ReviewEuropean spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society2026
Beyond albumin: a systematic review, meta-analysis, and GRADE assessment of seven preoperative nutritional and inflammatory biomarkers in metastatic spine surgery.
Review in European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeTo evaluate the prognostic value of preoperative nutritional and inflammatory biomarkers-including serum albumin, prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), modified Glasgow Prognostic Score (mGPS), systemic immune-inflammation index (SII), and C-reactive protein/albumin ratio (CAR)-for clinical outcomes following open surgery for spinal metastases.
methodsA comprehensive literature search of PubMed/MEDLINE, Embase, Cochrane CENTRAL, Scopus, and Web of Science (January 2010-April 2026) identified studies of adult patients who underwent open surgery for histologically or radiologically confirmed spinal metastases and had at least one preoperative biomarker measurement. Percutaneous-only procedures were ineligible. Paired reviewers independently extracted data and appraised methodological quality (QUIPS tool). Effect estimates were pooled in DerSimonian-Laird random-effects models where at least two studies reported comparable metrics, and the certainty of evidence was graded with the GRADE framework.
resultsFifteen studies (N = 6,253 patients; 14 retrospective cohorts, 1 prospective multicenter) met eligibility criteria. Serum albumin was consistently associated with overall survival (pooled HR = 1.88 per 1 g/dL decrease, 95%CI 1.60-2.20; I²=0%; p < 0.001; GRADE: LOW). PLR elevation was associated with worse survival (pooled HR = 1.50, 95%CI 1.22-1.85; I²=55%; p < 0.001). NLR showed a significant but substantially heterogeneous association (pooled HR = 2.40, 95%CI 1.12-5.12; I²=86%). PNI demonstrated a consistent protective association across three studies (OR range 0.86-0.93 per unit increase), though disparate effect measures (OR vs. HR) and endpoints (90-day mortality, wound complications, overall survival) precluded quantitative pooling. In the only prospective multicenter study (JASA; n = 336, 35 centres), mGPS was the sole independent nutritional predictor of 3-month mortality (OR = 1.99, 95%CI 1.21-3.48; AUC = 0.716). Hypoalbuminemia (< 3.5 g/dL) was associated with a 5-fold increase in 30-day mortality in 1,498 NSQIP patients (OR = 5.20, 95%CI 3.36-8.04).
conclusionsPreoperative nutritional and inflammatory biomarkers-particularly serum albumin, PNI, and mGPS-are consistently associated with outcomes following metastatic spine surgery. Although the certainty of evidence is predominantly LOW-to-VERY-LOW-reflecting observational study designs rather than inconsistent findings-the large effect magnitudes, biological plausibility, and cross-cohort consistency suggest that albumin and PNI may warrant consideration for incorporation into preoperative risk stratification. A tiered preoperative nutritional risk stratification pathway is hypothesised for future prospective validation. This pathway uses only routinely available laboratory values and can be readily implemented alongside existing prognostic scoring systems.
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