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

An analysis of decision making and treatment in thoracolumbar metastases

STUDY DESIGN

Systematic review of literature.

OBJECTIVE

To determine whether surgical approach and technique to be used in thoracolumbar metastases is influenced by anatomic region of the spine.

SUMMARY OF BACKGROUND DATA

There is a significant debate about the best surgical approach for the treatment of thoracolumbar metastasis.

METHODS

Two research questions below were determined through a consensus among a panel of spine experts. A systematic review of literature was conducted using Pubmed. The search terms included "spin*" and "metasta*." This was to include the terms, "metastatic," "metastasis," "metastases," "spinal," and "spine." 1. In the T2 to T5 region, what is the impact of different surgical approaches (anterior, posterior, combined anteroposterior [AP]) on local recurrence, adverse events, pain alleviation, and neurologic recovery? 2. Within the thoracolumbar spine (T6-T10; T11-L2; and L3-L5) what is the impact of different surgical approaches on outcomes as per question one. The results of the systematic review were discussed with spine oncology experts through a modified Delphi technique to arrive at treatment recommendations.

RESULTS

From the search terms used 5176 abstracts were found. Based on the review of these abstracts, 161 were deemed acceptable. These abstracts were reviewed according to an inclusion and exclusion criteria, leaving 60 articles. These 60 articles were reviewed in detail leaving 32 articles for inclusion. There was no level I study. There was 1 level II study, 5 level III studies, and 26 level IV studies. Most of these studies selected their approach by tumor topography. The quality of evidence was very low.

CONCLUSION

There is very low quality evidence to support the superiority of one approach over another. There is a strong recommendation for posterior or posterior-lateral approach from T2 through T5. For the T6-L5 regions of the spine we recommend either anterior, posterior, or combined anterior and posterior surgery depending on the clinical presentation, surgeon and patient preference.

The effect of early surgical treatment on recovery in patients with metastatic compression of the spinal cord

We analysed the influence of the timing of surgery (< 48 hours, group 1, 21 patients vs > 48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression.

Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%).

These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.

Neurological outcome following laminectomy in spinal metastases

STUDY DESIGN

Retrospective outcome measurement study.

OBJECTIVES

Patients suffering from malignant tumour disease and metastases to the spine develop a variety of clinical complaints including radicular symptoms and/or spinal cord compression syndromes. Palliative decompressive laminectomy with total or partial tumour resection is an acknowledged method of treatment, despite controversy.

SETTING

The Department of Neurosurgery of the University of Vienna.

METHOD

Patients suffering from metastases with predominant infiltration of the dorsal epidural parts, or patients who could not be operated on via an anterior approach, were included. Eighty-four patients who met these criteria underwent decompressive laminectomy with total or partial tumour removal. The study analyzed motor function, pain relief and continence in a 2- and 4-month post-operative follow-up. According to the criteria of motor performance, 20% of the patients had been mobile pre-operatively.

RESULTS

In the immediate post-operative period 45%, after 2 months 33% and after 4 months 26%, were considered mobile. None of the paraplegic patients showed functional improvement. The median survival time was 6.5 months. Pre-operatively, 56% of the patients had shown continence dysfunction. Post-operatively, 38%, and after 2 months 46% of the patients, developed continence disorders. A significant reduction in analgesic medication was also observed in the post-operative period.

CONCLUSION

In our series, palliative laminectomy with total or subtotal tumour reduction in patients with malignant spinal metastatic disease resulted in amelioration of motor function, pain and continence and therefore improved the patients' quality of life. The improvement in quality of life shows that this method is a valuable option in neurosurgical therapy, except for cases with pre-operative paraplegia. However, in patients with severe pre-operative paraparesis, the authors recommend laminectomy only in very exceptional cases, because of the poor post-operative neurological results.