Surgical strategy for spinal metastases

Total en bloc spondylectomy for lung cancer metastasis to the spine

OBJECT

The prognosis in patients with a distant spinal metastasis from the lung is dismal. The role of radical surgery in such cases has been questioned because of the excessive morbidity, blood loss, and operative time as well as the tumor's extreme malignancy. The purpose of this study was to evaluate the surgical results and the prognosis associated with radical surgery for lung cancer metastasis to the spine in carefully selected patients and to clarify whether there is an indication for radical surgery such as total en bloc spondylectomy (TES) in lung cancer metastasis.

METHODS

The author performed a retrospective review of patients with lung cancer spinal metastasis treated by TES during a 10-year period. Total en bloc spondylectomy for lung cancer metastasis to the spine was performed in 6 patients without visceral or other bony metastases. Outcome measures were prognostic score, mean survival time, and perioperative complications. The histological type was adenocarcinoma in all 6 cases. In 4 cases the surgical strategy prognostic score was 5. In the other 2 cases the score was 6 because there were skip metastases to adjacent vertebra. In the 2 cases with adjacent vertebral metastasis, the adjacent vertebra was excised en bloc together.

RESULTS

The mean estimated blood loss was 1076 ml and the mean operative time was 7 hours 20 minutes. Perioperative complications were found in 2 cases. One was deep infection after CSF leakage, and the other was paralysis due to postoperative hematoma. At the end of follow-up period, 4 of 6 patients are still living after a mean of 46.3 months (range 36–62 months). In the other 2 cases, 1 patient died of a heart attack and the other of mediastinitis due to surgical site infection by methicillin-resistant Staphylococcus aureus. In this series, local recurrence was not found.

CONCLUSIONS

Total en bloc spondylectomy has been shown to be associated with excessive morbidity, blood loss, and operative time; however, the procedure is becoming less invasive. The authors conclude that TES is appropriate in selected cases with controllable primary lung cancer, localized spinal metastasis, and no visceral metastasis. In such patients, improvement in the prognosis can be expected after TES. However, even in selected cases and with skilled surgical technique, the complication rate remains high. Total en bloc spondylectomy should be performed after a thorough discussion of the risks and benefits.

A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group

STUDY DESIGN

Systematic review and modified Delphi technique.

OBJECTIVE

To use an evidence-based medicine process using the best available literature and expert opinion consensus to develop a comprehensive classification system to diagnose neoplastic spinal instability.

SUMMARY OF BACKGROUND DATA

Spinal instability is poorly defined in the literature and presently there is a lack of guidelines available to aid in defining the degree of spinal instability in the setting of neoplastic spinal disease. The concept of spinal instability remains important in the clinical decision-making process for patients with spine tumors.

METHODS

We have integrated the evidence provided by systematic reviews through a modified Delphi technique to generate a consensus of best evidence and expert opinion to develop a classification system to define neoplastic spinal instability.

RESULTS

A comprehensive classification system based on patient symptoms and radiographic criteria of the spine was developed to aid in predicting spine stability of neoplastic lesions. The classification system includes global spinal location of the tumor, type and presence of pain, bone lesion quality, spinal alignment, extent of vertebral body collapse, and posterolateral spinal element involvement. Qualitative scores were assigned based on relative importance of particular factors gleaned from the literature and refined by expert consensus.

CONCLUSION

The Spine Instability Neoplastic Score is a comprehensive classification system with content validity that can guide clinicians in identifying when patients with neoplastic disease of the spine may benefit from surgical consultation. It can also aid surgeons in assessing the key components of spinal instability due to neoplasia and may become a prognostic tool for surgical decision-making when put in context with other key elements such as neurologic symptoms, extent of disease, prognosis, patient health factors, oncologic subtype, and radiosensitivity of the tumor.

Survival prognostic factors and clinical outcomes in patients with spinal metastases

PURPOSE

In patients with metastatic disease to the spine, patient selection for surgery and the extent of surgery to perform thereafter remains controversial, with the patient's survival prognosis the most important consideration. For this reason, we conducted a prospective study investigating prognostic factors and clinical outcomes in a consecutive series of patients with vertebral metastases.

METHODS

A total of 142 consecutive patients with vertebral metastases referred to us for consideration of surgery were prospectively enrolled into this study. Of these, 118 patients subsequently underwent palliative surgery for intractable pain or radiculopathy, bony instability or spinal cord compression. Patients were followed up for 12 months or until death. A multivariate analysis of the patients was conducted using the Cox proportional hazards model. The survival predictive accuracy of the Tokuhashi score was also investigated. For the patients who underwent surgery, pre- and post-operative outcomes were assessed on pain, neurological deficit, function and overall quality of life.

RESULTS

The overall 12-month mortality rate was 50.7% and the median survival was 5 months. Multivariate analysis showed that independent prognostic factors for survival after spinal metastases include primary tumour type, Karnofsky functional status, ASA score and pain. Neither the original nor revised Tokuhashi scores were reliable in predicting survival in our European population. In the patients who underwent operative intervention, there was an immediate and prolonged improvement in pain, neurological deficit, function and quality of life in the majority of cases.

CONCLUSIONS

The potential for rapid and maintained improvement in clinical outcome and quality of life should be considered when selecting patients with metastatic disease to the spine for surgery rather than basing decisions solely on survival prognostic factors comprising current scoring systems.

The surgical management of metastatic epidural compression of the spinal cord

Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases. In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.

Diagnosis and management of metastatic spine disease. A review

With continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. Advancements in surgical techniques of resection and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally increased overall survival in patients with metastatic spine disease, and a recent randomized trial by Patchell and colleagues demonstrating the superiority of a combined surgical/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. Optimal management of spinal metastases encompasses numerous medical specialties, including neurosurgery, orthopedic surgery, medical and radiation oncology, radiology, and rehabilitation medicine. In this review, the clinical presentation, diagnosis, and management of spinal metastatic disease are discussed. Ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required to select the appropriate patients for surgical intervention.

En Bloc Resection for Primary and Metastatic Tumors of the Spine

BACKGROUND

The efficacy of en bloc resection for spinal tumors is unknown because most of the current evidence is provided by small, single-institution clinical series or case reports.

OBJECTIVE

To combine all previously published reports of en bloc resection for primary and metastatic spinal tumors, to describe the overall pattern of disease-free survival, and to investigate potentially prognostic factors for recurrence.

METHODS

A complete MEDLINE search for all articles reporting survival data for en bloc resection of spinal tumors was undertaken; 44 articles met inclusion criteria from which 306 eligible patients were identified.

RESULTS

There were 229 cases of primary tumors with a mean follow-up of 65.0 months and 77 cases of solitary metastatic tumors with a mean follow-up of 26.5 months. Median time to recurrence was 113 months for the primary group and 24 months for the metastatic group. Disease-free survival rates at 1, 5, and 10 years were 92.6%, 63.2%, and 43.9%, respectively, for the primary group and 61.8%, 37.5%, and 0%, respectively, for the metastatic group; 5-year disease-free survival rates were 58.4% for chordoma and 62.9% for chondrosarcoma. After adjusting for covariates, age, male sex, metastatic tumors, and osteosarcomas were significantly associated with a tumor recurrence.

CONCLUSION

This study provides the largest published series of patients undergoing en bloc resection for spinal tumors. Median time to recurrence reached almost 10 years in patients with primary tumors; however, it was only 2 years in those with isolated metastatic tumors.

Efficacy evaluation of a new treatment algorithm for spinal metastases

STUDY DESIGN

A semiprospective clinical study was conducted.

OBJECTIVE

To evaluate the efficacy of a new treatment algorithm for spinal metastases.

SUMMARY OF BACKGROUND DATA

The surgical treatments in spinal metastatic have been progressing in recent years, while the surgical indications have been controversial. A new treatment algorithm for spinal metastases was developed and prospectively applied clinically in our department since 2002.

METHODS

This study included 202 patients with 206 lesions treated in January 1997 to December 2006 and continuously followed-up for more than 6 months or dead within this period. A total of 124 patients with 124 lesions were operated before 2002 were allocated to the control group and 78 patients with 82 lesions prospectively treated after 2002 were allocated to the prospective study group. The primary managements were nonsurgical treatment, palliative surgery, debulking, and en bloc resection. Neurologic evolvement, postoperative survival time, and local recurrence/development rates were statistically compared as the indexes of treatment outcome.

RESULTS

Although there was no significant difference of neurologic evolvement immediately after operation (P = 0.24), the prospective study group achieved significantly better neurologic function than the control group long time after operation (P = 0.03). No significant difference (P = 0.26) was shown in local recurrence/development rate comparison. The mean postoperative survival time comparison showed significant difference (P < 0.01).

CONCLUSION

The efficacy of the algorithm has been validated preliminarily by the significantly longer survival time and better long-time neurologic function evolvement in the prospectively study group. But the algorithm should continuously be in development and be updated with the latest improvement in metastatic treatment.

Repeat decompression surgery for recurrent spinal metastases

Object

In this paper, the authors' goal was to determine the outcome of reoperation for recurrent epidural spinal cord compression in patients with metastatic spine disease.

Methods

A retrospective chart review was conducted of all patients who underwent spine surgery at the Memorial Sloan-Kettering Cancer Center between 1996 and 2007. Thirty-nine patients who underwent reoperation of the spine at the level previously treated with surgery were identified. Only patients whose reoperation was performed because of tumor recurrence leading to high-grade epidural spinal cord compression or recurrence with no further radiation options were included in the study. Patients who underwent reoperations exclusively for instrumentation failure were excluded. All patients underwent additional decompression via a posterolateral approach without removal of the spinal instrumentation.

Results

Patients underwent 1–4 reoperations at the same level. A median survival time of 12.4 months was noted after the first reoperation, and a median survival time of 9.1 months was noted after the last reoperation. At last follow-up 22 (65%) of 34 patients were ambulatory at the time of last follow-up or death, and the median time between loss-of-ambulation and death was 1 month. Functional status was maintained or improved by one Eastern Cooperative Oncology Group grade in 97% of patients. A major surgical complication rate of 5% was noted.

Conclusions

Reoperation represents a viable option in patients with high-grade epidural spinal cord compression who have recurrent metastatic tumors at previously operated spinal levels. In carefully selected patients, reoperation can prolong ambulation and result in good functional and neurological outcomes.

Spine metastases: current treatments and future directions

Spinal metastases are the most frequently encountered spinal tumour and can affect up to 50% of cancer patients. Both the incidence and prevalence of metastases are thought to be rising due to better detection and treatment options of the systemic malignancy resulting in increased patient survival. Further, the development and access to newer imaging modalities have resulted in easier screening and diagnosis of spine metastases. Current evidence suggests that pain, neurological symptoms and quality of life are all improved if patients with spine metastases are treated early and aggressively. However, selection of the appropriate therapy depends on several factors including primary histology, extent of the systemic disease, existing co-morbidities, prior treatment modalities, patient age and performance status, predicted life expectancy and available resources. This article reviews the currently available therapeutic options for spinal metastases including conventional external beam radiation therapy, open surgical decompression and stabilisation, vertebral augmentation and other minimally invasive surgery (MIS) options, stereotactic spine radiosurgery, bisphosphonates, systemic radioisotopes and chemotherapy. An algorithm for the management of spine metastases is also proposed. It outlines a multidisciplinary and integrated approach to these patients and it is hoped that this along with future advances and research will result in improved patient care and outcomes.

Solitary spinal metastasis of Hürthle cell thyroid carcinoma

Hürthle cell carcinoma is a rare variant of differentiated thyroid cancer that occasionally forms distant metastases. However, even in the presence of metastases, patients with Hürthle cell carcinoma have a relatively good prognosis. There are few reports of Hürthle cell carcinoma metastases to the vertebral column, and none describing aggressive resection of spinal metastases. Here, we report a 68-year-old woman with a solitary metastasis of Hürthle cell carcinoma to the T1 vertebral body causing severe kyphotic deformity, myelopathy, and pain. The patient was treated with aggressive excisional decompression of the spinal cord and T1 vertebral body resection from an entirely posterior approach. Reconstruction and stabilization of the anterior spine was accomplished with a transforaminal lumbar interbody fusion allograft spacer and posterior instrumentation. We discuss aspects of the diagnosis, management, patient selection, and surgical treatment of metastatic Hürthle cell carcinoma in reference to the literature.

Outcome of Surgical Treatment for Metastatic Vertebra Bone Tumor in Advanced Lung Cancer

Background

Spinal metastases of patients with advanced stage lung cancer are an important target for palliative therapy, because their incidence is high, and they often cause severe symptoms and worsen the quality of life. Surgery is one of the most effective treatment options, but the indication of surgery is unclear as the procedure is invasive and patients with spinal metastasis have a rather short life expectancy. Furthermore, there have been few studies that have focused on lung cancer with poor prognosis.

Methods

We reviewed all of the cases of lung cancer from January 1999 to July 2007 in the Department of Respiratory Medicine, Kyoto University Hospital, Japan. Thirteen patients with metastatic spinal tumor of lung cancer underwent surgery, and all of them had a poor performance status score (3 or 4).

Results

Neurological improvement by at least 1 Frankel grade was seen in 10 of 14 cases (71%). Improvement of the movement capacity was noted in 9 of 14 cases (64%), and pain improvement was noted in 12 of 14 (86%). Median postoperative survival was 5 months (1–25 months). In particular, the group with a good postoperative performance status score (0–2) was shown to have a better median postoperative survival of 13 months.

Conclusions

Surgical treatment for symptomatic metastatic spinal tumor of lung cancer can improve quality of life in a substantially high percentage of patients. Surgery should be considered even if preoperative performance status is poor.

One-stage combined posterior and anterior approaches for excising thoracolumbar and lumbar tumors: surgical and oncological outcomes

STUDY DESIGN

Retrospective clinical and radiologic evaluation.

OBJECTIVE

To investigate the feasibility of a 1-stage combined posterior and anterior approaches for excising thoracolumbar and lumbar tumors with the patient lying in the lateral position.

SUMMARY OF BACKGROUND DATA

Traditional anteroposterior approaches for total spondylectomy require a 2-stage operation or changing the patient's position, with secondary sterilization in the one stage. So the surgical time, cost and trauma, as well as blood loss, would be increased. One-stage en bloc spondylectomy with the patient lying in the lateral position may be a good way for improving it.

METHODS

This study retrospectively reviewed 18 patients with thoracolumbar and lumbar spinal tumors who underwent spondylectomy. All patients were observed up, and their status was evaluated by clinical and imaging studies.

RESULTS

Total en bloc spondylectomy was performed successfully in 15 patients, and 3 patients underwent bulk vertebrectomy. All patients were observed up for 18 months to 3 years (mean, 2 years). Posterior pedicle screw fixation and anterior intervertebral titanium mesh placement were stable in all patients, with satisfactory positions. Two patients with preoperative neurologic deficits recovered less than 3 weeks after surgery. One patient with thyroid metastasis underwent artificial joint replacement 5 months after surgery. Two patients with metastatic tumor died 6 months and 8 months, respectively, after surgery. Ten months after surgery, local tumor recurred in one patient with chondrosarcoma. One patient with Ewing's sarcoma died due to distal metastasis 1 year after surgery.

CONCLUSION

The 1-stage combined posterior and anterior approaches with the patient lying in the lateral position, used to excise thoracolumbar and lumbar spinal tumors, is feasible and permits sufficient exposure, reduces the risk of neurovascular injury and blood loss during surgery, facilitates total en bloc spondylectomy and spinal reconstruction, and reduces the surgical time of a 2-stage procedure and repositioning the patient. This method can be used effectively for excising spinal tumors.

Perioperative complications and prognosis for elderly patients with spinal metastases treated by surgical strategy

The rapidly aging population and improved long-term survival due to advancement of cancer treatment have expanded the role of surgical treatment in elderly patients with metastatic spinal disease. The purpose of this study was to evaluate in elderly patients the perioperative complications and prognosis for metastatic spinal disease. Thirty-two elderly patients (>70 years) who underwent surgical treatment based on Tomita's surgical strategy for spinal metastasis since 1999 were retrospectively reviewed. Mean survival time of 15 patients with 2 to 4 points in surgical strategy was 23.6 months; of 10 patients with 5 to 7 points was 15.2 months; and of 7 patients with 8 to 10 points was 5.2 months. In 5 elderly patients (15.6%), the appropriate surgical choice based on the surgical strategy was not possible due to their preoperative conditions. Perioperative complications encountered were respiratory in 6 patients (18.8%), cardiovascular in 3 (9.4%), and delirium in 4 (12.5%). In the nonelderly 161 patients, respiratory complications occurred in 4 patients (2.5%), cardiovascular in 1 (0.6%), and delirium in 2 (1.2%). Respiratory complications and delirium occurred at a significantly higher frequency in the elderly group. Even for elderly patients, the postoperative prognosis could be predicted by the surgical strategy. However, the optimal surgical procedure may deviate from that predicted by the surgical strategy due to their preoperative conditions and an increased risk for perioperative complications. Despite the increased potential for complications, more radical procedures, such as total en bloc spondylectomy, should not be avoided solely due to advanced patient age.

The use of expandable cages in patients undergoing multilevel corpectomies for metastatic tumors in the cervical spine

Expandable cages have been used successfully to reconstruct the anterior spinal column in the treatment of traumatic, neoplastic, infectious, and degenerative spine disease. To the best of our knowledge, no studies report the results of the use of expandable cages in patients undergoing multilevel corpectomies for cervical spine metastatic disease. We report our experience with the use of expandable cages in this subgroup of patients.From August 2006 to May 2008, 5 patients presenting with myelopathy, pain, and/or radiculopathy secondary to metastatic disease of the cervical spine underwent multilevel cervical corpectomies and placement of expandable cages in our institution. All procedures were supplemented with an anterior cervical plate and with posterior instrumentation to achieve a 360 degrees fusion. A visual analog scale (VAS), Nurick grade, Frankel grade, American Spinal Injuries Association (ASIA) grade, and Ranawat grade were used to evaluate patients pre- and postoperatively. The mean follow-up period was 13.2 months. Three patients underwent a 2-level corpectomy, 1 a 3-level corpectomy, and 1 a 4-level corpectomy. Postoperative imaging studies showed that all patients had correction of preoperative kyphosis. The mean VAS score was reduced from 6.4 to 1. All other indices of spinal cord injury measured improved postoperatively or were stabilized. Postoperative imaging studies showed stable constructs in 4 patients.The use of expandable cages in multilevel corpectomies for the treatment of metastatic cervical spine disease appears to be a safe and effective way to reconstruct the anterior column of the cervical spine, preventing further neurologic deterioration.

The value of palliative surgery for metastatic spinal disease: satisfaction of patients and their families

BACKGROUND CONTEXT

Although there have been several studies in which the surgical outcomes were evaluated by pain reduction or neurological improvement, there have been few studies focused on the quality of life (QOL) of the patients after the surgery. We considered that the most important consideration in palliative surgery was to respect the wishes of patients and their families, which are likely to be influenced by the patients' QOL for their limited life span.

PURPOSE

To evaluate the value of palliative surgery for spinal metastasis and to identify the factors predicting satisfaction of patients and their families after the surgery.

STUDY DESIGN

Questionnaire-based survey of palliative surgery for spinal metastasis.

PATIENT SAMPLE

Seventy-one consecutive patients who had undergone palliative surgery and their families.

OUTCOME MEASURES

Survival period after surgery, neurological status, ambulatory period, pain scale, and satisfaction of patients and their families.

METHODS

The QOL of the patients after surgery was evaluated by analyzing the satisfaction and related parameters of patients and their families. Questionnaires were sent to 71 consecutive patients who had undergone palliative surgery for spinal metastasis. To identify the factors predicting satisfaction of patients and their families, multivariate logistic regression analyses were performed.

RESULTS

Questionnaires were successfully delivered to 71 patients or their families. Full responses were collected from 37 patients, giving an overall response rate of 52.2%. Overall, 80% of patients were satisfied with the results of the surgical treatment. Age (below 65 years) and neurological improvement after surgery were significant predictors of patient's satisfaction. Pain reduction and the continued survival of the patient were significant predictors of family member's satisfaction.

CONCLUSIONS

These results strongly suggested that palliative surgery is a valuable treatment for metastatic spinal disease. Younger patients were more likely to want active treatment and to seek any functional improvement that contributed to an improved QOL in their limited life span. Pain control and the length of patient survival were important factors for people caring for patients.

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Choosing the right operation for metastatic spinal tumours is often difficult, and depends on many factors, including life expectancy and the balance of the risk of surgery against the likelihood of improving quality of life. Several prognostic scores have been devised to help the clinician decide the most appropriate course of action, but there still remains controversy over how to choose the best option; more often the decision is influenced by habit, belief and subjective experience. The purpose of this article is to review the present systems available for classifying spinal metastases, how these classifications can be used to help surgical planning, discuss surgical outcomes, and make suggestions for future research. It is important for spinal surgeons to reach a consensus regarding the classification of spinal metastases and surgical strategies. The authors of this article constitute the Global Spine Tumour Study Group: an international group of spinal surgeons who are dedicated to studying the techniques and outcomes of surgery for spinal tumours, to build on the existing evidence base for the surgical treatment of spinal tumours.

Survival of patients with skeletal metastases from hepatocellular carcinoma after surgical management

Skeletal metastases from hepatocellular carcinoma are highly destructive vascular lesions which severely reduce the quality of life. Pre-existing liver cirrhosis presents unique challenges during the surgical management of such lesions. We carried out a retrospective study of 42 patients who had been managed surgically for skeletal metastases from hepatocellular carcinoma affecting the appendicular skeleton between January 2000 and December 2006. There were 38 men and four women with a mean age of 60.2 years (46 to 77). Surgery for a pathological fracture was undertaken in 30 patients and because of a high risk of fracture in 12. An intralesional surgical margin was achieved in 36 and a wide margin in six. Factors influencing survival were determined by univariate and multivariate analyses. The survival rates at one, two and three years after surgery were 42.2%, 25.8% and 19.8%, respectively. The median survival time was ten months (95% confidence interval 6.29 to 13.71). The number of skeletal metastases and the Child-Pugh grade were identified as independent prognostic factors by Cox regression analysis. The method of management of the hepatocellular carcinoma, its status in the liver, the surgical margin for skeletal metastases, the presence of a pathological fracture and adjuvant radiotherapy were not found to be significantly related to the survival of the patient, which was affected by hepatic function, as represented by the Child-Pugh grade.

Posterior-Only Approach For Total En Bloc Spondylectomy For Malignant Primary Spinal Neoplasms: Anatomic Considerations and Operative Nuances

MALIGNANT PRIMARY SPINAL tumors are rare tumors that are locally invasive and can metastasize. The majority of these tumors have a poor response rate to chemotherapy and conventional radiotherapy. Studies have shown that long-term survival and the potential for cure is best achieved with en bloc surgical excision of these tumors with negative surgical margins. Total en bloc spondylectomy involves removal of vertebral segment(s) in whole to achieve wide tumor excision. Total en bloc spondylectomy can be performed through staged or combined anterior and posterior approaches, or from a posterior-only approach. The posterior-only approach offers the advantage of achieving complete tumor excision and circumferential spinal reconstruction in a single setting. In this report, we discuss the operative management of malignant primary vertebral tumors using the posterior-only approach for total en bloc spondylectomy. The oncological considerations and surgical nuances that allow for safe but aggressive surgical excision of primary spinal tumors to achieve favorable oncological and neurological outcomes are highlighted.

Treatment of pathologic spinal fractures with combined radiofrequency ablation and balloon kyphoplasty

Background

In oncologic patients with metastatic spinal disease, the ideal treatment should be well tolerated, relieve the pain, and preserve or restore the neurological function.

The combination of fluoroscopic guided radiofrequency ablation (RFA) and kyphoplasty may fulfill these criteria.

Methods

We describe three pathological vertebral fractures treated with a combination of fluoroscopic guided RFA and kyphoplasty in one session: a 62-year-old man suffering from a painful L4 pathological fracture due to a plasmocytoma, a 68-year-old man with a T12 pathological fracture from metastatic hepatocellular carcinoma, and a 71-year-old man with a Th12 and L1 pathological fracture from multiple myeloma.

Results

The choice of patients was carried out according to the classification of Tomita. Visual analog score (VAS) and Oswestry disability index (ODI) were used for the evaluation of the functional outcomes. The treatment was successful in all patients and no complications were reported. The mean follow-up was 6 months. Marked pain relief and functional restoration was observed.

Conclusion

In our experience the treatment of pathologic spinal fractures with combined radiofrequency ablation and balloon kyphoplasty is safe and effective for immediate pain relief in painful spinal lesions in neurologically intact patients.

Survival rate and neurological outcome after operation for advanced spinal metastasis (Tomita's classification > or = type 4)

PURPOSE

We investigated whether primary malignancy entities and the extent of tumor resection have an effect on the survival rate and neurological improvement in patients with spinal metastases that extend beyond the vertebral compartment (Tomita's classification > or = type 4).

MATERIALS AND METHODS

We retrospectively reviewed 87 patients with advanced spinal metastasis who underwent surgery. They were divided into groups 1 and 2 according to whether they responded to adjuvant therapy or not, respectively. They were subdivided according to the extent of tumor resection: group 1, gross total resection (G1GT); group 1, subtotal resection (G1ST); group 2, gross total resection (G2GT); and group 2, subtotal resection (G2ST). The origin of the tumor, survival rate, extent of resection, and neurological improvement were analyzed.

RESULTS

Group 1 had a better survival rate than group 2. The G1GT subgroup showed a better prognosis than the G1ST subgroup. In group 2, the extent of tumor resection (G2GT vs. G2ST) did not affect survival rate. In all subgroups, neurological status improved one month after surgery, however, the G2ST subgroup had worsened at the last follow-up. There was no local recurrence at the last follow-up in the G1GT subgroup. Four out of 13 patients in the G2GT subgroup showed a local recurrence of spinal tumors and progressive worsening of neurological status.

CONCLUSION

In patients with spinal metastases (Tomita's classification > or = type 4), individuals who underwent gross total resection of tumors that responded to adjuvant therapy showed a higher survival rate than those who underwent subtotal resection. For tumors not responding to adjuvant therapy, we suggest palliative surgical decompression.

State of the art management in spine oncology: a worldwide perspective on its evolution, current state, and future

STUDY DESIGN

A review of the past and current status of the evolving field of spine oncology.

OBJECTIVE

To provide a framework of reference for developments in the field, particularly the rapidly evolving field of molecular biology, as well as contemporary practice in the management of spine tumors.

METHODS

Literature review of the surgical treatment of spine tumors in the past and present, the emerging radiologic and biologic technologies, as well as the field of targeted therapy in cancer and the economic implications of technological advances.

RESULTS

A vast contemporary literature is currently available that provides a clear rational basis for treatment. Most treatment recommendations are currently based on retrospective data and small Phase II prospective studies. Treatment paradigms continue to evolve without their relative merits being evaluated by randomized controlled trials. The current lack of randomized trials in spine oncology reflect both the rarity of spine tumors and strongly held biases based on retrospective studies and institutional bias.

CONCLUSION

Spine oncology is a rapidly evolving field with contributions in surgery, radiation therapy, and targeted chemotherapy resulting in overall improvement in quality of life and survival in patients with spine tumors. However, the economic consequences of these improvements are substantial and need to be kept in proper perspective.

Shifting paradigms in the treatment of metastatic spine disease

STUDY DESIGN

Systematic review and evidence appraisal.

OBJECTIVE

To evaluate the optimal treatment for patients with spinal cord compression secondary to solid metastases and in patients with solitary renal metastases, without spinal cord compression.

METHODS

Focused Medline and OVID database searches were conducted using relevant keywords. Only clinical articles that evaluated specific end points of interest were included in the literature review. The quality of evidence provided by each article was assessed using the ATS guidelines. The expert opinion was synthesized based on the evidence and rated as strong or weak, depending on the quality of the supporting literature.

RESULTS

Twelve surgical and 7 radiation clinical series were identified that evaluated post-treatment ambulation in patients with metastatic spinal cord compression. Only 1 surgical article met the criteria for moderate quality evidence while the remaining surgical and radiation articles presented very low quality of evidence. All articles that evaluated treatment of solitary renal metastases presented very low quality of evidence.

CONCLUSION

A strong recommendation is made for patients with high-grade cord compression due to solid tumor metastases to undergo surgical decompression with stabilization followed by radiation therapy. A weak recommendation is made for patients with solitary renal metastases without spinal cord compression to undergo spinal stereotactic radiosurgery.

Health related quality of life assessment in metastatic disease of the spine: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To examine the available literature on health related quality of life (HRQOL) assessment in metastatic disease of the spine and identify the optimal functional outcome scales to be used in developing a disease-specific tool.

SUMMARY OF BACKGROUND DATA

There is a lack of consensus in the use of HRQOL measures in patients with metastatic spine disease.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, the Science Citation Index (ISI), the Cumulative Index to Nursing and Allied Health Literature, the PsycINFO, the Allied and Complementary Medicine (AMED), Cochrane Reviews and Global Health databases for clinical studies addressing metastatic spine disease from 1966 through 2008. The validity of outcome tools was established by linkage analysis with the International Classification of Functioning Disability and Health (ICF).

RESULTS

One hundred forty-one clinical studies met inclusion criteria including 10,347 patients. Only 5 moderate grade and 1 high grade study were identified. Thirty- four studies used a patient self-assessment instrument to assess health status. None of the instruments were validated for metastatic spine patients. The most commonly used Pi-by-no tools were SF-36, SIP 5, and the ADL. None of the studies defined health related quality of life (HRQOL) or justified the choice of instrument. The most commonly used cancer-specific tools were ECOG, EORTC QCQ-C30, and EUROQOL 5D. Based on frequency of citation and on correlation with the International Classification of Functioning Disability and Health, the ECOG and SF36 were judged as most valid and reliable.

CONCLUSION

A systematic review of the available evidence suggests that valid and reliable health related quality of life measures exist for the assessment of oncology patients; however, a disease-specific tool for metastatic spine disease awaits development. Until such time as a disease-specific tool is available, we recommend that the ECOG and SF-36 be considered for use in studies addressing the outcome assessment of patients with metastatic spine disease.

Loss of p16INK4, alone and with overexpression of osteopontin, correlates with survival of patients with spinal metastasis from hepatocellular carcinoma

The survival of patients with hepatocellular carcinoma (HCC) has been improved with various diagnostic tools and treatment modalities. Consequently, spinal metastases from HCC are diagnosed more frequently. We investigated the clinical biomarkers of HCC patients presenting with spinal metastasis. Between January 2001 and December 2007, we recruited 30 consecutive HCC patients presenting with spinal metastasis. Their tissue samples were collected and analyzed by immunohistochemistry in a tissue microarray. A total of 16 proteins were assessed in the tissue microarray; we found that expression of p16(INK4) correlated with the survival time (log-rank test, P = 0.05), and loss of p16(INK4) was significantly associated with osteopontin overexpression (Fisher exact test: P = 0.045, logistic regression: P = 0.024, OR = 0.184, 95% CI 0.035-0.963). Patients with osteopontin (-) and with p16(INK4) (+) lived longer than patients with osteopontin (+) and with p16(INK4) (-). We found that p16(INK4) and osteopontin might be the biomarkers of patients with spinal metastasis from HCC, a more large-scaled randomized study might be required to confirm the result and study the mechanism.

The management of spinal metastases from renal cell carcinoma

INTRODUCTION

Osseous metastases occur in 50% of patients with renal cell carcinoma; of these, 15% occur in the spine. The treatment options for spinal metastases secondary to renal cell carcinoma are limited. This paper considers the current management options available for spinal metastases secondary to renal cell carcinoma.

PATIENTS AND METHODS

A review of four patients with spinal metastases secondary to renal cell carcinoma.

RESULTS

The presentation of four cases highlighting the current management options for spinal metastases secondary to renal cell carcinoma.

CONCLUSIONS

Historically, spinal metastases from renal cell carcinoma have been poorly managed; however, as the treatment of the primary disease improves, better treatment of the secondary disease is needed. Cement augmentation, used alone for prophylactic stabilisation or in conjunction with a posterior decompression and fixation, provides a useful addition in the management of these patients optimising their chance to remain ambulant, continent, and pain-free.

Outcome of excisional surgeries for the patients with spinal metastases

To evaluate the outcome of the excisional surgeries (en bloc/debulking) in spinal metastatic treatment in 10 years. A total of 131 patients (134 lesions) with spinal metastases were studied. The postoperative survival time and the local recurrence rate were calculated statistically. The comparison of the two procedures on the survival time, local recurrence rate, and neurologic change were made. The median survival time of the en bloc surgery and the debulking surgery was 40.93 and 24.73 months, respectively, with no significant difference. The significant difference was shown in the local recurrence rate comparison, but not in neurological change comparison. 19.85% patients combined with surgical complications. The en bloc surgery can achieve a lower local recurrence rate than the debulking surgery, while was similar in survival outcome, neurological salvage, and incidence of complications. The risk of the excisional surgeries is high, however, good outcomes could be expected.

Surgical management of metastatic bone disease

Metastatic bone disease is a major contributor to the deterioration of the quality of life of patients with cancer; it causes pain, impending and actual pathological fractures, and loss of function and may also be associated with considerable metabolic alterations. Operative treatment may be required for an impending or existing fracture and intractable pain. The goals of surgery are to provide local tumor control and allow immediate weight-bearing and function. Radiation therapy is often indicated postoperatively. Detailed preoperative evaluation is required to assess the local extent of bone destruction and soft-tissue involvement, involvement of other skeletal sites, and the overall medical and oncological status.

Prophylactic stabilization of vertebral body metastasis at risk of imminent fracture using balloon kyphoplasty

STUDY DESIGN

Case report.

OBJECTIVE

Presentation of the previously unreported technique of balloon kyphoplasty being used to prophylactically stabilize a vertebral body metastasis at risk of imminent fracture.

SUMMARY OF BACKGROUND DATA

Many patients with spinal metastases are not suitable for a total en bloc resection. Untreated these metastases may fracture, with the risk of cord compression.

METHODS

We present the case of a 53-year-old gentleman with an isolated T10 renal cell metastasis. This gentleman presented with back pain, and was deemed to be at risk of imminent fracture. The metastasis was prophylactically stabilized using balloon kyphoplasty.

RESULTS

Lasting pain relief and spinal stability were achieved following treatment with balloon kyphoplasty. He remains pain free 14-months post treatment.

CONCLUSION

This is the first reported case of balloon kyphoplasty being used to prophylactically stabilize a vertebral body containing a metastasis, achieving both mechanical stability and pain relief.

Surgical management of prostate cancer metastatic to the spine

Object

Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome.

Methods

The authors retrospectively reviewed the records of all patients who were treated with surgery for prostate cancer metastases to the spine between 1993 and 2005 at a single institution. Particular attention was given to initial presentation, operative management, clinical and neurological outcomes, and factors associated with complications and overall survival.

Results

Forty-four patients underwent a total of 47 procedures. The median age at spinal metastasis was 66 years (range 50–84 years). Twenty-four patients had received previous external-beam radiation to the site of spinal involvement, with a median dose of 70 Gy (range 30–74 Gy). Frankel scores on discharge were significantly improved when compared with preoperative scores (p = 0.001). Preoperatively, 32 patients (73%) were walking and 33 (75%) were continent. On discharge, 36 (86%) of 42 patients were walking, and 37 (88%) of 42 were continent. Preoperatively, 40 patients (91%) were taking narcotics, with a median morphine equivalent dose of 21.5 mg/day, and 28 patients (64%) were taking steroids, with a median dose of 16 mg/day. At discharge, the median postoperative morphine equivalent dose was 12 mg/day, and the median steroid dose was 0 mg/day (p < 0.001). Complications occurred in 15 (32%) of 47 procedures, with 9 (19%) considered major, and there were 4 deaths within 30 days of surgery. The median overall survival was 5.4 months. Gleason score (p = 0.002), total number of metastases (p = 0.001), and the degree of spinal canal compression (p = 0.001) were independent predictors of survival. Age ≥ 65 years at the time of surgery was an independent predictor of a postoperative complication (p = 0.005).

Conclusions

In selected patients with prostate cancer metastases to the spine, aggressive surgical decompression and spinal reconstruction is a useful treatment option. The results show that on average, neurological outcome is improved and use of analgesics is reduced. Gleason score, metastatic burden, and degree of spinal canal compression may be associated with survival following surgery, and thus should be considered carefully prior to opting for surgical management.

Diagnosis and management of sacral tumors

Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.

Metastatic carcinoma related long segment thoracic spinal epidural hematoma: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a long segment epidural hematoma with thoracic cord compression caused by a metastatic carcinoma.

SUMMARY OF BACKGROUND DATA

To our knowledge, there have been no previous reports of spontaneous spinal epidural hematoma caused by metastatic carcinoma.

METHODS

A 60-year-old woman with back pain and progressive leg weakness suddenly developed complete paraplegia and anesthesia below T8. A thoracic spine MRI showed an epidural hematoma and metastatic tumor. We describe the clinical course, radiographic imaging, operative findings, and treatment results.

RESULTS

Despite immediate surgery, the patient failed to have any significant improvement in her neurologic symptoms. A previously unsuspected primary lung tumor was diagnosed. She died 6 months after spine surgery.

CONCLUSION

Spinal epidural hematoma can occur in association with metastatic tumors in that area.

Selecting treatment for patients with malignant epidural spinal cord compression-does age matter?: results from a randomized clinical trial

STUDY DESIGN

Randomized clinical trial. OBJECTIVE.: To determine if age affects outcomes from differing treatments in patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

Recently, class I data were published supporting surgery with radiation over radiation alone for patients with malignant epidural spinal cord compression (MESCC). However, the criteria to properly select candidates for surgery remains controversial and few independent variables which predict success after treatment have been identified.

METHODS

Data for this study was obtained in a randomized clinical trial comparing surgery versus radiation for MESCC. Hazard ratios were determined for the effect of age and the interaction between age and treatment. Age estimates at which prespecified relative risks could be expected were calculated with greater than 95% confidence to suggest possible age cut points for further stratification. Multivariate models and Kaplan-Meier curves were tested using stratified cohorts for both treatment groups in the randomized trial each divided into 2 age groups.

RESULTS

Secondary data analysis with age stratification demonstrated a strong interaction between age and treatment (hazard ratio = 1.61, P = 0.01), such that as age increases, the chances of surgery being equal to radiation alone increases. The best estimate for the age at which surgery is no longer superior to radiation alone was calculated to be between 60 and 70 years of age (95% CI), using sequential prespecified relative risk ratios. Multivariate modeling and Kaplan-Meier curves for stratified treatment groups showed that there was no difference in outcome between treatments for patients >or=65 years of age. Ambulation preservation was significantly prolonged in patients <65 years of age undergoing surgery compared to radiation alone (P = 0.002).

CONCLUSION

Age is an important variable in predicting preservation of ambulation and survival for patients being treated for spinal metastases. Our results provide compelling evidence for the first time that particular age cut points may help in selecting patients for surgical or nonsurgical intervention based on outcome.

Fratura na coluna vertebral por mieloma múltiplo: correlação entre sobrevida e índices de Tomita e Tokuhashi

OBJETIVO: o mieloma múltiplo (MM) é a neoplasia óssea primária mais freqüente na coluna vertebral. Em razão da grande morbi-mortalidade destas lesões, discute-se qual o melhor tratamento nestes pacientes. Na prática, observamos similaridade das opções de tratamento entre os pacientes portadores de metástases ósseas e MM. Os índices de sobrevida de Tomita e Tokuhashi são utilizados com o intuito de auxiliar na escolha do tratamento nos portadores de metástases. Faltam estudos sobre a aplicabilidade destes índices em pacientes portadores de MM. Neste trabalho vamos avaliar a aplicabilidade dos índices de Tomita e Tokuhashi nos pacientes portadores de MM e lesão vertebral. MÉTODOS: estudo retrospectivo mediante avaliação de prontuários e radiografias de portadores de MM por meio da aplicação dos critérios de Tomita e Tokuhashi. RESULTADOS: em um ano, 19 (63,3%) estavam vivos, em dois anos 13 (43,3%) e em cinco anos quatro (13,3%) pacientes estavam vivos. Não houve correlação entre os índices (Tomita e Tokuhashi) e a taxa de sobrevida nestes pacientes (p= 0,2255). CONCLUSÃO: há necessidade de adaptação dos índices de Tomita e Tokuhashi para apresentarem aplicabilidade nos portadores de MM na coluna.

Cervical and thoracic spine tumor management: surgical indications, techniques, and outcomes

Since the first pioneering work in the area of tumors of the spine, medical professionals have sought to determine the proper role of spine surgery in the management of spinal tumors. Experience has proven that spine surgery is effective in the treatment of spinal cord compression for decreasing pain and improving quality of life with low rates of surgical complications. We use several staging systems to assess the patient's prognosis, to determine the best type of tumoral resection in preoperative surgical planning, and to provide guidance as to the best therapeutic option for the patient. In the surgical treatment of spine tumors, one of two opposing strategies must be chosen: (1) palliative surgery with cord decompression and spine stabilization or (2) curative surgery with en bloc radical resection of the tumor and stabilization. In this article, we describe indications and surgical techniques related to cervical spinal tumors: fixation and laminectomy of the upper and lower cervical spines, corporectomy, and partial and total vertebrectomy. For tumors of the cervicothoracic region, the most frequent level of spine metastasis and thoracic spine tumors, we describe the fixation and laminectomy technique, en bloc tumor resection, and partial and total vertebrectomy. The last part of the article addresses outcomes following spinal surgery, including outcomes related to en bloc Pancoast Tobias tumor resection, malignant dumbbell schwanomas, and metastasis.

Diagnosis and staging of spine tumors

Persistent axial pain with or without neurologic changes should prompt workup for a possible tumor of the spine. Metastatic disease is more predominant than primary tumors, but still needs adequate evaluation before any management. The various steps of evaluation, diagnosis, and staging are reviewed.

Solitary vertebral metastasis

As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate our treatment outcome for spinal metastases using our treatment strategy based on prognostic scoring system.

SUMMARY OF BACKGROUND DATA

In the treatment of spinal metastases, life expectancy is most important, and our scoring system for metastatic spine tumor prognosis has been useful for such prognostic evaluation.

METHODS

Conservative treatment or palliative surgery was indicated in patients with a predicted prognosis of less than 6 months or in those with multiple vertebral metastases, whereas excisional surgery was performed in patients with a predicated prognosis of 1 year or more, or with a predicted prognosis of 6 months or more, and with metastasis in a single vertebra. One hundred eighty-three patients were prospectively treated according to this principle using our prognostic scoring system, and the outcome was evaluated.

RESULTS

The consistency rate between the predicted prognosis from the criteria of the scoring system and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 87.9% in the 183 patients. Only the palliative surgery group (n = 55) showed a significant improvement of the Barthel index between before and after treatment (P < 0.01). The mean maximum Barthel index after treatment in any modality ran parallel to the total scores of our scoring system.

CONCLUSION

The prognostic criteria using our scoring system were useful for the pretreatment evaluation of prognosis irrespective of the treatment modality. In any treatment, the survival period of the patients affected the functional prognosis; therefore, it may be appropriate and realistic to select treatment methods by giving first priority to the life expectancy of patients.