Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression

Diagnosis and treatment of vertebral column metastases

The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and qualilty of life.

Systematic Review of the Diagnosis and Management of Malignant Extradural Spinal Cord Compression: The Cancer Care Ontario Practice Guidelines Initiative‘s Neuro-Oncology Disease Site Group

Purpose

This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MSCC).

Methods

MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to January 2004 using the following terms: spinal cord compression, nerve compression syndromes, spinal cord neoplasms, clinical trial, meta-analysis, and systematic review.

Results

Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC. The sensitivity and specificity for magnetic resonance imaging (MRI) range from 0.44 to 0.93 and 0.90 to 0.98, respectively, in the diagnosis of MSCC. The sensitivity and specificity for myelography range from 0.71 to 0.97 and 0.88 to 1.00, respectively. A randomized study detected higher ambulation rates in patients with MSCC who received high-dose dexamethasone before radiotherapy (RT) compared with patients who did not receive corticosteroids before RT (81% v 63% at 3 months, respectively; P = .046). There is no direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted if patient is progressing on or shortly after RT, and whether patients with spinal instability should be treated with surgery.

Conclusion

Patients with symptoms of MSCC should be managed to minimize treatment delay. MRI is the preferred imaging technique. Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.

Pre- and post-treatment daily life function in patients with hormone resistant prostate carcinoma treated with radiotherapy for spinal cord compression

BACKGROUND AND PURPOSE

To identify prognostic factors and prospectively evaluate daily life function and pain experience in hormone resistant prostate cancer patients with spinal cord compression treated with radiotherapy.

PATIENTS AND METHODS

Consecutive patients treated at the Norwegian Radium Hospital from May 1996 to October 1999 participated in the study. Daily life activities were assessed at start and discontinuation of radiotherapy and 2 and 6 months thereafter using a questionnaire based on a slightly modified Barthel activity of daily living Index. The patients were followed to death. Clinical parameters (histology, extent of disease at diagnosis, time from cancer diagnosis to start of radiotherapy, time from neurological symptoms to start of radiotherapy, age, number of spinal lesions, pre-treatment function) were assessed to try to prognosticate post-treatment function.

RESULTS

Forty-nine patients were evaluable. Time from debut of neurological deficits to start of radiotherapy was median 4 days (range 1-66). Median target dose was 30 Gy (range 9-40). Overall survival from start of radiotherapy was median 3.5 months (range 0.3-36.0). In general, improvement with regard to mobility, daily life activities and sphincter control was reported after irradiation. Post-treatment the majority of patients reported pain, usually intermittent, although they used analgesics. No clinically relevant pre-treatment parameters that predicted function after radiotherapy were identified.

CONCLUSIONS

Radiotherapy may improve mobility, daily life activity and sphincter control in patients with metastatic spinal cord compression due to hormone resistant prostate cancer. Radiotherapy should therefore be considered in all patients irrespective of the neurological deficits.

Posterior surgical approaches and outcomes in metastatic spine-disease

Spinal cord compression represents a major cause of morbidity and suffering in cancer patients. Surgery should be considered a form of primary therapy in many of these patients. The goals of surgery and the approach used are functions of a number of variables, including the surgeon's preference, the location of disease within the spine (cervical, thoracic, or lumbar),the extent of disease within each vertebra, the number of levels affected, and the patient's medical health and overall prognosis. Currently,the goals of any major debulking surgery are to decompress the spinal cord, prevent local recurrence, reconstruct the spine, and provide immediate stabilization with the use of fixation devices. Posterior approaches, starting with the decompressive laminectomy, have traditionally been the most common surgical procedures for metastatic spine disease. The laminectomy should only be used for disease isolated to the dorsal spine without evidence of concomitant instability. A laminectomy combined with instrumentation has been shown to provide superior results but should be reserved for those patients who cannot tolerate or would not benefit from more aggressive surgery. Various posterolateral approaches have been devised to access more ventrally placed lesions. These include the transpedicular approach, the costotransversectomy, and the lateral extracavitary/parascapular approach. Each of these allows adequate spinal cord decompression anteriorly and posteriorly and the ability to reconstruct and stabilize with acceptable peri-operative risk. It must be remembered that surgery for this disease is almost always palliative.Thus, surgery should be a means to maximize the patient's quality of life while minimizing the risk of suffering surgical complications.

Clinical trials and evidence-based medicine for metastatic spine disease

Treatment of metastatic epidural spinal disease has undergone significant changes over the last 20 years. No longer is indiscriminate decompressive laminectomy offered as the only surgical treatment. It carries all the risks associated with an invasive procedure and offers the patient little benefit unless it is used to remove disease isolated to the posterior elements. The existing literature suggests that surgery that frees the spinal cord at the site of compression in addition to reconstructing and stabilizing the spinal column is more effective at preserving and regaining neural function, notably ambulatory function and sphincter function, than conventional radiotherapy. It is also highly effective in relieving pain. The preliminary results ofa recent RCT provide the first class I evidence to support a reversal in the current philosophy of primary treatment for many patients with meta-static disease. Conventional radiotherapy has a clearly defined role as adjuvant therapy and as primary therapy in those who are unable to tolerate or benefit significantly from surgery. The role of nonconventional radiation therapy, such as IMRT and SRS, remains to be elucidated.

Evolution of treatment for metastatic spine disease

The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.

Management of pain associated with spinal tumor

Metastatic spinal disease is common in cancer patients, and it is a frequent source of pain and disability. Expert management of the patient's pain and neurologic dysfunction is required. Neurosurgical advances have afforded the patient the opportunity to have improved symptom management and improved quality-of-life outcomes. Patients and their families are best served by the provision of supportive care by specialty pain medicine and palliative care services (especially neurology based) working with the primary neurosurgical team in an integrated model.

Anterior spinal arthrodesis with structural cortical allografts and instrumentation for spine tumor surgery

STUDY DESIGN

The authors report on anterior vertebral reconstruction following tumor resection with use of fresh-frozen, cortical, long-segment allografts prepared from diaphyseal sections of long bones. A retrospective analysis of clinical outcomes is presented.

OBJECTIVE

To analyze the results following the use of cortical allografts in the treatment of spine tumors.

SUMMARY OF BACKGROUND DATA

Metastatic disease and primary spinal bone tumors may result in progressive vertebral collapse, instability, deformity, pain, and neurologic deficit. Controversy as to the appropriate type of anterior reconstruction and/or graft material persists.

METHODS

From 1995 until 2001, 30 patients with primary spinal bone tumors or metastases to the spine were treated by anterior vertebral reconstruction with fresh-frozen cortical bone allografts. Grafts were used in combination with anterior and posterior instrumentation.

RESULTS

The median survival was 14 months. Ninety-three percent of all allografts were radiographically incorporated as early as 6 months after surgery in spite of adjuvant chemotherapy and radiation therapy. Fourteen patients (46%) had intraoperative or postoperative complications. Two patients underwent revision surgery for local recurrence. There were no allograft infections, fractures, or collapse.

CONCLUSION

Anterior column reconstruction with structural cortical allografts proved to be a reliable technique in patients with spine tumors. Postoperative complications can often be successfully managed.

Epidural metastatic spinal cord compression: functional outcome and survival after inpatient rehabilitation

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVES

(1). To obtain an overall appraisal of patients with epidural metastatic spinal cord compression (SCC) admitted to nine Dutch spinal cord units (SCUs) between 01-01-1990 and 01-01-2000. (2). To identify factors that predict survival >1 year after in-patient rehabilitation of patients with epidural metastatic SCC.

SETTING

Dutch SCUs. Rehabilitation Center Amsterdam, Amsterdam. Rehabilitation Center Heliomare, Wijk aan Zee. Rehabilitation Center De Hoogstraat, Utrecht. Rehabilitation Center Rijndam, Rotterdam. Rehabilitation Center Sophia Stichting, Den Haag. Rehabilitation Center Beatrixoord, Haren. Rehabilitation Center Het Roessingh, Enschede. Rehabilitation Center Sint Maartenskliniek, Nijmegen. Rehabilitation Center SRL Hoensbroeck, Hoensbroek.

METHODS

(1). Clinical records were reviewed and demographic, clinical and functional data were collected according to a protocol. The date of admittance to the SCU, rehabilitation goals, date of discharge and date of death were recorded. (2). The odds ratio (OR) was calculated for all determinants on admittance to the SCU in order to find indicators that predict survival >1 year after discharge from the SCU. An OR >or=2 was considered to be clinically significant.

RESULTS

In total, 131 patients with epidural metastatic SCC were admitted. In all, 117 clinical records were retrieved and 97 clinical records provided complete data. The average age on admittance was 58 years. Among the patients 53% were male. The average Barthel score on admittance was 7.2/20 points. The average length of stay in the SCU was 104 days (3-336). Overall, 66% of the patients were discharged. The average Barthel score on discharge was 12.0 points. The average survival after discharge was 808 (0-3669) days. During their stay on the SCU, seven patients died. At 1 year after discharge, 52% of the patients were still alive. These patients suffered less complications, had been admitted less often to a hospital during rehabilitation, had made better functional progress and had been discharged home more often. A survival >1 year after discharge is related to ASIA D (OR 4.3), MRC 4 and 5 (OR 5.4), tumour in remission (OR 3.8) and independence or partial independence on the Barthel items: dressing (OR 4.3) and making transfers (OR 5.0).

CONCLUSIONS

Patients with epidural metastatic SCC may benefit from in-patient rehabilitation.

Evidence-based review of the surgical management of vertebral column metastatic disease

Object

Significant controversy exists over the most appropriate treatment for patients with metastatic disease of the vertebral column. Treatment options include surgical intervention, radiotherapy, or a combination of the two; nevertheless, a standard of care that yields the best survival, outcome, and quality of life has not been established. The purpose of this review was to determine the foundation in the literature of views favoring surgical intervention for spinal metastatic disease.

Methods

A search of the English-language literature published between 1964 and 2003 was performed for the subject of spinal metastatic disease. Papers were selected based on the inclusion criteria described, and evidentiary information was compiled and graded using previously described methods.

Conclusions

Although there is insufficient evidence to support a standard for surgical treatment in patients with metastatic spinal disease, the authors present guidelines and recommendations based on the evidence provided by the current literature.

Postacute management of patients with spinal cord injury due to metastatic tumour disease: survival and efficacy of rehabilitation

STUDY DESIGN

Retrospective study utilising clinical records and public administration databases.

OBJECTIVES

This study was performed to analyse the clinical presentation and survival rate of individuals with spinal cord injury (SCI) due to spinal metastasis after primary treatment, and to evaluate the efficacy of rehabilitative efforts.

SETTING

Spinal Cord Injury Unit, University Hospital, Heidelberg.

METHODS

A total of 68 consecutive patients were included. Demographics, clinical data, tumour type, level and completeness of SCI, initial treatment, functional independence measure (FIM) and survival time were derived from hospital and public administration databases. Cox regression and fuzzy logic rule generation were used for statistical analysis.

RESULTS

Of the 68 patients, 66 patients died 11 months (median, interquartile range (IQR) 4-29 months) after the onset of neurological symptoms at an average age of 58 years. The functional independence measure (FIM) score describing the general clinical and functional status proved to be the most reliable prognostic factor of survival. Other more specific parameters (eg tumour type or level of lesion) did not have such an impact. In total, 51 patients completed the rehabilitation programme within 50 days (median, IQR 27-99 days). The FIM score improved from 62 at admission to 84 at discharge.

CONCLUSION

The clinical and functional status is a valuable prognostic factor for survival. Since institutionalised rehabilitative efforts are effective, this group of patients should be accepted into such a program.

Spinal cord compression

Back pain and suspected spinal cord compression remains one of the most frequent reasons for neurologic consultation in cancer patients. While treatment generally results in stabilization or improvement, early diagnosis remains the cornerstone of improving neurologic outcome. This article reviews the clinical features, differential diagnosis, and management of neoplastic epidural spinal cord compression.

Clinical outcome and survival after palliative surgery for spinal metastases: palliative surgery in spinal metastases

BACKGROUND

The authors sought to identify treatment-related factors that influenced survival after surgical treatment for metastatic spinal tumors and to evaluate the relationship between survival and postoperative ambulation time as a factor related to quality of life.

METHODS

The medical records of 81 patients with metastatic spinal tumors who underwent palliative surgery at the study institution were assessed. Univariate analysis for factors influencing survival used the Kaplan-Meier log rank statistic and multivariate analysis used the Cox proportional hazards model. The Spearman correlation test was used to analyze the relationship between postoperative ambulation and survival time.

RESULTS

The patients had a median age of 59.9 years and a median survival of 10.6 months after surgery. For patients, postoperative ambulatory median survival was 16.5 months and median ambulation time was 13.8 months. By univariate analysis, anatomic site of the primary tumor, postoperative ambulation, and combined adjuvant therapy (chemotherapy plus radiotherapy) were associated with prolonged survival (P < 0.05). Multivariate analysis identified primary site and postoperative ambulatory function as independent predictors of prolonged survival (P < 0.0001). Significant correlations were found between ambulation time and survival time of patients who were able to walk after surgery (P < 0.0001), even in patients with liver (P < 0.05) or lung carcinoma (P < 0.05).

CONCLUSIONS

The anatomic site of primary carcinoma and postoperative ambulation were associated with longer survival after palliative surgery for metastatic spinal tumor. When ambulation is attained after surgery, it can be preserved until late in remaining life even when the primary tumor is unfavorable. Palliative surgery for spinal metastasis can improve the quality and quantity of life.

Don't wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression

AIM

To report details concerning symptoms (especially pain) preceding the development of malignant cord compression (MCC); delays between onset/reporting of symptoms and confirmed diagnosis of MCC; accuracy of investigations carried out.

METHODS

A prospective observational study examined the diagnosis, management and outcome of 319 patients diagnosed with MCC at three Scottish cancer centres between January 1998-April 1999. The process was considered from the perspectives of the patient, the GP and the hospital doctor.

RESULTS

At diagnosis, most patients (82%) were either unable to walk or only able to do so with help. Pain was reported by nearly all patients interviewed (94%) and had been present for approximately 3 months (median=90 days). It was severe in 84% of cases, with the distribution and characteristics of nerve root pain in 79%. The site of pain did not correspond to the site of compression. Where reported, weakness and/or sensory problems had been noticed by the patient for some time before diagnosis (median intervals 20 and 12 days, respectively). Most patients reported early symptoms to their General Practitioner (GP) and diagnosis was established, following referral and investigation, approximately 2 months (median=66 days) later.

CONCLUSION

Patients who develop spinal metastases are at risk of irreversible spinal cord damage. Weakness and sensory abnormalities are reported late and identified even later, despite patients having reported pain for a considerable time. Patients with cancer who describe severe back or spinal nerve root pain need urgent assessment on the basis of their symptoms, as signs may occur too late. Plain films and bone scans requested for patients in this audit predicted accurately the level of compression in only 21% and 19% of cases, respectively. The only accurate investigation to establish the presence and site of a compressive lesion is magnetic resonance imaging (MRI). A referral guideline based on suspicious symptoms in addition to suspicious signs is suggested.

Neurological outcome following laminectomy in spinal metastases

STUDY DESIGN

Retrospective outcome measurement study.

OBJECTIVES

Patients suffering from malignant tumour disease and metastases to the spine develop a variety of clinical complaints including radicular symptoms and/or spinal cord compression syndromes. Palliative decompressive laminectomy with total or partial tumour resection is an acknowledged method of treatment, despite controversy.

SETTING

The Department of Neurosurgery of the University of Vienna.

METHOD

Patients suffering from metastases with predominant infiltration of the dorsal epidural parts, or patients who could not be operated on via an anterior approach, were included. Eighty-four patients who met these criteria underwent decompressive laminectomy with total or partial tumour removal. The study analyzed motor function, pain relief and continence in a 2- and 4-month post-operative follow-up. According to the criteria of motor performance, 20% of the patients had been mobile pre-operatively.

RESULTS

In the immediate post-operative period 45%, after 2 months 33% and after 4 months 26%, were considered mobile. None of the paraplegic patients showed functional improvement. The median survival time was 6.5 months. Pre-operatively, 56% of the patients had shown continence dysfunction. Post-operatively, 38%, and after 2 months 46% of the patients, developed continence disorders. A significant reduction in analgesic medication was also observed in the post-operative period.

CONCLUSION

In our series, palliative laminectomy with total or subtotal tumour reduction in patients with malignant spinal metastatic disease resulted in amelioration of motor function, pain and continence and therefore improved the patients' quality of life. The improvement in quality of life shows that this method is a valuable option in neurosurgical therapy, except for cases with pre-operative paraplegia. However, in patients with severe pre-operative paraparesis, the authors recommend laminectomy only in very exceptional cases, because of the poor post-operative neurological results.

Spinal cord compression--a personal and palliative care perspective

Malignant spinal cord compression is recognized as an oncological emergency. In spite of this, treatment in the U.K. varies widely from one area of the country to another. The reported survey shows that this variation is especially noticeable at weekends. Palliative care physicians and clinical nurse specialists working in the community are trained in the recognition of cord compression and are able to improve the early diagnosis and referral of these patients. In addition, they have an essential role in the follow-up of those who remain paraplegic.

Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors

OBJECT

Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach-related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure. To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome.

METHODS

Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, preoperative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups.

CONCLUSIONS

Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

A prospective study of factors predicting clinically occult spinal cord compression in patients with metastatic prostate carcinoma

BACKGROUND

The objective of this study was to identify clinical parameters that predict occult subarachnoid space or spinal cord (SAS/SC) compression, as determined by magnetic resonance imaging (MRI), in patients with metastatic prostate carcinoma.

METHODS

A prospective study was performed in which 68 patients with bone metastases from prostate carcinoma and a normal neurologic examination underwent MRI of the entire spine after documentation of clinical, X-ray, and bone scan parameters potentially predictive of occult SAS/SC compression.

RESULTS

Occult SAS/SC compression was diagnosed in 22 patients (32%) using MRI. Nine patients (13%) had compressions at two discontinuous spinal levels. Extensive disease on bone scan, the duration of continuous hormonal therapy prior to study entry, and hemoglobin concentration were found to predict SAS/SC compression by univariate analysis. The extent of disease on bone scan and the duration of continuous hormonal therapy were independent predictors of SAS/SC compression by multivariate analysis (P = 0.02 and P = 0.04, respectively). The risk of occult SAS/SC compression increased from 32% to 44% in patients with a bone scan that showed > 20 metastases as the duration on hormones increased from 0 to 24 months. The risk in patients with fewer metastases increased from 11% to 17% over the same interval. The presence or absence of back pain was not predictive of SAS/SC compression.

CONCLUSIONS

Patients who are at high risk for occult SAS/SC compression can be identified using clinical parameters and readily available diagnostic tests. These high-risk patients should undergo MRI screening with the aim of diagnosing and treating spinal cord compression before the development of neurologic deficits that may be irreversible.

Intramedullary spinal cord metastases (ISCM) and non-small cell lung carcinoma (NSCLC): clinical patterns, diagnosis and therapeutic considerations

Intramedullary spinal cord metastasis (ISCM) is an unusual occurrence in systemic cancer, occurring in as few as 2% of autopsy cases and also represents 8.5% of all cases of central nervous system metastases. Although ISCM from small cell lung carcinoma is well documented, ISCM from non-small cell lung carcinoma of the lung is rarely diagnosed prior to the patients' demise and very little data regarding outcomes exists in such patients. We present the results of our observational case series to better delineate the presentation and clinical course of this uncommon entity which shows that ISCM may present atypically and should be considered in any patient with a previous history of bronchogenic carcinoma and neurologic symptoms.

MRI in the diagnosis and treatment of suspected malignant spinal cord compression

It remains unclear whether MRI is essential in all patients with suspected malignant spinal cord compression (MSCC), or whether some patients can be treated on the basis of plain radiographic findings and neurological examination. A prospective study was carried out of 280 consecutive patients with suspected MSCC, and the results of neurological examination plus plain radiographs were compared with MRI. 201 patients had MSCC (186 extradural, 5 intradural extramedullary and 10 intramedullary) and 11 patients had thecal sac compression without evidence of spinal cord compression. 25% of patients with MSCC had two or more levels of compression, 69% of these involving more than one region of the spine. A paraspinal mass was noted at the site of extradural spinal cord compression in 28%, and only one-third of these were detected on plain radiography. Focal radiographic changes and consistent neurology were present in 91 (33%) patients who had not had previous radiotherapy. MRI confirmed the presence of MSCC in 89/91 patients (specificity and positive predictive value of radiographic/clinical findings 98%) and the level of disease in all. MRI led to a change in the radiotherapy plan in 53% of patients (21% major change). The sensory level when present was four or more segments below the MRI level in 25/121 (21%) patients, and two or more levels above in 8/121 (7%) patients. Although focal radiographic abnormalities with consistent neurological findings, when present, accurately predicted the presence and level of MSCC, whole spine MRI is indicated in most patients with suspected MSCC because the additional information may alter the management plan. Treatment may be appropriately initiated on the basis of focal radiographic changes and consistent neurology if MRI is contraindicated or delayed, and in patients with a poor prognosis. In patients in whom there are no focal radiographic abnormalities and consistent neurological findings, urgent MRI is mandatory before radiotherapy is commenced.

Metastatic testicular cancer presenting as spinal cord compression: report of two cases

BACKGROUND

Testicular cancers are heterogenous neoplasms often found in young adults. They tend to metastasize to the chest, retroperitoneum, or neck, but rarely to the long bones or skeleton. However, they can cause neurologic compromise and should be considered in young male patients who present with symptoms of a spine lesion and no known primary cancer.

METHODS

Two patients presented with back pain and a rapid progression of lower extremity weakness. Both underwent radiographic workup and emergency surgery. Metastatic workup revealed testicular cancer and widespread metastases.

RESULTS

Both patients improved neurologically after surgery, but neither regained the ability to ambulate independently. They both underwent chemotherapy. One patient is alive at 1 year follow-up; the other died 9 months after surgery of widespread metastases.

CONCLUSIONS

Vertebral metastases from testicular tumors, although rare, should be considered in young men presenting with spinal cord compression. Work-up should include magnetic resonance imaging (MRI) of the spine and computed tomography (CT) of the chest, abdomen, and pelvis. Urgent intervention may be required, as these two cases show that loss of neurologic function can be rapid and permanent.

Prognostic factors in metastatic spinal cord compression: a prospective study using multivariate analysis of variables influencing survival and gait function in 153 patients

PURPOSE

Based on a very large patient cohort followed prospectively for at least a year or until death, we analyzed the prognostic significance of various clinical and radiological variables on posttreatment ambulatory function and survival.

METHODS AND MATERIALS

During a 312-year period we prospectively included 153 consecutive patients with a diagnosis of spinal cord compression due to metastatic disease. The patients were followed with regular neurological examinations by the same neurologist for a minimum period of 11 months or until death. The prognostic significance of five variables on gait function and survival time after treatment was analyzed.

RESULTS

The type of the primary tumor had a direct influence on the interval between the diagnosis of the primary malignancy and the occurrence of spinal cord compression (p < 0. 0005), and on the ambulatory function at time of diagnosis (p = 0. 016). There was a clear correlation between the degree of myelographic blockage and gait function (p = 0.000) and between gait function and sensory disturbances (p = 0.000). The final gait was dependent on the gait function at time of diagnosis (p < 0.0005). Survival time after diagnosis depended directly on the time from primary tumor diagnosis until spinal cord compression (p = 0.002), on the ambulatory function at the time of diagnosis (p = 0.018), and on the ambulatory function after treatment.

CONCLUSIONS

The pretreatment ambulatory function is the main determinant for posttreatment gait function. Survival time is rather short, especially in nonambulatory patients, and can only be improved by restoration of gait function in nonambulatory patients by immediate treatment.

Radiotherapy for the palliation of prostate cancer

The large population of men who will develop metastatic prostate cancer creates a strong need for good palliative care. For many men, androgen ablation works well; however, when this fails, the quality of a man's life can quickly degrade. Pain from skeletal metastases, neurologic involvement, bleeding, and obstruction can all occur. Radiotherapy has long been the gold standard for palliation of symptomatic disease. However, a new approach using hemibody irradiation (HBI) earlier in the disease course, as well as more effective and tolerable dose and fractionation schemes for local field radiation, are providing excellent amelioration of symptoms and the possibility of living longer and more comfortably to many men with metastatic prostate cancer. The indications and use of therapeutic systemic radioisotopes to help achieve these objectives are also discussed.

Transthoracic vertebrectomy for metastatic spinal tumors

OBJECT

Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region.

METHODS

Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwent transthoracic vertebrectomy, decompression, reconstruction with methylmethacrylate, and anterior fixation with locking plate and screw constructs. Supplemental posterior instrumentation was required in seven patients with disease involving the cervicothoracic or thoracolumbar junction, which was causing severe kyphosis. After surgery, pain improved in 60 of 65 patients. This improvement was found to be statistically significant (p < 0.001) based on visual analog scales and narcotic analgesic medication use. Thirty-five of the 46 patients who presented with neurological dysfunction improved significantly (p < 0.001) following the procedure. Thirty-three patients had weakness but could ambulate preoperatively. Seventeen of these 33 regained normal strength, 15 patients continued to have weakness, and one patient was neurologically worse postoperatively. Of the 13 preoperatively nonambulatory patients, 10 could walk after surgery and three were still unable to walk but showed improved motor function. Twenty-one patients had complications ranging from minor atelectasis to pulmonary embolism. The 30-day mortality rate was 3%. The 1-year survival rate for the entire study population was 62%.

CONCLUSIONS

These results suggest that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.

Suspected spinal cord compression in breast cancer patients: a multidisciplinary risk assessment

Breast cancer is the most common cause of metastatic epidural spinal cord compression (SCC) in women, and this condition results in significant neurologic dysfunction and morbidity. Prior studies of patients with suspected SCC did not employ multivariate analysis techniques, often included persons with a wide variety of malignancies, and generally focused on identifying associated neurologic and radiologic features. We therefore conducted a study examining a more comprehensive set of potential clinical risk factors in breast cancer patients with suspected SCC. We retrospectively analysed 123 episodes of suspected SCC among 93 breast cancer patients evaluated by spine computed tomography (CT) scanning. Multiple logistic regression analysis was employed to identify independent predictors of SCC. Clinically significant metastatic epidural cancer was defined as thecal sac compression (TSC), which occurred in 33 episodes (27%). Four independent predictors of TSC were identified and included oncologic features (known bone metastases > or = 2 years, metastatic disease at initial diagnosis) in addition to neurologic and radiologic features (objective weakness, vertebral compression fracture on spine radiograph). These four predictors stratified episodes into subgroups with widely varying risks of TSC, ranging from 12% (0 risk factors) to 85% (> or = 3 risk factors). These results suggest that the evaluation of breast cancer patients with suspected SCC should include clinical information about their disease course in addition to neurologic examination and prior imaging studies. If confirmed, these predictors may help clinicians assess risk in this patient population.

Transthoracic vertebrectomy for metastatic spinal tumors

Anterior approaches to the spine for the treatment of spinal tumors have gained acceptance; however, in most published reports, patients with primary, metastatic, or chest wall tumors involving cervical, thoracic, or lumbar regions of the spine are combined. The purpose of this study was to provide a clear perspective of results that can be expected in patients who undergo anterior vertebral body resection, reconstruction, and stabilization for spinal metastases that are limited to the thoracic region.

Outcome is presented for 72 patients with metastatic spinal tumors who were treated by transthoracic vertebrectomy at The University of Texas M. D. Anderson Cancer Center. The predominant primary tumors included renal cancer in 19 patients, breast cancer in 10, melanoma or sarcoma in 10, and lung cancer in nine patients. The most common presenting symptoms were back pain, which occurred in 90% of patients, and lower-extremity weakness, which occurred in 64% of patients. All patients underwent transthoracic vertebrectomy, decompression, reconstruction with methylmethacrylate, and anterior fixation with locking plate and screw constructs. Supplemental posterior instrumentation was required in seven patients with disease involving the cervicothoracic or thoracolumbar junction, which was causing severe kyphosis. After surgery, pain improved in 60 of 65 patients. This improvement was found to be statistically significant (p < 0.001) based on visual analog scales and narcotic analgesic medication use. Thirty-five of the 46 patients who presented with neurological dysfunction improved significantly (p < 0.001) following the procedure. Thirty-three patients had weakness but could ambulate preoperatively. Seventeen of these 33 regained normal strength, 15 patients continued to have weakness, and one patient was neurologically worse postoperatively. Of the 13 preoperatively nonambulatory patients, 10 could walk after surgery and three were still unable to walk but showed improved motor function. Twenty-one patients had complications ranging from minor atelectasis to pulmonary embolism. The 30-day mortality rate was 3%. The 1-year survival rate for the entire study population was 62%.

These results suggest that transthoracic vertebrectomy and spinal stabilization can improve the quality of life considerably in cancer patients with spinal metastasis by restoring or preserving ambulation and by controlling intractable spinal pain with acceptable rates of morbidity and mortality.

Malignant spinal cord compression: prospective study of delays in referral and treatment

OBJECTIVES

To examine the delay in presentation, diagnosis, and treatment of malignant spinal cord compression and to define the effect of this delay on motor and bladder function at the time of treatment.

DESIGN

Prospective study of all new patients presenting to a regional cancer centre with this condition.

SETTING

Regional cancer centre.

SUBJECTS

301 consecutive patients.

MAIN OUTCOME MEASURES

Interval from onset of symptoms to presentation and treatment, delay at each stage of referral, and functional deterioration.

RESULTS

The median (range) delay from onset of symptoms of spinal cord compression to treatment was 14 (0-840) days. Of the total delay, 3 (0-300) days were accounted for by patients, 3 (0-330) days by general practitioners, 4 (0-794) days by the district general hospital, and 0 (0-114) days by the treatment unit. Initial presentation to the regional cancer centre with symptoms of malignant spinal cord compression led to a significant reduction in delay to treatment and improved functional status at the time of treatment. Deterioration of motor or bladder function >=1 grade occurred at the general practice stage in 28% (57) and 18% (36) of patients, the general hospital stage in 36% (83) and 29% (66), and the treatment unit stage in 6% (19) and 5% (15), respectively.

CONCLUSIONS

Unacceptable delay in diagnosis, investigation, and referral occurs in most patients with malignant spinal cord compression and results in preventable loss of function before treatment. Improvement in the outcome of such patients requires earlier diagnosis and treatment.

Neurologic emergencies in cancer patients

Neurologic emergencies are common among cancer patients and their incidence is increasing as patients live longer as a result of improved antineoplastic therapy. This article reviews acute neurologic complications in cancer patients. Among those complications reviewed are brain metastases, epidural spinal cord compression, leptomeningeal metastases, cerebrovascular disorders, complications of antineoplastic therapy, and paraneoplastic syndromes.

Anterior approaches to the thoracic spine in patients with cancer: indications and results

BACKGROUND

Multidisciplinary surgical teams enable an aggressive approach to tumors involving the thoracic spine.

METHODS

From February 1994 to July 1996, 61 patients underwent anterior resections of thoracic spine tumors. Their median age was 56 years. The indications for operation were curative in intent in 7 of 61 and palliative in 54 of 61 (to relieve intractable metastatic bone pain with neurologic compromise [n = 38] and pain alone [n = 16]). Sixteen patients came to our institution unable to ambulate with impending paraplegia.

RESULTS

Anterior approaches included combined left side of the neck and median sternotomy for lesions involving vertebrae T-1 through T-3 (n = 9), posterolateral thoracotomy for T-3 through T-10 (n = 39), and thoracoabdominal approach at T-11 and T-12 (n = 13). Median hospital stay was 9.0 days (range, 4 to 57 days). Complications occurred in 18 of 61 (29.5%). In 55 of 61 (90%), pain was significantly improved after the operation. Twelve of the 16 patients who initially presented in wheelchairs regained ambulatory function. There were five perioperative deaths (8.2%). The 1-year cumulative survival for the entire group was 60%.

CONCLUSIONS

An aggressive surgical approach in cancer patients with locally advanced or metastatic disease in the thoracic spine was associated with acceptable morbidity and mortality. There was significant improvement in their quality of life by control of intractable pain in 90% and recovery of ambulatory function in 75% of patients who presented with critical spinal cord compromise.

Spinal cord compression in prostate cancer: treatment outcome and prognostic factors

BACKGROUND AND PURPOSE

Spinal cord compression (SCC) is an important complication of metastatic prostate cancer. We have analysed patients treated at the Royal Marsden Hospital to assess treatment outcome and prognostic factors in this patients group.

MATERIALS AND METHODS

We performed retrospective analysis of 69 patients with spinal cord compression and prostate cancer treated at the Royal Marsden Hospital.

RESULTS

At presentation 40 (58%) patients were non-ambulant and 52% were catheterised. Diagnosis was established by myelography in 42% and magnetic resonance imaging (MRI) in 47% of patients. MRI detected significantly more patients with multiple sites of compression (51 versus 7%, P < 0.001). SCC was present at the initial diagnosis of prostatic cancer in 13 patients and 17 patients had received no hormone treatment prior to diagnosis. Following treatment 36 (52%) patients had a functional improvement of motor power with 25/40 (63%) non-ambulant patients becoming ambulant. Seventy-seven percent of patients who had eventual improvement had some improvement in power within 7 days. On multivariate analysis a single level of compression, no previous hormone therapy and a young age (<65 years) predicted for better outcome. When these factors were included an increased radiation dose (>30 Gy) or the addition of surgery did not improve the functional outcome. Following initial recovery; there was a 45% risk of developing a further episode of cord compression at the same or new site by 2 years with a median time to progression of 236 days (range 47-1215 days). The median survival was 115 days (range 5-2016 days) with 25% of patients surviving for 2 years. Patients with no prior hormone therapy had a median survival of 627 days (range 46-1516 days). Other predictors of improved survival on multivariate analysis were a single site of compression and a haemoglobin over 12 g.

CONCLUSIONS

Treatment of SCC in prostate cancer results in improved motor function in the majority of patients. Long-term survival is possible, especially in good performance status patients with no prior hormone treatment. Survivors remain at high risk of subsequent neurological relapse. An early improvement in motor power is a strong predictor of subsequent functional improvement. MRI detects additional sites of asymptomatic SCC which makes it the investigation of choice.

Clinical outcome in metastatic spinal cord compression. A prospective study of 153 patients

BACKGROUND

Despite many reports on metastatic spinal cord compression, only very few prospective studies of the clinical outcome of spinal cord compression have been carried out.

METHODS

153 consecutive patients with a known malignant solid tumor and a myelographically verified diagnosis of spinal cord compression were followed with regular neurological examination.

RESULTS

At time of diagnosis 79 patients were walking, while the remaining were bedridden. In total 21 of the 74 initially non-walking patients began walking after therapy. There was a need for urinary catheter in 57 (37%) patients at the time of diagnosis. During follow-up, 10 of 57 patients (18%) dispensed with the catheter. A total of 116 patients experienced radicular pain at the time of diagnosis, while in 95 of 116 patients (83%) the pain disappeared after therapy.

CONCLUSION

the present study confirms, that early diagnosis, i.e., while the patients are still ambulatory, is most important, but the prognosis for recovery of ambulatory function is not as pessimistic as earlier described. In addition the results indicate that supplementary systemic therapy, when available, may have a positive influence on recovery.

Intramedullary spinal cord metastasis: report of three cases and review of the literature

BACKGROUND

Intramedullary spinal cord metastasis is rare; but it is being encountered with increasing frequency. Optimal treatment after diagnosis remains controversial.

METHODS

In the last 3 years, we have encountered three cases of intramedullary metastasis presenting as focal mass lesions with minimal systemic evidence of cancer. We present our results in these patients and review the literature in an effort to more optimally define both the natural course of this disease, as well as a potential subset of patients who might benefit from more aggressive treatment.

RESULTS

With the availability of more sensitive imaging techniques, these tumors are being diagnosed with increasing frequency. Magnetic resonance imaging is sensitive, but nonspecific, in distinguishing intramedullary spinal cord metastases from primary cord tumors. Urgent biopsy is often necessary prior to definitive treatment. Radiation with chemotherapy significantly prolongs survival. Radical subtotal resection may offer additional quality survival, especially in cases of metastatic melanoma with an occult primary.

CONCLUSIONS

Regardless of treatment, many patients survive less than 1 year. Intramedullary spinal cord metastasis is a devastating condition, but with appropriate diagnosis and aggressive treatment, selected patients may have substantially increased survival.

Rehabilitative functional outcome of patients with neoplastic spinal cord compressions

OBJECTIVE

To examine functional outcome and descriptive data of individuals with neoplastic spinal cord compression admitted to a rehabilitation unit.

DESIGN

A 5-year review of consecutive patients admitted to a spinal cord injury rehabilitation unit with a diagnosis of neoplastic spinal cord compression.

SETTING

A tertiary university medical center.

PATIENTS

Thirty-two consecutive patients with neoplastic spinal cord compression who met standard rehabilitation admission criteria and had a prognosis of no less than 3 months' survival.

MAIN OUTCOME MEASURES

Functional data, including length of stay, functional outcomes (utilizing Functional Independent Measurement scores in mobility and self-care), bladder management, and disposition.

RESULTS

Lung (28%) and prostate (17%) were the most common tumor types, and upper thoracic (40%) was the most common level of spinal cord involvement. Functional Independent Measure improvements were found in all areas, with significant improvements (paired t test, p < .005) noted in the areas of upper and lower extremity dressing, grooming, toilet and tub transfers, wheelchair use and transfers, ambulation, and stair climbing. Average length of rehabilitation stay was 27 days, and 84% of the patients were discharged to home. Seventy-five percent of the 20 responders to a follow-up survey had maintained or improved their discharge functional abilities at 3 months after discharge.

CONCLUSIONS

These data suggest that in individuals with spinal cord compression caused by neoplastic invasion, functional improvements in mobility and self-care can be achieved and maintained for at least 3 months after discharge.

Indications and results of combined anterior-posterior approaches for spine tumor surgery

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

Anterior decompression and stabilization using a microsurgical endoscopic technique for metastatic tumors of the thoracic spine

It is well accepted that the treatment of spinal tumors that threaten neurological integrity comprises resection, vertebral body reconstruction, and stabilization if the patient's condition is suitable. In spite of the excellent results reported using thoracotomy, the majority of investigators recommend posterolateral techniques because of lower morbidity, shorter hospitalization time, and the possibility of performing dorsal stabilization via the same incision. To overcome some of the disadvantages of thoracotomy, the authors developed an anterior procedure that permits vertebrectomy, reconstruction, and stabilization to be performed entirely by endoscopic technique. Microsurgical endoscopy and stabilization were performed in four patients with metastatic disease of the thoracic spine. All were ambulatory after surgery and at follow up; preoperative neurological and neurophysiological deficits improved as well. No complications occurred in this small series. Microsurgical endoscopy achieves a substantial reduction in trauma, use of analgesic medications, and hospitalization time. Early results seem to indicate that adequate decompression, stabilization and reduction of surgical morbidity can be achieved with this technique.

Skeletal metastases

This synthesis of the literature on radiotherapy for skeletal metastases is based on 171 scientific articles, including 13 randomized studies, 24 prospective studies, and 79 retrospective studies. These studies involve 13054 patients. Radiotherapy has been well documented as a method for alleviating pain, but the mechanisms underlying this effect are largely unknown. When used for pain palliation, radiotherapy achieves freedom from pain, or substantial alleviation of pain in nearly all cases, with few side effects. Half-body irradiation is effective in treating multiple metastatic sites and should be considered for use more frequently. However, this increases the requirements on equipment, dosimetry, and hospital beds. Systemic radiotherapy with radionuclides may be indicated for generalized skeletal pain. The role of radiotherapy in preventing or healing fractures is not fully evaluated. Optimum dose levels and fractionation schedules have not been established. Early radiotherapy for spinal cord compression may prevent symptoms from worsening, but the effects on existing paralysis are modest.

Outcome after spinal reirradiation for malignant epidural spinal cord compression

Radiotherapy is effective for most cases of spinal cord compression. Although recurrent spinal cord compression is a common problem, little is known about whether reirradiation preserves neurologic function and what risk of radiation myelopathy it carries. To investigate this question, we reviewed patients at the Mayo Clinic between 1975 and 1992 undergoing two or more courses of radiotherapy to the same segment of the spinal column with radiographically documented epidural disease at the time of reirradiation to determine outcome as measured by the ability to walk and by survival. Fifty-four patients met the study criteria. Radiation doses for the first course ranged from 2,250 to 5,400 cGy (median, 3,000 cGy), and total dose for all courses to the reirradiated spinal segment ranged from 3,650 to 8,089 cGy (median, 5,425 cGy). All patients were ambulatory following the first course of radiation, 40 (74%) were ambulatory at the onset of reirradiation, and 42 (78%) were ambulatory at the end of reirradiation. Thirty-seven patients (69%) remained ambulatory at their last follow-up 6 days to 80 months following reirradiation (median, 4.7 months). Five patients eventually became nonambulatory 6.5 to 35 months following reirradiation. Median survival for all patients following reirradiation was 4.2 months. We conclude that for cancer patients with progressive epidural disease following radiotherapy, reirradiation frequently preserves ambulation and carries minimal risk of radiation myelopathy during the patients' lifetime.

Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients

The symptoms in metastatic compression of the spinal cord or cauda equine are described after a systematic recording of the sequence of symptoms in 153 patients. Radicular pain was predominant in patients with metastases located in the lumbar area, while the severity of motor symptoms was positively correlated with thoracic metastases. The most common initial symptom was radicular pain, followed, with decreasing frequency, by motor weakness, sensory complaints and bladder dysfunction. The progression of motor weakness influenced the probability of establishing the diagnosis of spinal cord compression by stepwise marked increased probability when patients lost gait function or progressed into total paralysis.

A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine

The anterior approach to the thoracic and lumbar spine for neoplastic disease is now a well-accepted procedure, with results, for the most part, superior to those achieved with laminectomy. However, the specific indications for anterior decompression and the selection of reconstruction techniques based on the location and extent of bony destruction have received surprisingly little attention. The authors report their experience with the operative management of 33 patients with benign and malignant tumors of the thoracic and lumbar spine, using the anterior transthoracic or retroperitoneal approach. The role of stabilization and the relative indications for anterior or posterior instrumentation are emphasized. The mean age of patients was 58 years. Twenty-three patients were male. Five patients had benign tumors, and the remainder had a variety of metastatic lesions. Twenty-nine patients had lower extremity motor deficits, although 25 were ambulatory preoperatively. Thirty-seven noncontiguous resections were performed in 33 patients. In 13 patients, the resected vertebral body was replaced with acrylic or bone without instrumentation; in 18, the acrylic was supplemented with anterior instrumentation; and in 6, both anterior and posterior instrumentation were used. Above T11, vertebral reconstruction techniques were used to restore stability after decompression. Between T11 and L4, anterior instrumentation was used to supplement vertebral reconstruction in all patients. Supplemental posterior instrumentation was used for three-column involvement. Motor function was stabilized or improved in 94% of patients, and 88% of patients were ambulatory postoperatively. Of 28 patients with malignant disease, 23 died after a mean survival of 10.2 months (range, 2-51 mo) and 5 are alive a mean of 34.4 months since their operation.(ABSTRACT TRUNCATED AT 250 WORDS)