Surgical strategy for spinal metastases

Total en bloc spondylectomy for spinal tumors: surgical techniques and related basic background

The authors' group has developed a new surgical technique of spondylectomy (vertebrectomy) called "total en bloc spondylectomy" (TES). This technique is different from spondylectomy in that it involves en bloc removal of the lesion, that is, removal of the whole vertebra, body and lamina, as one compartment. The surgical technique of TES has been remarkably improved based on adequate knowledge and consideration of the surgical anatomy, physiology, and biomechanics of the spine and spinal cord. Review of the developmental process of this operation leads to recognition of the tips, pitfalls, and solutions.

Algorithms and planning in metastatic spine tumors

Metastatic spine tumors cause the loss of the supporting function of the spine through vertebral destruction or invade and compress the spinal cord or cauda equine. As a result, metastatic spine tumor causes severe pain, paralysis, or impairment of activities of daily living (ADL). Also, because the finding of metastatic foci in the spine suggests a generalized disorder, life expectancy and treatment options have many limitations. For this reason, treatment is primarily symptomatic, and the major goals in selecting therapeutic modalities are to relieve pain, prevent paralysis, and improve ADL. This article discusses the selection of treatment for metastatic spine tumors and, in particular, the indications for surgical treatment.

The effectiveness of gefitinib on spinal metastases of lung cancer - report of two cases -

Lung cancer has a high mortality rate and is often diagnosed at the metastatic stage. Recently, gefitinib, a molecule target therapeutic drug, has offered a new approach for patients with non-small-cell lung cancer (NSCLC). This report describes the effects of gefitinib on bone metastases in two patients with NSCLC. The pain induced by a bone metastasis was relieved after the administration of gefitinib. Furthermore, the radiographs and CT findings showed sclerotic changes that matched those of the metastatic bone tumor after gefitinib administration in both patients. It is believed that gefitinib inhibited tumor cell proliferation and induced normal bone formation. In patients with NSCLC, gefitinib may be effective in the treatment of bone metastases.

[Role and technical aspects of surgery for spinal metastases from urological malignancies]

The improved survival rate in urologic carcinoma notably due to anti-angiogenic drugs is directly associated with increased incidence of spinal metastases. During spinal metastasis cord compression it has been proved that surgery associated with radiotherapy gives better results that radiotherapy alone. The neurotoxic risk of the spine metastasis must be evaluated before neurological signs appear in order to propose, if necessary decompressive surgery with stabilisation of the lesion. The choices of therapeutic approach are quite large ranging from percutaneous cimentoplasty to vertebral replacement. It is essential that the initial treatment of metastasis be discussed before neurologic signs appear.

Tokuhashi prognosis score: an important tool in prediction of the neurological outcome in metastatic spinal cord compression: a retrospective clinical study

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

The aim of this study was to examine whether the Tokuhashi score correlates with the neurologic outcome in early surgical treatment in metastatic spinal cord compression (MSCC). A retrospective analysis of 35 consecutive incomplete tetraplegic and paraplegic patients with vertebral metastases (VM) and spinal cord compression (SCC) was performed.

SUMMARY OF BACKGROUND DATA

MSCC is a challenging problem in VM and constitutes an oncologic emergency. The Tokuhashi score has been modified recently and seems to constitute the best method of prediction for real survival in patients with VM. Until now the influence of the neurologic status as a prognostic factor has been discussed controversially.

METHODS

Data of 35 patients with VM and incomplete tetraplegia or paraplegia, who underwent surgical treatment, were reviewed retrospectively from 2005 to 2006 at our hospital. All patients were classified among the American Spinal Injury Association (ASIA) Impairment Scale (AIS) before and after surgery and at the follow-up. Data were analyzed with SPSS 15.0 and correlation coefficients (Spearman rho) were computed.

RESULTS

Analysis showed that 19 patients (54.3%) with an average Tokuhashi score of 9 showed an improvement in the AIS, whereas 12 (34.3%) patients with an average score of 8 had no change and 4 (11.4%) patients with a score of 7 had deterioration. AIS changes showed a positive correlation with Tokuhashi score (r = 0.33; P = 0.048).

CONCLUSION

Our clinical observation suggests that patients with spinal metastases and a high Tokuhashi score benefit from surgical treatment with moderate improvement in sensomotoric function even in a heterogenic collective.

The role of embolization in radical surgery of renal cell carcinoma spinal metastases

BACKGROUND

Radical surgery of renal cell carcinoma spinal metastases carries a high risk due to potentially life-threatening extreme blood loss. Radical preoperative embolization of renal cell carcinoma metastases alone is not necessarily a guarantee of extreme blood loss not occurring during operation.

METHODS

A retrospective analysis of 15 patients following radical surgery for a spinal metastases of a renal cell carcinoma was performed. Eight patients were embolized preoperatively and 7 were not. We analysed features influencing peroperative blood loss: size and extent of tumour, complexity of surgical approaches and radicality of embolization.

RESULTS

The embolized and non embolized groups were not comparable before treatment. They differed markedly in size of tumour as well as the complexity of approach. In the embolized group the size of the tumour was, on average, twice as large as that in non embolized patients and more complex approaches were used twice as frequently. Despite findings suggesting that embolization was effective, blood loss was greater in the embolized group of 8 patients (4750 ml), compared to the non-embolized group of 7 patients (1786 ml).

CONCLUSION

Metastasis size, extent of tumour, technical complexity of surgery and the completeness of preoperative embolization had an important effect on the amount of peroperative blood loss. The evaluation of the benefits of preoperative embolization only on the basis of blood loss is not an adequate method.

Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases

Object

The authors report on a series of 145 consecutive patients with different types of spine lesions surgically treated via an anterior approach (AA) at the thoracic and lumbar levels during the past 10 years. Indications, techniques, and surgical results are described.

Methods

This series included 92 patients with fractures, 30 with neoplasms, 13 with thoracic disc hernias, and 10 with spinal infections. Based on the lesion to be addressed, the AA was used for lesion excision, corpectomy, vertebral body reconstruction with cages, realignment, and/or plating or screwing. The approach was extracavitary in 55 patients and intracavitary in 90. In 126 patients (86.8%), neural decompression and spine stabilization were achieved via a stand-alone AA (SA-AA), whereas 19 patients (13.1%) were treated using a 2-stage anteroposterior approach. This circumferential approach was reserved for select cases of severe traumatic dislocation, particular types of tumors, or specific anatomical locations. The authors developed a simple neuronavigation-based method of identifying the severely injured patients who were eligible for the SA-AA by evaluating the angle of lateral dislocation.

Results

There were no deaths and no instances of major surgery-related morbidity. Minor morbidity was almost always transitory and was reported in 13 patients (8.9%). Neurological improvement was reported in 20% of injured patients with a preoperative incomplete lesion. Postoperatively, all patients were able to stand or at least sit without load pain. During the follow-up (mean ± standard deviation 3.8 ± 2.4 years), there were no cases of failure, fracture, dislocation, or bending of the anterior instrumentation, and the rate of pseudarthrosis was 0%.

Conclusion

The anterior route provides direct access to most spine diseases and allows optimal neural decompression and the possibility of adequate realignment and strong reconstruction/fixation. Stability of the vertebral column is achieved, resolution of clinical pain is rapid and almost complete, and the rate of surgical complications is very low. The authors assert that the SA-AA offers so many advantages and has such good results that the 2-stage anteroposterior approach can be reserved for a minority of select cases and that the time for using the posterior approach alone is over.

Interventions for the treatment of metastatic extradural spinal cord compression in adults

BACKGROUND

Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery.

OBJECTIVES

To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity.

MAIN RESULTS

We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97).

AUTHORS' CONCLUSIONS

Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.

Changes in physical function after palliative surgery for metastatic spinal tumor: association of the revised Tokuhashi score with neurologic recovery

STUDY DESIGN

A retrospective study of patients undergoing palliative surgery for metastatic spinal tumors.

OBJECTIVE

To investigate short-term functional recovery and duration of improvement after palliative surgery, to correlate these outcomes with the revised Tokuhashi score, and to examine the relationship between function and neurologic deterioration.

SUMMARY OF BACKGROUND DATA

The revised Tokuhashi score is a scoring system used to predict life expectancy for patients with metastatic spinal tumors. The relationship between the revised Tokuhashi score and physical functional improvement after palliative surgery has not been examined previously.

METHODS

The clinical charts of 86 patients were reviewed. The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was used to assess physical function. Each score was documented before surgery and at every month after surgery. The duration of ECOG-PS improvement, defined as the period between surgery and deterioration to the preoperative ECOG-PS grade, was correlated with the revised Tokuhashi score.

RESULTS

The ECOG-PS grade improved in 44 (51.1%) patients at 1 month postoperative. When ECOG-PS improvement was found after surgery, it persisted above the preoperative level for an average of 9.3 months. At 1 month postoperative, patients scoring 0 to 8 on the total revised Tokuhashi score had significantly lower ECOG-PS improvement (26 of 55 patients) when compared to patients with higher scores (18 of 27 patients, P < 0.05). In 44 patients with ECOG-PS improvement, the existence of major internal organ metastases significantly shortened the duration of improvement (P < 0.05).

CONCLUSION

Palliative surgery benefited half of the patients with metastatic spinal tumor, with a greater probability of benefit found in persons with a higher total revised Tokuhashi score (score 9-15) and/or primary cancers with longer survival times.

Predictive value of seven preoperative prognostic scoring systems for spinal metastases

Predicting prognosis is the key factor in selecting the proper treatment modality for patients with spinal metastases. Therefore, various assessment systems have been designed in order to provide a basis for deciding the course of treatment. Such systems have been proposed by Tokuhashi, Sioutos, Tomita, Van der Linden, and Bauer. The scores differ greatly in the kind of parameters assessed. The aim of this study was to evaluate the prognostic value of each score. Eight parameters were assessed for 69 patients (37 male, 32 female): location, general condition, number of extraspinal bone metastases, number of spinal metastases, visceral metastases, primary tumour, severity of spinal cord palsy, and pathological fracture. Scores according to Tokuhashi (original and revised), Sioutos, Tomita, Van der Linden, and Bauer were assessed as well as a modified Bauer score without scoring for pathologic fracture. Nineteen patients were still alive as of September 2006 with a minimum follow-up of 12 months. All other patients died after a mean period of 17 months after operation. The mean overall survival period was only 3 months for lung cancer, followed by prostate (7 months), kidney (23 months), breast (35 months), and multiple myeloma (51 months). At univariate survival analysis, primary tumour and visceral metastases were significant parameters, while Karnofsky score was only significant in the group including myeloma patients. In multivariate analysis of all seven parameters assessed, primary tumour and visceral metastases were the only significant parameters. Of all seven scoring systems, the original Bauer score and a Bauer score without scoring for pathologic fracture had the best association with survival (P < 0.001). The data of the present study emphasize that the original Bauer score and a modified Bauer score without scoring for pathologic fracture seem to be practicable and highly predictive preoperative scoring systems for patients with spinal metastases. However, decision for or against surgery should never be based alone on a prognostic score but should take symptoms like pain or neurological compromise into account.

[Oncological surgery of the spine]

Spine surgery has been significantly influenced during the past 20 years by improvements in anaesthesia and radiology. This progress has also been promoted by technical developments in spinal instrumentation, mainly the introduction of pedicle screws and anterior support with cages. Both techniques allow correction and stabilisation methods that have had a major effect on tumour surgery. These advancements have allowed less experienced spine surgeons to perform tumour surgery, which may have a negative effect on the outcome. From our point of view, it should be required that tumour surgery be performed only in hospitals managing a certain number of tumours annually. For optimal results, en bloc resection and intralesional marginal resection in particular are highly demanding of the surgeon's technical skills and experience. Second and third operations complicate the intervention unnecessarily. Normally, R0 resection can not be achieved by a second or third revision. For this reason tumour surgery requires a standardised overall concept which must be suited to individual problems. This can be best decided in a tumour board meeting for choosing the options for adjuvant therapy. Only by such a coordinated effort may good mid- and long-term results be achieved.It must be pointed out that en bloc resection is the only surgical therapy that makes a curative approach possible. On the other hand it can also be demonstrated that by making extended, intralesional marginal resections as radical as possible, good mid-term results can be achieved. Here the adjuvant chemo- and radiotherapy play an important role.

[En-bloc spondylectomy and reconstruction for primary tumors and solitary metastasis of the spine]

In primary tumors of the spine and, with limitations, solitary metastasis, the surgical approach should aim for curative treatment of the disease. Because the prognosis of malignant bone tumors is extremely limited, if an intralesional approach is performed, an extralesional en bloc resection is the treatment of choice. Therefore, it is mandatory to use an appropriate staging system. For the spine, the WBB staging system has been approved, which transfers the principles of the Enneking classification for treating primary malignant tumors of the limb to the spine. After en bloc spondylectomy, rigid and primary stable instrumented dorsoventral reconstruction must be performed - posteriorly with a dual-rod system using pedicle screws, and anteriorly in the ideal case by means of a vertebral body replacement cage. The possibility of extralesional (wide or marginal) resection of spinal tumors depends on tumor size and location. Extralesional resection and, if indicated, other neoadjuvant, adjuvant, or local therapeutic modalities have a strong positive influence on long-term survival rates. A good prognosis for primary tumors is associated with a good response to chemotherapy and extralesional resection. Solitary metastases have a much worse quod vitam prognosis. Therefore, local control of the disease in en bloc resections of solitary metastasis is a second relevant goal, although curative treatment is the primary aim.

Surgical management of primary and metastatic sarcoma of the mobile spine

Object

Sarcomas of the spine are a challenging problem due to their frequent and extensive involvement of multiple spinal segments and high recurrence rates. Gross-total resection to negative margins, with preservation of neurological function and palliation of pain, is the surgical goal and may be achieved using either intralesional resection or en bloc excision. The authors report outcomes of surgery for primary and metastatic sarcomas of the mobile spine in a large patient series.

Methods

A retrospective review of patients undergoing resection for sarcomas of the mobile spine between 1993 and 2005 was undertaken. Sarcomas were classified by histology study results and as either primary or metastatic. Details of the surgical approach, levels of involvement, and operative complications were recorded. Outcome measures included neurological function, palliation of pain, local recurrence, and overall survival.

Results

Eighty patients underwent 110 resections of either primary or metastatic sarcomas of the mobile spine. Twenty-nine lesions were primary sarcomas (36%) and 51 were metastatic sarcomas (64%). Intralesional resections were performed in 98 surgeries (89%) and en bloc resections were performed in 12 (11%). Median survival from surgery for all patients was 20.6 months. Median survival for patients with a primary sarcoma of the spine was 40.2 months and was 17.3 months for patients with a metastatic sarcoma. Predictors of improved survival included a chondrosarcoma histological type and a better preoperative functional status, whereas osteosarcoma and a high-grade tumor were negative influences on survival. Multivariate analysis showed that only a high-grade tumor was an independent predictor of shorter overall survival. American Spinal Injury Association scale grades were maintained or improved in 97% of patients postoperatively, and there was a significant decrease in pain scores postoperatively. No significant differences in survival or local recurrence rates between intralesional or en bloc resections for either primary or metastatic spine sarcomas were found.

Conclusions

Surgery for primary or metastatic sarcoma of the spine is associated with an improvement in neurological function and palliation of pain. The results of this study show a significant difference in patient survival for primary versus metastatic spine sarcomas. The results do not show a statistically significant benefit in survival or local recurrence rates for en bloc versus intralesional resections for either metastatic or primary sarcomas of the spine, but this may be due to the small number of patients undergoing en bloc resections.

Palliative surgery for metastatic thoracic and lumbar tumors using posterolateral transpedicular approach with posterior instrumentation

BACKGROUND

The purpose of this study was to evaluate the clinical outcomes of patients with metastatic thoracic and lumbar tumors after palliative surgery using PTA with posterior instrumentation.

METHODS

Twenty-one consecutive patients with metastatic thoracic and lumbar spine tumors were treated using a PTA with posterior instrumentation. The patient group is composed of 14 men and 7 women with mean age of 56.6 years (range, 32-76 years). The average extent of vertebral involvement was 2.2 segments.

RESULTS

The mean operative time was 3.1 hours (range, 2-4.5 hours), and the mean blood loss was 1400 mL (range, 600-2500 mL). All patients with pain showed improved or similar pain levels after surgery, and Frankel grades were decreased significantly by operation. Postoperative mean survival was 8.9 months and ranged from 2 to 36 months. There were 4 (26.7%) patients who died at less than 3 months after surgery and 3 patients (14%) who required a repeat operation. Of 5 patients treated using a PTA despite a Tomita's prognostic score of more than 8, 3 patients (with preoperative ECOG grade IV) died within 6 weeks postoperatively, and the other 2 patients (with preoperative ECOG grade III) survived longer than 10 weeks (1 patient survived for 10 weeks, and the other for 12 weeks).

CONCLUSION

The PTA with posterior instrumentation for metastatic thoracic and lumbar spinal tumors achieved good surgical results. Palliative surgery for patients with a Tomita's prognostic score of more than 8 may be considered in selected cases, especially in those with ECOG grade III.

Effects on spinal cord blood flow and neurologic function secondary to interruption of bilateral segmental arteries which supply the artery of Adamkiewicz: an experimental study using a dog model

STUDY DESIGN

Segmental arteries including the level of Adamkiewicz artery were interrupted bilaterally for up to 4 levels to study the effects on spinal cord blood flow and neurologic function in dogs.

OBJECTIVE

To examine how many ligations of bilateral segmental arteries including the level of Adamkiewicz artery cause ischemic spinal cord dysfunction.

SUMMARY OF BACKGROUND DATA

Interruption of bilateral segmental arteries at >or=5 consecutive levels without the level of Adamkiewicz artery has been reported to risk producing ischemic spinal cord dysfunction in dog model. However, the effects of ligating including the level of Adamkiewicz artery have not been elucidated.

METHODS

The 25 dogs in which Adamkiewicz artery originated from L5 level were taken in this study. There were 15 dogs divided into 5 groups: sham group, no ligation; group 1, ligation of bilateral segmental arteries at 1 level (L5); group 2, at 2 levels (L4-L5); group 3, at 3 levels (L4-L6); and group 4, at 4 levels (L3-L6). Spinal cord blood flow at the L5 spinal cord segment by laser-Doppler flowmetry, and spinal cord-evoked and compound muscle action potentials were measured simultaneously until 10 hours after ligation. Neurologic function was assessed using a modified Tarlov grading system 1 week after operation in 10 other dogs divided into 2 groups: 3 pairs group, ligation at 3 levels (L4-L6); 4 pairs group, at 4 levels (L3-L6).

RESULTS

Spinal cord blood flow was 98.2%, 76.1%, 66.6%, 61.4%, and 53.5% in the sham group, groups 1, 2, 3, and 4, respectively, 10 hours after ligation. Abnormal spinal cord-evoked and compound muscle action potentials were observed in 1 out of 3 dogs in group 4. Postoperative neurologic evaluation identified all 5 dogs in 3 pairs group and 4 in 4 pairs group as having grade 5. There was 1 dog in 4 pairs group that had grade 4.

CONCLUSION

Interruption of bilateral segmental arteries at >or=4 consecutive levels including the level of Adamkiewicz artery risks producing ischemic spinal cord dysfunction.

Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007

OBJECT

Opinions vary widely as to the role of surgery (from none to wide margin excision) in the management of spinal metastases. In this study the authors set out to ascertain if surgery improves the quality of remaining life in patients with spinal metastatic and tumor-related systemic disease.

METHODS

The authors included 223 patients in this study who were referred by oncologists and physicians over a 2-year period. All underwent surgery. Surgery was classified according to extent of excision ranging from en bloc excision or debulking to palliative surgery. All patients had a histologically confirmed diagnosis of epithelial spinal metastasis, and an oncology specialist undertook appropriately indicated adjuvant therapy in almost half of the patients.

RESULTS

The mean patient age was 61 years. Excisional en bloc or debulking surgery was performed in 74%; the rest had (minimal) palliative decompression. All patients considered for surgery were included in the study. Patients presented with pain in 92% of cases, paraparesis in 24%, and abnormal urinary sphincter function in 22% (5% were incontinent). Breast, renal, lung, and prostate accounted for 65% of the cancers, and in 60% of patients there were widespread spinal metastases (Tomita Type 6 or 7). The incidence of perioperative death (within 30 days of surgery) was 5.8%. Postoperatively 71% of the entire group had improved pain control, 53% regained or maintained their independent mobility, and 39% regained urinary sphincter function. The median survival for the cohort was 352 days (11.7 months); those who underwent excision survived significantly longer than those in the palliative group (p = 0.003). As with survival results, functional improvement outcome was better in those who underwent excision.

CONCLUSIONS

Surgical treatment was effective in improving quality of life by providing better pain control, enabling patients to regain or maintain mobility, and offering improved sphincter control. Although not a treatment of the systemic cancer, surgery is feasible, has acceptably low mortality and morbidity rates, and for many will improve the quality of their remaining life.

En bloc spondylectomy in malignant tumors of the spine

En bloc spondylectomy is a technique that enables wide or marginal resection of malignant lesions of the spine. Both all posterior techniques as well as combined approaches are reported. Aim of the present study was to analyse the results of 21 patients with malignant lesions of the spine, all treated with en bloc excision in a combined posteroanterior (n = 19) or all posterior approach (n = 2). Twenty-one consecutive patients, operated between 1997 and 2005, were included into this retrospective study. Thirteen patients had primary malignant lesions, eight patients had solitary metastases, all located in the thoracolumbar spine. There were 16 single level, three two-level, one three-level and one four-level spondylectomy. The patients were followed clinically and radiographically (including CT studies) with an average follow-up of 4 years. Out of 11 patients with primary Ewing or osteosarcoma seven patients are alive without any evidence of disease. One patient died after 5 years from other causes and three are alive with evidence of disease. Latter had either a poor histologic response to the preoperative chemotherapy (n = 2) or an intralesional resection (n = 1). All three patients with solitary spinal metastases of Ewing or osteosarcoma died of the disease. Five patients with solitary metastases of mainly hypernephroma are alive. In total, six resections were intralesional, mainly due to large intraspinal tumor masses, with two patients having had previous surgery. In the remaining cases, wide (n = 10) or marginal (n = 5) resection was accomplished. There were one pseudarthrosis requiring extension of the fusion and two cases with local recurrences and repeated excisional surgery. At follow-up CT studies, all cages were fused. Health related quality of life analysis (SF-36) revealed only slightly decreased physical component and normal mental component scores compared to normals in those patients with no evidence of disease. En bloc spondylectomy enables wide or marginal resection of malignant lesions of the spine in most cases with acceptable morbidity. Intralesional resection, poor histologic response, and solitary spinal metastases of Ewing and osteosarcoma are associated with a poor prognosis.

Posterior decompression and stabilization for metastatic compression of the thoracic spinal cord: is this procedure still state of the art?

STUDY DESIGN

Retrospective study utilizing the standard patient data documentation of a spinal cord injury (SCI) unit.

OBJECTIVE

To examine the efficacy and outcome of posterior decompression and stabilization for metastatic cord compression.

SETTING

Orthopedic university hospital with large SCI unit.

METHODS

The 34 consecutive patients who had presented with symptoms of spinal cord compression due to metastatic disease and progressive neurologic deficit were treated using a uniform surgical approach (posterior decompression and stabilization). After surgery, all treatment options available in a full-featured SCI unit were applied as necessary and suitable. Outcome was rated concerning neurologic function (American Spinal Injury Association, ASIA), functional status (Functional Independence Measure) and pain. The results were compared to the published results, focusing on publications describing results of anterior surgical approaches to the spine.

RESULTS

Evaluation of the results of the ASIA exams showed that progression of the neurologic deficit could be stopped in the majority of cases-however recovery of neurologic function was rare. The functional status could be improved markedly and good pain reduction was achieved.

CONCLUSION

I mmediate surgery can be recommended if the general condition of the patient warrants surgical intervention. Using accepted standards of documentation for SCI, a clear perspective of the results that can be expected is provided. Comparing the results of this study with the current literature there is no evidence that anterior approaches are superior.

Predictors of survival in patients with bone metastasis of lung cancer

The prognosis of patients with bone metastasis from lung cancer has not been well documented. We assessed the survival rates after bone metastasis and prognostic factors in 118 patients with bone metastases from lung cancer. The cumulative survival rates after bone metastasis from lung cancer were 59.9% at 6 months, 31.6% at 1 year, and 11.3% at 2 years. The mean survival was 9.7 months (median, 7.2 months; range, 0.1-74.5 months). A favorable prognosis was more likely in women and patients with adenocarcinoma, solitary bone metastasis, no metastases to the appendicular bone, no pathologic fractures, performance status 1 or less, use of systemic chemotherapy, and use of an epithelial growth factor receptor inhibitor. Analyses of single and multiple variables indicated better prognoses for patients with adenocarcinoma, no evidence of appendicular bone metastases, and treatment with an epithelial growth factor receptor inhibitor. The mean survival period was longer in a small group treated with an epithelial growth factor receptor inhibitor than in the larger untreated group. The data preliminarily suggest treatment with an epithelial growth factor receptor inhibitor may improve survival after bone metastasis.

The use of an expandable cage for corpectomy reconstruction of vertebral body tumors through a posterior extracavitary approach: a multicenter consecutive case series of prospectively followed patients

BACKGROUND CONTEXT

Posterior decompressions in the form of laminectomies for vertebral body tumors have poor outcomes. Surgical management typically requires anterior decompression and reconstruction; however, these procedures can be associated with significant morbidity and mortality.

PURPOSE

To evaluate the feasibility of anterior spinal column reconstruction using an expandable cage through a posterior approach.

STUDY DESIGN/SETTING

Multicenter consecutive case series of 21 prospectively followed patients.

PATIENT SAMPLE

Twenty-one patients with vertebral body tumors treated with anterior and posterior resection and reconstruction from a single posterior approach were followed prospectively.

OUTCOME MEASURES

Pre- and postoperative neurologic status, number of levels instrumented and fused, length of surgery, length of stay after surgery, and complications related directly or indirectly to surgery were analyzed. In addition, pre- and postoperative radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans were evaluated for involvement of the vertebral body and associated posterior elements. Particular attention was paid to the presence of either unilateral or bilateral pedicle and/or middle column involvement.

METHODS

Patients were placed in a prone position on a rotating radiolucent table. Corpectomy was performed from an extracavitary approach, and anterior column reconstruction was completed with an expandable cage. The posterior tension band and spinal fusion was completed with segmental pedicle screw fixation and performed through the same posterior exposure. No patient required a separate anterior procedure.

RESULTS

Patients' average age was 60.3 years (range, 17-78); there were 12 women and 9 men. Eighteen underwent single-level corpectomies (11 thoracic and 7 lumbar), and 3 underwent two-level corpectomies (T4-T5, T11-T12, and T12-L1). Average estimated blood loss (EBL) and length of surgery per level were 1,360 cc (range, 200-2,500) and 5.3 hours (range, 2.7-8.6), respectively. Average postoperative stay was 4.7 days. Nine patients had at least one partial motor grade improvement. One patient had postoperative left lower extremity weakness after surgical decompression and reconstruction secondary to iatrogenic nerve root traction but remained ambulatory. No chest tubes or postoperative bracing was required. At the most recent follow-up, six patients were alive at an average of 16.1 months (range, 3-33). For the 15 patients who died, the average life span after surgery was 6.8 months (range, 1-16). In addition to the iatrogenic nerve root injury, one cage required repositioning on postoperative Day 2 and one cage demonstrated radiographic evidence of settling but did not require surgical intervention; there were no deep venous thromboses (DVTs), pneumothoraces, pneumonias, ileus, or other complications, with a total complication rate of 14.3%.

CONCLUSIONS

This is the largest study that specifically examines the use of an expandable cage through a posterior extracavitary approach for reconstruction after vertebral body tumor resection. The use of an expandable cage combined with an extracavitary approach is feasible and allows the surgeon to address both the anterior and posterior columns through a single incision. Although technically challenging, both one- and two-level corpectomies in the thoracic and/or lumbar spine can be performed with this technique. Furthermore, insertion of the expandable cage in the collapsed position and then expansion in situ after implantation allowed for all lumbar reconstructions to be completed without sacrificing any of the lumbar nerve roots. Our 14.3% complication rate is similar to those reported in anterior-alone and circumferential spinal procedures.

En bloc spondylectomy reconstructions in a biomechanical in-vitro study

Wide surgical margins make en bloc spondylectomy and stabilization a referred treatment for certain tumoral lesions. With a total resection of a vertebra, the removal of the segment's stabilizing structures is complete and the instrumentation guidelines derived from a thoracolumbar corpectomy may not apply. The influence of one or two adjacent segment instrumentation, adjunct anterior plate stabilization and vertebral body replacement (VBR) designs on post-implantational stability was investigated in an in-vitro en bloc spondylectomy model. Biomechanical in-vitro testing was performed in a six degrees of freedom spine simulator using six human thoracolumbar spinal specimens with an age at death of 64 (+/- 20) years. Following en bloc spondylectomy eight stabilization techniques were performed using long and short posterior instrumentation, two VBR systems [(1) an expandable titanium cage; (2) a connected long carbon fiber reinforced composite VBR pedicle screw system)] and an adjunct anterior plate. Test-sequences were loaded with pure moments (+/- 7.5 Nm) in the three planes of motion. Intersegmental motion was measured between Th12 and L2, using an ultrasound based analysis system. In flexion/extension, long posterior fixations showed significantly less range of motion (ROM) than the short posterior fixations. In axial rotation and extension, the ROM of short posterior fixation was equivalent or higher when compared to the intact state. There were only small, nonsignificant ROM differences between the long carbon fiber VBR and the expandable system. Antero-lateral plating stabilized short posterior fixations, but did not markedly effect long construct stability. Following thoracolumbar en bloc spondylectomy, it is the posterior fixation of more than one adjacent segment that determines stability. In contrast, short posterior fixation does not sufficiently restore stability, even with an antero-lateral plate. Expandable verses nonexpandable VBR system design does not markedly affect stability.

Palliative care in orthopaedic surgical oncology

Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.

Metastatic bone disease: a 36-year single centre trend-analysis of patients admitted to a tertiary orthopaedic surgical department

BACKGROUND AND OBJECTIVES

The treatment and outcome of primary malignant bone tumours has changed with the advances in diagnostic and treatment modalities. A trend-analysis on a large cohort of patients with metastatic bone disease was performed.

METHODS

A retrospective chart review of all cases with metastatic bone disease admitted to a single tertiary orthopaedic referral centre, registered with the Vienna Bone and Soft Tissue Tumour Registry between 1968 and 2003 was conducted. For trend-analysis of frequency, survival, primary site, treatment methods, and others, the 36-year study duration was divided into four periods.

RESULTS

The study identified 601 females and 580 males (mean: 60 years) with metastatic bone disease. The most common metastases were secondary to breast cancer (n = 275; 23%) and renal cell carcinoma (n = 242; 21%) and the majority were located in the femur (n = 332; 28%) and spine (n = 348; 29%). Overall, the proportion of patients who underwent surgery decreased. At follow-up, 887 (75%) patients were verified to have died of their disease.

CONCLUSIONS

Over the 36-year period, the frequency of bone metastases has increased at our centre. Although survival increased over time, the difference was not significant; this was most likely attributable to the seriousness of cases referred to our tertiary care centre.

Total spondylectomy of a symptomatic hemangioma of the lumbar spine

A vertebral hemangioma with dural compression and neurological deficit is rare. We report a symptomatic lumbar vertebral hemangioma which was successfully managed with total spondylectomy. The patient was a 31-year-old man whose chief complaint was low back pain. He had a slight sensory disturbance in the right thigh. Plain radiography and magnetic resonance imaging (MRI) revealed a tumor in the second lumbar vertebra, which extended into the spinal canal, compressing the dura. A percutaneous needle biopsy did not provide a pathological diagnosis. Before surgery, the arteries feeding the tumor were embolized using coils. We performed a total spondylectomy of the second lumbar vertebra with anterior reconstruction with a glass ceramic spacer and posterior instrumentation. The intraoperative pathological examination revealed a hemangioma of the lumbar spine. At the 4-year follow-up examination, the patient is completely asymptomatic without evidence of tumor recurrence.

Komplikationen bei operativer Dekompression an der tumorinfiltrierten Wirbelsäule

INTRODUCTION

This study evaluated the intra- and post-surgical complications on tumor affected spines. Complications were analyzed according to selected patient groups so that risk factors could be determined.

MATERIAL AND METHODS

Between January 1999 and December 2004, 401 patients underwent surgery because of spinal metastases in the Department of Traumatology, General Hospital St. Georg in Hamburg. Data were obtained from the hospital's documentary system. The results of this study were compared to other published studies.

RESULTS

The average age of patients was 63 years (24-88) and there were 172 (42.9%) females and 229 (57.1%) males. A total of 118 (29.4%) patients suffered from 235 complications and 22 (5.5%) died.

DISCUSSION

Patient's age >70 years, patients with a preoperative neurological deficit, and patients with heavily bleeding metastases are at high risk for complications. The dorsoventral/dorsolateral approach had the highest complication rate.

Total L-5 spondylectomy and reconstruction of the lumbosacral junction

✓The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4–5 and L5–S1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4–5 and L5–S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

Surgical results of metastatic spinal cord compression secondary to non-small cell lung cancer

STUDY DESIGN

The results for 37 surgical interventions in 31 consecutive patients with non-small cell lung cancer (NSCLC) with symptomatic spinal cord compression were reviewed retrospectively.

OBJECTIVES

To evaluate postoperative outcomes and survival rates of NSCLC patients surgically treated for symptomatic spinal metastasis.

SUMMARY OF BACKGROUND DATA

For patients with spinal cord compression secondary to lung cancer, the prognosis is usually poor. However, with the development of new chemotherapeutic drugs and targeted therapeutic agents, the survival rate may be better.

METHODS

From November 2000 to March 2005, 31 patients with symptomatic metastatic spinal cord compression secondary to NSCLC underwent palliative surgery using a posterolateral transpedicular approach (PTA) or combined posterior and anterior procedures. The indication for surgery was neurologic progression due to spinal cord compression.

RESULTS

The patients ranged in age from 20 to 81 years (mean, 61.4 years). Twenty-eight patients (90%) underwent PTA, and 3 patients had combined posterior and anterior procedures. Neurologic improvement by at least one Frankel grade was noted in 25 of 31 cases (80%). Overall, 74% of patients (23 of 31) were able to walk after surgery. There was no case of intraoperative mortality, but two deaths occurred in the postoperative period. Median survival time was 8.8 months.

CONCLUSIONS

Even though lung cancer is considered an aggressive tumor, it is justifiable to aggressively treat patients with symptomatic spinal cord compression. Surgery by PTA can lead to good results in these patients.

Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients

Aggressive surgical management of spinal metastatic disease can provide improvement of neurological function and significant pain relief. However, there is limited literature analyzing such management as is pertains to individual histopathology of the primary tumor, which may be linked to overall prognosis for the patient. In this study, clinical outcomes were reviewed for patients undergoing spinal surgery for metastatic breast cancer. Respective review was done to identify all patients with breast cancer over an eight-year period at a major cancer center and then to select those with symptomatic spinal metastatic disease who underwent spinal surgery. Pre- and postoperative pain levels (visual analog scale [VAS]), analgesic medication usage, and modified Frankel grade scores were compared on all patients who underwent surgery. Univariate and multivariate analyses were used to assess risks for complications. A total of 16,977 patients were diagnosed with breast cancer, and 479 patients (2.8%) were diagnosed with spinal metastases from breast cancer. Of these patients, 87 patients (18%) underwent 125 spinal surgeries. Of the 76 patients (87%) who were ambulatory preoperatively, the majority (98%) were still ambulatory. Of the 11 patients (13%) who were nonambulatory preoperatively, four patients were alive at 3 months postoperatively, three of which (75%) regained ambulation. The preoperative median VAS of six was significantly reduced to a median score of two at the time of discharge and at 3, 6, and 12 months postoperatively (P < 0.001 for all time points). A total of 39% of patients experienced complications; 87% were early (within 30 days of surgery), and 13% were late. Early major surgical complications were significantly greater when five or more levels were instrumented. In patients with spinal metastases specifically from breast cancer, aggressive surgical management provides significant pain relief and preservation or improvement of neurological function with an acceptably low rate of complications.

Chirurgisches Management von Wirbelsäulenmetastasen

The spine is the most frequent site of skeletal metastases. Among all spinal malignancies metastatic disease is most frequent and indicative of disseminating tumor disease. Depending on primary tumor entity, estimated survival time, general health status of the patient, presence of spinal instability and neurological deficits an oncological useful and patient-specific therapeutic intervention should be performed. New anterior approaches, resections and reconstruction techniques are making surgery a preferred method over radiation therapy. For differential indication of the multiple surgical treatment modalities prognostic scores are available to assist individual decision making. Indications for surgery include survival prognosis of minimum 3 months, intractable pain, progress of myelon compression and/or neurological deficits under radiochemotherapy, spinal instability and necessity for histological diagnosis. Resulting quality of life depends on efficient decompression of the spinal cord and restoration of spinal stability. To achieve these ultimate goals there are different anterior and posterior approaches, instrumentations and vertebral body replacement implants available. Preoperative embolization should be performed in hypervascular tumors, e.g., renal cell cancer. Vertebro-/Kyphoplasty as a percutaneous intervention should be considered for painful multisegmental disease and symptomatic osteolysis without epidural tumor compression to reach analgesia and stability. A multidisciplinary approach in patient selection, decision making and management is an essential precondition for complication avoidance and acceptable quality of life.

Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy

Primary malignant spinal tumors and solitary vertebral metastases of selected tumor entities in the thoracolumbar spine are indications for total en bloc spondylectomy (TES). This study aimed to describe our oncological and surgical management and to analyze the treatment results by management with TES for extra- and intracompartmental solitary spinal metastases and primary malignant vertebral bone tumors. In 15 patients (3 malignant bone tumors and 12 solitary metastases), tumors were distributed in the thoracic (n = 8) and lumbar (n = 7) spine. Tumors were classified as intra- (n = 8) and extracompartmental (n = 7). All patients underwent TES via a laterally extended posterior approach followed by dorsoventral reconstruction. Function and quality of life were assessed by Oswestry disability index (ODI) and SF-36 score. At follow-up (100%; mean: 33 +/- 22 months), 11 patients had no evidence of disease. Two patients were alive with the disease and two were dead of the disease (no primary bone tumors). Histology revealed negative margins (R0) in all patients with wide (n = 11) and marginal (n = 4) resections. Two patients developed pulmonal metastases of which they died at 4 and 16 months of survival. No local recurrence was observed. Major complications did not occur. TES resulted in an acceptable outcome in the quality of life and function. TES is a demanding procedure reaching wide to marginal resections in a curative approach. In conjunction with multimodal therapies, local recurrences can effectively be prevented while control of distant disease needs to be improved. Proper selection of adequate patients combined with careful surgical planning are prerequisites for low complication rates, acceptable function and improved overall prognosis.

Evaluation of the Tokuhashi prognosis score and its modifications in 217 patients with vertebral metastases

AIM

The Tokuhashi prognosis score consists of six parameters. The sum of points rated for each parameter can be correlated with the prognosis. This study evaluates the score variations that have been done by different authors and Tokuhashi et al. themselves.

METHODS

Two hundred and seventeen consecutive patients, surgically treated for vertebral metastases, were studied retrospectively. We calculated the original and modified score of Tokuhashi and evaluated the predictive value for the individual life expectancy.

RESULTS

The original and modified Tokuhashi score assured a significant predictive value. Modified criteria by the authors showed the highest reliability between the predicted and real survival, and the patients could be allocated correctly to the desirable instrumentation.

CONCLUSION

The original and modified Tokuhashi score showed a significant predictive value. The modified criteria by the authors showed the highest reliability between predicted and real survival.

Development of a model with which to predict the life expectancy of patients with spinal epidural metastasis

BACKGROUND

The surgical treatment of spinal epidural metastasis is evolving. To be a surgical candidate, a patient should have a life expectancy of at least 3 months. Estimation of survival by experienced specialists has proven to be unreliable.

METHODS

The Cox proportional hazards model was used to make a prediction model. To validate the model, Efron optimism correction by bootstrapping was performed. Retrospective data of patients treated for a spinal metastasis were used. Possible predictive factors were defined based on clinical experience and the literature. Statistical methods and clinical knowledge were also used to reveal an optimal set of predictors of survival. Data from patients treated at the Department of Radiation Oncology for spinal metastasis between 1998 and 2005 were evaluated.

RESULTS

The case notes of 219 patients form the base of this study. In the final model, only 5 variables were required to predict the survival of a patient with spinal metastasis: sex, location of the primary lesion, intentional curative treatment of the primary tumor, cervical location of the spinal metastasis, and Karnofsky performance score. Examples with different predictors are given. The R(2) (N) index of Nagelkerke was 0.36 (95% confidence interval [95% CI], 0.28-0.48) and the c-index 0.72 (95% CI, 0.68-0.77).

CONCLUSIONS

A reliable and simple model with which to predict the survival of a patient with spinal epidural metastasis is presented. Without the need for extensive investigations, survival can be predicted and only 5 easily obtainable parameters are required.

Prognosis Scores of Tokuhashi and Tomita for Patients With Spinal Metastases of Renal Cancer

BACKGROUND

Retrospective evaluation of the prognosis scores of Tokuhashi and Tomita for life expectancy in 37 consecutive patients with spinal metastases secondary to renal cancer who underwent surgery. The score of Tokuhashi, composed of six parameters, each rated from zero to two, has been proposed in 1990 for the prognostic assessment of patients with spinal metastases. In 2001, Tomita et al. created another prognostic score, composed of three parameters, growth behaviour of the primary tumor (slow, moderate and rapid) and the evidence of visceral and bony metastases.

METHODS

Thirty-seven patients, surgically treated for vertebral metastases secondary to renal cancer were studied. The scores according to Tokuhashi and Tomita were calculated for each patient.

RESULTS

Applying the Tokuhashi Score for the estimation of life expectancy of renal cancer patients with vertebral metastases was found to provide very reliable results with a statistically high significance. The analysis according to Tomita showed no correlation between predicted and real survival. The statistical analysis did not show any significance.

CONCLUSION

For surgical decisions in renal cancer patients with spinal metastases, the prognostic score of Tokuhashi appears to be much more valuable than the Tomita score.

Chirurgie et cimentoplastie dans la prise en charge des métastases osseuses

The first step for treatment of bone metastases is to confirm the diagnosis, particularly if there is only one localisation, so as to exclude a primary bone tumour. Surgery and percutaneous injection of acrylic cement are both efficient to relieve pain. Their indications and timing have to be discussed in pluridisciplinary staff. Long bones metastases have to be nailed before pathologic fracture. If there is suspicion of hypervascularisation, the lesion has to be embolized before any procedure. Treatment of spinal metastases with neurological impairment is an emergency. Paraplegia may be a consequence within a few hours. They have to be treated in an orthopedic or neurosurgery department with the experience of posterior and anterior approach of the spine. Surveillance may be useful to diagnose these metastases before neurological impairment. Depending from the type of cancer, the chemo- and radiotherapy sensibility, the number of metastases, the condition of the posterior wall of the vertebra and the general condition of the patient, different surgical treatments may be possible going from complete resection of the lesion to percutaneous injection of acrylic cement. Conventional radiotherapy is associated to surgery. Satisfactory results of such treatments justify greater involvement of orthopaedic surgery team in multidisciplinary staff.

How many ligations of bilateral segmental arteries cause ischemic spinal cord dysfunction? An experimental study using a dog model

STUDY DESIGN

Segmental arteries were interrupted bilaterally for up to 7 levels to study the effects on spinal cord blood flow and neurologic function in dogs.

OBJECTIVE

To examine how many ligations of bilateral segmental arteries cause ischemic spinal cord dysfunction.

SUMMARY OF BACKGROUND DATA

Interruption of bilateral segmental arteries for up to 3 levels has been reported not to damage spinal cord function. However, to our knowledge, the effects of ligating more than 3 levels have not yet been clearly determined.

METHODS

There were 15 dogs divided into 5 groups: sham group, no ligation; group 1, ligation of bilateral segmental arteries at 3 levels (T11-T13); group 2, at 4 levels (T10-T13); group 3, at 5 levels (T10-L1); and group 4, at 7 levels (T9-L2). Spinal cord blood flow at T12 measured by laser Doppler flowmetry, and spinal cord-evoked and motor-evoked potentials were measured simultaneously until 10 hours after ligation. Neurologic function was assessed using a modified Tarlov grading system 1 week after operation in 20 other dogs divided into 4 groups (1, 2, 3, and 4).

RESULTS

Spinal cord blood flow was 99.3%, 80.7%, 71.5%, 44.3%, and 25.0% in the sham group, and groups 1, 2, 3, and 4, respectively, 10 hours after ligation. Abnormal spinal cord-evoked potentials were observed in 2 of 3 dogs in group 3 and all 3 in group 4. Abnormal motor-evoked potentials were observed in 1 of 3 dogs in group 3 and all 3 in group 4. Postoperative neurologic evaluation identified all 5 dogs in groups 1 and 2, respectively, and 3 in group 3 as having grade 5. There were 2 dogs in group 3 and 3 in group 4 that had grade 4, and 2 in group 4 had grade 3.

CONCLUSION

Interruption of bilateral segmental arteries at > or =5 consecutive levels risks producing a spinal cord ischemia capable of injuring the spinal cord.

Primary Ewing’s sarcoma of the spine: case report

Primary malignant sarcomas of the spine are extremely rare. Because of biological heterogeneity, these tumors have variable sensitivity to radiation and chemotherapy. Adequate local control through complete tumor removal is an important therapeutic goal. However, aggressive resection of tumors in the spinal column must be coupled with restoration of spinal column stability and minimization of neural deficits. The balance of these factors makes treatment of primary sarcomas of the spine challenging, and dictates an individual approach to treatment. We report on a 18 years old man with primary Ewing's sarcoma of the nonsacral spine. The clinical picture and imaging characteristics were analyzed as well as the management modalities and outcome.

Prognostic factors for patients with spinal metastases from lung cancer

STUDY DESIGN

We conducted a retrospective study to identify prognostic factors of patients with spinal metastases from lung cancer.

OBJECTIVE

To provide clinical data with strong association to the prognosis and to propose criteria determining indication of operation for spinal metastases.

SUMMARY OF BACKGROUND DATA

To make a proper selection of patients for whom surgery is indicated, forecasting short-time survival after spinal metastases is very important. In the past, there has been no report of prognostic factors of patients with such metastases from this cancer.

METHODS

This study included 114 patients with spinal metastases of lung cancer. Tumors were histologically categorized as non-small cell lung cancer (NSCLC) in 94 patients and small cell lung cancer (SCLC) in 20 patients. We investigated prognostic factors after spinal metastases using Cox comparative hazard model and a preoperative prognostic score proposed by Tokuhashi. We also investigated the patients who underwent operation for spinal metastases from lung cancer in our hospital.

RESULTS

Multivariate analysis showed that the significant prognostic factors for survival after spinal metastases from NSCLC were performance status (PS), Ca, Alb. Among SCLC patients, Ca, Alb, and a history of chemotherapy were significant (P < 0.05) in univariate analysis. The score of Tokuhashi was not correlative to the survival period. Among the operated patients, postoperative PS was significant for the period of postoperative survival.

CONCLUSION

PS, Ca, and Alb in NSCLC and Ca, Alb, and a history of chemotherapy in SCLC are useful for determining an indication of operation for spinal metastases from lung cancer.

Clinical profile of long-term survivors of breast or thyroid cancer with metastatic spinal tumours

Patients with breast or thyroid cancer with metastatic spinal tumours are expected to survive relatively longer than patients with other cancers with metastatic spinal tumours. The purpose of this study was to determine the clinical characteristics of long-term survivors of breast or thyroid cancer with metastatic spinal tumours. We studied the clinical profile of long-term survivors by comparing the characteristics of nine patients who had survived for at least 5 years after a spinal operation with the characteristics of 16 patients who had not. Our results showed that the longer the time from the diagnosis of the primary cancer to the spinal operation, the longer patients with breast or thyroid cancer and metastatic spinal tumours would survive. Six of the eight patients (75.0%) who had undergone the spinal operation at least 5 years after the diagnosis of the primary cancer survived especially long. In conclusion, the duration from the diagnosis of the primary cancer to the spinal operation is very useful for predicting a prognosis in patients with breast or thyroid cancer and metastatic spinal tumours.

Surgical management of metastatic spine tumors

Recent advances in diagnostic tests and radiologic imaging, and the development of novel chemotherapeutic agents and radiation methods have greatly altered the treatment options in patients who have spinal tumors. Improvements in fundamental understanding of the mechanisms of bone metastases, developments in spinal instrumentation, and recent introduction of recombinant bone morphogenetic proteins for spinal reconstruction offer promising strategies in selected patients. Clear applications of the fundamental surgical oncology still apply to spinal tumors. This article considers recent advances in management of the metastatic tumors to the spine.

Metastatic meningioma to the eleventh dorsal vertebral body: total en bloc spondylectomy. Case report and review of the literature

INTRODUCTION

One in every thousand intracranial meningiomas metastatize extracranially. Lung and intraabdominal organs are most frequently affected. Only 7% involve vertebrae and just a dozen cases have been reported in the literature. To our knowledge, this is the first description of a total en bloc spondylectomy through a posterior approach for the treatment of an intraosseous metastatic meningioma to the eleventh dorsal vertebra.

CASE REPORT

In March 1996, a 37 year-old male underwent surgical resection for a left occipital intraventricular benign meningioma (WHO I). He was reoperated in February 2002 due to local recurrence. By the end on 2003 he developed progressively invalidating dorsolumbar pain. MRI studies revealed a T11 intraosseous mass. In March 2004, a percutaneous biopsy and vertebroplasty were performed. The pathological specimen was identified as adenocarcinoma and he initiated chemotherapy. Advice from a second pathologist was seeked, who suggested the diagnosis of intraosseous meningioma. Workup studies failed to reveal any primary tumor. In May 2004 the patient was admitted to our department and a new transpedicular biopsy confirmed the diagnosis. In June 2004 he underwent T11 total en bloc spondylectomy (Tomita's procedure), fusion with bone and calcium substitute-filled stackable carbon-fiber cages, and T9 to L1 transpedicular screw fixation. No postoperative complications ocurred and he is, so far, free from primary and secondary disease. Definite pathology: benign meningioma (WHO I).

DISCUSSION

Distant metastases from intracranial meningiomas are rare entities, arising from benign lesions in, at least, 60% of cases. Enam et al proposed a specific pathological score to differentiate benign, atypic and malignant meningiomas. Such score correlates with the chance of metastatizing: more than 40% in malignant meningiomas compared to 3.8% of brain tumors overall. The ability to metastatize seems to be linked to vascular or lifatic invasiveness. Metastases ocurr more frequently in angioblastic, papillary and meningothelial variants. Hematogenous (especially venous; Batson's perivertebral plexus), linfatic and cerebrospinal fluid are the main routes involved in the spreading of the tumor. Craniotomy itself may also play a role, for the majority of patients have been previously operated on repeatedly. The interval between the onset of the intracranial disease and the appearance of the metastasis varies from months to many years. The value of transpedicular biopsy is widely recognized (efficacy over 80%) and the suitability of the specimen for pathological examination improves when wide inner caliber trephines are used. In the case presented we applied the oncologic concept of vertebral en bloc resection. We believe this case represents a paradigmatic indication of this technique because it respects the concepts of radical resection and spinal stability, and offers an opportunity for the curation of the disease.