Modern Techniques for the Management of Metastatic Spine Disease

The management of metastatic spine disease has evolved substantially in the past 5 years. Early treatment approaches with more aggressive surgical indications were based on studies that misinterpreted or overemphasized the advantages of the surgical management of metastatic spine disease. However, substantial advantages in radiation therapy, chemotherapy, and biologic agents have led to considerable improvements in patient outcomes and have, in many patients, shifted the paradigm back to nonsurgical or less invasive treatment modalities. Surgeons should be aware of critiques of earlier treatment strategies and associated frameworks for the management of metastatic spine disease. The Medical, Oncologic, Stenosis, and Stability framework was developed to address some of the shortcomings of early metastatic spine disease treatment approaches.

Outcomes of Instrumented and Noninstrumented Posterolateral Lumbar Fusion

The purpose of this study was to evaluate the long-term clinical and radiographic outcomes of posterolateral lumbar fusion for lumbar stenosis cases requiring bilateral facetectomy in conjunction with a laminectomy. The authors evaluated 34 consecutive patients who had undergone a lumbar laminectomy, bilateral partial facetectomy, and posterolateral fusion at a single institution between 1981 and 1996. They included 25 men and 9 women with a mean age of 42 years (range, 27-57 years). Twenty-three cases were instrumented and 11 were noninstrumented. Mean follow-up was 21 years (range, 15-29 years). Outcomes evaluated included reoperation rate, clinical outcomes evaluated by the Oswestry Disability Index (ODI) score, radiographic evaluations of adjacent segmental degeneration (ASD) and lumbar lordosis, and contributing demographic factors to disease progression. At final follow-up, 17 of the 34 patients had undergone reoperation (43% of the instrumented group and 64% of the noninstrumented group). There were no differences in the reoperation rate or ODI improvement between the instrumented and noninstrumented groups (P>.05). Female patients required more revisions, had less ODI improvement, had greater postoperative ASD, and had less maintenance of their postoperative lumbar lordosis. There was no difference in maintenance of postoperative lumbar lordosis or ASD between the instrumented and noninstrumented groups. Instrumentation did not improve revision rates, clinical outcomes, or radiographic outcomes in laminectomies requiring contemporaneous facetectomies.