Complication avoidance in vertebral column spine tumors

The role of surgery for metastatic spine disease is palliative with the goals of achieving excellent neurologic and functional status, spinal stability, pain relief, and local tumor control. Although patients with metastatic spine tumors often have numerous medical and oncologic issues, careful perioperative planning and surgical techniques can help limit complications and help improve patient outcomes significantly.     

Laminectomy for metastatic epidural spinal cord tumors. Posterior stabilization, radiotherapy, and preoperative assessment

In a retrospective analysis of 149 patients with metastatic spinal tumors, the postoperative outcome was compared in patients who had posterior decompressive laminectomies alone (PL) and patients who had supplemental posterior stabilization at the time of laminectomy (PLS). The object of the analysis was to define the indications for stabilization. Posterior stabilization relieved pain, improved sphincter function, and encouraged ambulatory status. The use of adjunctive radiotherapy preceding laminectomy did not significantly improve the patient's postoperative course. Sex, age, initial symptom, length of time from onset of initial neurologic symptom to the time of laminectomy, the presence or duration of pain or sensory loss, the number of vertebrae involved with tumor, and the presence of widespread metastatic disease did not seem to influence the results of the surgical treatment. The presence of significant motor dysfunction, which was rapidly progressive before surgery, or profound sphincteric dysfunction prior to decompressive laminectomy was more frequent in patients who had unsatisfactory results. Decompressive laminectomy with stabilization should be considered in patients: with progressive neurologic symptoms, who are ambulatory, but whose pain increases despite radiotherapy, and who are ambulatory and were receiving radiotherapy for pain relief but who display neurologic dysfunction. For patients with established paraplegia and sphincter dysfunction, decompressive laminectomy and posterior stabilization are adjunctive measures of pain control.     

脊柱转移性肿瘤的手术切除与脊柱稳定性重建

目的观察脊柱转移性肿瘤的手术切除和脊柱稳定性重建的外科疗效。方法对29例脊柱转移眭肿瘤患者进行脊椎肿瘤切除减压，单纯植骨或钛网、人工椎体植骨加椎弓根钉棒或钢板螺钉内固定，一期重建脊柱稳定性，术后根据病理结果均给予化疗、放疗和激素等综合治疗。观察术后局部疼痛缓解，脊髓神经功能恢复及脊柱椎节的稳定性情况。结果随访6个月～62个月，平均26个月。所有病人术后局部疼痛缓解，脊髓神经功能无加重损伤，其中12例患者脊髓神经功能得到不同程度恢复。术后影像学检查提示：脊柱内固定物在位，椎体序列恢复良好，椎问高度恢复。结论脊柱转移性肿瘤的手术切除和脊柱稳定性重建的外科疗效肯定，适应征具备者应积极手术治疗。     

Treatment of spinal cord tumors

Opinion statement  Tumors associated with the spinal cord can have devastating effects on patient function and quality of life. Most of these tumors are from metastatic disease, usually to the epidural space. Less frequently, the tumors are intrinsic to the spinal cord itself (ie, primary tumor). Regardless of the etiology, spinal cord tumors often present first with progressive local or radicular pain, or both. Other symptoms include weakness, sensory changes, or sphincter dysfunction. The timeliness of diagnosis of spinal cord tumors and promptness of treatment are important, as they directly affect outcome. Dexamethasone, a corticosteroid, is used as a temporizing measure to improve or stabilize neurologic function until definitive treatment. For nonambulatory patients with epidural metastatic tumors, surgery followed by radiation therapy maximizes neurologic function and modestly lengthens survival. However, palliative radiotherapy alone is recommended for those with neurologic deficits lasting longer than 48 hours, survival prognosis less than 3 months, inability to tolerate surgery, multiple areas of compression, or radiosensitive tumors. An ambulatory patient with a stable spine should be considered for radiation treatment only. The role of chemotherapy for epidural metastatic tumors is not well established. For intramedullary metastases, the role of surgery and chemo therapy remains controversial and radiation is the mainstay. For low-grade or benign primary spinal cord tumors, resective surgery is of benefit and can be curative. For high-grade tumors, the benefit of resection is less clear, and radiotherapy and/or chemotherapy may be helpful. The use of chemotherapy for primary spinal cord tumors has rarely been assessed. Agents reported in the literature for treatment of spinal cord gliomas include temozolomide, irinotecan, cisplatin, and carboplatin. A multidisciplinary approach is often required to maximize the therapeutic and functional outcome of patients with metastatic and primary spinal cord tumors.     

An Overview of Decision Making in the Management of Metastatic Spinal Tumors

IntroductionSpinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern ‘separation’ surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors.MethodsA MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed.DiscussionTreatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatmentConclusionThe management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.     

Complication, survival rates, and risk factors of surgery for metastatic disease of the spine.

STUDY DESIGN: The risk factors for complications and complication and survival rates in patients with metastatic disease of the spine were reviewed. A retrospective study was performed. OBJECTIVES: To determine the surgical complication and survival rates of patients with metastatic disease of the spine and risk factors for complication occurrence. SUMMARY OF BACKGROUND DATA: The role of surgical intervention for patients with metastatic disease of the spine has been controversial. Several risk factors for surgical complications have been identified. Short survival times and high complication rates have failed to justify surgical intervention in many cases. METHODS: Patients (n = 80) undergoing surgical treatment for metastatic disease of the spine were reviewed. Surgical indications included progressive neurologic deficit, neurologic deficit failing to respond to, or progressing after, radiation treatment; intractable pain; radioresistant tumors; or the need for histologic diagnosis. Patients underwent anterior, posterior, or combined decompression and stabilization procedures. Neurologic examination was recorded before surgery, postoperative period, and at least follow-up. Complication and survival rates were calculated. Several variables were examined for risk of complication. RESULTS: The mean age at time of surgery was 55.6 years (range, 20-84 years). Mean survival time after the diagnosis of spinal metastasis was 26.0 months (range, 1-107.25 months). Mean survival time after surgery was 15.9 months (range, 0.25-55.5 months). Sixty-five patients showed no change in Frankel grade, 19 improved one Frankel grade, and 1 deteriorated one Frankel grade; 1 patient had paraplegia. Thirty-five complications occurred in 20 patients (25.0%). Ten patients (12.5%) had multiple complications accounting for 23 of the 35 postoperative problems (65.7%). Sixty patients had no surgical complications (75%). There were no intraoperative deaths. CONCLUSIONS: The likelihood that a complication occurred was significantly related to Harrington classifications demonstrating significant neurologic deficits and the use of preoperative radiation therapy. In general, Harrington classifications with neurologic deficits and lower Frankel grades before and after surgery were associated with an increased risk of complication. Overall, the major complication rate was relatively low, and minor complications were successfully treated with minimal morbidity. The relatively long survival time after spinal surgery in this group of patients justifies surgical treatment for metastatic disease. Most complications occurred in a small percentage of patients. To minimize complications, patients must be carefully selected based on expected length of survival, the use of radiation therapy, presence of neurologic deficit, and impending spinal instability or collapse caused by bone destruction.     

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life

STUDY DESIGN: Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively. OBJECTIVES: To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases. SUMMARY OF BACKGROUND DATA: The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential. METHODS: The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted. RESULTS: First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients. CONCLUSIONS: Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.     

Surgical treatment of metastatic spine disease.

The results of surgical intervention for metastatic disease on 56 consecutive patients since 1980 were reviewed. Two patients underwent a second procedure to stabilize remote levels of spinal involvement, for a total of 58 surgeries. All 56 patients presented with pain. After surgery, significant relief was noted by 51 (91%). Twenty-seven patients presented with neurologic compromise. After operation, neurologic improvement was noted in 20 (74%). No patient's neurologic function deteriorated secondary to surgical intervention. Twenty-one patients were bedridden before surgery secondary to pain or paresis. After operation, improvement in activity level was achieved in 16 (76%) of these patients. In summary, the goal of surgical treatment of metastatic spine disease is to improve the quality of the remaining life, by the relief of pain and preservation or restoration of neurologic function. The dismal consequences of prolonged bed rest, paraplegia, and a painful premature demise can be avoided with thoughtful and timely surgical intervention.     

Spinal instability as defined by the spinal instability neoplastic score is associated with radiotherapy failure in metastatic spinal disease

Background contextAlthough radiotherapy is effective in achieving pain relief in most patients, it is not completely understood why some patients respond well to radiotherapy and others do not. Our hypothesis was that metastatic bone pain, if predominantly caused by mechanical instability of the spine, responds less well to radiotherapy than metastatic bone pain caused by local tumor activity. Recently, the spinal instability neoplastic score (SINS) was proposed as a standardized referral tool for nonspine specialists to facilitate early diagnosis of spinal instability.PurposeTo investigate the association between spinal instability as defined by the SINS and response to radiotherapy in patients with spinal metastases.Study designA retrospectively matched case-control study in an academic tertiary referral center, conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.Patient sampleThirty-eight patients with spinal metastases who were retreated after initial palliative radiotherapy from January 2009 to December 2010 were matched to 76 control patients who were not retreated.Outcome measuresRadiotherapy failure as defined by retreatment (radiotherapy, surgery, and conservative) after palliative radiotherapy for spinal metastases.MethodsRadiotherapy planning computed tomography scans were scored by a blinded spine surgeon according to the SINS criteria. The association between SINS and radiotherapy failure was estimated by univariate and multivariate conditional logistic regression analysis.ResultsMedian SINS was 10 (range 4–16) for cases and 7 (range 1–16) for controls. The SINS was significantly and independently associated with radiotherapy failure (adjusted odds ratio, 1.3; 95% confidence interval, 1.1–1.5; p=.01).ConclusionsThis study shows that a higher spinal instability score increases the risk of radiotherapy failure in patients with spinal metastases, independent of performance status, primary tumor, and symptoms. These results may support the hypothesis that metastatic spinal bone pain, predominantly caused by mechanical instability, responds less well to radiotherapy than pain mainly resulting from local tumor activity.     

Metastatic spinal cord compression — options for surgical treatment

Summary Fourty-three cases with metastatic spinal cord compression were reviewed post-operatively to clarify the usefulness of the procedures concerning restoration of neurological function, and pain relief. Only patients with pathological spinal instability and neurological sequelae were included. Posterior decompression and stabilization was performed in all but six patients. All but four patients (91%) reported decrease of pain symptoms. Amelioration of neurological function was achieved in 58%. Re-establishment of walking ability was obtained in 57%. Post-surgery life expectancy averaged 11 months. In patients with widespread metastatic disease and/or multi-level instability of the spine restriction to palliative dorsal procedures is sensible. Post-operative ancillary treatment is necessary.     

Radiotherapy of Bone Metastasis in Breast Cancer Patients - Current Approaches

Bone metastases (BM) represent the most frequent indication for palliative radiotherapy in patients with breast cancer. BM increase the risk of skeletal-related events defined as pathological fractures, spinal cord compression, and, most frequently, bone pain. The therapeutic goals of palliative radiotherapy for BM are pain relief, recalcification, and stabilization, reducing spinal cord compression and minimizing the risk of paraplegia. In advanced tumor stages radiotherapy may also be used to alleviate symptoms of generalized bone metastasis. This requires an individual approach including factors, such as life expectancy and tumor progression at different sites. Side effects of radiation therapy of the middle and lower spine may include nausea and emesis requiring adequate antiemetic prophylaxis. Irradiation of large bone marrow areas may cause myelotoxicity making monitoring of blood cell counts mandatory. Radiotherapy is an effective tool in palliation treatment of BM and is part of an interdisciplinary approach. Preferred technique, targeting, and different dose schedules are described in the guidelines of the German Society for Radiooncology (DEGRO) which are also integrated in 2012 recommendations of the Working Group Gynecologic Oncology (AGO).     

Die transorale Vertebroplastie

Analogue to the demographic changes and the accompanying increased incidence of tumorous diseases, the number of patients with metastatic bone tumors of the spine is also increasing. Metastatic bone tumors are the most significant cause of pain in cancer patients. Pain and instability are the main indications for surgery. Minimally invasive procedures are recommended in patients with a poor medical condition and with a poor prognosis. Transoral vertebroplasty can be successfully used to reduce pain and provide stability in the palliative treatment of metastases of the vertebral axis. This procedure has the advantage of providing rapid pain relief and spinal stabilization. The operative technique is described and discussed with reference to the current literature. As an example the case of a 67-year-old patient is described, who was suffering from prostate cancer and a painful metastasis of the dens axis. After interdisciplinary consensus, transoral vertebroplasty was performed. The procedure was effective in achieving pain relief and providing stability and 7 months after the operation no further spinal metastases had occurred.     

Treatment strategies of space-occupying intradural metastases of the cauda equina of nonneurogenic origin

Background  Compressive intradural metastases of the cauda equina are a rare site of metastatic spread in systemic cancer. So far, only few reports have been published with conflicting statements concerning a surgical versus nonsurgical approach. Method  Five patients with symptomatic space-occupying intradural metastases of the cauda equina were analyzed retrospectively, focusing on the influence of surgical intervention on pain relief, neurological outcome and thus the patients’ quality of life. Findings  At the time of diagnosis, all patients were in an advanced metastatic state. Surgical resection was the primary treatment in four patients and radiotherapy in one. Despite infiltration of the cauda rootlets, gross total tumour resection could be achieved in two of the four patients treated surgically. Functional outcome was beneficial in these patients with marked and immediate relief of pain and improvement of motor function even following incomplete tumour resection. Conclusions  Surgical treatment of compressive intradural metastases of the cauda equina seems to be feasible with low operative risk and with the potential benefit of an immediate relief of pain and improvement in motor function and thus an increase in quality of life.     

Percutaneous vertebroplasty for pain relief and spinal stabilization

STUDY DESIGN: This was a retrospective review of 47 consecutive patients (1995-1998) in whom percutaneous intraosseous methylmethacrylate cement injection (percutaneous vertebroplasty) was used to treat osteoporotic vertebral compression fractures and spinal column neoplasms. OBJECTIVES: To present initial results regarding pain relief, spinal stabilization, and complications after treatment with percutaneous vertebroplasty. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty was developed in France in the late 1980s. Several European reports have described excellent results for treatment of compression fractures and neoplasms. The procedure was not performed in the United States until 1994. Only a single series of 29 patients treated in the United States has been reported. METHODS: A retrospective review was conducted of 47 consecutive patients with 84 vertebrae treated with percutaneous vertebroplasty. Thirty-eight patients with 70 vertebrae had symptomatic, osteoporotic fractures and had failed medical therapy. Eight patients with 13 vertebrae had primary or metastatic neoplasms. One patient had a hemangioma. Immediate and long-term pain response, spinal stability, and complications were evaluated. RESULTS: Among the 38 patients treated for osteoporotic fractures, 24 (63%) had marked to complete pain relief, 12 (32%) moderate relief and 2 (5%) no significant change. Only 4 of the 8 patients with malignancies had significant pain relief. In 7 of these patients, no further vertebral compression occurred, and spinal canal compromise was prevented. The patient with the hemangioma had no significant pain reduction. Minor complications occurred in 3 (6%) patients. CONCLUSIONS: Percutaneous vertebroplasty provided significant pain relief in a high percentage of patients with osteoporotic fractures. The procedure provided spinal stabilization in patients with malignancies but did not produce consistent pain relief. Complications were minor and infrequent. Percutaneous vertebroplasty is a promising therapy for patients with osteoporotic fractures and for selected vertebral column neoplasms.     

Decompression/Stabilization of the Metastatic Spine: Cotrel-Dubousset-Lnstrumentation in 50 Patients Jan

50 patients with metastatic disease of the spine underwent dorsal decompression and stabilization with the Cotrel-Dubousset-lnstrumentation from 1987 to 1991. Indications for surgical treatment were neurologic deficit, spinal instability, and/or pain resistant to medical or radiation treatment. No external orthotics were used postoperatively. Pain was relieved dramatically in 45 patients. Among 25 patients suffering from neurologic deficit preoperatively, 13 improved, 15 remained unchanged, whereas 2 developed an incomplete, transient paraplegia. 15 (7) patients were alive after 1 (2) years. Postoperative complications were frequent, but there were only 2 failures of the stabilization device requiring reoperation.     

The results of surgical treatment of primary spinal tumors

A series of 72 primary spinal tumors including 57 malignant and 15 benign ones were treated surgically from the years 1961 to 1987. Neurologic complications developed in 52 patients, with paraplegia in 20, spastic paraparesis in 19, cauda damage in 11, and brachial plexus injury in two cases. The principles of the treatment were excision of the tumor, decompression of nervous elements, and stabilization of the spine. Surgical treatment was supplemented with radiotherapy or chemotherapy, or both. In the group of benign tumors, no deaths occurred and the clinical results were good. The results obtained in the group of malignant neoplasms were evaluated according to survival time and were analyzed separately for the dying and the surviving patients. In this group of 57 patients, 42 died, 17 dying within one year (three died from postoperative complications). In the remaining 25 patients surviving over one year, the mean survival time was four years and four months. Fifteen patients are alive, and their mean survival is five years and three months. The neurologic results in 39 patients surviving over six months were good in 92.3% of cases. Regression, or significant improvement of neurologic disturbances, was of considerable importance for the survival time. At the present time, surgical treatment combined with radiotherapy and chemotherapy is the most favorable method for the treatment of primary spinal tumors.     

Reconstructive spinal surgery as palliation for metastatic malignancies of the spine

Metastatic tumors of the spine often cause severe pain and paralysis because of deformity and neural encroachment. As oncology now extends the life expectancies of these patients, spinal decompression and stabilization is necessary. We consider that prophylactic stabilization of the spine is analogous to prophylactic nailing of a femur with a pathologic lesion. Both the femur and spine are weight-bearing structures. The advent of segmental instrumentation makes this a feasible accomplishment with minimal morbidity. Seventeen patients with metastatic disease of the spine at Rush-Presbyterian-St. Luke's Medical Center, Chicago, were reviewed. All maintained spinal stability postoperatively. Eleven of the 17 had significant pain relief for 3 months or more. Five of 11 paralyzed patients had significant neural recovery. A classification for treatment purposes regardless of tissue type was developed. Once classified, the surgical goals for these patients were to decrease pain, to preserve or to improve neurologic function and to mobilize the patient without external orthosis.     

Treatment of metastatic prostate cancer of the spine

There is a wide spectrum of presentations for prostate cancer metastatic to the spine. Important factors are the patient's age and general health; the extent and location of spinal involvement; the patient's neurologic status and degree of pain; the relative contribution of a blastic or lytic response; and the experience and training of the spinal surgeon, medical oncologist, and radiation oncologist. The spine is both a weight-bearing structure and a housing for the spinal cord, and failure to consider both functions may lead to unsatisfactory treatment results. Treatment options include hormonal therapy, inhibitors of bone metabolism, glucocorticoid therapy, radiotherapy, halo-vest, surgical debridement, decompression and stabilization, and appropriate pain management and support. One must not lose sight of the fact that the goals are palliation and that ultimate demise is unavoidable in patients with metastatic prostate cancer.     

Minimally invasive transpedicular vertebrectomy for metastatic disease to the thoracic spine

STUDY DESIGN AND OBJECTIVE: We present a series of 8 patients with thoracic metastatic disease causing acute neurologic decline. We present minimally invasive posterolateral vertebrectomy and decompression as an effective approach in patients with significant comorbidities and as palliative care. BACKGROUND: Metastatic disease to the spine is common and frequently occurs in the thoracic vertebrae. Posterior laminectomy alone has generally been found to be ineffective in the management of spinal metastatic disease with neurologic compromise as most compression occurs ventrally. Patients with significant comorbidities are often unable to tolerate extensive surgery involving a thoracotomy. Limited life expectancy and quality of life issues also often argue against extensive surgery. METHODS: Eight patients (mean age 74 y) with thoracic metastatic disease and acute neurologic compromise underwent a minimally invasive posterolateral vertebrectomy and partial tumor resection. Patients were considered unsuitable for an open anterior approach owing to age, comorbidities, and limited life expectancies. In the operating room, patients were positioned prone. A paramedian incision measuring 3 cm allowed the introduction of sequential dilators and the placement of a 22-mm diameter tubular retractor. Dorsal decompression was accomplished and partial vertebrectomy was performed for ventral decompression. Radiation was used postoperatively in all patients. RESULTS: There were no complications due to the procedure. Improvement of at least 1 grade on the Nurick scale was noted in 5 of 8 (62.5%) patients. Two patients were able to ambulate independently immediately after surgery despite having significant paraparesis preoperatively. Pain improved in 5 of 8 (62.5%) patients postoperatively according to the numerical pain score. Average inpatient length of stay was 4 days after the procedure. Mean blood loss was 227 mL and mean length of the procedure was 2.2 hours. CONCLUSIONS: Minimally invasive transpedicular vertebrectomy is an effective palliative treatment option for thoracic metastatic disease in patients not eligible for more extensive anterior transthoracic surgery and stabilization.     

Distraction rod stabilization in the treatment of metastatic carcinoma

Stabilization of the spinal column with Harrington distraction rods and acrylic fusion was the primary form of treatment in a select group of patients with metastatic carcinoma of the spinal column. Clinical criteria included patients in poor general medical condition with intractable pain originating from metastatic tumor involvement in the ventral components of the thoracic or upper lumbar spinal column and minimal evidence or absence of spinal cord compression. After stabilization, pain relief was almost total and sustained, and neurological status generally remained unchanged from preoperative findings without any evidence of improvement of preexisting abnormalities or occasions of rapid neurological deterioration. This form of spinal stabilization may offer significant relief of debilitating pain, lessen the risk of pathological fracture-dislocation of the thoracic or upper lumbar vertebral column, and reduction in the local compressive effects on the spinal cord caused by ventrally situated metastatic tumor.