The surgical treatment of metastatic disease of the spine

doi:10.1016/S0167-8140(00)00199-7

Radiotherapy and Oncology

Volume 56, Issue 3, 1 September 2000, Pages 335-339

https://doi.org/10.1016/S0167-8140(00)00199-7 Get rights and content

Abstract

Background and purpose: The spine is the commonest site for skeletal metastases. The majority of patients with spinal metastases can be managed conservatively, at least initially, but a significant number will develop complications, either neurological or mechanical, requiring surgical intervention. This paper emphasizes the need for a spinal surgeon to be involved early in the care of these patients.

Materials and methods: Forty-two patients undergoing surgery for metastatic disease of the spine between January 1995 and June 1997 were reviewed. Thirty-five of the patients had ‘instability’ pain secondary to pathological vertebral fracture, 25 of whom also had radicular pain secondary to nerve root compression. Six patients had radicular pain but no symptoms of instability. Two of these patients had symptoms of spinal claudication and one further patient had symptoms of spinal claudication alone. Forty of the patients had evidence of thecal compression on magnetic resonance imaging scans and 29 had neurological signs. According to the grading of Frankel (Paraplegia 7 (1969) 179), 14 had a major neurological deficit and 15 had a minor neurological deficit. All patients underwent decompression of the cord or nerve roots and spinal stabilization, 25 via a posterior approach, 15 via an anterior approach and two combined.

Results: Post-operatively pain improved in 38 of the 42 patients (90%), the neurological deficit in 20 of the 29 patients with a deficit (69%) and the ambulatory ability in 25 of the 32 patients (78%) with very restricted mobility.

Conclusions: Identification of the cause of a patient's symptoms allows appropriate surgical intervention with favourable results.

Introduction

Skeletal metastases are found in 60% of cancer patients at autopsy and the spine accounts for 50% of these osseous metastases [1]. Pain is the predominant presenting symptom and its cause should be identified to allow appropriate treatment.

Radiotherapy remains the most common treatment for metastases with 80% of patients experiencing an improvement in their pain [10]. However, with vertebral collapse and segmental instability, pain is often unresponsive to conservative management [4], [6]. Patients with deteriorating neurological function despite radiotherapy or with a radioresistant tumour may also require surgical intervention.

The pain of vertebral collapse and segmental instability is provoked by movement and exacerbated by sitting or standing. It often responds poorly to high dose narcotics, steroids or radiotherapy. Root compression, either due to direct extension of tumour or secondary to vertebral collapse, presents with typical radicular pain. Less commonly the pain may be severe and unremitting due to cord or cauda equina compression either by tumour or posterior extrusion of material into the canal following vertebral collapse. In a few cases, where tumour encroaches on the spinal canal but is not associated with vertebral collapse, the patient may experience the pain of spinal claudication when they walk. In many cases there may be more than one cause for the patient's pain.

The aim of the present study was to see whether by identifying the cause of a patient's symptoms and targeting surgery appropriately we were able to achieve satisfactory results.

Section snippets

Materials and methods

Forty-two patients who underwent definitive surgery for spinal metastases between January 1995 and June 1997 were reviewed (Table 1). The patients were referred by oncologists after the failure of conservative management which included analgesics, corticosteroids and, in 35 patients, radiotherapy.

The primary tumour was known in 39 patients but three patients who presented with acute neurological compromise had no histological diagnosis before surgery (Table 2).

Pre-operative assessment included

Results

Pain was relieved in 38 of the 42 patients (90%) post-operatively. Thirty patients were able to significantly reduce their analgesic requirement and were able to move with much less incident pain. Eight patients noticed a partial improvement in their pain, particularly that associated with movement. Four patients did not feel their pain had improved following surgery.

Twenty of the 29 patients (69%) with a neurological deficit prior to surgery improved post-operatively. Motor deficit improved in

Discussion

Back pain is common in patients with cancer. Although pain may be due to causes other than spinal metastases [3], it should be investigated especially if there are associated neurological symptoms and signs. A number of mechanisms are responsible for the development of these symptoms and signs in metastatic disease of the spine [7]. The pain of spinal instability secondary to pathological vertebral collapse or extensive destruction of the posterior elements can be managed successfully by

Conclusion

Presentation with spinal metastases may not be a terminal event. The aim of surgery is the relief of pain and the preservation or improvement of neurological function. Close co-operation between surgeon and oncologist is required in patient selection and in the early identification of the patients at risk.

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The spine is a common site of metastatic disease spread.1
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Short communicationThe surgical treatment of metastatic disease of the spine

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Osseous complications of malignancy

The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia 1

Paraplegia

Back pain in patients treated for malignant tumours

Clin. Oncol.

Spinal instability secondary to metastatic cancer

J. Bone Jt. Surg.

Surgical treatment of metastatic spine disease

Spine

Short communication
The surgical treatment of metastatic disease of the spine