Metástases do segmento torácico e lombar da coluna vertebral: estudo prospectivo comparativo entre o tratamento cirúrgico e radioterápico com a imobilização externa e radioterapia

Non-pharmacological interventions in patients with spinal cord compression: a systematic review

Spinal cord compression is a complex and challenging condition that greatly affects the quality of life. Non-pharmacological techniques have only been studied to a very lesser extent; although they are evidence to be beneficial. We performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) analysis of the scientific literature in several databases (Medline, Cochrane, Scopus, Cuiden, Pubmed, Lilacs and Embase); using the following keywords: spinal cord compression, spine compression, mobilization, positioning, brace and bracing. Eleven studies met the inclusion criteria and were finally included in the systematic review. 3 of them were related to metastatic spinal cord compression, 5 to spinal cord compression due to other causes and the last 3 of them regarded the health professional´s knowledge in oncology patients. In all cases, it seems possible to manage spinal cord compression by using external mobilization and braces and that this treatment is beneficial to patients. Positioning plays a massive role in the disease and can improve or worsen the condition when used improperly; the supine position is overused and can have a negative impact both physically and psychologically. Non-pharmacological interventions could be useful for pain management, cardiovascular alterations and patients' well-being. One randomized clinical trial demonstrated that massage therapy, using either broad compression massage or light contact touch massage improved pain control. There is an urgent need of randomized clinical trials with these interventions in order to achieve an improved care of these patients.

Direct decompressive surgery followed by radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression: a meta-analysis

STUDY DESIGN

A systemic review and meta-analysis.

OBJECTIVE

To compare the ambulatory status and survival for metastatic epidural spinal cord compression (MESCC) in patients treated with direct decompressive surgical resection (DDSR) followed by radiotherapy (RTx) with those in patients treated with RTx alone.

SUMMARY OF BACKGROUND DATA

Surgical techniques have remarkably evolved from decompressive laminectomy without ventral tumor excision to DDSR, which has displayed favorable outcomes since the 2000s. RTx alone has also evolved and is regarded to have accomplished outcome comparable with that of the surgery. The optimal treatment of MESCC has not been clearly defined yet.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane library in July 2013. Comparative studies enrolled patients with similar performance, primary cancer, age, and sex at the baseline state were included. Outcome measures included ambulatory status and overall survival rate. We did a fixed-effects meta-analysis of the ambulatory status and survival in patients with MESCC compared with DDSR+RTx and RTx alone.

RESULTS

Five studies were used to obtain data from 238 and 1137 patients treated with DDSR+RTx and RTx alone, respectively. The DDSR+RTx group displayed substantial improvement in ambulatory status after the treatment that was superior to the improvement in the RTx-alone group (relative risk [RR], 1.43; 95% confidence interval [CI], 1.14-1.78) in a fixed-effects model and significantly lower deterioration after treatment than the RTx group (RR, 0.35; 95% CI, 0.19-0.63). The DDSR+RTx group showed significant improvement in the survival rate at 6 months post-treatment (RR, 1.21; 95% CI, 1.09-1.33). Similar findings were observed at 12 months post-treatment (RR, 1.32; 95% CI, 1.12-1.56).

CONCLUSION

The meta-analysis indicates that DDSR+RTx may produce better clinical improvement of ambulation status and survival than RTx alone in the treatment of MESCC. Additional prospective studies are warranted to better address this question.

LEVEL OF EVIDENCE

1.

Single-stage posterior decompression and stabilization for metastasis of the thoracic spine: prognostic factors for functional outcome and patients' survival

BACKGROUND CONTEXT

There are limited data analyzing radiological and clinical factors for the functional outcomes of surgery for spinal metastasis. Also, there are few studies to investigate the relationship between the functional outcome and the patients' survival. Thus, analysis of both functional outcomes and the survival with their relationship in a possibly homogenous group of patients is worth being reported.

PURPOSE

To assess treatment outcomes of single-stage posterior decompression and stabilization (PDS) with or without corpectomy for thoracic vertebral metastases and to analyze factors affecting both the functional outcome and the patients' survival after the surgical intervention.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

A consecutive series of 105 patients, who underwent the previously stated surgery for metastatic spinal cord compression (MSCC) of thoracic spine, were included and retrospectively analyzed.

OUTCOME MEASURES

The postoperative functional outcomes were evaluated using visual analog scale and Frankel grade at postoperative 2 weeks, and all patients were followed for survival analysis.

METHODS

An institutional database was searched to identify all patients who underwent single-stage PDS for thoracic metastatic spinal tumors between March 2002 and June 2010. Demographic data as well as preoperative and postoperative medical conditions were collected from medical records. Radiological findings were confirmed on electronic archive. Survival data were obtained either on medical records or with a reference to governmental cancer registry system.

RESULTS

Postoperative pain improvement was more evident in patients receiving anterior column reconstruction and four or more levels of fixation (p=.02 and <0.01, respectively). Twenty-one patients (20%) showed improvement of the Frankel grade, and 10 of 21 Frankel C patients became ambulatory. The preoperative Karnofsky Performance Scale (≥70) and ambulatory status were significant predictors for the postoperative ambulatory function. After surgery, the median overall survival of the patients was 6.0 months. In the univariate analysis, the patient's age (younger than 60 years), type of primary cancer (ie, moderate and slow growth), no visceral metastases, less than three levels of spinal metastases, and postoperative adjuvant therapy were positively significant for the patients' survival (p<.05). In the multivariate analysis, limited (less than three levels) spinal metastases and postoperative adjuvant therapy were proven to significantly prolong the patient's survival (hazard ratios of 0.53 and 0.48, respectively, p<.05). Although the functional outcomes did not directly influence the patients' survival, the patients with better functional outcome showed increased chance of receiving postoperative adjuvant therapy (p<.01).

CONCLUSIONS

Single-stage PDS with or without corpectomy effectively improved the functional status of patients with MSCC of the thoracic spine and also afforded the patients to have more chances of postoperative adjuvant therapy, which was significant for patients' survival. Therefore, we suggest that the role of surgery in the management of MSCC could be not only a symptomatic palliation but also a strategy to prolong patients' survival.