Bisserié" 3 => "E. Judet" 4 => "E. Hautefort" 5 => "P. Mamoudy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Chir Orthop Repar Appar Mot" "fecha" => "1981" "volumen" => "67" "paginaInicial" => "421" "paginaFinal" => "430" ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0310" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Total en bloc spondylectomy for solitary spinal metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. Tomita" 1 => "N. Kawahara" 2 => "H. Baba" 3 => "H. Tsuchiya" 4 => "S. Nagata" 5 => "Y. Toribatake" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/BF00180229" "Revista" => array:6 [ "tituloSerie" => "Int Orthop" "fecha" => "1994" "volumen" => "18" "paginaInicial" => "291" "paginaFinal" => "298" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7852009" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0315" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary bone tumors of the spine: terminology and surgical staging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Boriani" 1 => "J.N. Weinstein" 2 => "R. Biagini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Spine" "fecha" => "1980" "volumen" => "22" "paginaInicial" => "1036" "paginaFinal" => "1044" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0320" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Total en bloc Spondylectomy for the L5 metastasis of a carcinoid tumor: illustrative case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.P. Jódar" 1 => "S. Fuentes Caparrós" 2 => "M. Marín" 3 => "J. Osuna Soto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Neurosurg Case Lesson" "fecha" => "2022" "volumen" => "4" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0325" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stereotactic body radiotherapy in the treatment of spinal metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Katsoulakis" 1 => "K. Kumar" 2 => "I. Laufer" 3 => "Y. Yamada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Semin Radiot Oncol" "fecha" => "2017" "volumen" => "27" "paginaInicial" => "209" "paginaFinal" => "217" ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0330" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hybrid therapy for metastatic epidural spinal cord compression: technique for separation surgery and spinal radiosurgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O. Barzilai" 1 => "I. Laufer" 2 => "A. Robin" 3 => "R. Xu" 4 => "Y. Yamada" 5 => "M.H. Bilsky" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Oper Neurosurg" "fecha" => "2019" "volumen" => "16" "paginaInicial" => "310" "paginaFinal" => "318" ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0335" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Carbon-fiber reinforced PEEK fixation system in the treatment of spine tumors: a preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Boriani" 1 => "G. Tedesco" 2 => "L. Ming" 3 => "R. Ghermandi" 4 => "M. Amichetti" 5 => "P. Fossati" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00586-017-5258-5" "Revista" => array:6 [ "tituloSerie" => "Eur Spine J" "fecha" => "2018" "volumen" => "27" "paginaInicial" => "874" "paginaFinal" => "881" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28815357" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0340" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Separation surgery for metastatic epidural spinal cord compression: a qualitative review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Di Perna" 1 => "F. Cofano" 2 => "C. Mantovani" 3 => "S. Badellino" 4 => "N. Marengo" 5 => "M. Ajello" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jbo.2020.100320" "Revista" => array:5 [ "tituloSerie" => "J Bone Oncol" "fecha" => "2020" "volumen" => "25" "paginaInicial" => "100320" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33088700" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0345" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastatic epidural spinal cord compression" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.S. Cole" 1 => "R.A. Patchell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Lancet Neurol" "fecha" => "2008" "volumen" => "2" "paginaInicial" => "87" "paginaFinal" => "94" ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0350" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The timing of surgical intervention in the treatment of complete motor paralysis in patients with spinal metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Fan" 1 => "X. Zhou" 2 => "H. Wang" 3 => "J. Pengxiang" 4 => "S. Cai" 5 => "J. Zhang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Spin J" "fecha" => "2016" "volumen" => "25" "paginaInicial" => "4060" "paginaFinal" => "4066" ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0355" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Metastatic Spinal Cord Compression. Diagnosis and management of patients at risk of or with metastatic spinal cord compression 2008; Developed for NICE by the National Collaborative Centre for Cancer (CG75)." ] ] ] 34 => array:3 [ "identificador" => "bib0360" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicting neurologic recovery after surgery in patients with deficit secondary to MESCC: systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Laufer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BRS.0000000000001827" "Revista" => array:7 [ "tituloSerie" => "Spine" "fecha" => "2016" "volumen" => "41" "numero" => "Suppl 20" "paginaInicial" => "S224" "paginaFinal" => "S230" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27488300" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0365" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "N.A. Quaraishi" 1 => "T.S. Rajagopal" 2 => "S.R. Manoharan" 3 => "S. Elsayed" 4 => "K.L. Edwards" 5 => "B.M. Boszczyk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00586-012-2635-y" "Revista" => array:6 [ "tituloSerie" => "Eur Spine J" "fecha" => "2013" "volumen" => "22" "paginaInicial" => "1383" "paginaFinal" => "1388" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23275041" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0370" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Destructive pathological changes in the rat spinal cord due to chronic mechanical compression" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Xu" 1 => "W. Gong" 2 => "Y. Li" 3 => "T. Zhang" 4 => "K. Zhang" 5 => "D.Z. Yin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Neurosurg Spine" "fecha" => "2008" "volumen" => "8" "paginaInicial" => "279" "paginaFinal" => "285" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/18884415/0000006700000006/v3_202403090752/S188844152300173X/v3_202403090752/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/18884415/0000006700000006/v3_202403090752/S188844152300173X/v3_202403090752/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S188844152300173X?idApp=UINPBA00004N"]

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Spinal Monograph

Preoperative assessment and surgical indications: Separation surgery

Valoración e indicaciones quirúrgicas: cirugía de separación

S. Fuentes Caparrós

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sfuentesc@telefonica.net

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, F. Rodríguez de Tembleque Aguilar, M.Á. Marín Luján, J.A. Gutiérrez Castro

Unidad de Columna, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Reina Sofía, Córdoba, Spain

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in terms of improved neurological results&#44; better quality of life and lower economic and social cost&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Since then&#44; the change in the approach to the treatment of these patients has progressed beyond a single vision&#59; the approach must be made by evaluating multiple parameters&#58; quality of life&#44; neurological status&#44; primary tumour&#44; extension&#44; stability&#44; etc&#46;&#44; in order to adapt the treatment to the clinical characteristics of each patient&#46; In this regard&#44; we would like to highlight three now classic studies that have enabled a multidisciplinary consensus categorisation to be made&#44; and thus achieve a better treatment adaptation&#58; the revised scale of Tokuhashi et al&#46;&#44; 2005<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; for the assessment of tumour disease and its metastatic burden&#44; the Spinal Instability Neoplastic Score &#40;SINS&#41; 2010 for biomechanical assessment<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and the Epidural Spinal Cord Compression &#40;ESCC&#41; scale of Bilsky et al&#46;&#44; 2010<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; for the assessment of the possibility of spinal cord risk in radiotherapeutic treatment&#46; The integration of these concepts has given rise to the current approach to the treatment of metastatic pathology&#44; the NOMS algorithm &#40;Neurologic&#44; Oncologic&#44; Mechanical&#44; Systemic framework&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">5</span></a> which is the basis for the work of the current commissions on spinal metastases&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Surgical indication&#58; changes in patient assessment</span><p id="par0015" class="elsevierStylePara elsevierViewall">Today we consider a survival expectancy of less than 3 or 6 months as the threshold for offering invasive treatment&#44; but how can we refuse treatment to patients when we cannot be sure of this life expectancy&#63; Or how can we refuse treatment to patients with disabling pain or progressive neurological impairments because their life expectancy is less than 3 months&#63;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This vision&#44; established on knowledge and evidence that dates back to the first decade of this century&#44; is also changing with the development of new oncological treatments based on genetic and molecular therapy &#40;the most widely used scales&#44; Tomita or Tokuhashi&#44; do not include this consideration&#41;&#59; changes in radiotherapy algorithms based on single major targeted doses &#40;Stereotactic Body RadioTherapy &#91;SBRT&#93;&#59; extracranial stereotactic radiosurgery&#41; or with protons that achieve high percentages &#40;70&#37;&#8211;90&#37;&#41; of local control independently of the primary<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> tumour or&#44; in surgery&#44; the change from the concept of &#8220;excisional&#8221; surgery to &#8220;separation&#8221; surgery associated with radiosurgery &#40;SBRT&#41;&#44; the former being mainly indicated in the treatment of radioresistant tumours&#46; All of these are giving patients a better life expectancy&#44; and oncologists and surgeons new therapeutic weapons&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this sense of focusing surgical treatment on the patient&#39;s expectations and quality of life&#44; it is worth evaluating the results of the study by Dea et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a> in which they evaluated an international cohort of 466 patients&#44; from countries of different cultures&#44; with a survival prognosis of less than 3 months&#46; Their results showed that 76&#46;9&#37; of patients were satisfied with their treatment at 6 weeks and none reported not recommending it&#46; However&#44; as expected&#44; they found a greater number of adverse effects in the group of patients with lower life expectancy compared to those with higher life expectancy&#44; effects which&#44; when analysed&#44; did not occur during intraoperative management &#40;they were not associated with the &#8220;surgical burden&#8221; measured in duration of surgery or blood loss&#41;&#44; but in the postoperative period&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For all these reasons&#44; they conclude&#44; and we agree&#44; that the preoperative baseline clinical condition should be the main determinant of surgical indication rather than the expected survival&#46; These indications should also take into account the concept of outcome effectiveness&#44; with recommendation of the least aggressive possible&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Predictive scales review</span><p id="par0035" class="elsevierStylePara elsevierViewall">This improvement in the survival of tumour patients with metastatic disease has been achieved thanks to a better understanding and treatment of the biology of metastasis &#40;RANKL-RANK association mechanism and the development of drugs such as denosumab that block it by preventing the osteolysis process&#41;&#59; the progress of new knowledge in immunogenetics which has made treatments with target drugs directed against tumour cells a reality&#44; allowing better survival rates in classically more aggressive tumours such as lung&#44; melanoma or ovarian tumours&#44; and the improved knowledge of spinal biomechanics in the context of metastatic tumours in these patients&#46; In recent years these factors have given rise to numerous studies reviewing predictive scales based on the analysis of success according to the area under the curve &#40;AUC&#41; technique&#46; These studies show good predictive results &#40;discrimination &#8220;c-statistic&#58; patients who survive&#47;death with the best result being &#8220;1&#8221; and a result equal to chance &#8220;&#46;5&#8221;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this regard&#44; the analysis of the predictive results of the Tokuhashi scale carried out by Zoccali et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a> in which the reliability of the scale&#39;s survival prognosis from 2007 to 2013 is analysed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; may be highlighted&#46; In this meta-analysis of the results of 10 studies involving 1&#44; 686 patients&#44; prediction is analysed according to the 3 groups defined by the Tokuhashi scale &#40;group 1&#58; survival &#60;6 months&#44; group 2&#58; survival 6&#8211;12 months and group 3&#58; survival &#62;12 months&#41;&#44; finding that if the overall predictive accuracy of the scale was 63&#37;&#44; it was very different depending on the group&#44; being higher for the group with the longest survival &#40;group 3&#58; 77&#46;21&#37;&#41;&#44; decreasing for group 1 &#40;64&#46;10&#37;&#41; and no higher than chance for group 2 &#40;55&#46;12&#37;&#41;&#46; The decrease in prediction has increased from the appearance of the scale in 2005 to the present day&#44; reflecting the lack of sensitivity of the parameters in the groups with the poorest prognosis&#44; which are those that have benefited most from the development of the most up-to-date treatments&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">New scales and parameters are proposed to improve the reliability of predictions in higher risk groups&#44; a first example of which is the one made by the group of Katagiri et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; For the first time this establishes prognostic differences depending on sensitivity to hormone-dependent treatment in the case of breast or prostate or with specific target drugs in lung cancer&#44; and biochemical parameters are also included in the assessment&#46; The scale&#44; with a score between 0 and 10&#44; in our view improves the prognostic results &#40;&#62;&#46;75&#44; &#60;&#46;25&#41; for the high and low survival groups&#44; as well as in the 6-month survival of patients classified as intermediate&#46; Thus&#44; the recommendations for patients with score 0&#8211;3&#44; whose life expectancy is greater than one year in 91&#37;&#44; treatment with radiosurgery or combined with separation surgery would be indicated&#46; However&#44; for patients with a score between 7 and 10&#44; with a 6-month survival expectancy of 27&#37; and only a one-year expectancy of 6&#37;&#44; the most indicated option would be conventional radiotherapy combined with internal fixation in case of instability or neurological progression&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">However&#44; although the predictive capacity of these scales has improved to reach a statistic <span class="elsevierStyleItalic">c</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;78 for prediction at one year&#44; their predictive capacity for the most severe patients has improved to the same extent&#46; Thus&#44; in order to improve the reliability of survival prediction&#44; new&#44; especially biochemical parameters have been proposed for inclusion&#46; As a useful and simple example&#44; Karhade et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; proposed serum alkaline phosphatase levels under 100 &#40;<span class="elsevierStyleItalic">c</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;75&#41; as an independent prognostic factor for survival longer than 6 months and&#47;or metastatic tumour burden&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">FA is a metalloenzyme that is expressed on the surface of osteoblasts and whose level indicates increased activity&#46; In osteolytic lesions it is produced secondarily in an attempt to compensate for destruction and in osteoblastic lesions by direct stimulation&#46; FA is also a marker of intrahepatic bile duct obstruction due to liver metastases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding tumour metastatic burden&#44; levels &#62;100<span class="elsevierStyleHsp" style=""></span>UI&#47;l are associated with statistically significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41; for the presence of multiple spine metastases &#40;102<span class="elsevierStyleHsp" style=""></span>UI&#47;l&#41;&#44; presence of extra-spinal bone mx &#40;105<span class="elsevierStyleHsp" style=""></span>UI&#47;l&#41; or presence of visceral mx &#40;105<span class="elsevierStyleHsp" style=""></span>UI&#47;l&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally&#44; the prognostic role of FA in patients treated only with RT&#44; CT or palliative measures has not been studied and neither have the changes in FA in patients treated with antiresorptive drugs before or after surgery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">New scales based on algorithms</span><p id="par0070" class="elsevierStylePara elsevierViewall">Outstanding in this attempt to ensure survival prediction is the work of the Paulino et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">11&#44;12</span></a> group from the Massachusetts General Hospital&#46; It described a first algorithm&#44; the &#8220;SORG normogram&#8221;&#44; based on multiple parameters to reach a prediction of &#46;70 at 30&#44; 90 and 365 days&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Since the publication of the &#8220;SORG normogram&#8221; staging&#44; work has continued on more complete decision algorithms based on the capabilities of artificial intelligence &#40;&#8220;machine learning&#8221;&#41;&#46; Led by Karhade&#39;s group at Harvard Medical School&#44; and joined by Sciubba&#39;s group at Johns Hopkins University School of Medicine&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">13&#44;14</span></a> they created the survival prediction algorithm &#8220;SORG Machine-Learning&#8221; &#40;SORG-ML&#41;&#44; an algorithm based on 15 clinical and biochemical parameters which&#44; entered into a computerised database&#44; provide an automated prediction&#46; This algorithm&#44; externally validated&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> improves results in discrimination &#40;c-statistic &#46;75&#8211;&#46;81 for 90 days and &#46;77&#8211;&#46;78 for one year&#41;&#44; calibration&#44; Brier score &#40;mean squared difference between model predicted and observed&#41; and decision curve&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">This study is based on the detection methodology described above&#44; and on the study of a sample of 781 patients and 15 variables&#44; both qualitative &#40;primary tumour&#44; ECOG or Charlson morbidity scale<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">16&#44;17</span></a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; and quantitative &#40;Alk&#46; P levels&#44; haemogram&#44; etc&#46;&#41;&#44; creating a computerised algorithm with free access that assesses survival at 90 and 365 days on 15 parameters of different characteristics &#40;<a href="https://sorg-apps.shinyapps.io/spinemetssurvival/">https&#58;&#47;&#47;sorg-apps&#46;shinyapps&#46;io&#47;spinemetssurvival&#47;</a>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding mortality at 90 days&#44; the prediction of the algorithm obtained a <span class="elsevierStyleItalic">c</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;83 with the most predictive variables being the primary tumour&#44; preoperative albumin and ECOG grade&#46; Regarding mortality at one year&#44; it reached a statistic of <span class="elsevierStyleItalic">c</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;85&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">External validation of the SORG-ML algorithm was made compared with 9 prognostic scales &#40;Tokuhashi&#44; revised Tokuhashi&#44; Tomita&#44; Bauer&#44; revised Bauer&#44; Katagiri&#44; van der Linden&#44; SORG classic and Sorg normogram&#41; concluding that it presents a better prediction in mortality at 90 days &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;75&#8211;&#46;81&#41; and similar for one year &#40;AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;77&#8211;&#46;78&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Our indications according to the NOMS concept</span><p id="par0095" class="elsevierStylePara elsevierViewall">In 2015&#44; the Metastatic Spine Disease Multidisciplinary Working Group&#44; a group that includes radiation oncologists&#44; interventional radiologists and surgeons&#44; proposed consensus treatment guidelines based on 5 clinical groups&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> corrected in 2019<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#44; in accordance with this multidisciplinary concept in the approach to the treatment of metastatic patients&#46; Following this idea and the updated literature&#44; in which the patient&#39;s general condition and stability are the first factors to be evaluated when it comes to the indication&#44; rather than the symptomatology itself&#44; we have proposed the following treatment groups&#58;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Low aggressiveness treatment</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Palliative radiotherapy&#58;</span> only indicated in patients with a poor systemic status&#44; ECOG 3&#8211;4 and&#47;or neurological involvement ASIA A of over 48<span class="elsevierStyleHsp" style=""></span>h evolution&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">SBRT</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5<span class="elsevierStyleItalic">a&#8211;d</span></a>&#41;&#58; our indication for single high-dose stereotactic radiosurgery is established in patients with good clinical status ECOG 1&#8211;2&#44; stable with SINS &#60;6 and with epidural compression &#60;2&#46; Preferably life expectancy &#62;6 months and with single metastasis&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> It is important to take into account the determination of spinal stability prior to the indication of SBRT as a single treatment even in patients without epidural compression&#46; In a study of patients<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> with vertebral mx without epidural compression&#44; prior RT or surgery undergoing SBRT they found that patients with SINS<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>11 were associated with a higher number of adverse effects in the radiated area &#40;vertebral fractures&#44; admission for pain&#44; emergency or scheduled surgery&#44; new neurological symptoms and&#47;or epidural compression&#41;&#46; A higher frequency of adverse effects is also observed when comparing SBRT versus conventional multifraction <span class="elsevierStyleItalic">Minimally aggressive techniques</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6&#44; <span class="elsevierStyleItalic">a&#8211;h</span></a>&#41;&#58; the combination of RT with percutaneous techniques such as ablation or cementation is a useful option for fragile patients&#46; Our indication is the same in patients up to ECOG 2&#44; with slow growing tumours and multiple metastases or metastases which progress despite satisfactory control of the systemic disease&#44; particularly in areas of thoracolumbar hinge zones with SINS up to 9 &#40;according to the considerations indicated by Lam et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a>&#41; and preferably with low degrees of spinal cord compression &#40;Bilsky 1C&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Some considerations in the application of this technique must be taken into account in order to avoid the complications described with its application &#40;up to 20&#37;&#41;&#46; Contraindications for the use of cementation are the involvement of the posterior wall or the presence of a neurological lesion&#46; Regarding ablation&#44; a minimum of 5<span class="elsevierStyleHsp" style=""></span>mm must be established between the ablation area and the spinal cord in order to avoid lesion and to assess the cementation in order to avoid the development of a fracture&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Preventive treatment&#58; SINS 7&#8211;12</span><p id="par0120" class="elsevierStylePara elsevierViewall">In the evaluation of the mechanical stability of patients assessed by the SINS scale&#44; the guidelines for action are clear for the &#8220;stable&#8221; &#40;0&#8211;6&#41; and &#8220;unstable&#8221; &#40;13&#8211;18&#41; groups&#46; However&#44; for the &#8220;potentially unstable&#8221; category &#40;7&#8211;12&#41;&#44; which accounts for 75&#37; of the patients consulted&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> there is no consensus agreement on the parameters for deciding whether or not to stabilise&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In this sense&#44; Pennigtong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> carried out a review of the therapeutic decisions indicated in a series of patients classified in this group&#44; and of their clinical characteristics&#46; They present a series of patients with a median SINS of 9 &#40;IQR&#58; 7&#8211;10 and mode 10&#41; with a Tokuhashi of 8 &#40;IQR&#58; 7&#8211;11&#41; and 75&#37; of unstable lesions&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Their conclusions were that 79&#37; of patients with SINS 10-12 were operated on&#44; compared with only 11&#37; with SINS 7&#8211;9&#46; The reasons for operating on patients with SINS 7&#8211;9 was an epidural compression ESCC 2&#8211;3&#44; while patients with high SINS with low survival probability &#40;ECOG 3 and multiple lesions&#41; were not operated on&#46; The operated patients&#44; irrespective of their SINS&#44; were significantly younger&#44; had a higher Tokuhashi&#44; thus associated with longer survival and also a higher Karnofsky&#46; A sub-analysis in these patients also found a higher lytic lesion involvement and pain&#46; This finding is similar to that given by Versteeg et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> who also give cut-offs of 10&#46;7 vs&#46; 7&#46;2 &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">In keeping with this&#44; our unit is particularly interventionist in patients with SINS 9&#8211;12&#44; especially in patients with multiple sites or who have undergone previous radiotherapy&#46; The main limiting factor for us is the general status of the patient and secondly the neurological condition&#46; Estimated survival is much less important with our main aim being to ensure quality of life and neurological status during survival &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8a&#8211;f</a>&#41;&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Separation surgery</span><p id="par0140" class="elsevierStylePara elsevierViewall">For many groups&#44; including ours&#44; during the last decade of the last century and the first decade of the present century&#44; the indicated surgical treatment for patients with single metastasis was en bloc vertebrectomy described by Roy-Camille et al&#46; and popularised by Tomita et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">24&#44;25</span></a> whose aim was to perform surgery &#8220;as compartmental as possible&#8221;&#44; transferring the excisional concept of oncological surgery of the extremities to the spine&#46; The objections to this treatment lie&#44; firstly&#44; in the characteristics of the metastatic disease itself and the presence of &#8220;skip metastases&#8221; metastases not detectable at the time of indication and the extension of the tumour into the epidural space &#40;layer D in the classification of Weinstein et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a>&#41; which implies that this compartmental resection is impossible except in patients with Tomita&#39;s type 1 intraosseous involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">This concept changed radically in the second decade of this century with the appearance of stereotactic radiosurgery &#40;SRS or SBRT&#41; which allows the total application of the dose in single fractions&#44; minimising the exposure of the tissues at risk&#44; especially the spinal cord&#46; This achieves a direct cytotoxic effect and local control of up to 98&#37; at 2 years&#44; changing the objectives of radiotherapy from traditional pain relief to ablative radiotherapeutic treatment of vertebral metastasis<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> and&#44; therefore&#44; from surgical indications based on the need for vertebral tumour reduction or excision &#40;corporectomies or vertebrectomies&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">However&#44; these high doses with a tumour-killing effect need a safety margin&#44; estimated to be about 2<span class="elsevierStyleHsp" style=""></span>mm&#44; to be delivered&#44; which is why the concept of &#8220;hybrid therapy&#8221; is defined&#44; in which surgery aims to create this margin to allow safe treatment with radiosurgery in a second phase&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In their article Barzilai et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> give a detailed description of the technique&#44; which is based on a first step of instrumented stabilisation&#44; at least 2 levels above and below the lesion in order to restore a mechanical instability present or secondary to the removal of bone from the posterior elements&#46; A second step of decompression that must take into account the use of technical gestures that avoid putting pressure on the compression&#44; using drills as much as possible &#40;areas free of tumour involvement&#41; and being careful in the intracanal manipulation of the Kerrison heel&#46; This posterior part should end with the achievement of an access corridor to the anterior component that allows the resection of 20&#37; of the vertebral body&#44; the separation of the thecal sac from the posterior common vertebral ligament and the depression of the tumour component in order to obtain a circumferential separation of the dura&#46; Excision of the remaining vertebral tumour within the body or in paraspinal tissues is not necessary as they fall within the treatment field of radiosurgery&#46; Anterior support is only needed in case of a vertebral body resection of more than 50&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9a&#8211;c</a>&#41;&#46; In our unit&#44; protocolised preoperative tumour embolisation is almost routinely performed&#44; especially in patients with hypervascular tumours&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">In recent years&#44; various technological innovations have improved the separation technique&#46; From the surgical point of view&#44; the development of implants made of carbon fibres reinforced with PEEK&#174; &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10a&#8211;g</a>&#41; has led to an improvement in the quality of the planning and application of radiotherapy by avoiding the scattering effect induced by titanium implants on ionising radiation and particles without reducing the safety offered by the implants in mechanical terms&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a> as well as improving the quality of postoperative use of MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">31</span></a></p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">In our unit the technique of choice in the treatment of single metastasis is SBRT radiosurgery when spinal cord compression is Bilsky &#60;2 and the hybrid protocol described for separation surgery with carbon instrumentation combined with early SBRT &#40;2 weeks&#41; in Bilsky &#8805;2 compression cases&#46; According to the literature&#44; the indication for the hybrid technique does not depend on the type of tumour or age of the patient&#44; but above all on the patient&#39;s functional status&#44; the degree of spinal cord injury and the prognosis according to the NOMS&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Spinal cord compression associated with neurological impairment</span><p id="par0170" class="elsevierStylePara elsevierViewall">In this section on &#8220;preventive&#8221; treatment&#44; we also wanted to include the indications&#44; especially in terms of time&#44; of spinal cord compression with neurological impairment&#46; In this regard&#44; we should highlight the work of Patchel et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#44;32</span></a> and Cole et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> in which they report a 62&#37; recovery of ambulatory capacity after decompression surgery plus stabilisation and radiotherapy performed before 48<span class="elsevierStyleHsp" style=""></span>h in patients with incomplete or progressive lesions&#44; or that of Fan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">33</span></a> the latter performed on a group of 43 patients with complete paraplegia &#40;34 Frankel A and 9 Frankel B&#41; in which they observed that those Frankel B patients operated on in a period of less than 48<span class="elsevierStyleHsp" style=""></span>h also improved by at least 2 grades on the scale&#46; None of the Frankel A patients regained ambulation postoperatively&#46; This recommendation is set at 24<span class="elsevierStyleHsp" style=""></span>h&#44; the treatment recommendations given by the NICE guideline&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">34</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Regarding other predictors&#44; Laufer<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a> established as a poor predictor of functional recovery the established vesicle dysfunction and&#44; in contrast&#44; presented a muscle balance of 3&#46; No relationship has been found between functional recovery with other types of variables such as age&#44; sex and type &#40;aggressiveness&#41; of the tumour&#46; No statistically significant relationship was found with an increase in complications&#44; infections or hospital stay either&#44; compared with preoperative neurological involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In this sense&#44; our approach is the same as studies that have been commented upon&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#44;32&#8211;34</span></a> indicating&#44; firstly&#44; that general medical treatment &#40;analgesia&#44; thromboprophylaxis&#41; be used&#44; specifically with large doses of dexametasone in 16<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h doses&#44; neurological status control and surgery in ECOG 0&#8211;2 patients who present with a neurological status up to ASIA B of under 48<span class="elsevierStyleHsp" style=""></span>h evolution&#44; regardless of the type of tumour and above all if this is associated with the impossibility of radiosurgery &#40;Bilsky<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2&#41; and&#47;or the presence of oligometastasis&#46; Early decompression may prevent the cascade of vascular changes which trigger ischaemia and spinal infarction&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a> and thereby the ability of reversibility of the neurological involvement&#44; facilitating a particularly significant qualitative neurological improvement &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11a&#8211;e</a>&#41;&#46;</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Level of evidence</span><p id="par0185" class="elsevierStylePara elsevierViewall">Level of evidence I&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">No funding was received for this article&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Surgical indication&#58; changes in patient assessment"
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            1 => "Rachis"
            2 => "Separation surgery"
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            0 => "Met&#225;stasis"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neurological compression occurs in 10&#37;&#8211;20&#37; of patients who develop spinal metastases&#46; In the last decade&#44; the evolution of oncological diagnostic and medical techniques&#44; the change from conventional external radiation to radiosurgery and the new surgical instruments have meant that the treatment of these patients must be indicated in a personalized manner and by consensus&#44; multidisciplinary way&#44; in specific commissions&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Today&#44; the biological state of the patient&#44; the presence of mechanical instability&#44; the neurological assessment and degree of epidural compression&#44; as well as the best prognostic categorization of the tumor&#44; are established as decision factors prior to the indication of surgical treatment&#44; treatment that has passed from a cytoreductive concept to that of a spinal cord release from tumor in order to ensure safe radiosurgery&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La compresi&#243;n neurol&#243;gica se presenta entre el 10-20&#37; de los pacientes que desarrollan una met&#225;stasis vertebral&#46; En la &#250;ltima d&#233;cada&#44; la evoluci&#243;n de las t&#233;cnicas diagn&#243;sticas y m&#233;dicas oncol&#243;gicas&#44; el cambio de la radiaci&#243;n convencional externa a la radiocirug&#237;a y los nuevos instrumentales quir&#250;rgicos&#44; han hecho que el tratamiento de estos pacientes deba de ser indicado de forma personalizada y en consenso&#44; de forma multidisciplinar&#44; en comisiones espec&#237;ficas&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hoy&#44; el estado biol&#243;gico del paciente&#44; la presencia de inestabilidad mec&#225;nica&#44; la valoraci&#243;n neurol&#243;gica y el grado de compresi&#243;n epidural&#44; as&#237; como la mejor categorizaci&#243;n pron&#243;stica del tumor&#44; se establecen como los factores de decisi&#243;n previa a la indicaci&#243;n del tratamiento quir&#250;rgico&#44; tratamiento que ha pasado de un concepto &#171;citorreductor&#187; al de &#171;separador&#187; o &#171;preparador&#187; de la m&#233;dula para asegurar una radiocirug&#237;a segura&#46;</p></span>"
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Good &#40;EF 80&#37;&#8211;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#8211;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">4&#46; Metastases in major internal organs</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">5&#46; Primary tumour</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lung&#44; osteosarcoma&#44; oesophagus&#44; stomach&#44; bladder&#44; pancreas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liver&#44; unidentified&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kidney&#44; uterus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rectum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Thyroid&#44; breast&#44; prostate&#44; carcinoid tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">6&#46; Paralysis</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Complete &#40;Frankel A&#44; B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Incomplete &#40;Frankel C&#44; D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No paralysis &#40;Frankel E&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Prognostic criteria according to score</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#8211;8 &#60;6 months survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#8211;11 &#8805;6 months survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#8211;15 &#8805;1 year survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 2"
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        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
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        "tabla" => array:1 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spinal instability neoplastic score &#40;SINS&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">1&#46; Site</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transitional &#40;Occ-C2&#44; C7-T2&#44; T11-L1&#44; L5-S1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Flexible spine &#40;C3-C6&#44; L2-L4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Semi-rigid spine &#40;T3-T10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rigid spine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2&#46; Pain</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Occasional but not mechanical pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lesion with no pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">3&#46; Bone lesion</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lytic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mixed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Blastic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">4&#46; Al Radiographic spine alignment</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Subluxation&#47;movement present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">de novo</span> deformity &#40;Cyphosis&#47;escoliosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal alignment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">5&#46; Vertebral body collaps</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;50&#37; collaps&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;50&#37; collapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No collapse with &#62;50&#37; of the body affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None of the above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">6&#46; Involvement of posterolateral elements</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None of the above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Prognostic criteria according to score</span>&#58;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#8211;6&#58; stable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#8211;12&#58; indeterminate or imminent instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>13&#8211;18&#58; unstable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SINS 7&#8211;18&#58; ensure interconsultation to surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evaluation scale for prognosis of spine metastases</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1&#46; Primary tumour</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">A&#46; Slow growing&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Breast and hormone dependent prostate&#44; thyroid&#44; myeloma&#44; lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">B&#46; Moderate growing&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Lung with capacity for targeted molecular treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Non hormone dependent breast and prostate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Renal&#44; endometric&#44; ovarian&#44; sarcomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">C&#58; Fast growing&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Lung without capacity for targeted molecular treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Colorectal&#44; stomach&#44; pancreas&#44; oesophagus&#44; hepatocellular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Head and neck&#44; spleen&#44; unknown origin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2&#46; Visceral metastases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">A&#46; Nodular or cerebral metastases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">B&#46; Disseminated metastases&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Pleurals&#44; peritoneals&#44; leptomeningeal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">3&#46; Lab data</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">A&#46; Abnormal&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- CRP<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; LDH<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>250<span class="elsevierStyleHsp" style=""></span>IU&#47;dl&#44; albumin<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dl&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">B&#46; Critical&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>- Platelets<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100&#44;000&#44; Ca<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>10&#46;3<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; bilirrubina &#62;1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">4&#46; ECOG 3-4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1&#46; Previous chemotherapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46; Multiple vertebral metastases</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prognostic criteria according to score &#40;95&#37;&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">6 months&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#8211;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;981&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;914&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;778&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8211;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;740&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;493&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;276&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;060&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">HIV&#58; human immunodeficiency virus&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Charlson comorbidity index</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Myocardial infarction or congestive mycardiopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Peripheral vascular disease or aortic aneurism &#62;6<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Cerebrovascular accident&#44; dementia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Chronic obstructive pulmonary disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Connective tissue disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Peptic ulcer disease or liver disease &#40;without portal hypertension&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Diabetes without organ involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Hemiplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Moderate to severe kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Diabetes with organ involvement &#40;retinopathy&#44; neuropathy&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Non metastic tumour&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Leukaemia&#44; lymphoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Moderate to severe liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">- Metastatic disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Defined aids &#40;not only HIV positive&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">For each decade above 40 years of age add 1 point to the total&#46;&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer&#58; a randomized trial"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;A&#46; Patchell"
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                            2 => "W&#46;F&#46; Regine"
                            3 => "R&#46; Payne"
                            4 => "S&#46; Saris"
                            5 => "R&#46;J&#46; Kryscio"
                          ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(05)66954-1"
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                        "tituloSerie" => "Lancet"
                        "fecha" => "2005"
                        "volumen" => "366"
                        "paginaInicial" => "643"
                        "paginaFinal" => "648"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16112300"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Y&#46; Tokuhashi"
                            1 => "H&#46; Matsuzaki"
                            2 => "H&#46; Oda"
                            3 => "M&#46; Oshima"
                            4 => "J&#46; Ryu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.brs.0000180401.06919.a5"
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                        "tituloSerie" => "Spine"
                        "fecha" => "2005"
                        "volumen" => "30"
                        "paginaInicial" => "2186"
                        "paginaFinal" => "2221"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16205345"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0200"
              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A novel classification system for spinal instability in neoplastic disease&#58; an evidence-based approach and expert consensus from Spine Oncology Study Group"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "C&#46; DiPaola"
                            2 => "T&#46;C&#46; Ryken"
                            3 => "M&#46;H&#46; Bilsky"
                            4 => "C&#46;I&#46; Shaffrey"
                            5 => "S&#46;H&#46; Berven"
                          ]
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                      ]
                    ]
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                    0 => array:2 [
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                        "fecha" => "2010"
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                        "paginaInicial" => "e1221"
                        "paginaFinal" => "e1229"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20562730"
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                          ]
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                    ]
                  ]
                ]
              ]
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reliability analysis of the epidural spinal cord compression scale"
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                            0 => "M&#46;H&#46; Bilsky"
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                    0 => array:2 [
                      "titulo" => "The NOMS framework&#58; approach to the treatment of spinal metastatic tumors"
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                            4 => "M&#46;D&#46; Stubblefield"
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                        "fecha" => "2013"
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                        "paginaInicial" => "744"
                        "paginaFinal" => "751"
                        "link" => array:1 [
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                            "web" => "Medline"
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                        "paginaFinal" => "1091"
                        "link" => array:1 [
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                            3 => "J&#46;J&#46; Verlaan"
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                    0 => array:2 [
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                        "fecha" => "2020"
                        "volumen" => "2"
                        "paginaInicial" => "303"
                        "paginaFinal" => "311"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/732986"
                            "web" => "Medline"
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                    0 => array:2 [
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                            5 => "A&#46;A&#46; Baaj"
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                        "tituloSerie" => "Eur Spine J"
                        "fecha" => "2016"
                        "volumen" => "25"
                        "paginaInicial" => "673"
                        "paginaFinal" => "678"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26626082"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0230"
              "etiqueta" => "9"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "New prognostic factors and scoring system for patients with skeletal metastasis"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Katagiri"
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                            2 => "T&#46; Takagi"
                            3 => "M&#46; Takahashi"
                            4 => "H&#46; Murata"
                            5 => "H&#46; Harada"
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                        ]
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                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cancer Med"
                        "fecha" => "2014"
                        "volumen" => "3"
                        "paginaInicial" => "1359"
                        "paginaFinal" => "1367"
                      ]
                    ]
                  ]
                ]
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              "etiqueta" => "10"
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                      "titulo" => "Prognostic value of serum alkaline phosphatase in spinal metastatic disease"
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                          "autores" => array:6 [
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                            2 => "M&#46; Kuverji"
                            3 => "P&#46;T&#46; Ogink"
                            4 => "M&#46;L&#46; Ferrone"
                            5 => "J&#46;H&#46; Schwabb"
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                        ]
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                    0 => array:2 [
                      "doi" => "10.1038/s41416-019-0407-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Cancer"
                        "fecha" => "2019"
                        "volumen" => "120"
                        "paginaInicial" => "640"
                        "paginaFinal" => "646"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30792532"
                            "web" => "Medline"
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                0 => array:2 [
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                      "titulo" => "Development of a pronostical survival algorithm for patients with metastatic spine disease"
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                          "autores" => array:6 [
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                            3 => "M&#46;B&#46; Harris"
                            4 => "F&#46;J&#46; Hornicek"
                            5 => "M&#46;L&#46; Ferrone"
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                    ]
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                    0 => array:2 [
                      "doi" => "10.2106/JBJS.15.00975"
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                        "tituloSerie" => "J Bone Joint Surg Am"
                        "fecha" => "2016"
                        "volumen" => "98"
                        "paginaInicial" => "1767"
                        "paginaFinal" => "1776"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
                          ]
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                      ]
                    ]
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                ]
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            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The SORG nomogram accurately predicts 3&#8211;12 months survival for operable spine metastatic disease&#58; external validation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46;R&#46; Paulino Pereira"
                            1 => "L&#46; Mc Laughlin"
                            2 => "S&#46;J&#46; Janssen"
                            3 => "E&#46; Van Dijk"
                            4 => "J&#46;A&#46;M&#46; Bramer"
                            5 => "I&#46; Laufer"
                          ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/jso.24620"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Surg Oncol"
                        "fecha" => "2017"
                        "volumen" => "115"
                        "paginaInicial" => "1019"
                        "paginaFinal" => "1027"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28346699"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0250"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Development of machine learning algorithms for prediction of 30-day mortality after surgery for spinal metastasis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;V&#46; Karhade"
                            1 => "C&#46;B&#46;S&#46; Quirina"
                            2 => "P&#46;T&#46; Ogink"
                            3 => "A&#46;A&#46; Shah"
                            4 => "C&#46;M&#46; Bono"
                            5 => "P&#46;J&#46; Saylor"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/neuros/nyy469"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurosurgery"
                        "fecha" => "2019"
                        "volumen" => "85"
                        "paginaInicial" => "E83"
                        "paginaFinal" => "E91"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30476188"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predicting 90-Day and 1-year mortality in spinal metastatic disease&#58; development and internal validation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;V&#46; Karhade"
                            1 => "C&#46;B&#46;S&#46; Quirina"
                            2 => "P&#46;T&#46; Ogink"
                            3 => "C&#46;M&#46; Bono"
                            4 => "M&#46;L&#46; Ferrone"
                            5 => "K&#46;S&#46; Oh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/neuros/nyz070"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurosurgery"
                        "fecha" => "2019"
                        "volumen" => "85"
                        "paginaInicial" => "E671"
                        "paginaFinal" => "E681"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30869143"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "External validation of the SORG 90-day and 1 year machine learning algorithms for survival in spinal metastatic disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;V&#46; Karhade"
                            1 => "A&#46;K&#46; Ahmed"
                            2 => "Z&#46; Pennington"
                            3 => "A&#46; Chara"
                            4 => "A&#46; Schilling"
                            5 => "C&#46;B&#46;S&#46; Quirina"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.spinee.2019.09.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Spine J"
                        "fecha" => "2020"
                        "volumen" => "20"
                        "paginaInicial" => "14"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31505303"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A new method of classifying prognostic comorbidity in longitudinal studies&#58; development and validation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;E&#46; Charlson"
                            1 => "P&#46; Pompei"
                            2 => "K&#46;L&#46; Ales"
                            3 => "C&#46;R&#46; MacKenzie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Chronic"
                        "fecha" => "1987"
                        "volumen" => "40"
                        "paginaInicial" => "373"
                        "paginaFinal" => "383"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;E&#46; Charlson"
                            1 => "R&#46;E&#46; Charlson"
                            2 => "J&#46;C&#46; Peterson"
                            3 => "S&#46;S&#46; Marinopoulos"
                            4 => "W&#46;M&#46; Briggs"
                            5 => "J&#46;P&#46; Hollenber"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Clin Epid"
                        "fecha" => "2008"
                        "volumen" => "61"
                        "paginaInicial" => "1234"
                        "paginaFinal" => "1240"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "18"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The metastatic Spine Disease Multidisciplinary Study Working Group Algorithms"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;N&#46; Wallace"
                            1 => "C&#46;G&#46; Robinson"
                            2 => "J&#46; Meyer"
                            3 => "N&#46;D&#46; Tran"
                            4 => "A&#46; Gangi"
                            5 => "M&#46;R&#46; Callstrom"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1634/theoncologist.2015-0085"
                      "Revista" => array:6 [
                        "tituloSerie" => "Oncologist"
                        "fecha" => "2015"
                        "volumen" => "20"
                        "paginaInicial" => "1205"
                        "paginaFinal" => "1215"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26354526"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The metastatic Spine Disease Multidisciplinary Study Working Group Algorithms"
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                        0 => array:2 [
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                            0 => "A&#46;N&#46; Wallace"
                            1 => "C&#46;G&#46; Robinson"
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                            3 => "N&#46;D&#46; Tran"
                            4 => "A&#46; Gangi"
                            5 => "M&#46;R&#46; Callstrom"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Oncologist"
                        "fecha" => "2019"
                        "volumen" => "24"
                        "paginaInicial" => "424"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consensus guidelines for postoperative stereotactic body radiation therapy for spinal metastases&#58; results of an international survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;J&#46; Redmon"
                            1 => "S&#46;L&#46; Simons"
                            2 => "S&#46;G&#46; Soltys"
                            3 => "Y&#46; Yamada"
                            4 => "I&#46;J&#46; Barani"
                            5 => "P&#46;D&#46; Brown"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/2016.8.SPINE16121"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg Spine"
                        "fecha" => "2017"
                        "volumen" => "26"
                        "paginaInicial" => "299"
                        "paginaFinal" => "306"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27834628"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adverse outcomes after palliative radiation therapy for uncomplicated spine metastasis&#58; role of spinal instability and single-fraction radiation therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46;C&#46; Lam"
                            1 => "H&#46; Uno"
                            2 => "M&#46; Krisham"
                            3 => "S&#46; Lutz"
                            4 => "M&#46; Groff"
                            5 => "M&#46; Cheney"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Radiat Oncol Biol Phys"
                        "fecha" => "2015"
                        "volumen" => "93"
                        "paginaInicial" => "373"
                        "paginaFinal" => "381"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0295"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "SINS score and stability&#58; evaluating the need for stabilization within the uncertain category"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Z&#46; Pennington"
                            1 => "A&#46;K&#46; Ahmed"
                            2 => "E&#46;M&#46; Westbroek"
                            3 => "E&#46; Cottrill"
                            4 => "D&#46; Lubelski"
                            5 => "M&#46;L&#46; Goodwin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "World Neurosurg"
                        "fecha" => "2019"
                        "volumen" => "127"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effect of introducing the Spinal Instability Neoplastic Score in routine clinical practice for patients with spinal metastases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;L&#46; Versteeg"
                            1 => "J&#46;M&#46; Van der Velden"
                            2 => "H&#46;M&#46; Verkooijen"
                            3 => "M&#46; Van Vulpen"
                            4 => "F&#46;C&#46; Oner"
                            5 => "C&#46;G&#46; Fisher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1634/theoncologist.2015-0266"
                      "Revista" => array:6 [
                        "tituloSerie" => "Oncologist"
                        "fecha" => "2016"
                        "volumen" => "21"
                        "paginaInicial" => "95"
                        "paginaFinal" => "101"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26668252"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Total excision of thoracic vertebrae &#40;author&#39;s transl&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Roy-Camille"
                            1 => "G&#46; Saillant"
                            2 => "M&#46; Bisseri&#233;"
                            3 => "E&#46; Judet"
                            4 => "E&#46; Hautefort"
                            5 => "P&#46; Mamoudy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Chir Orthop Repar Appar Mot"
                        "fecha" => "1981"
                        "volumen" => "67"
                        "paginaInicial" => "421"
                        "paginaFinal" => "430"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Total en bloc spondylectomy for solitary spinal metastases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46; Tomita"
                            1 => "N&#46; Kawahara"
                            2 => "H&#46; Baba"
                            3 => "H&#46; Tsuchiya"
                            4 => "S&#46; Nagata"
                            5 => "Y&#46; Toribatake"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/BF00180229"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Orthop"
                        "fecha" => "1994"
                        "volumen" => "18"
                        "paginaInicial" => "291"
                        "paginaFinal" => "298"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7852009"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Primary bone tumors of the spine&#58; terminology and surgical staging"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Boriani"
                            1 => "J&#46;N&#46; Weinstein"
                            2 => "R&#46; Biagini"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1980"
                        "volumen" => "22"
                        "paginaInicial" => "1036"
                        "paginaFinal" => "1044"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Total en bloc Spondylectomy for the L5 metastasis of a carcinoid tumor&#58; illustrative case"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46;P&#46; J&#243;dar"
                            1 => "S&#46; Fuentes Caparr&#243;s"
                            2 => "M&#46; Mar&#237;n"
                            3 => "J&#46; Osuna Soto"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "J Neurosurg Case Lesson"
                        "fecha" => "2022"
                        "volumen" => "4"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stereotactic body radiotherapy in the treatment of spinal metastases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; Katsoulakis"
                            1 => "K&#46; Kumar"
                            2 => "I&#46; Laufer"
                            3 => "Y&#46; Yamada"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Semin Radiot Oncol"
                        "fecha" => "2017"
                        "volumen" => "27"
                        "paginaInicial" => "209"
                        "paginaFinal" => "217"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hybrid therapy for metastatic epidural spinal cord compression&#58; technique for separation surgery and spinal radiosurgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "O&#46; Barzilai"
                            1 => "I&#46; Laufer"
                            2 => "A&#46; Robin"
                            3 => "R&#46; Xu"
                            4 => "Y&#46; Yamada"
                            5 => "M&#46;H&#46; Bilsky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Oper Neurosurg"
                        "fecha" => "2019"
                        "volumen" => "16"
                        "paginaInicial" => "310"
                        "paginaFinal" => "318"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Carbon-fiber reinforced PEEK fixation system in the treatment of spine tumors&#58; a preliminary report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Boriani"
                            1 => "G&#46; Tedesco"
                            2 => "L&#46; Ming"
                            3 => "R&#46; Ghermandi"
                            4 => "M&#46; Amichetti"
                            5 => "P&#46; Fossati"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00586-017-5258-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Spine J"
                        "fecha" => "2018"
                        "volumen" => "27"
                        "paginaInicial" => "874"
                        "paginaFinal" => "881"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28815357"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Separation surgery for metastatic epidural spinal cord compression&#58; a qualitative review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Di Perna"
                            1 => "F&#46; Cofano"
                            2 => "C&#46; Mantovani"
                            3 => "S&#46; Badellino"
                            4 => "N&#46; Marengo"
                            5 => "M&#46; Ajello"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jbo.2020.100320"
                      "Revista" => array:5 [
                        "tituloSerie" => "J Bone Oncol"
                        "fecha" => "2020"
                        "volumen" => "25"
                        "paginaInicial" => "100320"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33088700"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Metastatic epidural spinal cord compression"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;S&#46; Cole"
                            1 => "R&#46;A&#46; Patchell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Lancet Neurol"
                        "fecha" => "2008"
                        "volumen" => "2"
                        "paginaInicial" => "87"
                        "paginaFinal" => "94"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The timing of surgical intervention in the treatment of complete motor paralysis in patients with spinal metastases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Y&#46; Fan"
                            1 => "X&#46; Zhou"
                            2 => "H&#46; Wang"
                            3 => "J&#46; Pengxiang"
                            4 => "S&#46; Cai"
                            5 => "J&#46; Zhang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Spin J"
                        "fecha" => "2016"
                        "volumen" => "25"
                        "paginaInicial" => "4060"
                        "paginaFinal" => "4066"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Metastatic Spinal Cord Compression&#46; Diagnosis and management of patients at risk of or with metastatic spinal cord compression 2008&#59; Developed for NICE by the National Collaborative Centre for Cancer &#40;CG75&#41;&#46;"
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predicting neurologic recovery after surgery in patients with deficit secondary to MESCC&#58; systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "I&#46; Laufer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BRS.0000000000001827"
                      "Revista" => array:7 [
                        "tituloSerie" => "Spine"
                        "fecha" => "2016"
                        "volumen" => "41"
                        "numero" => "Suppl 20"
                        "paginaInicial" => "S224"
                        "paginaFinal" => "S230"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27488300"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46;A&#46; Quaraishi"
                            1 => "T&#46;S&#46; Rajagopal"
                            2 => "S&#46;R&#46; Manoharan"
                            3 => "S&#46; Elsayed"
                            4 => "K&#46;L&#46; Edwards"
                            5 => "B&#46;M&#46; Boszczyk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00586-012-2635-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Spine J"
                        "fecha" => "2013"
                        "volumen" => "22"
                        "paginaInicial" => "1383"
                        "paginaFinal" => "1388"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23275041"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Destructive pathological changes in the rat spinal cord due to chronic mechanical compression"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Xu"
                            1 => "W&#46; Gong"
                            2 => "Y&#46; Li"
                            3 => "T&#46; Zhang"
                            4 => "K&#46; Zhang"
                            5 => "D&#46;Z&#46; Yin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Neurosurg Spine"
                        "fecha" => "2008"
                        "volumen" => "8"
                        "paginaInicial" => "279"
                        "paginaFinal" => "285"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
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Article information

ISSN: 18884415
Original language: English

DOI:10.1016/j.recot.2023.08.002

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2024 October	20	3	23
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