The management of malignant spinal cord compression compression

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Choosing the right operation for metastatic spinal tumours is often difficult, and depends on many factors, including life expectancy and the balance of the risk of surgery against the likelihood of improving quality of life. Several prognostic scores have been devised to help the clinician decide the most appropriate course of action, but there still remains controversy over how to choose the best option; more often the decision is influenced by habit, belief and subjective experience. The purpose of this article is to review the present systems available for classifying spinal metastases, how these classifications can be used to help surgical planning, discuss surgical outcomes, and make suggestions for future research. It is important for spinal surgeons to reach a consensus regarding the classification of spinal metastases and surgical strategies. The authors of this article constitute the Global Spine Tumour Study Group: an international group of spinal surgeons who are dedicated to studying the techniques and outcomes of surgery for spinal tumours, to build on the existing evidence base for the surgical treatment of spinal tumours.

Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis

STUDY DESIGN

Prospective study.

OBJECTIVE

To evaluate our treatment outcome for spinal metastases using our treatment strategy based on prognostic scoring system.

SUMMARY OF BACKGROUND DATA

In the treatment of spinal metastases, life expectancy is most important, and our scoring system for metastatic spine tumor prognosis has been useful for such prognostic evaluation.

METHODS

Conservative treatment or palliative surgery was indicated in patients with a predicted prognosis of less than 6 months or in those with multiple vertebral metastases, whereas excisional surgery was performed in patients with a predicated prognosis of 1 year or more, or with a predicted prognosis of 6 months or more, and with metastasis in a single vertebra. One hundred eighty-three patients were prospectively treated according to this principle using our prognostic scoring system, and the outcome was evaluated.

RESULTS

The consistency rate between the predicted prognosis from the criteria of the scoring system and the actual survival period was high in patients within each score range (0-8, 9-11, or 12-15), 87.9% in the 183 patients. Only the palliative surgery group (n = 55) showed a significant improvement of the Barthel index between before and after treatment (P < 0.01). The mean maximum Barthel index after treatment in any modality ran parallel to the total scores of our scoring system.

CONCLUSION

The prognostic criteria using our scoring system were useful for the pretreatment evaluation of prognosis irrespective of the treatment modality. In any treatment, the survival period of the patients affected the functional prognosis; therefore, it may be appropriate and realistic to select treatment methods by giving first priority to the life expectancy of patients.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Surgical Management of Spinal Metastases

Metastatic spread to the spinal column is a growing problem in patients with cancer. It can cause a number of sequelae including pain, instability, and neurologic deficit. If left untreated, progressive myelopathy results in the loss of motor, sensory, and autonomic functions. Except in rare circumstances, treatment is palliative. Traditionally, conventional fractionated external beam radiotherapy has been the treatment of choice. "Surgery" for metastatic spinal disease was, and generally continues to be, equated with laminectomy by many physicians. However, there has been a remarkable evolution in surgical techniques over the last 20 years. Today, the goal of surgery is to achieve circumferential decompression of the neural elements while reconstructing and immediately stabilizing the spinal column. This has been made possible by the use of different surgical approaches and the exploitation of a burgeoning array of internal fixation devices. More recently, minimally invasive surgical techniques, such as endoscopy, kyphoplasty/vertebroplasty, and stereotactic radiosurgery, have been added to the surgeon's armamentarium. As the number of treatment options for metastatic spinal disease grows, it has become clear that effective implementation of treatment can only be achieved by a multidisciplinary approach. This will provide the surest means of maximizing the quality of the remainder of the patient's life.