Prognostic Factors and Comparison of Conservative Treatment, Percutaneous Vertebroplasty, and Open Surgery in the Treatment of Spinal Metastases from Lung Cancer

Overall Survival of Non-Small Cell Lung Cancer With Spinal Metastasis: A Systematic Review and Meta-Analysis

OBJECTIVE

The long-term survival data of lung cancer patients with spinal metastases are crucial for informed treatment decision-making. However, most studies in this field involve small sample sizes. Moreover, survival benchmarking and an analysis of changes in survival over time are required, but data are unavailable. To meet this need, we performed a metaanalysis of survival data from small studies to obtain a survival function based on largescale data.

METHODS

We performed a single-arm systematic review of survival function following a published protocol. Data of patients who received surgical, nonsurgical, and mixed modes of treatment were meta-analyzed separately. Survival data were extracted from published figures with a digitizer program and then processed in R. Median survival time was used as an effect size for moderator analysis to explain the heterogeneity.

RESULTS

Sixty-two studies with 5,242 participants were included for pooling. The survival functions showed a median survival of 6.72 months for surgery (95% confidence interval [CI], 61.9-7.01; 2,367 participants; 36 studies), 5.99 months for nonsurgery (95% CI, 5.33-6.47; 891 participants; 12 studies), and 5.96 months for mixed (95% CI, 5.67-6.43; 1,984 participants; 18 studies). Patients enrolled since 2010 showed the highest survival rates.

CONCLUSION

This study provides the first large-scale data for lung cancer with spinal metastasis that allows survival benchmarking. Data from patients enrolled since 2010 had the best survival and thus may more accurately reflect current survival. Researchers should focus on this subset in future benchmarking and remain optimistic in the management of these patients.

Balloon kyphoplasty as palliative care for painful pathological spinal fracture followed by lung cancer metastasis: A cohort study

Background

Pathological spine fractures caused by metastases of lung cancer have brought great suffering to patients. Percutaneous kyphoplasty (PKP) has been considered a preferred alternative for painful spinal metastases. The clinical efficacy and safety of PKP for metastatic spinal lesions are urgently to be evaluated.

Methods

A cohort study was conducted on 54 cases with pathologic spine fractures caused by metastasis of lung cancer. The correction of kyphosis was assessed by the Cobb angle. The life dependence and quality of the patients were evaluated by the Barthel Index of activities of daily living (ADL) and the quality-adjusted life year (QALY). Patients' survival was carefully recorded.

Results

PKP significantly corrected the kyphosis compared with conservative treatment. The ratio of moderate dependence after fracture was clearly increased by PKP. QALY indicated a better life quality brought by PKP. However, PKP could not improve the survival rate of patients.

Conclusion

PKP can be used as an effective palliative care treatment for patients with metastatic pathologic spinal fractures of lung cancer.

Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review

Systemic assessment is a pillar in the neurological, oncological, mechanical, and systemic (NOMS) decision-making framework for the treatment of patients with spinal metastatic disease. Despite this importance, emerging evidence relating systemic considerations to clinical outcomes following surgery for spinal metastatic disease has not been comprehensively summarised. We aimed to conduct a scoping literature review of this broad topic. We searched MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and CINAHL databases from Jan 1, 2000, to July 31, 2021. 61 articles were included, accounting for a total of 22 335 patients. Preoperative systemic variables negatively associated with postoperative clinical outcomes included demographics (eg, older age [>60 years], Black race, male sex, low or elevated body-mass index, and smoking status), medical comorbidities (eg, cardiac, pulmonary, hepatic, renal, endocrine, vascular, and rheumatological), biochemical abnormalities (eg, hypoalbuminaemia, atypical blood cell counts, and elevated C-reactive protein concentration), low muscle mass, generalised motor weakness (American Spinal Cord Injury Association Impairment Scale grade and Frankel grade) and poor ambulation, reduced performance status, and systemic disease burden. This is the first comprehensive scoping review to broadly summarise emerging evidence relevant to the systemic assessment component of the widely used NOMS framework for spinal metastatic disease decision making. Medical, surgical, and radiation oncologists can consider these findings when prognosticating spinal metastatic disease-related surgical outcomes on the basis of patients' systemic condition. These factors might inform a shared decision-making approach with patients and their families.

Posterior Decompression Surgery and Radiofrequency Ablation Followed by Vertebroplasty in Spinal Metastases from Lung Cancer

Background

Spinal metastases can cause metastatic epidural spinal cord compression (MESCC), which can result in neurological dysfunction and impaired quality of life. This study investigated the safety and effectiveness of posterior decompression surgery and radiofrequency ablation followed by vertebroplasty in spinal metastasis from lung cancer.

Material/Methods

From June 2008 to September 2015, a retrospective analysis was conducted in 15 patients with spinal metastasis from lung cancer. All cases suffered MESCC and underwent posterior decompression surgery to relieve the compression of spinal cord, and had radiofrequency ablation followed by vertebroplasty. All patients received postoperative multidisciplinary therapy. The operative time, blood loss, complications, pain, neurologic deficit, quality of life, and survival were assessed preoperatively and postoperatively.

Results

Patients were followed from 6 to 56 months. The mean time of operation was 154±50 minutes and the mean blood loss was 210±90 mL. In the pre-operation analysis found the mean visual analogue scale (VAS) was 7.86±0.86. In the post-operation analysis at 3 months, the mean VAS score was 3.51±1.32. The VAS improved significantly (t=7.95, P<0.01). The Frankel grade was improved 1 grade or 2 grades in 14 patients when pre-operation was compared to post-operation. Only 1 patient kept Frankel grade D after surgery. Eight patients with sphincteric dysfunction preoperatively were improved after surgery. The EORTC QLQ-C30 score was 86.13±8.51 preoperatively and 52.21±13.28 postoperatively. The quality of life was improved significantly (t=11.8, P<0.01). The median survival time was 11 months.

Conclusions

Through posterior decompression surgery and radiofrequency ablation followed by vertebroplasty, the quality of life was improved significantly. This palliative treatment was effective and safe in spinal metastasis from lung cancer.

Long Term Survival of Pathological Thoracolumbar Fractures Treated with Vertebroplasty: Analysis Using a Nationwide Insurance Claim Database

Background: There are still debates on the long-term outcome of treating pathological thoracolumbar fractures, including osteoporosis and oncologic problems, using vertebroplasty. Methods: We collected 8625 patients with pathological thoracolumbar fractures (ICD-9-CM codes 733.13 combined with 805.2 or 805.4) between the years of 2003 to 2013, from the two million random samples from the National Health Insurance Research Database in Taiwan. Survival analysis was conducted to estimate the mortality risks of different treatments, including vertebroplasty (n = 1389), conventional open surgery (n = 1219), or conservative treatment (n = 6017). A multivariable Cox proportional hazard model was constructed for adjustment of age, gender, comorbidities and complications. Results: Crude incidence rate of patients with pathological thoracolumbar fractures in Taiwan gradually increased year by year. Compared with conservative treatment, conventional open surgery and vertebroplasty seemed to improve long-term survival with adjusted hazard ratios (aHR) of 0.80 (95% confidence interval (CI) 0.70–0.93), and 0.87 (95% CI 0.77–0.99), respectively. The survival advantage of vertebroplasty appeared more evident for those aged over 75. However, we were unable to rule out confounding by indication. Conclusion: Although conventional open surgery would usually be the best choice for the treatment of patients with pathological thoracolumbar fractures, database information from current real-world practice appears to support vertebroplasty as a viable choice for elderly people over 75 years of age.

A study on the puncture method of extrapedicular infiltration anesthesia applied during lumbar percutaneous vertebroplasty or percutaneous kyphoplasty

Extrapedicular infiltration anesthesia (EPIA) was reported for percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) and provided good local anesthetic effects. Because of differences in anatomical morphology at each lumbar level, the puncture method of EPIA is not uniform in each lumbar vertebrae. To accurately insert the anesthetic needle into the extrapedicular region, we researched the puncture method of EPIA at each lumbar level.We retrospectively analyzed computed tomography (CT) images in 230 patients with lumbar osteoporotic fractures, including 59 L1 fractures, 54 L2 fractures, 50 L3 fractures, 36 L4 fractures, and 31 L5 fractures. The puncture of EPIA was simulated in every fractured vertebrae through CT, and the skin puncture point, puncture direction, and puncture depth of the anesthetic needle were observed. These specific parameters were the distance from the skin puncture point to the superior border of the pedicle projection on the skin (distance AD), distance from the skin puncture point to the lateral border of the pedicle projection on the skin (distance BC), sagittal section angle (SSA), transverse section angle (TSA), and depth of EPIA.As the lumbar ordinal number increased, the SSA, distance AD, TSA, and distance BC for each lumbar level gradually increased, and the puncture depth gradually decreased, all these parameters showed significant differences among the 5 lumbar levels (P < .001). The recommended puncture methods for EPIA at each lumbar level, including distance AD, distance BC, SSA, and TSA, were as follows: in L1, 4 mm, 8 mm, 9° and 8°; in L2, 6 mm, 10 mm, 11° and 10°; in L3, 9 mm, 13 mm, 12° and 12°; in L4, 12 mm, 18 mm, 16° and 18°; and in L5, 20 mm, 26 mm, 24° and 24°. The depth of EPIA was 13 mm in L1-L3 and 11 mm in L4-L5.By confirming the skin puncture point and puncture direction of the anesthetic needle, from an anatomical perspective, EPIA is feasible for lumbar PVP (PKP).