Unilateral posterolateral decompression without stabilization for neurological palliation of symptomatic spinal metastasis in debilitated patients

Transpedicular 3D endoscope-assisted thoracic corpectomy for separation surgery in spinal metastases: feasibility of the technique and preliminary results of a promising experience

Surgery for spinal metastases has undergone multiple transformations in terms of surgical technique. The need for a more aggressive surgical strategy for local control of the disease, given the advances in radiosurgery and immunotherapy, has met the incorporation of many different technological adjuncts. Separation surgery has become one of the main targets to achieve for surgeons in the treatment of spinal metastases. In this paper a prospective series of 3D endoscope-assisted transpedicular thoracic corpectomies is described. Adult patients with a diagnosis of single-level thoracic metastases requiring surgery for epidural compression were included. Data recorded for each case concerned patient demographics, surgical technique, clinical, radiological and surgical data, intra- and postoperative complications, follow-up. The goal of this study was to verify the achievement of separation surgery with this technique, while confirming the safety and feasibility of the procedure. A total number of nine patients were treated from January to April 2019 with a 3D endoscope-assisted procedure. A circumferential bilateral decompression was achieved in seven cases, while monolateral in the other two. A proper separation between the tumor and the spinal cord was achieved in all cases as confirmed by imaging. Axial pain always improved after the procedure as well as neurological functions, when compromised before surgery. No intra-operative and postoperative complications were recorded. Mean hospital stay was 4 days after surgery with early mobilization. At last follow-up no local recurrences were registered. According to preliminary results, the transpedicular 3D endoscope-assisted approach for corpectomies appeared to be a safe and effective technique to achieve proper circumferential decompression and valid separation surgery in thoracic metastases, potentially decreasing the need for costotransversectomy.

Posterolateral thoracic decompression with anterior column cage reconstruction versus decompression alone for spinal metastases with cord compression: analysis of perioperative complications and outcomes

Background

The optimal surgical strategy for patients with spinal metastases remains unknown. The aim of this study was to determine if performing an anterior column reconstruction to a posterolateral approach adds to perioperative complications.

Methods

A retrospective review of all adult patients with spinal metastases who had a posterolateral approach for resection between January 2000 and December 2008. Perioperative complications and functional outcomes were determined.

Results

A total of 23 patients met the study criteria. Eleven patients underwent a costotransversectomy (CT) approach with anterior column reconstruction while 12 patients had a transpedicular (TP) approach without anterior column reconstruction. The mean age was 55.9 and 59.3 years in the CT and TP groups, respectively. There was no intraoperative death in either group. One death attributed to sepsis occurred in the TP group. A total of 5 (45.5%) complications occurred in the CT group and 7 (58.3%) in the TP group (P=0.68). An improvement in American Spinal Injury Association (ASIA) impairment scale grades was observed in 3 (27.3%) patients in the CT group and 1 (8.3%) in TP group. ASIA grades remained the same in 8 (72.7%) patients in CT and 10 (83.3%) patients in TP groups. No patient worsened in the CT group whereas 1 (8.3%) patient in TP group worsened. The median survival was 12.2 months in the CT group and 19.0 months in the TP group (P=0.37).

Conclusions

The addition of anterior column reconstruction does not appear to be associated with more operative or perioperative complications when compared to decompression alone. Anterior column reconstruction should not be aborted in fear of increasing perioperative complications.

Systematic Review of the Outcomes of Surgical Treatment of Prostate Metastases to the Spine

STUDY DESIGN

Systematic review.

OBJECTIVE

Surgical decompression and reconstruction of symptomatic spinal metastases has improved the quality of life in cancer patients. However, most data has been collected on cohorts of patients with mixed tumor histopathology. We systematically reviewed the literature for prognostic factors specific to the surgical treatment of prostate metastases to the spine.

METHODS

A systemic review of the literature was conducted to answer the following questions: Question 1. Describe the survival and functional outcomes of surgery or vertebral augmentation for prostate metastases to the spine. Question 2. Determine whether overall tumor burden, Gleason score, preoperative functional markers, and hormonal naivety favor operative intervention. Question 3. Establish whether clinical outcomes vary with the evolution of operative techniques.

RESULTS

A total of 16 studies met the preset inclusion criteria. All included studies were retrospective series with a level of evidence of IV. Included studies consistently showed a large effect of hormone-naivety on overall survival. Additionally, studies consistently demonstrated an improvement in motor function and the ability to maintain/regain ambulation following surgery resulting in moderate strength of recommendation. All other parameters were of insufficient or low strength.

CONCLUSIONS

There is a dearth of literature regarding the surgical treatment of prostate metastases to the spine, which represents an opportunity for future research. Based on existing evidence, it appears that the surgical treatment of prostate metastases to the spine has consistently favorable results. While no consistent preoperative indicators favor nonoperative treatment, hormone-naivety and high Karnofsky performance scores have positive effects on survival and clinical outcomes.

Posterior approaches for symptomatic metastatic spinal cord compression

Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.

Optimal approach to circumferential decompression and reconstruction for thoracic spine metastatic disease

BACKGROUND

Circumferential decompression has been demonstrated to be the first-line therapy for patients with metastatic tumors in the thoracic spine requiring surgical intervention. However, there is significant debate regarding whether these tumors are best accessed anteriorly utilizing a thoracotomy or posteriorly. We used decision analysis to determine which approach yields greater health-related quality of life (QOL).

METHODS

We searched Medline, Embase, and the Cochrane Library for relevant articles published between 1990 and 2011 on anterior and posterior approaches to metastatic disease in the thoracic spine. QOL values for major treatment outcomes were determined using the existing literature. Separate models were created for ambulatory and nonambulatory patients. A Monte Carlo simulation and sensitivity analyses were used to determine which treatment strategy resulted in the highest QOL.

RESULTS

For ambulatory patients, an anterior approach resulted in a slightly higher QOL, and for nonambulatory patients, a posterior approach was favored, but these differences were not statistically significant.

CONCLUSIONS

Using a decision-analytic model, we found no significant difference in QOL resulting from anterior versus posterior approaches to metastatic lesions in the thoracic spine. Decisions should instead be based on surgeon comfort, tumor characteristics, anatomy of the lesion, patient-related factors, and goals of the operation.

Surgical management of spinal metastases: analysis of prognostic factors during a 10-year experience

OBJECT

Refinement of surgical techniques, especially anterior approaches, for the management of spinal metastases has improved patient outcomes, despite the fact that a complete analysis of the prognostic factors that would inform patient selection has not been undertaken. The authors sought to identify such prognostic factors for neurological outcome and life expectancy in patients with spinal metastases.

METHODS

The authors used Kaplan-Meier techniques, log-rank comparisons, and a multivariate model stratified by tumor type to identify prognostic factors for duration of ability to walk and survival in patients who underwent surgical treatment for spinal metastases during a decade when all current treatment options were available. Preoperatively, 53 (87%) of the 61 patients in the study population suffered neurological symptoms (for example, weakness) and 52 (85%) were ambulatory. Postoperatively, 59 (97%) were ambulatory. Most patients who survived 6 months (81%) remained ambulatory, as did 66% of those alive at 1.6 years. The median postoperative survival was 10 months. The risk factors for loss of ambulation were preoperative loss of ambulatory ability, recurrent or persistent disease after primary radiotherapy of the operative site, a procedure other than corpectomy, and tumor type other than breast cancer. Prognostic factors for reduced survival were surgical intervention extending over two or more spinal segments, recurrent or persistent disease after primary radiotherapy involving the operative site, diagnosis other than breast cancer, and a cervical spinal procedure.

CONCLUSIONS

The results of this analysis allowed the authors to create a simple prognostic factor scoring system that can be applied to individual patients. The positive experience derived from this study supports an expanded role for the surgical treatment of metastatic spinal disease.

A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease

Radiotherapy has been the primary therapy for managing metastatic spinal disease; however, surgery that decompresses the spinal cord circumferentially, followed by reconstruction and immediate stabilization, has also proven effective. We provide a quantitative comparison between the "new" surgery and radiotherapy, based on articles that report on ambulatory status before and after treatment, age, sex, primary neoplasm pathology, and spinal disease distribution. Ambulation was categorized as "success" or "rescue" (proportion of patients ambulatory after treatment and proportion regaining ambulatory function, respectively). Secondary outcomes were also analyzed. We calculated cumulative success and rescue rates for our ambulatory measurements and quantified heterogeneity using a mixed-effects model. We investigated the source of the heterogeneity in both a univariate and multivariate manner with a meta-regression model. Our analysis included data from 24 surgical articles (999 patients) and 4 radiation articles (543 patients), mostly uncontrolled cohort studies (Class III). Surgical patients were 1.3 times more likely to be ambulatory after treatment and twice as likely to regain ambulatory function. Overall ambulatory success rates for surgery and radiation were 85% and 64%, respectively. Primary pathology was the principal factor determining survival. We present the first known formal meta-analysis using data from nonrandomized clinical studies. Although we attempted to control for imbalances between the surgical and radiation groups, significant heterogeneity undoubtedly still exists. Nonetheless, we believe the differences in the outcomes indicate a true difference resulting from treatment. We conclude that surgery should usually be the primary treatment with radiation given as adjuvant therapy. Neurologic status, overall health, extent of disease (spinal and extraspinal), and primary pathology all impact proper treatment selection.

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.

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.

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.

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.

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.

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.

Cervical laminectomy without fusion in patients with rheumatoid arthritis

OBJECT

The authors performed a prospective study to determine whether cervical laminectomy without simultaneous fusion results in spinal instability.

METHODS

Because of clinical and radiographic signs of cord compression, 15 patients with rheumatoid arthritis (including one with Bechterew's disease) and severe involvement of the cervical spine underwent decompressive laminectomy without fusion performed on one or more levels. Preoperative flexion-extension radiographs demonstrated dislocation but no signs of instability at the level of cord compression. Clinical and radiological reexamination were performed twice at a median of 15 months (6-24 months) and 43 months (28-72 months) postoperatively. One patient developed severe vertical translocation 28 months after undergoing a C-1 laminectomy, which led to sudden tetraplegia. She required reoperation in which posterior fusion was performed. No signs of additional instability at the operated levels were found in the remaining 14 patients. In three patients increased but stable dislocation was demonstrated. The results of clinical examination were favorable in most patients, with improvement of neurological symptoms and less pain.

CONCLUSIONS

The authors conclude that decompressive laminectomy in which the facet joints are preserved can be performed in the rheumatoid arthritis-affected cervical spine in selected patients in whom signs of cord compression are demonstrated, but in whom radiographic and preoperative signs of instability are not. Performing a simultaneous fusion procedure does not always appear necessary. Vertical translocation must be detected early, and if present, a C-1 laminectomy should be followed by occipitocervical fusion.

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.

Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis

The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple columns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resection of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid surgeons in selecting the optimum approach for individual patients.