Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice

Separation surgery for metastatic epidural spinal cord compression: A qualitative review

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Separation surgery is a new concept for metastatic spinal cord compression treatment.

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Stereotactic radiosurgery increased local control, overcoming radio-resistance’s idea.

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The surgery goal shifted towards creating targets for radiations avoiding cord damages.

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Minimal invasive strategies could allow quick return to systemic therapies.

Introduction

The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease’s local control.

Discussion

In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration.

Conclusion

Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.

Surgical treatment of metastatic spine disease: an update on national trends and clinical outcomes from 2010 to 2014

BACKGROUND CONTEXT

Metastatic spine disease (MSD) is becoming more prevalent as medical treatment for cancers advance and extend survival. More MSD patients are treated surgically to maintain neurological function, ambulation, and quality of life.

PURPOSE

The purpose of this study was to use a large, nationally representative database to examine the trends, patient outcomes, and health-care resource utilization associated with surgical treatment of MSD.

DESIGN

This was an epidemiologic study using national administrative data from the Nationwide Readmissions Database (NRD).

PATIENT SAMPLE

All patients in the NRD from 2010 to 2014 who underwent spinal surgery were included in the study.

OUTCOME MEASURES

Mortality, blood transfusion, complications, length of stay, cost, and discharge location during index hospitalization as well as hospital readmission and revision surgery within 90-days of surgery were analyzed.

METHODS

International Classification of Diseases, Ninth Revision, (ICD-9) codes was used to identify patients of interest within the NRD from 2010 to 2014. Patients were separated into two cohorts - those with MSD and those without. Trends for surgical treatment of MSD were assessed and outcomes measures for both cohorts were analyzed and compared.

RESULTS

The number of surgical treatments for MSD increased from 6,007 in 2010 to 7,032 in 2014 (p-trend<.0001) which represented a 17.1% increase. During index hospitalization, MSD patients had an increased risk of mortality (odds ratio [OR]=3.22, 95% confidence interval [CI]: 2.85-3.63, p<.0001), blood transfusion (OR=2.93, 95% CI: 2.66-3.23, p<.0001), any complication (OR=1.24, 95% CI: 1.18-1.31, p<.0001), and discharge to skilled nursing facility (OR=1.51, 95% CI:1.41-1.61, p<.0001). MSD patients had longer average length of stay (13.05 vs. 4.56 days, p<.0001) and cost ($49,421.75 vs. $26,190.37, p<.0001) during index hospitalization. Furthermore, MSD patients had an increased risk of hospital readmission (OR=2.82, 95% CI: 2.68-2.96, p<.0001), readmission for surgical site infection (OR=2.38, 95% CI: 2.20-2.58, p<.0001), and readmission with neurologic deficits (OR=1.62, 95% CI: 1.27-2.06, p<.0001) despite a decreased risk of revision fusion (OR=0.71, 95% CI: 0.53-0.96, p=.026).

CONCLUSIONS

The number of MSD patients who undergo surgical treatments is increasing. Not only do these patients have worse outcomes during index hospitalization, but they are also at an increased risk of hospital readmission for surgical site infection and neurologic complications. These findings stress the need for multidisciplinary perioperative treatment plans that mitigate risks and facilitate quick, effective recovery in these unique, at-risk patients.

The Neurology-Stability-Epidural compression assessment: A new score to establish the need for surgery in spinal metastases

OBJECTIVE

The aim of this study was to translate new evidence about management of spinal metastases in a practical and reliable score for surgeons, radiation oncologists and oncologists, able to establish the need for surgery regardless the available technology and settings.

PATIENTS AND METHODS

Three main items were identified and graded: Neurological status (0-5 points), Stability of the spine according to the Spinal Instability Neoplastic Score (SINS) Score (0-5 points), and Epidural compression according to the Epidural Spinal Cord Compression (ESCC) scale (0-3 points). Patients were considered suitable for surgery with ASA score < 4 and ECOG score <3. A retrospective clinical validation of the NSE score was made on 145 patients that underwent surgical or non surgical treatment.

RESULTS

Agreement between the undertaken treatment and the score (88.3% of patients), resulted in a strong association with improvement or preservation of clinical status (neurological functions and mechanical pain) (p < 0.001) at 3 and 6 months. In the non-agreement group no association was recorded at the 3 and 6 months follow-up (p 0.486 and 0.343 for neurological functions, 0.063 and 0.858 for mechanical pain).

CONCLUSION

Functional outcomes of the study group showed that the proposed NSE score could represent a practical and reliable tool to establish the need for surgery. Agreement between the score and the performed treatments resulted in better clinical outcomes, when compared with patients without agreement. Further validation is needed with a larger number of patients and to assess reproducibility among surgeons, radiation oncologists, and oncologists.

Vertebral Artery Sacrifice versus Skeletonization in the Setting of Cervical Spine Tumor Resection: Case Series

OBJECTIVE

Tumors of the cervical spine often encase 1 or both vertebral arteries (VA), presenting the treating surgeon with the dilemma of whether to sacrifice or skeletonize the artery. We propose an algorithm for VA management in surgeries for cervical neoplasms METHODS: A retrospective review was carried out of 67 patients undergoing resection of cervical spine tumors with VA involvement. Patients were categorized by tumor origin (primary vs. metastatic) and degree of circumferential VA involvement: 1) abutment only; 2) <180° circumferential involvement; 3) >180° circumferential involvement without complete encasement; or 4) complete encasement.

RESULTS

Twelve patients (18%) underwent VA sacrifice, whereas 55 (82%) underwent VA skeletonization. Compared with 11/30 patients with primary tumors (37%), only 1/37 patients (3%) with metastatic disease underwent VA sacrifice (P < 0.01). This patient had invasion of the V2 arterial wall, requiring VA sacrifice. Odds of VA sacrifice also increased with increasing circumferential involvement (P < 0.01). No patients with simple abutment or 0°-180° circumferential involvement underwent sacrifice, whereas 6 of 10 (60%) with 180°-359° involvement and 6 of 29 (21%) with complete encasement underwent VA sacrifice. Of the 27 patients with ≥180° involvement, the reasons for preserving the VA were metastatic disease at the time of treatment (n = 18), a compromised contralateral VA (n = 7), vertebrobasilar junction aplasia (n = 1), and presence of a radiculomedullary artery at the affected level (n = 1).

CONCLUSIONS

Primary tumor disease and >180° of circumferential VA involvement should be considered as indications for intraoperative sacrifice of the VA pending preoperative angiographic evaluation for contraindications.

Rates, Risk Factors, and Complications of Red Blood Cell Transfusion in Metastatic Spinal Tumor Surgery: An Analysis of a Prospective Multicenter Surgical Database

OBJECTIVE

To identify rates, risks, and complications of red blood cell (RBC) transfusion in metastatic spinal tumor surgery.

METHODS

The multicenter prospective American College of Surgeons National Quality Improvement Program database was queried for the years 2012-2016. Adult patients with disseminated cancer who underwent metastatic spinal tumor surgery were identified. Transfusion was defined as having received at least 1 intraoperative/postoperative RBC transfusion within the first 72 hours of surgery start time. A stepwise multiple logistic regression model with backward elimination was used.

RESULTS

Of 1601 patients identified, 623 patients (38.9%) received a RBC transfusion. Independent predictors of RBC transfusion included higher American Society of Anesthesiologists class (odds ratio [OR] = 1.54), preoperative anemia (OR = 3.10), instrumentation (OR = 1.63), and longer operative time (OR = 1.52). The overall complication rate was significantly higher in patients who received a transfusion compared with patients who did not receive a transfusion (22.3% vs. 15.0%, P < 0.001). Individual complications that were more common in patients who received a transfusion were sepsis (3.5% vs. 1.9%, P = 0.050), deep vein thrombosis (6.1% vs. 3.3%, P = 0.007), and prolonged ventilation (3.9% vs. 1.3%, P = 0.001). RBC transfusion (OR = 1.65), hypoalbuminemia (OR = 1.53), and anterior/anterolateral approaches for corpectomy (OR = 2.11) were independent risk factors for developing a postoperative complication.

CONCLUSIONS

RBC transfusion after metastatic spinal tumor surgery may increase the risk of early postoperative complications. Future research into preoperative patient optimization and decreasing intraoperative blood loss is needed.

Instrumented surgical treatment for metastatic spinal tumors: is fusion necessary?

OBJECTIVE

The goal of this study was to evaluate the radiographic and clinical results of instrumentation surgery without fusion for metastases to the spine.

METHODS

Between 2010 and 2017, patients with spinal tumors who underwent instrumentation without fusion surgery were consecutively evaluated. Preoperative and postoperative clinical data were evaluated. Data were inclusive for last follow-up and just prior to death if the patient died. Instrumentation-related complications included screw migration, screw or rod breakage, cage migration, and screw loosening.

RESULTS

Excluding patients who died within 6 months, a total of 136 patients (140 operations) were recruited. The average follow-up duration was 16.5 months (median 12.4 months). The pain visual analog scale score decreased from 6.4 to 2.5 (p < 0.001) and the Eastern Cooperative Oncology Group scale score improved (p < 0.001). There were only 3 cases (2.1%) of symptomatic instrumentation-related complications that resulted in revisions. There were 6 cases of nonsymptomatic complications. The most common complication was screw migration or pull-out (5 cases). There were 3 cases of screw or rod breakage and 1 case of cage migration. Two-thirds of the cases of instrumentation-related complications occurred after 6 months, with a mean postoperative period of 1 year.

CONCLUSIONS

The current study reported successful outcomes with very low complication rates after nonfusion surgery for patients with spinal metastases, even among those who survived for more than 6 months. More than half of the instrumentation-related complications were asymptomatic and did not require revision. The results suggest that nonfusion surgery might be sufficient for a majority of patients with spinal metastases.

Outcomes of surgical treatments of spinal metastases: a prospective study

BACKGROUND

Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases.

OBJECTIVE

To analyse the outcomes of surgical treatments of spinal metastases.

METHODS

Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status.

RESULTS

A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function.

CONCLUSION

Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.