Ho-ho-ho! Gather around, my dear friends, as I tell you a tale from the land of spine surgeons and their quest to tackle the tricky challenge of vertebral metastasis (VM) – a story as intricate as the journey to deliver presents all around the world in one night! In the magical realm of medicine, there exists a list, not of who’s naughty or nice, but of how to determine the stability of these spine-invading lesions. This list, known as the Spinal Instability Neoplastic Score (SINS), helps our surgeon elves decide who gets what treatment – a bit like deciding who gets toys and who gets coal.

Now, in this tale, there was a group of ten wise spine surgeon elves from the AO Spine Region, each with a sack full of expertise in managing VMs. They embarked on a single-round online sleigh ride, surveying the snowy landscape of 36 real-life cases of patients whose VMs scored a puzzling 7 to 12 on the SINS – a range as indeterminate as guessing what children really want for Christmas.

As they journeyed through the data, these elves had to decide, much like I do when choosing toys for the good children, whether to go down the chimney of conservative treatment or to place a surgical gift under the tree. They pondered over various factors, much like considering the size of a chimney or the appetite of reindeer.

The elves found that ‘mechanical pain’, a discomfort not unlike carrying a heavy sack of presents, was their guiding star, deemed important in 44.4% of cases. The ‘type of lesion’, akin to the type of toy to craft, was crucial in 36.1% of cases. The ‘degree of vertebral collapse’, reminiscent of a slightly too narrow chimney, and the non-SINS factor ‘tumor histology’, as varied as the cookies left out on Christmas Eve, were considered in 13.9% of cases. However, ‘posterior element compromise’, perhaps as overlooked as the need for a snack for Santa’s reindeer, was deemed unimportant in a whopping 72.2% of cases.

In this festive narrative, our surgeon elves leaned heavily on mechanical pain and the nature of the metastatic lesion to decide on the treatment path, much like I rely on my list (and cookies) to guide my Christmas Eve journey. Vertebral collapse and spinal malalignment, though important, were like deciding on the color of wrapping paper – not as critical as what’s inside the package. Spinal mobility, however, was a predictor of choosing surgery over conservative treatment, a bit like deciding whether to use the sleigh or magic dust for those hard-to-reach places.

In the end, the only aspect not guiding the surgeons’ sleigh was the involvement of posterolateral/posterior elements, showing that even in the complex world of spine surgery, some things are considered less important, much like my decision on whether to wear my red or green suit.

And so, my friends, as we close this chapter of our holiday tale, let us remember the importance of guiding stars, be they in making treatment decisions or navigating a sleigh through the night sky. Merry Christmas to all, and to all a good spine!