Vertebral body resection in the treatment of cancer involving the spine

Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm

STUDY DESIGN

Narrative Review. The spine remains the most common site for bony metastasis. It is estimated that up to 70% of cancer patients harbor secondary spinal disease. And up to 10% will develop a clinically significant lesion. The last two decades have seen a substantial leap forward in the advancements of the management of spinal metastases. What once was a death sentence is now a manageable, even potentially treatable condition. With marked advancements in the surgical treatment and post-operative radiotherapy, a standardized approach to stratify and manage these patients is both prudent and now feasible.

OBJECTIVES

This article looks to examine the best available evidence in the stratification and surgical management of patients with spinal metastases. So the aim of this review is to offer a standardized approach for surgical management and surgical planning of patients with spinal metastases.

Evolution of surgical treatment of metastatic spine tumors

PURPOSE

The treatment of cancer has transformed over the past 40 years, with medical oncologists, radiation oncologists and surgeons working together to prolong survival times and minimize treatment related morbidity. With each advancement, the risk-benefit scale has been calibrated to provide an accurate assessment of surgical hazard. The goal of this review is to look back at how the role of surgery has evolved with each new medical advance, and to explore the role of surgeons in the future of cancer care.

METHODS

A literature review was conducted, highlighting the key papers guiding surgical management of spinal metastatic lesions.

CONCLUSION

The roles of surgery, medical therapy, and radiation have evolved over the past 40 years, with new advances requiring complex multidisciplinary care.

Separation Surgery in the Treatment of Spinal Metastasis

The life expectancy of patients with advanced cancer has been prolonged with the development of systemic treatment technology. Spinal metastasis is one of the common ways of metastasis of advanced tumors, leading to spinal cord compression and compression fractures, which often lead to a significant reduction in patients’ quality of life and physical function. Therefore, surgical treatment is still needed for functional recovery and local control. Separation surgery has been known since 2014 when it was purposed. Combined with radiotherapy, it can achieve an ideal goal of local control. This paper gives a brief introduction to separation surgery, hoping to increase the reader's understanding and consider this method in the course of treatment.

Posterolateral thoracic decompression with anterior column cage reconstruction versus decompression alone for spinal metastases with cord compression: analysis of perioperative complications and outcomes

Background

The optimal surgical strategy for patients with spinal metastases remains unknown. The aim of this study was to determine if performing an anterior column reconstruction to a posterolateral approach adds to perioperative complications.

Methods

A retrospective review of all adult patients with spinal metastases who had a posterolateral approach for resection between January 2000 and December 2008. Perioperative complications and functional outcomes were determined.

Results

A total of 23 patients met the study criteria. Eleven patients underwent a costotransversectomy (CT) approach with anterior column reconstruction while 12 patients had a transpedicular (TP) approach without anterior column reconstruction. The mean age was 55.9 and 59.3 years in the CT and TP groups, respectively. There was no intraoperative death in either group. One death attributed to sepsis occurred in the TP group. A total of 5 (45.5%) complications occurred in the CT group and 7 (58.3%) in the TP group (P=0.68). An improvement in American Spinal Injury Association (ASIA) impairment scale grades was observed in 3 (27.3%) patients in the CT group and 1 (8.3%) in TP group. ASIA grades remained the same in 8 (72.7%) patients in CT and 10 (83.3%) patients in TP groups. No patient worsened in the CT group whereas 1 (8.3%) patient in TP group worsened. The median survival was 12.2 months in the CT group and 19.0 months in the TP group (P=0.37).

Conclusions

The addition of anterior column reconstruction does not appear to be associated with more operative or perioperative complications when compared to decompression alone. Anterior column reconstruction should not be aborted in fear of increasing perioperative complications.

Reducing kyphotic deformity by posterior vertebral column resection with 360° osteosynthesis in metastatic epidural spinal cord compression (MESCC)

PURPOSE

Metastatic epidural spinal cord compression (MESCC) often requires anterior-posterior decompression and stabilization. To reduce approach-related complications, single-stage posterolateral vertebrectomy and 360° fusion is often performed. However, a sufficient reduction of kyphotic deformity through this approach has not been reported. The purpose of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in MESCC.

METHODS

A retrospective analysis and chart review was performed for 14 consecutive patients who underwent a vertebrectomy and decompression from a posterolateral approach. Anterior mesh stabilization of the ventral column is used as hypomochlion for the posterior compression manoeuvre, which leads to reduction of the kyphotic deformity.

RESULTS

Pre-operative back pain was 7.2 on a visual analogue scale. Back pain was reduced to 4.4 at discharge and 2.0 at the latest follow-up with a mean follow-up of 12 months (p < 0.001). The Frankel score remains constant or improved from D to E. Radiological segmental kyphosis was corrected from a mean of 16° to 4° (p < 0.001) post-operatively with a loss of 3° at the final follow-up, but still with significant corrections compared with the pre-operative measurements (p < 0.003).

CONCLUSION

Single-stage posterolateral vertebrectomy and reconstruction is a safe and less invasive approach that allows a sufficient reduction of hyperkyphosis and preservation of neurological function in patients with MESCC. This approach is an efficient alternative to anterior-posterior fusion with good pain reduction and improved sagittal profile.

Optimal approach to circumferential decompression and reconstruction for thoracic spine metastatic disease

BACKGROUND

Circumferential decompression has been demonstrated to be the first-line therapy for patients with metastatic tumors in the thoracic spine requiring surgical intervention. However, there is significant debate regarding whether these tumors are best accessed anteriorly utilizing a thoracotomy or posteriorly. We used decision analysis to determine which approach yields greater health-related quality of life (QOL).

METHODS

We searched Medline, Embase, and the Cochrane Library for relevant articles published between 1990 and 2011 on anterior and posterior approaches to metastatic disease in the thoracic spine. QOL values for major treatment outcomes were determined using the existing literature. Separate models were created for ambulatory and nonambulatory patients. A Monte Carlo simulation and sensitivity analyses were used to determine which treatment strategy resulted in the highest QOL.

RESULTS

For ambulatory patients, an anterior approach resulted in a slightly higher QOL, and for nonambulatory patients, a posterior approach was favored, but these differences were not statistically significant.

CONCLUSIONS

Using a decision-analytic model, we found no significant difference in QOL resulting from anterior versus posterior approaches to metastatic lesions in the thoracic spine. Decisions should instead be based on surgeon comfort, tumor characteristics, anatomy of the lesion, patient-related factors, and goals of the operation.

Treatment of spinal cord compression: are we overusing radiotherapy alone compared to surgery and radiotherapy?

INTRODUCTION

This article describes how patients with metastatic spinal cord compression (MSCC) were treated from 2005 to 2011 at a single institution. A comparison is made with an international and standardized scoring system which would have predicted which patients would have a better outcome with neurosurgery in addition to radiotherapy in accordance with current best practice standards.

METHOD

A retrospective audit of all MSCC patients presenting from 2005 to 2011 was undertaken. An assessment of outcome was made by using ambulatory assessment tool and by comparing overall survival with published standards.

RESULTS

In all, 39 patients were identified, of whom 37 received radiotherapy alone and two (5%) received surgery and postoperative radiotherapy. The international standardized scoring system predicted 28 (72%) of the 39 patients might have had a better outcome with neurosurgery in addition to radiotherapy. MSCC patients generally had reasonable outcomes, but selected patients could potentially do better with decompressive surgery.

CONCLUSION

There is a subset of MSCC patients who have poor predicted ambulatory rates after radiotherapy alone and who may benefit from decompressive surgery. It is recommended that MSCC patients be categorized according to the international scoring system to identify appropriate candidates for surgical intervention and postoperative radiotherapy or radiotherapy alone.

Preoperative embolization significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis

Several studies have evaluated the efficacy of preoperative embolization in devascularizing tumors. However, no study has measured intraoperative blood loss in a single palliative surgery compared with a control group without preoperative embolization. The purpose of this retrospective study was to evaluate the efficacy of preoperative embolization on intraoperative blood loss in palliative decompression and instrumented surgery using a posterior approach for spinal metastasis. Between 2000 and 2010, forty-six patients underwent palliative decompression and instrumented surgery using a posterior approach for spinal metastasis in the thoracic and lumbar spine. Preoperative embolization was performed in 23 patients (embolization group), and surgery was performed within 3 days after embolization. The embolic materials used were polyvinyl alcohol particles, gelatin sponge, and metallic coils. Twenty-three patients did not undergo embolization (no embolization group). Pain and neurologic symptoms in all 46 patients were relieved postoperatively. Average intraoperative blood loss was 520 mL (range, 140-1380 mL) in the embolization group and 1128 mL (range, 100-3260 mL) in the no embolization group (P<.05). In the embolization group, intraoperative blood loss was not correlated with the degree of tumor vascularization, completeness of embolization, or time between embolization and surgery. Intraoperative blood loss after preoperative embolization was less than half that after no preoperative embolization.

Complications in the management of metastatic spinal disease

Metastatic spine disease accounts for 10% to 30% of new cancer diagnoses annually. The most frequent presentation is axial spinal pain. No treatment has been proven to increase the life expectancy of patients with spinal metastasis. The goals of therapy are pain control and functional preservation. The most important prognostic indicator for spinal metastases is the initial functional score. Treatment is multidisciplinary, and virtually all treatment is palliative. Management is guided by three key issues; neurologic compromise, spinal instability, and individual patient factors. Site-directed radiation, with or without chemotherapy is the most commonly used treatment modality for those patients presenting with spinal pain, causative by tumours which are not impinging on neural elements. Operative intervention has, until recently been advocated for establishing a tissue diagnosis, mechanical stabilization and for reduction of tumor burden but not for a curative approach. It is treatment of choice patients with diseaseadvancement despite radiotherapy and in those with known radiotherapy-resistant tumors. Vertebral resection and anterior stabilization with methacrylate or hardware (e.g., cages) has been advocated.Surgical decompression and stabilization, however, along with radiotherapy, may provide the most promising treatment. It stabilizes the metastatic deposited areaand allows ambulation with pain relief. In general, patients who are nonambulatory at diagnosis do poorly, as do patients in whom more than one vertebra is involved. Surgical intervention is indicated in patients with radiation-resistant tumors, spinal instability, spinal compression with bone or disk fragments, progressive neurologic deterioration, previous radiation exposure, and uncertain diagnosis that requires tissue diagnosis. The main goal in the management of spinal metastatic deposits is always palliative rather than curative, with the primary aim being pain relief and improved mobility. This however, does not come without complications, regardless of the surgical intervention technique used. These complication range from the general surgical complications of bleeding, infection, damage to surrounding structures and post operative DT/PE to spinal specific complications of persistent neurologic deficit and paralysis.

GROWTH AFTER RUBBING BY TUMOR CUT SURFACE: COMPARATIVE STUDY BETWEEN THREADWIRE SAW-CUT AND BLUNTLY-CUT TUMORS

Spondylectomy for extripation of spinal tumors would be performed through piecemeal excision or by total en bloc spondylectomy with cutting at the neural arch by the threadwire saw (T-saw) that is sometimes inevitably intralesional. The purpose of this study was to compare the potential for tumor growth after rubbing of the cut surface of tumors cut by either T-saw or blunt instrument against the subcutaneous tissues of nude mice. Tumors were prepared by subcutaneous injection of human HT 1080 fibrosarcoma cells in nude mice. The animals were sacrificed, and tumors were harvested en bloc and cut with either a T-saw or artery forceps. A 3-cm wound was created on the backs of other (plain) nude mice. The tumor's cut surface was rubbed for 10 seconds against the subcutaneous tissue of one of these nude mice. The wounds were then sutured. Tumor blocks were inoculated into other nude mice. Nude mice were followed for occurrence of tumor growth. Tumor growth occurred in all nude mice after block inoculation. The incidence of tumor growth after rubbing with the tumor surfaces cut with T-saw and artery forceps were 16.7% and 58.3% respectively (P = 0.035). Onset of tumor growth after tumor rubbing and inoculation of tumor blocks were 30.1 ± 25 and 12.2 ± 5 days respectively (P = 0.015). Rubbing of T-saw-cut tumor surface has less possibility of causing tumor growth than rubbing of surface of bluntly-cut tumors.

Postoperative survival and ambulatory outcome in metastatic spinal tumors : prognostic factor analysis

OBJECTIVE

The purposes of this study are to estimate postoperative survival and ambulatory outcome and to identify prognostic factors thereafter of metastatic spinal tumors in a single institute.

METHODS

We reviewed the medical records of 182 patients who underwent surgery for a metastatic spinal tumor from January 1987 to January 2009 retrospectively. Twelve potential prognostic factors (age, gender, primary tumor, extent and location of spinal metastases, interval between primary tumor diagnosis and metastatic spinal cord compression, preoperative treatment, surgical approach and extent, preoperative Eastern Cooperative Oncology Group (ECOG) performance status, Nurick score, Tokuhashi and Tomita score) were investigated.

RESULTS

The median survival of the entire patients was 8 months. Of the 182 patients, 80 (44%) died within 6 months after surgery, 113 (62%) died within 1 year after surgery, 138 (76%) died within 2 years after surgery. Postoperatively 47 (26%) patients had improvement in ambulatory function, 126 (69%) had no change, and 9 (5%) had deterioration. On multivariate analysis, better ambulatory outcome was associated with being ambulatory before surgery (p=0.026) and lower preoperative ECOG score (p=0.016). Survival rate was affected by preoperative ECOG performance status (p<0.001) and Tomita score (p<0.001).

CONCLUSION

Survival after metastatic spinal tumor surgery was dependent on preoperative ECOG performance status and Tomita score. The ambulatory functional outcomes after surgery were dependent on preoperative ambulatory status and preoperative ECOG performance status. Thus, prompt decompressive surgery may be warranted to improve patient's survival and gait, before general condition and ambulatory function of patient become worse.

Metastatic paraplegia and vital prognosis: perspectives and limitations for rehabilitation care. Part 1

OBJECTIVE

To evaluate the vital prognosis of patients with metastatic epidural spinal cord compression (MESCC) to determine the relevance and duration of physical medicine and rehabilitation (PM&R) admission.

DATA SOURCES

Publications from 1980 to January 2010 selected from 3 databases.

STUDY SELECTION

Publications reporting data correlated with survival and prognosis factors, highlighting publications with level A scientific evidence (prospective randomized controlled studies with significant casuistry and relevant judgment criteria). The work focused on patients with MESCC below T1.

DATA EXTRACTION

Standardized reading grid.

DATA SYNTHESIS

Thirty-eight studies met the inclusion criteria. Most were retrospective. For survival rate at 1 year, they reported data ranging from 12% to 58%. The 12-month and median survival rates were the data reported most often in the articles. The median survival rate ranged from 2.4 to 30 months, and 12-month survival rates ranged from 12% to 58%. Of publications that chose this parameter, 95% reported 12-month survival rates less than 55.2% (95th percentile) regardless of patients' functional status and associated risk factors (eg, location of primary cancer, metastases spreading, pretreatment ambulatory status).

CONCLUSIONS

Despite major progress in cancer care, patients with MESCC still have a limited vital prognosis. The relevance and duration of PM&R care must be evaluated against the patient's functional need for rehabilitation while making time for family. The hypothesis of a 1-month stay extended only once appears reasonable for patients to adapt to their new functional status without taking precious time away from their loved ones.

Shifting paradigms in the treatment of metastatic spine disease

STUDY DESIGN

Systematic review and evidence appraisal.

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Minimally invasive thoracoscopic approach for anterior decompression and stabilization of metastatic spine disease

Object

The choices available in the management of metastatic spine disease are complex, and the role of surgical therapy is increasing. Recent studies have indicated that patients treated with direct surgical decompression and stabilization before radiation have better functional outcomes than those treated with radiation alone. The most common anterior surgical approach for direct spinal cord decompression and stabilization in the thoracic spine is open thoracotomy; however, thoracotomy for spinal access is associated with morbidity that can be avoided with minimally invasive techniques like thoracoscopy.

Methods

A minimally invasive thoracoscopic approach was used for the surgical treatment of thoracic and thoracolumbar metastatic spinal cord compression. This technique allows ventral decompression via corpectomy, inter-body reconstruction with expandable cages, and stabilization with an anterolateral plating system designed specifically for minimally invasive implantation. This technique was performed in 5 patients with metastatic disease of the thoracic spine, including the thoracolumbar junction.

Results

All patients had improvement in preoperative symptoms and neurological deficits. No complications occurred in this small series.

Conclusions

The minimally invasive thoracoscopic approach can be applied to the treatment of thoracic and thoracolumbar metastatic spine disease in an effort to reduce access morbidity. Preliminary results have indicated that adequate decompression, reconstruction, and stabilization can be achieved with this technique.

Oncologic Emergencies

It has been estimated that genitourinary malignancies will account for 25% of new cancer diagnoses in the United States in 2005 (Jemal et al. 2005). While the incidence of many of these malignancies has increased over the past two decades, the mortality rates appear to be decreasing. Early cancer detection combined with improvements in surgical and nonsurgical oncologic therapy account for these trends. Although not common, newly diagnosed cancer patients occasionally present in an emergent, life-threatening manner that warrants immediate medical or surgical intervention. As the prevalence of genitourinary malignancies continues to expand, additional patients can be expected to develop disease or treatment-related complications. This chapter will serve to review the diagnosis and management of oncologic emergencies as they pertain to the urologist.

Diagnosis and treatment of vertebral column metastases

The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and qualilty of life.

Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial

BACKGROUND

The standard treatment for spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery.

METHODS

In this randomised, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat.

FINDINGS

After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomised. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.

INTERPRETATION

Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.

Surgical management of cervical spinal metastasis: anterior reconstruction and stabilization techniques

Anterior cervical corpectomy followed by reconstruction and stabilization is an effective strategy in the management of spinal metastasis in some patients. Various techniques are available in the armamentarium of the spine tumor surgeon. In patients with a limited life expectancy,reconstruction with PMMA achieves immediate stability and thus obviates the need for an external orthosis and allows for early mobilization. The addition of anterior cervical plate fixation provides extra support to prevent distraction failure. In some cases, posterior stabilization may be necessary to achieve adequate stability.

Cervical spinal metastasis: anterior reconstruction and stabilization techniques after tumor resection

Object

In a review of the literature, the authors provide an overview of various techniques that have evolved for reconstruction and stabilization after resection for metastatic disease in the subaxial cervical spine.

Methods

Reconstruction and stabilization of the cervical spine after vertebral body (VB) resection for metastatic tumor is an important goal in the surgical management of spinal metastasis. Generally, the VB defect is reconstructed with bone autograft or allograft, polymethylmethacrylate (PMMA), interbody spacers, and/or cages. In cases of PMMA-assisted reconstruction, internal devices are used to augment the fixation of PMMA. Stabilization is then achieved with anterior instrumentation, usually an anterior cervical locking plate. In some cases, posterior instrumentation may be necessary to supplement the anterior construct.

Conclusions

Anterior cervical corpectomy followed by reconstruction and stabilization is an effective strategy in the management of spinal metastases in patients.

Lung cancer. Palliative care

The majority of patients who acquire lung cancer will have troublesome symptoms at some time during the course of their disease. Some of the symptoms are common to many types of cancers, while others are more often encountered with lung cancer than other primary sites. The most common symptoms are pain, dyspnea, and cough. This document will address the management of these symptoms, and it will also address the palliation of specific problems that are commonly seen in lung cancer: metastases to the brain, spinal cord, and bones; hemoptysis; tracheoesophageal fistula; and obstruction of the superior vena cava.

Evaluation and treatment of spinal metastases: an overview

Metastases to the spine are a common and somber manifestation of systemic neoplasia. The incidence of spinal metastases continues to increase, likely a result of increasing survival times for patients with cancer. Historically, surgery for spinal metastases has consisted of simple decompressive laminectomy. Results obtained in retrospective case series, however, have shown that this treatment provides little benefit to the patient. With the advent of better patient-related selection practices, in conjunction with new surgical techniques and improved postoperative care, the ability of surgical therapy to play an important and beneficial role in the multidisciplinary care of cancer patients with spinal disease has improved significantly. Controversy remains, however, with respect to the relative merits of surgery, radiotherapy, chemotherapy, or a combination of these treatments.

In this topic review, the literature on spinal column and spinal cord metastases is collated to provide a description of the presentation, investigations, indications for surgical therapy, and the role of adjuvant cancer therapies for patients with spinal metastases. In addition, the authors discuss the different surgical strategies available in the armamentarium of the neurosurgeon treating patients with spinal metastasis.

Reconstructive surgery in spinal tumours

AIMS

This study reports 21 patients who underwent reconstructive surgery for destructive spinal tumours.

MATERIALS AND METHODS

The mean age was 49 years (range: 39-71 years). Primary lesions were met in two cases. Secondary spinal tumours were diagnosed in 19 cases. Thirteen were breast carcinoma metastases (61.9%). The cervical spine was involved in four cases, thoracic spine in six cases, and the lumbar spine in 11 cases. One patient underwent decompression laminectomy and posterior pedicle screw stabilization. The others underwent tumour tissue excision, with spinal reconstruction with autogenous bone grafting, with or without vertebral body replacement prosthesis. Anterior and posterior stabilization of the vertebral column was also used.

RESULTS

The objectives of surgery were achieved, in that early ambulation, easier nursing care, pain relief and neurological recovery were reported in all cases. No surgery-related complications were encountered.

CONCLUSIONS

We recommend surgical intervention for such lesions where reasonable longevity is anticipated.

Neoplastic vs. traumatic spinal cord injury: an inpatient rehabilitation comparison

OBJECTIVE

To compare demographics, injury characteristics, and functional outcomes of patients with neoplastic spinal cord compression with those with traumatic spinal cord injuries.

DESIGN

A prospective 5-yr comparison was undertaken comparing 34 patients with neoplastic spinal cord compression with 159 patients with traumatic spinal cord injury.

RESULTS

Patients with neoplastic spinal cord compression were significantly older, more often female, and unemployed than patients with traumatic spinal cord injury. Neoplastic spinal cord compression presented more often with paraplegia involving the thoracic spine, and injuries were more often incomplete compared with traumatic spinal cord injury. Patients with neoplastic spinal cord compression had a significantly shorter rehabilitation length of stay compared with those with traumatic spinal cord injury. The neoplastic group had significantly lower FIM change scores. Both groups had similar FIM efficiencies and discharge to home rates.

CONCLUSIONS

Patients with neoplastic spinal cord compression have different demographic and injury characteristics but can achieve comparable rates of functional gains as their traumatic spinal cord injury counterparts. Although patients with traumatic injuries achieve greater functional improvement, patients with neoplasms have a shorter rehabilitation length of stay and comparable FIM efficiencies and home discharge rates.

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation

OBJECTIVE

To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation.

DESIGN

A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification.

SETTING

Tertiary university medical centers.

PATIENTS

Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria.

MAIN OUTCOME MEASURES

Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home.

RESULTS

Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges.

CONCLUSIONS

Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.

Role of surgical treatment in 70 patients with vertebral metastasis causing cord or root compression

Spinal metastasis plays an important role in the survival rate and general condition of cancer patients. In this paper, we present 70 patients with metastatic spinal tumors, diagnosed and surgically treated in the Departments of Neurosurgery and Orthopedics of Ankara Numune State Hospital between 1984 and 1993. Our clinical observations suggest that the survival rate is influenced by the type of the primary lesion, pathology, and the patient's preoperative physical and neurological status.

Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis

The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple columns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resection of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid surgeons in selecting the optimum approach for individual patients.

Anterior decompression and stabilization using a microsurgical endoscopic technique for metastatic tumors of the thoracic spine

It is well accepted that the treatment of spinal tumors that threaten neurological integrity comprises resection, vertebral body reconstruction, and stabilization if the patient's condition is suitable. In spite of the excellent results reported using thoracotomy, the majority of investigators recommend posterolateral techniques because of lower morbidity, shorter hospitalization time, and the possibility of performing dorsal stabilization via the same incision. To overcome some of the disadvantages of thoracotomy, the authors developed an anterior procedure that permits vertebrectomy, reconstruction, and stabilization to be performed entirely by endoscopic technique. Microsurgical endoscopy and stabilization were performed in four patients with metastatic disease of the thoracic spine. All were ambulatory after surgery and at follow up; preoperative neurological and neurophysiological deficits improved as well. No complications occurred in this small series. Microsurgical endoscopy achieves a substantial reduction in trauma, use of analgesic medications, and hospitalization time. Early results seem to indicate that adequate decompression, stabilization and reduction of surgical morbidity can be achieved with this technique.

Spinal metastases from solid tumors. Analysis of factors affecting survival

BACKGROUND

Factors affecting survival were determined for 109 patients with thoracic spine metastases and cord compression. Lung, prostate, and breast were the most common primary sites (78%). All patients had surgical decompression of the spinal cord, and 99% received radiotherapy.

METHODS

Survival was determined based on anatomic site of primary carcinoma, preoperative neurologic deficit, extent of disease, number of vertebral bodies involved, tumor location (site of cord compression), and age. The respective compounding weight of the negative prognostic factors also was analyzed in terms of survival.

RESULTS

The overall median survival was 10 months. Patients preoperatively ambulatory survived statistically significantly longer than nonambulatory patients or those with sphincter incontinence (P = 3.469 x 10(-6)). Patients with renal cell carcinoma survived the longest, followed by those with breast, prostate, lung, and colon cancer. Patients with breast cancer survived statistically longer than those with lung cancer (P = 0.039). Patients with one vertebral body involved survived statistically significantly longer than patients with multiple vertebral level involvement (P = 0.027). Extent of disease, age, and tumor location did not significantly influence survival. In patients with vertebral column disease, the presence of two or more poor prognostic indicators (leg strength 0/5-3/5, lung or colon cancer, multiple vertebral body involvement), had a compounding adverse effect on survival.

CONCLUSIONS

For patients with spinal metastases and cord compression, the factors found to affect survival include preoperative neurological status, anatomic site of primary carcinoma, and number of vertebral bodies involved. Patients with vertebral column disease and two or more of the poor prognostic indicators have a short life expectancy, and, therefore, radical surgery is not recommended because the benefits may not be substantial.

Unilateral posterolateral decompression without stabilization for neurological palliation of symptomatic spinal metastasis in debilitated patients

Patients with symptomatic spinal metastases and limited life expectancy are often too debilitated to withstand anterior or posterolateral spinal cord decompression and segmental stabilization. More limited surgery aiming solely at preservation or restoration of neurological function and relief from pain offers the potential for significant improvement in the quality of remaining life without incurring undue perioperative morbidity and mortality. Eight patients with spinal metastases and limited life expectancy underwent a unilateral transpedicular decompression procedure on their most symptomatic side and/or the side of maximum tumor involvement. All patients were neurologically improved within the 1st postoperative week; all were ambulatory and continent postoperatively. Postoperatively, all five patients with preoperative motor deficits demonstrated increased motor strength, and the three patients with predominant radicular pain reported marked improvement. There were no perioperative deaths and two transient perioperative complications. The average length of hospitalization was 6 days for patients without complications and 10 days for the entire group. Unilateral transpedicular decompression without stabilization is an effective and safe method for palliating symptomatic spinal metastases in debilitated patients with widespread malignancy and limited life expectancy. This therapeutic option should be considered in select cases as an alternative to either nonoperative management or anterior or posterolateral decompression and segmental stabilization.

Microsurgery of the cervical spine in elderly patients. Part 2: Surgery of malignant tumourous disease

In this retrospective study, the results of surgery were examined in 25 patients, 65 years of age or older, suffering from malignant tumour growth along the cervical spine. The group consisted of 17 men and 8 women. The mean age was 73 years, ranging from 66 to 88 years. The pathology identified was metastasis in 23 patients, and plasmocytoma in two. The tumour localization involved a single segment of the cervical spine in 12 patients, two segments in 8 patients, three segments in 4 patients, and four segments in one patient. Pre-operatively, 8 patients (32%) suffered solely from severe pain. 6 patients (24%) showed severe pain and radicular nerve compression. 5 patients (20%) had incomplete para- or tetraparesis but were able to walk, and again 6 patients (24%) had incomplete para- or tetraparesis, and were unable to walk. A multitude of accompanying systemic diseases was present in the majority of patients. Evaluation of the peri-operative risk profile was performed using the American Society of Anaesthesiology (ASA) Grading of Physical Status Score. Operation consisted of microsurgical tumour removal, usually incorporating a single- or multi-level vertebrectomy, with radical epidural decompression, and grafting with bone cement followed by an appropriate osteosynthesis. Of the whole cohort of patients treated, four patients were still alive at the time of the last follow-up evaluation. 21 patients died. Four patients died within seven days after surgery. The remaining 17 patients died during the follow-up period. All of these patients died from systemic spread of their primary cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine

The anterior approach to the thoracic and lumbar spine for neoplastic disease is now a well-accepted procedure, with results, for the most part, superior to those achieved with laminectomy. However, the specific indications for anterior decompression and the selection of reconstruction techniques based on the location and extent of bony destruction have received surprisingly little attention. The authors report their experience with the operative management of 33 patients with benign and malignant tumors of the thoracic and lumbar spine, using the anterior transthoracic or retroperitoneal approach. The role of stabilization and the relative indications for anterior or posterior instrumentation are emphasized. The mean age of patients was 58 years. Twenty-three patients were male. Five patients had benign tumors, and the remainder had a variety of metastatic lesions. Twenty-nine patients had lower extremity motor deficits, although 25 were ambulatory preoperatively. Thirty-seven noncontiguous resections were performed in 33 patients. In 13 patients, the resected vertebral body was replaced with acrylic or bone without instrumentation; in 18, the acrylic was supplemented with anterior instrumentation; and in 6, both anterior and posterior instrumentation were used. Above T11, vertebral reconstruction techniques were used to restore stability after decompression. Between T11 and L4, anterior instrumentation was used to supplement vertebral reconstruction in all patients. Supplemental posterior instrumentation was used for three-column involvement. Motor function was stabilized or improved in 94% of patients, and 88% of patients were ambulatory postoperatively. Of 28 patients with malignant disease, 23 died after a mean survival of 10.2 months (range, 2-51 mo) and 5 are alive a mean of 34.4 months since their operation.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of spinal cord compression in patients with advanced malignancy

We retrospectively evaluated the medical records of 17 hospice patients who developed spinal cord or cauda equina compression due to metastatic epidural tumor to ascertain the nature and outcome of the disorder in this setting. Epidural compression occurred following admission to the hospice in five cases and prior to admission in 12 cases. Six patients were ambulatory following treatment, and this favorable outcome occurred only in those who were ambulatory at diagnosis. In the group of patients who were paraplegic after treatment, problems related to pain, decubitus ulcers, and constipation were most challenging. This experience highlights the need for a more vigilant approach to back pain in patients at risk of epidural compression in the hospice setting. Further studies are necessary to establish the appropriate management of these patients.

Early diagnosis and treatment of spinal epidural metastasis in breast cancer: a prospective study

This prospective study evaluated the usefulness of myelography in breast cancer patients who present with radiculopathy or myelopathy. A total of 124 consecutive myelograms were performed in 100 patients. Epidural metastasis (EM) was diagnosed in 67 myelograms (54%). Multiple epidural metastases were diagnosed in 15 (22%) of those, resulting in a total of 87 epidural lesions. A complete block was found in 13 EM (15%) and an incomplete block in 14 EM (16%). Clinical data could not predict the site of EM in 29 cases (33%). Fifteen asymptomatic EM were detected in myelograms with multiple EM. Plain radiographs were of no value in determining the site of EM in 29 cases (33%), including 13 cases (15%) without vertebral metastasis at the site of EM. Treatment consisted of radiotherapy (RT) with or without systemic treatment in 52 cases (80%), systemic treatment alone in 11 cases (17%) and surgery in two patients (3%). Clinical improvement was noticed in 72%, no change in 13%, and deterioration in 15%. No difference in response was noticed between RT and systemic therapy. Before treatment 21% and after treatment 15% of the patients could not walk. The one year survival was 42%. The ambulatory status at presentation was the most important prognostic factor. Examination of the spinal fluid, obtained at myelography, disclosed meningeal carcinomatosis in 9% of the patients. Imaging of the whole spinal canal with cytological examination of the spinal fluid is recommended in breast cancer patients suspected of epidural tumour with features of radiculopathy or myelopathy, irrespective of further clinical data and plain spinal radiographs.

Radiation therapy in metastatic spinal cord compression. A prospective analysis of 105 consecutive patients

One hundred thirty consecutive patients with metastatic spinal cord compression (MSCC) were entered in a therapeutic protocol in which radiation therapy (RT) played the main role. When MSCC is diagnosed by clinical-radiologic methods such as myelography with or without computed tomography (CT) or magnetic resonance imaging (MRI), steroids are given and RT treatment started within 24 hours. When diagnostic doubts exist or stabilization is necessary, surgery precedes RT. Chemohormonal potentially responsive tumors are also treated with chemotherapy or hormonal therapy. Twelve patients (9.2%) underwent surgery plus RT, and 118 (90.8%) received RT alone. Thirteen (11%) early death patients were not evaluable. The 105 evaluable cases that received RT alone were analyzed. Median follow-up was 15 months (range, 4 to 38 months). Response among patients with back pain was 80%. In cases with motor dysfunction, 48.6% improved, and in 33 of 105 patients (31.4%) without motor disability there was no deterioration. Forty percent of patients with autonomic dysfunction responded to RT. Median survival time was 7 months with a 36% probability of survival for 1 year. The median duration of improvement was 8 months. The most important prognostic factor was early diagnosis. Radiosensitivity of tumor was only important in paraparetic patients in predicting response to RT. Complete myelographic block significantly diminished response to RT. Vertebral collapse did not influence response or survival.