Surgical strategy for spinal metastases

Interdisciplinary clinical evaluation of 58 patients with lumbar-vertebral metastases from cervico-uterine cancer

INTRODUCTION

Metastases in the vertebrae of patients with cervical cancer (CeCa) can be difficult to diagnose, and the treatment is palliative in many cases.

OBJECTIVES

The aim of this study was to assess the ti-me required for diagnosis, the lesion's locoregional extent and the therapeutic schemes applied, in a retrospective series of 58 patients with CeCa and with lumbar spinal metastases.

METHODS

The cases were studied using an updated interdisciplinary analysis to determine the clinical and radiological variables. This study evaluated the site and extent of bone lesions and correlated these variables with instability of the spine and cord compression.

RESULTS

The diagnosis of vertebrae metastases of Ce-Ca required more than 3 months in most cases. Lumbar vertebrae L4 and L5 and specifically the vertebral body were the most-frequently affected si-tes. Systemic and/or extra-compartmental-extended metastases (MosV4) were observed in 44/58 patients. Radiotherapy was the only option in this group and the palliative effect achieved was minimal, or null. In 14/58 patients there was intra compartmental-extended (MosV2) and extra-compartmental limited (MosV3) single vertebral metastases and the 3 different treatment schemes were administered. In the cases treated with marginal resection of metastases, vertebroplasty plus adjuvant radiotherapy achieved significant palliative effect.

CONCLUSIONS

In the present series of patients, the diagnosis of metastases of the lumbar vertebrae was late, and the disease was advanced. The results obtained with radiotherapy in advanced stage disease did not improve the quality of life of patients. Metastasectomy was the therapeutic scheme in cases with intermediate stage disease and was the basis of the integrated treatment We believe that it is necessary to shorten the diagnostic time and to apply a staging system for vertebral metastases so that appropriate individualised selection of interdisciplinary treatment would be facilitated.

Metastasis to nervous system: spinal epidural and intramedullary metastases

Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer with an increasing incidence. Prostate, breast and lung cancer are the most common offenders. Metastasis usually arises in the posterior aspect of vertebral body with later invasion of epidural space. Pathophysiologically, vascular insufficiency is more important than direct spinal cord compression. The most common complaint is pain, and two thirds of patients with SEM have motor signs at initial diagnosis. Currently magnetic resonance imaging is the most sensitive diagnostic tool. The optimal management of SEM is still arguable, but recent advances in surgical management of SEM and higher complication rate of surgery following radiotherapy should persuade clinicians to consider de novo surgery where possible. Radiotherapy has an important role, particularly in treatment of radiosensitive tumors and in patients who are not candidates for surgery. Novel approaches such as stereotactic radiosurgery are promising; however, response to chemotherapy depends on inherent properties of primary tumor. Recurrent SEM is a substantial problem for which surgery or repeat radiotherapy may be options. Intramedullary metastasis is rare but should be considered in patients with systemic malignancy and asymmetrical presentation of myelopathic symptoms. The prognosis is usually poor and preferred modality of treatment is radiotherapy.

The transmission of stress to grafted bone inside a titanium mesh cage used in anterior column reconstruction after total spondylectomy: a finite-element analysis

STUDY DESIGN

A finite-element study of posterior alone or anterior/posterior combined instrumentation following total spondylectomy and replacement with a titanium mesh cage used as an anterior strut.

OBJECTIVES

To compare the effect of posterior instrumentation versus anterior/posterior instrumentation on transmission of the stress to grafted bone inside a titanium mesh cage following total spondylectomy.

SUMMARY OF BACKGROUND DATA

The most recent reconstruction techniques following total spondylectomy for malignant spinal tumor include a titanium mesh cage filled with autologous bone as an anterior strut. The need for additional anterior instrumentation with posterior pedicle screws and rods is controversial. Transmission of the mechanical stress to grafted bone inside a titanium mesh cage is important for fusion and remodeling. To our knowledge, there are no published reports comparing the load-sharing properties of the different reconstruction methods following total spondylectomy.

METHODS

A 3-dimensional finite-element model of the reconstructed spine (T10-L4) following total spondylectomy at T12 was constructed. A Harms titanium mesh cage (DePuy Spine, Raynham, MA) was positioned as an anterior replacement, and 3 types of the reconstruction methods were compared: (1) multilevel posterior instrumentation (MPI) (i.e., posterior pedicle screws and rods at T10-L2 without anterior instrumentation); (2) MPI with anterior instrumentation (MPAI) (i.e., MPAI [Kaneda SR; DePuy Spine] at T11-L1); and (3) short posterior and anterior instrumentation (SPAI) (i.e., posterior pedicle screws and rods with anterior instrumentation at T11-L1). The mechanical energy stress distribution exerted inside the titanium mesh cage was evaluated and compared by finite-element analysis for the 3 different reconstruction methods. Simulated forces were applied to give axial compression, flexion, extension, and lateral bending.

RESULTS

In flexion mode, the energy stress distribution in MPI was higher than 3.0 x 10 MPa in 73.0% of the total volume inside the titanium mesh cage, while 38.0% in MPAI, and 43.3% in SPAI. In axial compression and extension modes, there were no remarkable differences for each reconstruction method. In left-bending mode, there was little stress energy in the cancellous bone inside the titanium mesh cage in MPAI and SPAI.

CONCLUSIONS

This experiment shows that from the viewpoint of stress shielding, the reconstruction method, using additional anterior instrumentation with posterior pedicle screws (MPAI and SPAI), stress shields the cancellous bone inside the titanium mesh cage to a higher degree than does the system using posterior pedicle screw fixation alone (MPI). Thus, a reconstruction method with no anterior fixation should be better at allowing stress for remodeling of the bone graft inside the titanium mesh cage.

Influence on spinal cord blood flow and function by interruption of bilateral segmental arteries at up to three levels: experimental study in dogs

STUDY DESIGN

Segmental arteries were interrupted bilaterally at up to three levels to study the influence on spinal cord blood flow (SCBF) and function in dogs.

OBJECTIVES

Considering the need to limit blood loss during surgery for spinal tumors, such as total en bloc spondylectomy, we studied the SCBF and function after experimental interruption of segmental arteries at up to three levels.

SUMMARY OF BACKGROUND DATA

Interruption of bilateral segmental arteries at three consecutive levels (T11, T12, and T13) has reduced blood flow to the vertebral body of T12 by one fourth of the control flow, but effects on the spinal cord have not been determined.

METHODS

SCBF was measured in spinal cord gray matter at T12 using a hydrogen clearance method after ligation of bilateral segmental arteries at 1 to three levels (T11, T12, and T13) in 6 dogs. Spinal cord function was evaluated by spinal cord evoked potentials, motor-evoked potentials, and neurologic assessment in 6 dogs.

RESULTS

SCBF at T12 decreased to 92.4%, 87.8%, and 84.6% of control flow after ligation of bilateral segmental arteries at T12, T11 plus T12, and T11-T13, respectively. Spinal cord evoked potentials and motor-evoked potentials showed no significant changes in any dog after ligation at three levels. No neurologic degradation was observed in any dog.

CONCLUSIONS

Interruption of bilateral segmental arteries at three levels did not damage spinal cord function in dogs, suggesting that in patients, preoperative embolization at three levels to reduce blood loss during surgery for spinal tumors would not compromise spinal cord function.

The Tokuhashi score: significant predictive value for the life expectancy of patients with breast cancer with spinal metastases

STUDY DESIGN

Retrospective study of 55 consecutive patients with spinal metastases secondary to breast cancer who underwent surgery.

OBJECTIVE

To evaluate the predictive value of the Tokuhashi score for life expectancy in patients with breast cancer with spinal metastases.

SUMMARY OF BACKGROUND DATA

The score, composed of 6 parameters each rated from 0 to 2, has been proposed by Tokuhashi and colleagues for the prognostic assessment of patients with spinal metastases.

METHODS

A total of 55 patients surgically treated for vertebral metastases secondary to breast cancer were studied. The score was calculated for each patient and, according to Tokuhashi, the patients were divided into 3 groups with different life expectancy according to their total number of scoring points. In a second step, the grouping for prognosis was modified to get a better correlation of the predicted and definitive survival.

RESULTS

Applying the Tokuhashi score for the estimation of life expectancy of patients with breast cancer with vertebral metastases provided very reliable results. However, the original analysis by Tokuhashi showed a limited correlation between predicted and real survival for each prognostic group. Therefore, our patients were divided into modified prognostic groups regarding their total number of scoring points, leading to a higher significance of the predicted prognosis in each group (P < 0.0001), and a better correlation of the predicted and real survival.

CONCLUSION

The modified Tokuhashi score assists in decision making based on reliable estimators of life expectancy in patients with spinal metastases secondary to breast cancer.

A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis

STUDY DESIGN

A semi-prospective clinical study was conducted.

OBJECTIVES

To evaluate the accuracy of a revised scoring system predicting metastatic spinal tumor prognosis and the suitability of the subsequent treatment strategy.

SUMMARY OF THE BACKGROUND DATA

We used a scoring system for the preoperative evaluation of the prognosis of metastatic spinal tumors and selected treatment methods for the predicted prognosis. In the previous version of our scoring system, the reliability of the predicting prognosis was 63.3% in 128 patients with metastatic spinal tumors.

METHODS

The study participants were 164 patients who died after surgery and 82 who died after conservative treatment. Six parameters were used in the revised scoring system. Each parameter ranged from 0 to 5 points, and the total score was 15 points. In principle, conservative treatment or palliative procedures were indicated in patients with a total score of 8 or less (predicted survival period, less than 6 months) or those with multiple vertebral metastases, while excisional procedures were performed in patients with a total score of 12 or more (predicted survival period, 1 year or more) or those with a total score of 9 to 11 (predicted survival period, 6 months or more) and with metastasis in a single vertebra. The selection of treatment modality was followed faithfully according to the criteria of the revised scoring system after 1998. The prognosis predicted by the revised scoring system and the actual survival period after treatment were compared, and the reliability of the prognostic criteria was analyzed for the group subjected to it prospectively after 1998 (n = 118) and for all 246 patients it was applied to retrospectively.

RESULTS

The total score for each patient could be correlated with the survival period. This correlation was also observed in each treatment group. The consistency rate between the predicted prognosis from the criteria of the total scores and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 86.4% in the 118 patients evaluated prospectively after 1998, and 82.5% in the 246 patients evaluated retrospectively. Furthermore, a similar result was also observed in both the surgical procedure group and conservative treatment group. The rate of consistency between the predicted prognosis and the actual survival period in each local extension of the lesion was 75% or more in all types, excluding Type 6 in the surgical classification of Tomita et al.

CONCLUSION

The prognostic criteria using the total scores from our revised scoring system were useful for the pretreatment evaluation of metastatic spinal tumor prognosis irrespective of treatment modality or local extension of the lesion.

Function and health status in surgically treated bone metastases

In a prospective study, we evaluated if surgery substantially improved functional and quality of life outcomes in patients with nonspinal bone metastases. Sixty-seven patients were followed up prospectively. The Short Form-36, the Musculoskeletal Tumor Society 1987 form, the Musculoskeletal Tumor Society 1993 form, and the Toronto Extremity Salvage Score were administered preoperatively and 6 weeks and 3 months postoperatively. Fifty percent of the patients had pathologic fractures. Intramedullary nailing was done in 36 patients, prosthetic replacement was done in 24 patients, and plating was done in five patients. The average postoperative survival was 8 months. At 6 weeks, 13 patients had died and seven were lost to followup. Twenty-one percent of patients had complications, although only 4.5% needed additional surgery. The patients' Musculoskeletal Tumor Society 1987 form, Musculoskeletal Tumor Society 1993 form, and Toronto Extremity Salvage Score scores improved at 6 weeks and 3 months postoperatively. There were no improvements in the Short Form-36 mental and physical summary scales of the patients. The number of patients using pain medication did not decrease. Patients had functional improvements after surgical treatment of bone metastases, even patients with a limited life expectancy. Future prospective studies should anticipate a high rate of attrition with this population from death and loss to followup.

LEVEL OF EVIDENCE

Prognostic study, Level I (high quality prospective study-all patients were enrolled at the same point in their disease with > or = 80% followup of enrolled patients). See the Guidelines for Authors for a complete description of levels of evidence.

Prognostic relevance of clinical symptoms in patients with spinal metastases

Medical and surgical advances allow surgical treatment of many patients with spinal metastases. Although emerging surgical techniques facilitate stabilization of the collapsed spine, surgical candidates should be carefully selected. However, the lack of confirmed criteria to determine survival of these patients makes selection for surgery difficult. Clinical symptoms have been considered possible factors associated with prognosis, but their relevance has not been confirmed because of inadequate power for proper statistical analysis. We retrospectively reviewed 165 patients who had surgery for spinal metastases from various cancers. Clinical symptoms including pain, paresis, and walking status were recorded. Multivariate analysis indicated that the histologic type of the primary tumor was the strongest prognostic factor, followed by preoperative paresis and pain. Myeloma, thyroid cancer, renal cell cancer, breast cancer, and prostate cancer had better prognoses than other kinds of cancer. Patients without paresis before surgery had a better prognosis than patients with paresis, and patients with no pain before surgery had a better prognosis than those with pain. Preoperative walking status was not an independent prognostic factor.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Surgical management of spinal metastases: analysis of prognostic factors during a 10-year experience

OBJECT

Refinement of surgical techniques, especially anterior approaches, for the management of spinal metastases has improved patient outcomes, despite the fact that a complete analysis of the prognostic factors that would inform patient selection has not been undertaken. The authors sought to identify such prognostic factors for neurological outcome and life expectancy in patients with spinal metastases.

METHODS

The authors used Kaplan-Meier techniques, log-rank comparisons, and a multivariate model stratified by tumor type to identify prognostic factors for duration of ability to walk and survival in patients who underwent surgical treatment for spinal metastases during a decade when all current treatment options were available. Preoperatively, 53 (87%) of the 61 patients in the study population suffered neurological symptoms (for example, weakness) and 52 (85%) were ambulatory. Postoperatively, 59 (97%) were ambulatory. Most patients who survived 6 months (81%) remained ambulatory, as did 66% of those alive at 1.6 years. The median postoperative survival was 10 months. The risk factors for loss of ambulation were preoperative loss of ambulatory ability, recurrent or persistent disease after primary radiotherapy of the operative site, a procedure other than corpectomy, and tumor type other than breast cancer. Prognostic factors for reduced survival were surgical intervention extending over two or more spinal segments, recurrent or persistent disease after primary radiotherapy involving the operative site, diagnosis other than breast cancer, and a cervical spinal procedure.

CONCLUSIONS

The results of this analysis allowed the authors to create a simple prognostic factor scoring system that can be applied to individual patients. The positive experience derived from this study supports an expanded role for the surgical treatment of metastatic spinal disease.

Metastatic spinal cord syndromes: imaging appearances and treatment planning

Metastatic spinal cord syndromes usually result from neural compression by adjacent vertebral disease but are occasionally caused by intradural or intramedullary disease. MRI is the most accurate method for evaluation of such syndromes. Knowledge of the relevant imaging appearances and therapeutic options enables the radiologist to make an accurate assessment of the extent of disease and contribute information relevant to treatment planning.

Surgical management of metastatic disease of the lumbar spine: experience with 139 patients

Object. The surgical treatment of metastatic spinal tumors is an essential component of the comprehensive care of cancer patients. In most large series investigators have focused on the treatment of thoracic lesions because 70% of cases involve this region. The lumbar spine is less frequently involved (20% cases), and it is unclear whether its unique anatomical and biomechanical features affect surgery-related outcomes. The authors present a retrospective study of a large series of patients with lumbar metastatic lesions, assessing neurological and pain outcomes, complications, and survival.

Methods. The authors retrospectively reviewed data obtained in 139 patients who underwent 166 surgical procedures for lumbar metastatic disease between August 1994 and April 2001. The impact of operative approach on outcomes was also analyzed.

Among the wide variety of metastatic lesions, pain was the most common presenting symptom (96%), including local pain, radicular pain, and axial pain due to instability. Patients underwent anterior, posterior, and combined approaches depending on the anatomical distribution of disease. One month after surgery, complete or partial improvement in pain was demonstrated in 94% of the cases. The median survival duration for the entire population was 14.8 months.

Conclusions. The surgical treatment of metastatic lesions in the lumbar spine improved neurological and ambulatory function, significantly reducing axial spinal pain; results were comparable with those for other spinal regions. Analysis of results obtained in the present study suggests that outcomes are similar when the operative approach mirrors the anatomical distribution of disease. When lumbar vertebrectomy is necessary, however, anterior approaches minimize blood loss and wound-related complications.

Prognostic factors and a scoring system for patients with skeletal metastasis

Between 1992 and 1999, we treated 350 patients with skeletal metastases. A multivariable analysis of the patients was conducted using the Cox proportional hazards model. We identified five significant prognostic factors for survival, namely, the site of the primary lesion, the performance status (Eastern Cooperative Oncology Group status 3 or 4), the presence of visceral or cerebral metastases, any previous chemotherapy, and multiple skeletal metastases. The score for each significant factor was derived from the corresponding estimated regression coefficients (natural logarithm of the hazard ratio). The prognostic score was calculated by adding all the scores for individual factors.

The rate of survival was 31% at six months and 11% at one year for the patients with a prognostic score of 6 or more. By contrast, patients with a prognostic score of 2 or less had a rate of survival of 98% at six months and 89% at one year. This scoring system can be used to determine the optimal treatment for patients with pathological fractures or epidural compression.

Multilevel en bloc spondylectomy and chest wall excision via a simultaneous anterior and posterior approach for Ewing sarcoma

STUDY DESIGN

A case study of a patient with Ewing sarcoma of T8 and T9 with paravertebral and chest wall involvement, who underwent neoadjuvant chemotherapy and subsequent multilevel en bloc spondylectomy and chest wall excision using a simultaneous anterior and posterior approach.

OBJECTIVE

To show the feasibility of treating Ewing sarcoma of the thoracic spine with paravertebral and chest wall extension by multiagent chemotherapy followed by a multilevel en bloc spondylectomy and chest wall excision using a simultaneous anterior and posterior approach.

SUMMARY OF BACKGROUND DATA

Ewing sarcoma is a primary malignant bone tumor that occasionally involves the spinal column. Most patients with Ewing sarcoma of the spine are treated with systemic chemotherapy followed by definitive local control. Radiation therapy is the usual mode of local control in these patients because the spinal column has historically been considered a surgically inaccessible site where wide surgical margins are difficult to obtain. However, en bloc spondylectomy techniques have been described that can probably further decrease the risk of local recurrence, thereby minimizing or even eliminating the need for radiation therapy. To our knowledge, a combined en bloc spondylectomy and chest wall excision in a patient with Ewing sarcoma in the spine has not been previously reported.

METHODS

Neoadjuvant chemotherapy consisting of vincristine, doxorubicin, and cyclophosphamide was administered. After completion of the chemotherapy, an en bloc spondylectomy of T8 and T9 with removal of the chest wall was achieved using a simultaneous anterior and posterior approach to the spine. A stackable carbon fiber cage filled with autograft and allograft bone was inserted between T7 and T10. The spine was stabilized with anterior and posterior instrumentation. The chest wall was reconstructed with contoured polymethylmethacrylate and polypropylene (Marlex, Textile Development Associates, Inc., Franklin Square, NY) mesh.

RESULTS

The patient maintained normal neurologic function, and pain was lessened. The margins were free of tumor, and tumor necrosis was 100%. After surgery, radiotherapy was not administered. No local tumor recurrence or distant metastases were evident at the last follow-up. Balance in the coronal and sagittal planes was maintained. The patient has returned to work and resumed normal activities of daily living.

CONCLUSIONS

Multilevel en bloc spondylectomy and chest wall excision performed using a simultaneous anterior and posterior approach is a safe and effective technique that may be used to achieve adequate margins in select patients with malignant tumors involving the thoracic spine and chest wall. This technique can eliminate the need for radiation therapy in patients with Ewing sarcoma and probably decreases the risk of local recurrence compared with radiation therapy alone.

Ewing's sarcoma of the mobile spine

STUDY DESIGN

A retrospective analysis was performed.

OBJECTIVES

To determine the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic multiagent chemotherapy combined with radiation therapy for definitive local control.

SUMMARY OF BACKGROUND DATA

To our knowledge, there are no studies that evaluate the oncological outcome of patients with nonmetastatic Ewing's sarcoma of the mobile spine treated with systemic chemotherapy and radiation therapy for definitive local control.

METHODS

Thirteen patients with nonmetastatic Ewing's sarcoma of the mobile spine were treated with high-dose multiagent chemotherapy combined with radiation therapy for definitive local control from 1971 to 2000 at a single institution. Patients were observed for a minimum of 2 years or until death. Neurological function, local recurrence, distant relapse, and treatment-related complications were evaluated.

RESULTS

There were 8 females and 5 males with a mean age of 19 years (ranging from 7-26 years). The mean follow-up time was 65 months (median 28 months; ranging from 2 to 218 months). All patients presented with pain. Motor deficits were present in 6 patients. Ten patients had a decompressive laminectomy. Improved pain control, as determined by narcotic use, was noted in 12 (92%) patients. Ten patients maintained or improved motor function by at least 1 Frankel grade, while 3 had deterioration of motor function. The disease-free survival rate was 49% and 36% at 5 and 10 years. Five (38%) patients were free of disease at last follow-up. Seven patients developed metastatic disease. Three (23%) patients developed a local recurrence. One of these patients had paraplegia associated with the local recurrence. Five patients developed 8 treatment-related complications. Four of the 10 (40%) patients that had a laminectomy developed progressive kyphosis. Two of these patients also developed late-onset cauda equina syndrome along with the deformity. One of these patients also developed cardiomyopathy associated with adriamycin cardiotoxicity. One patient developed a nonhealing pressure ulcerover a prominent spinous process.

CONCLUSIONS

The current study provides historical data on a relatively homogeneous group of patients withEwing's sarcoma of the mobile spine treated with multiagent chemotherapy combined with radiation therapy for definitive local control. Systemic chemotherapy combined with current spinal resection and reconstruction techniques may lead to improved oncological and clinical outcomes.

Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases

We present survival, neurological function, and complications in a consecutive series of 282 patients operated for spinal metastases from January 1990 to December 2001. Our main surgical indication throughout this time period was neurological deficit rather than pain. Metastases from cancer of the prostate accounted for 40%, breast 15%, kidney 8%, and lung 7%. In 78% the level of decompression was thoracic and lumbar in 22%. Thirteen percent had a single metastases only, 64% had multiple skeletal metastases, and 23% had non-skeletal metastases also. Preoperatively 64% were non-walkers (Frankel A-C), 30% could walk with aids (Frankel D) and 8% had normal motor function (Frankel E). Posterior decompression and stabilization was applied in 212 patients, 47 had laminectomy only, and 23 had anterior decompressions and reconstruction. Complications were recorded at a level of 20%, and systemic complications were often associated with early death. The survival rate was 0.63 at 3 months, 0.47 at 6 months, 0.30 at 1 year, and 0.16 at 2 years. Twelve of 255 (5%) patients with motor deficits were worsened postoperatively, whereas 179 (70%) improved at least one Frankel grade. The ability to walk postoperatively was retained during follow-up in more than 80% of the patients. This study shows that important improvement of function can be gained by surgical treatment, but the complication rate was high and many patients died of their disease within the first months of surgery.

Use of "MAPs" for determining the optimal surgical approach to metastatic disease of the thoracolumbar spine: anterior, posterior, or combined. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

The surgical treatment of thoracolumbar metastases is controversial, and various approaches have been described. No single approach, however, is always applicable, and the optimal surgical strategy for any individual is determined by several interrelated factors. The authors have grouped these factors into four preoperative planning considerations that form the mnemonic "MAPS": 1) method of resection; 2) anatomy of spinal disease; 3) patient's level of fitness; and 4) stabilization. The choice of approach is also considered in light of the goals of surgery, including the relief of pain, neurological palliation, spinal stabilization, and oncological control.

Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy

BACKGROUND

Adequate prediction of survival is important in deciding on treatment for patients with symptomatic spinal metastases. The authors reviewed 342 patients with painful spinal metastases without neurologic impairment who were treated conservatively within a large, prospectively randomized radiotherapy trial. Response to radiotherapy and prognostic factors for survival were studied.

METHODS

The data base of the Dutch Bone Metastasis Study was used. Response to treatment and prognostic factors for overall survival (OS) were studied using a Cox regression model. A scoring system was developed to predict OS.

RESULTS

Responses were noted in 73% of patients. In 3% of patients, spinal cord compression was reported a mean of 3.5 months after randomization. The median OS was 7 months, and significant predictors for survival were Karnofsky performance score, primary tumor (multivariate analysis; both P < 0.001), and the absence of visceral metastases (multivariate analysis; P = 0.02). A scoring system based on these predictors was developed, and 34% of patients were in Group A (median OS = 3.0 months), 48% of patients were in Group B (median OS = 9.0 months), and 18% of patients were in Group C (median OS = 18.7 months). Group C was comprised of patients with breast carcinoma, a good performance, and no visceral metastases.

CONCLUSIONS

Most patients with spinal metastases have a limited life expectancy and should be treated with caution regarding surgical procedures. Radiotherapy is a safe and effective, noninvasive treatment modality for pain. The new scoring system will enable physicians to select patients who may survive long enough to benefit from more radical treatment.

Anterior approaches for thoracolumbar metastatic spine tumors

The management of patients with metastatic disease of the thoracolumbar spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tumor type, anticipated radio-sensitivity, tumor location, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Although no single approach is always applicable, anterior approaches provide several advantages, including minimal removal of uninvolved bone, rapid extirpation of the tumor, improved hemostasis, effective reconstruction of the weight-bearing anterior column, short-segment fixation,and improved wound healing. Wider acceptance and judicious use of current surgical techniques for metastatic spine disease may improve the quality of life of patients too often denied such treatment.

Transmandible approach for the treatment of upper cervical spine metastatic tumors

The transmandible tongue-splitting approach is a useful and safe procedure for treating secondary lesions of the upper cervical spine, with only minor cosmetic and functional impairment. This method requires a team approach and has the advantage of enhancing the surgical exposure, thus allowing for resection and stabilization on more levels. Two patients with metastases in the upper cervical spine were treated using this approach. In view of a relatively long life expectancy, a marginal resection was performed. The residual instability required a combined approach and internal fixation. Both patients were ambulant, neurologically intact, and pain free 24 and 26 months postoperatively.

Evolution of treatment for metastatic spine disease

The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.

Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients

Object. Patients with metastatic spine tumors often have multicolumn involvement and high-grade epidural compression, requiring circumferential decompression and instrumentation. Secondary medical and oncological issues add morbidity to combined approaches. The authors present their experience in using the single-stage posterolateral transpedicular approach (PTA) to decompress the spine circumferentially and to place instrumentation.

Methods. From September 1997 to February 2004, 140 patients with spine metastases underwent the PTA. Magnetic resonance imaging revealed high-grade spinal cord compression in 120 patients (86%) and lytic vertebral body destruction in all patients. Preoperatively 84 patients (60%) received radiotherapy directed to the involved level and 42 (30%) underwent tumor embolization. Following circumferential decompression, all patients underwent anterior reconstruction with polymethylmethacrylate and Steinmann pins, and posterior segmental fixation.

The median operative time was 5.1 hours, the median blood loss was 1500 ml, and the median hospital stay was 9 days. Ninety-six percent of the patients experienced postoperative pain improvement and improvement in or stabilization of neurological status. In 51 nonambulatory patients with poor Eastern Cooperative Oncology Group grades, 75% regained the ability to walk. One month postoperatively 90% of patients achieved good-to-excellent performance scores.

The overall median patient survival time was 7.7 months. Patients with colon and lung carcinomas had significantly shorter survival times. Major operative complications occurred in 20 patients (14.3%). Wound complications occurred in 16 patients (11.4%), but this was not correlated with preoperative radiation treatment.

Conclusions. The PTA allows circumferential epidural tumor decompression and the placement of anterior and posterior spinal column instrumention. Immediate spinal stability is achieved without the use of brace therapy. This technique achieved a high success rate for pain palliation, neurological preservation, and functional improvement, while avoiding the morbidity associated with combined approaches.

[Vertebral body replacement in spine surgery]

Autografts and allogeneous bone grafts as well as cages are used for the reconstruction of the anterior column after corpectomy. Recently, expandable cages for vertebral body replacement have been developed. Based on our own experience, the purpose of this study was to summarize the available biomechanical and clinical data of expandable corpectomy cages and to compare it with established fixation techniques. If used correctly, expandable cages offer several surgical advantages in comparison to non-expandable cages. However there were no significant differences between the biomechanical properties of expandable and non-expandable cages. Additionally, design variations of expandable corpectomy cages did not show any significant impact on the biomechanical stability. Currently available mid-term clinical and radiological data on the treatment of fractures, metastasis and infection of the cervical, thoracic and lumbar spine demonstrated no significant difference between expandable and non-expandable cages. However, the increased stress-shielding effect of expandable cages compared to non-expandable cages might result in a deterioration of the long-term clinical outcome.

Epidural spinal cord compression

Epidural spinal cord compression is a neurologic emergency requiring immediate attention. The therapy instituted depends on several factors, including the patient's condition at the time of presentation, the nature of the underlying malignancy, the extent of systemic disease burden, and patient prognosis. The most essential aspect of treatment is the establishment of the diagnosis. If one suspects malignant cord compression an emergency, magnetic resonance imaging of the entire spinal axis is indicated. If magnetic resonance imaging is unavailable, post-myelographic computed tomography is an alternative. However, treatment should not be delayed until imaging is performed, particularly if neurologic deficits are present. Pain should be adequately addressed and opioids administered if necessary. Steroids should be given. If significant neurologic deficits are present, a high-dose corticosteroid bolus, followed by standing doses, should be given. However, if pain is the predominant symptom, steroids can be withheld pending immediate imaging or lower doses can be given without a bolus. Neurosurgical consultation should be obtained, and surgery should be considered if the patient's condition permits. This is particularly true if spinal instability or significant kyphosis is present or compression is secondary to bony fragments. Other indications include patients with limited systemic disease burden in whom better survival is predicted and possibly those with radioresistant tumors. The type of surgery performed should be tailored to the distribution of disease within the spine and accessibility through anterior body cavities. Radiation therapy, an effective noninvasive treatment that can be delivered quickly and safely, is an appropriate option as well. This is particularly true in radio-responsive tumors, such as myeloma and lymphoma, in which surgery may be avoided entirely. Chemotherapy may play a role as adjuvant therapy in some tumors.

Anterior spinal arthrodesis with structural cortical allografts and instrumentation for spine tumor surgery

STUDY DESIGN

The authors report on anterior vertebral reconstruction following tumor resection with use of fresh-frozen, cortical, long-segment allografts prepared from diaphyseal sections of long bones. A retrospective analysis of clinical outcomes is presented.

OBJECTIVE

To analyze the results following the use of cortical allografts in the treatment of spine tumors.

SUMMARY OF BACKGROUND DATA

Metastatic disease and primary spinal bone tumors may result in progressive vertebral collapse, instability, deformity, pain, and neurologic deficit. Controversy as to the appropriate type of anterior reconstruction and/or graft material persists.

METHODS

From 1995 until 2001, 30 patients with primary spinal bone tumors or metastases to the spine were treated by anterior vertebral reconstruction with fresh-frozen cortical bone allografts. Grafts were used in combination with anterior and posterior instrumentation.

RESULTS

The median survival was 14 months. Ninety-three percent of all allografts were radiographically incorporated as early as 6 months after surgery in spite of adjuvant chemotherapy and radiation therapy. Fourteen patients (46%) had intraoperative or postoperative complications. Two patients underwent revision surgery for local recurrence. There were no allograft infections, fractures, or collapse.

CONCLUSION

Anterior column reconstruction with structural cortical allografts proved to be a reliable technique in patients with spine tumors. Postoperative complications can often be successfully managed.

Advances and challenges in the surgical treatment of metastatic bone disease

There are numerous challenges facing the orthopaedic surgeon who treats metastatic bone disease in the twenty-first century. The orthopaedic surgeon must be familiar with the indications for surgical intervention, the available implants for fixation of a given anatomic lesion, the appropriateness of fixation versus resection and replacement, and the viability of newer, less invasive treatment options for a given lesion. Determination of the best surgical candidates still is controversial, especially in the arena of prophylactic treatment. Recent advances have made fixation with intramedullary devices and standard plates simpler and more rigid. The advent and improvement of megaprostheses has made complex joint reconstructions more durable. Advances in interventional radiology such as radiofrequency ablation and percutaneous vertebroplasty and acetabuloplasty with polymethylmethacrylate (PMMA) continue to be promising options for future treatment. Better methods are necessary to evaluate the status of the patients preoperatively and postoperatively, to classify functional improvement after surgical treatment, and to determine the impact of treatment on the quality of life.

En bloc spondylectomy for spinal metastases: a review of techniques

Object

Spinal metastases are prevalent in the population of patients with cancer. Effective cancer therapy must incorporate treatment strategies for these lesions. Increasingly, surgery is being recognized as an effective treatment modality both for the patient's quality of life and potential oncological cure. En bloc spondylectomy is the surgical procedure of choice to obtain these goals. The purpose of this study was to examine critically the rationale, indications, and outcomes of en bloc spondylectomy for spinal metastases.

Methods

Outcomes in the authors' series of patients who underwent en bloc spondylectomy for spinal metastases are critically analyzed. The rationale and indications for this procedure are discussed. The Weinstein, Boriani, and Biagini surgical staging system for spinal tumors is described. A review of the literature is performed to examine further the rationale underlying this aggressive surgical approach to metastatic spinal disease.

Conclusions

En bloc spondylectomy is the treatment of choice for solitary and oligometastatic spinal metastases with biologically favorable histological findings. In appropriately selected patients, neurological outcome, pain control, and oncological control are significantly better after en bloc spondylectomy compared with radiation therapy. Oncological outcomes also exceed those of intralesional techniques. The Weinstein, Boriani, and Biagini surgical staging system provides a standard with which to plan surgical approaches and to compare surgical outcomes.

Principles and techniques of en bloc vertebrectomy for bone tumors of the thoracolumbar spine: an overview

Oncological principles for en bloc resection of bone tumors were initially developed for tumors of the long bone by orthopedic surgical oncologists. Recently, spine surgeons have adopted these principles for the treatment of vertebral column tumors. The goal of en bloc resection is to establish a surgical margin that can be designated marginal or wide. In this article, the principles of surgical oncology for bone tumors of the spine are briefly reviewed and the different surgical approaches used to remove these tumors in an en bloc fashion are described in detail.

Evidence-based review of the surgical management of vertebral column metastatic disease

Object

Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease.

Methods

A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods.

Conclusions

Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.

PMMA to stabilize bone and deliver antineoplastic and antiresorptive agents

Antineoplastic and antiresorptive drugs added to polymethylmethacrylate cement may prevent local cancer progression and failure of reconstructive devices used to treat patients with pathologic fractures. We tested the mechanical properties of cement containing various amounts of the drugs and found that as much as 2 g of either doxorubicin or pamidronate can be added to Simplex cement and the cement retains 87% of its compressive and tensile strength after 6 months of wet storage. Approximately 1 mg pamidronate elutes from experimental pellets. One half of the drug elution occurs within the first day in experiments that combined doxorubicin and pamidronate, and within 3 days when pamidronate was the only additive. Cement containing these drugs seems to be strong enough, but its fatigue strength should be tested before using it clinically. Sufficient amounts of the tested drugs elute to have potential biologic activity.

Spinal metastasis in the elderly

Bony metastases are a frequent problem in elderly patients affected by cancer, and those with bony metastases involve the spine in approx. 50%. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer. The chance that an elderly patient (60-79 years old) is affected by bony metastases is four times higher in men and three times higher in women than a middle-aged patient (40-59 years old). Since the medical treatment with all the adjuvant treatment options prolong the survival of this particular patient group, the spinal metastases may become a mechanical issue, thus requesting surgical treatment. Different classification systems have been proposed to rationalize surgical indications, some concentrating solely on the local spinal tumor involvement and some including the overall clinical situation. Since most of the surgical options are of palliative character, it is more important to base the decision on an overall clinical classification including the different treatment modalities-irradiation, chemotherapy, steroids, bisphosphonates, and surgery-to make a shared decision. In case surgery is indicated-neural compression, pathological fracture, instability, and progressive deformity, nursing reasons-the most straightforward procedures should be chosen, which may not need an intensive care unit stay. In the thoracolumbar spine a posterior decompression and posterolateral vertebral body resection through a posterior approach only, with a concomitant reconstruction and stabilization, has shown to work sufficiently well. In the middle and lower cervical spine the anterior approach with anterior decompression and anterior column reconstruction is most effective and has a low morbidity, whereas the occipitocervical junction can generally be treated by posterior resection and stabilization. The outcome should be determined by the survival time in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. Surgical management shows the greatest improvement in pain reduction, but also in other domains of quality of life. Since prospective randomized studies comparing different treatment modalities for spinal metastases including surgery are not available and are ethically difficult to achieve, each case remains an interdisciplinary, shared decision making process for what is considered best for a patient or elderly patient. However, whenever surgery is an option, it should be planned before irradiation since surgery after irradiation has a significant higher complication rate.

Metastatic disease of the spine: evaluation and treatment

Treatment of patients with metastatic disease of the spine continues to be a challenging problem. Advances in imaging studies and surgical techniques have improved patient outcomes with operative intervention. However, the lack of a validated set of criteria to determine spinal instability makes patient selection for surgical intervention difficult. Multiple classification systems that assist surgeons in determining appropriate operative candidates have been proposed. We will review current information on the evaluation and treatment of metastatic disease of the spine and discuss classification systems that assist in determining appropriate operative candidates.

Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases

STUDY DESIGN

A new surgical technique for en bloc resection of posterior mediastinum tumors invading the spine is described.

OBJECTIVE

To demonstrate that major soft tissue tumors of the thoracic apex (Pancoast Tobias syndrome) or posterior mediastinum tumors can be removed en bloc even though the vertebral body or the foramina are invaded.

SUMMARY OF BACKGROUND DATA

En bloc surgery of tumor is accepted today as being the goal of carcinologic surgery with the best results for survival. Until now, no surgical technique has been described for radical excision of soft tissue tumors invading the thoracic spine adjacent to the ribs and lung. We reviewed our 8 years' experience of 36 such cases and report outcome and survival rates.

METHOD

The authors have joined their abilities and technique to enable complete en bloc extratumoral resections of lung tumors or posterior mediastinum tumors invading the adjacent soft tissue and spine. The surgical technique recommended by the authors is different at the cervicothoracic and medium thoracic level. At the cervicothoracic level, the authors first perform an anterior approach with dislocation of the sternoclavicular joint and dissection of the subclavian vessels with exposure of the brachial plexus. Dissection of the tumor from the anterior soft tissues is then performed but is kept attached to the adjacent spine. Dissection of lung hilum and its division are done through the same approach. At the thoracic level, the authors perform a posterior lateral thoracotomy for dissection of lung hilum and division of its elements. The lung and the adjacent tumoral ribs are not removed but are carefully kept undissected against the spine. Thoracoscopy can replace the open thoracotomy in small and medium-sized tumors. En bloc extratumoral resection is the second step performed through a median posterior cervicothoracic or thoracic approach. Vertebrectomy is complete or partial depending on the type of extension against or inside the vertebrae.

RESULTS

Thirty-six cases have been operated on with this technique. Vertebrectomy was complete in seven cases and partial in 29. Follow-up ranges from 6 days to 7.2 years (average, 23.3 months). One patient died 1 year postoperatively from an unrelated cause. Only 35 patients are available for follow-up analysis. Twenty-one patients (60%) are dead, with an average survival of 16.7 months 8 days to 44 months. The 14 others (40%) are alive (average, 38.26 months; range, 8-87 months).

CONCLUSIONS

Even though a learning curve is necessary to achieve this extreme type of surgery, selective preoperative screening of patients is mandatory. Interesting results today confirm the feasibility of possible treatment of tumors still considered unresectable.

Postacute management of patients with spinal cord injury due to metastatic tumour disease: survival and efficacy of rehabilitation

STUDY DESIGN

Retrospective study utilising clinical records and public administration databases.

OBJECTIVES

This study was performed to analyse the clinical presentation and survival rate of individuals with spinal cord injury (SCI) due to spinal metastasis after primary treatment, and to evaluate the efficacy of rehabilitative efforts.

SETTING

Spinal Cord Injury Unit, University Hospital, Heidelberg.

METHODS

A total of 68 consecutive patients were included. Demographics, clinical data, tumour type, level and completeness of SCI, initial treatment, functional independence measure (FIM) and survival time were derived from hospital and public administration databases. Cox regression and fuzzy logic rule generation were used for statistical analysis.

RESULTS

Of the 68 patients, 66 patients died 11 months (median, interquartile range (IQR) 4-29 months) after the onset of neurological symptoms at an average age of 58 years. The functional independence measure (FIM) score describing the general clinical and functional status proved to be the most reliable prognostic factor of survival. Other more specific parameters (eg tumour type or level of lesion) did not have such an impact. In total, 51 patients completed the rehabilitation programme within 50 days (median, IQR 27-99 days). The FIM score improved from 62 at admission to 84 at discharge.

CONCLUSION

The clinical and functional status is a valuable prognostic factor for survival. Since institutionalised rehabilitative efforts are effective, this group of patients should be accepted into such a program.

Quality of life in surgical treatment of metastatic spine disease

STUDY DESIGN

Overall quality of life after surgical management of metastatic disease of the spine was prospectively assessed using a validated global health status quality-of-life instrument-the Edmonton Symptom Assessment Scale.

OBJECTIVES

To prospectively evaluate the efficacy of surgery in patients with metastatic spinal disease with respect to quality of life.

SUMMARY OF BACKGROUND DATA

Management of spinal metastases is palliative and is aimed at improving quality of life at an acceptable risk. Although previous studies have evaluated physical outcomes, improvements in pain, and neurologic function after surgery, a multidimensional assessment of quality of life is more relevant in the palliative patient.

METHODS

Twenty-five consecutive patients undergoing surgery for spinal metastases were prospectively evaluated. Pre- and postoperative assessments were performed using the Edmonton Symptom Assessment Scale. The surgical procedure consisted of decompression and instrumented stabilization.

RESULTS

After surgery, the largest improvement was noted in the domain of pain (P < 0.00001). There were also significant improvements noted in the domains of tiredness (P = 0.004), nausea (P = 0.01), anxiety (P = 0.006), drowsiness (P = 0.044), appetite (P = 0.02), and well-being (P = 0.004).

CONCLUSIONS

The current study demonstrates that in the appropriate patient, surgical management brings about a positive effect on the overall quality of life in patients with spinal metastases. The greatest benefit occurred in the reduction of a patient's level of pain.

Surgery for solitary metastases of the spine: rationale and results of treatment

STUDY DESIGN

A spine tumor database of patients with solitary sites of spine involvement from solid tumors was retrospectively reviewed.

OBJECTIVES

To analyze the long-term survival, neurologic outcome, and results of surgery in a well-defined subset of patients who had spinal metastases with epidural extension to define future treatment strategies.

SUMMARY OF BACKGROUND DATA

Currently accepted indications for surgical treatment of spinal metastases include histologic diagnosis, neurologic palliation in those who have failed prior irradiation, and spinal stabilization. In all others, external irradiation is considered the mainstay of therapy. Several studies have shown that prior irradiation increases the frequency of complications from surgery and affects functional outcome.

METHODS

A retrospective review of 80 consecutive patients with solitary sites of spine involvement from solid tumors with varying degrees of epidural extension was performed. Complete clinical and radiologic follow-up assessment was available for all the patients. Clinical parameters, neurologic grade, preoperative pain, radiologic evaluation, and outcome measures were analyzed. Survival analysis was performed using the Kaplan-Meier product limit method, and differences between subgroups were analyzed using chi2. Prognostic factors for long-term survival also were evaluated.

RESULTS

The overall median survival after surgery was 30 months, with 18% surviving 5 years or more. Survival varied by tumor type, with the best prognosis noted in patients with breast or kidney cancer. The surgical morbidity was significantly higher in those receiving prior irritation (P < 0.03), and the local recurrence rate also increased in patients who had received prior irradiation.

CONCLUSIONS

Patients with solitary sites of spine involvement from solid tumors represent a biologically favorable subgroup with potential for long-term survival. In this group, complete surgical excision before irradiation should be considered to increase the prospects of long-term palliation and possible cure.

Healing of autologous bone in a titanium mesh cage used in anterior column reconstruction after total spondylectomy

STUDY DESIGN

Autologous bone inside a titanium mesh cage, used as an anterior strut in a reconstruction after total spondylectomy, was histologically examined in a postmortem specimen.

OBJECTIVES

To determine whether the autologous bone inside the titanium mesh cage attained fusion and remodeling in a combined reconstruction, consisting of an anterior titanium mesh cage with posterior multilevel instrumentation, after total spondylectomy.

SUMMARY OF BACKGROUND DATA

There are few previous reports on the histologic analysis of the bone inside a titanium mesh cage when it is used clinically as an anterior column support in a spinal fusion. Attaining biologic bony fusion is desirable for long-term stability after total spondylectomy.

METHODS

A postmortem specimen from a 16-year-old boy with Ewing's sarcoma at T6, who died of lung metastasis 16 months after total spondylectomy and combined reconstruction, was analyzed.

RESULTS

Histologic examination revealed many viable cells and normal lamella of trabecular bone formation in the grafted bone inside the mesh. Consecutive trabecular cancellous bony fusion between the grafted bone and the adjacent vertebral bodies was achieved.

CONCLUSION

Remodeling and fusion of the grafted bone inside the titanium mesh cage was observed. Combined reconstruction using an anterior titanium mesh cage with posterior multilevel instrumentation after total spondylectomy makes it possible to achieve biologic fusion of the bone inside the mesh cage with the adjacent vertebral bodies.

Surgical strategy for spinal metastases

STUDY DESIGN

A new surgical strategy for treatment of patients with spinal metastases was designed, and 61 patients were treated based on this strategy.

OBJECTIVES

To propose a new surgical strategy for the treatment of patients with spinal metastases.

SUMMARY OF BACKGROUND DATA

A preoperative score composed of six parameters has been proposed by Tokuhashi et al for the prognostic assessment of patients with metastases to the spine. Their scoring system was designed for deciding between excisional or palliative procedures. Recently, aggressive surgery, such as total en bloc spondylectomy for spinal metastases, has been advocated for selected patients. Surgical strategies should include various treatments ranging from wide or marginal excision to palliative treatment with hospice care.

METHODS

Sixty-seven patients with spinal metastases who had been treated from 1987-1991 were reviewed, and prognostic factors were evaluated retrospectively (phase 1). A new scoring system for spinal metastases that was designed based on these data consists of three prognostic factors: 1) grade of malignancy (slow growth, 1 point; moderate growth, 2 points; rapid growth, 4 points), 2) visceral metastases (no metastasis, 0 points; treatable, 2 points: untreatable, 4 points), and 3) bone metastases (solitary or isolated, 1 point; multiple, 2 points). These three factors were added together to give a prognostic score between 2-10. The treatment goal for each patient was set according to this prognostic score. The strategy for each patient was decided along with the treatment goal: a prognostic score of 2-3 points suggested a wide or marginal excision for long-term local control; 4-5 points indicated marginal or intralesional excision for middle-term local control; 6-7 points justified palliative surgery for short-term palliation; and 8-10 points indicated nonoperative supportive care. Sixty-one patients were treated prospectively according to this surgical strategy between 1993-1996 (phase 2). The extent of the spinal metastases was stratified using the surgical classification of spinal tumors, and technically appropriate and feasible surgery was performed, such as en bloc spondylectomy, piecemeal thorough excision, curettage, or palliative surgery.

RESULTS

The mean survival time of the 28 patients treated with wide or marginal excision was 38.2 months (26 had successful local control). The mean survival time of the 13 patients treated with intralesional excision was 21.5 months (nine had successful local control). The mean survival time of the 11 patients treated with palliative surgery and stabilization was 10.1 months (eight had successful local control). The mean survival time of the patients with terminal care was 5.3 months.

CONCLUSIONS

A new surgical strategy for spinal metastases based on the prognostic scoring system is proposed. This strategy provides appropriate guidelines for treatment in all patients with spinal metastases.