Metastatic Spinal Tumors
Metastatic Spinal Tumors
Metastatic spinal tumors are the most common type of malignant lesions of the spine. Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors affect outcome including the nature of the primary cancer, the number of lesions, the presence of distant nonskeletal metastases, and the presence and/or severity of spinal cord compression. Initial management consists of chemotherapy, external beam radiotherapy, and external orthoses. Surgical intervention must be carefully considered in each case. Patients expected to live longer than 12 weeks should be considered as candidates for surgery. Indications for surgery include intractable pain, spinal cord compression, and the need for stabilization of impending pathological fractures. Whereas various surgical approaches have been advocated, anterior-approach surgery is the most accepted procedure for spinal cord decompression. Posterior approaches have also been used with success, but they require longer-length fusion. To obtain a stable fixation, the placement of instrumentation, in conjunction with judicious use of polymethylmethacrylate augmentation, is crucial. Preoperative embolization should be considered in patients with extremely vascular tumors such as renal cell carcinoma. Vertebroplasty, a newly described procedure in which the metastatic spinal lesions are treated via a percutaneous approach, may be indicated in selected cases of intractable pain caused by non-or minimally fractured vertebrae.
Bone is the third most frequent metastatic site of distant spread of carcinoma. The vertebral column is the most common site of skeletal metastases. Improvements in oncological management have increased survival times in patients with skeletal metastases. Spine surgeons are frequently faced with decisions of how to treat patients with these lesions. Although not curative, resection and stabilization can have beneficial effects on neurological status, function, pain, and mobility. These are important issues, particularly in individuals in whom remaining life expectancy is no more than 1 to 2 years.
Metastatic disease of the spine can manifest in many ways. Pain is present in virtually all cases and can be severe enough that basic activities such as walking become nearly impossible. Significant bone destruction can lead to fracture, instability, and deformity. Perhaps the most dreaded complication, spinal cord compression, can result from pathological fractures, direct invasion of the spinal canal by the tumor, or osteoblastic bone reaction. Surgical treatment has a role in each of these scenarios; however, the decision to proceed with operative intervention is not always clear cut. Although various attempts have been made to devise methods for predicting life expectancy in this population, none exists. Regardless, most authors agree that patients in whom expected survival is at least 12 weeks should be considered for palliative surgery. Numerous other factors must be weighed, however, including overall health, nutrition, the aggressiveness of the primary tumor, and extent of preoperative neurological deficit(s).
Once the decision for surgery has been made, the goals can be more defined. If the neural elements are compressed, the first fundamental step is to undertake decompressive surgery, excising either the anterior or posterior elements. Resection of tumoral material is also effective for pain relief. With various methods available, reconstruction of the spine, in which cement augmentation, bone graft, and instrumentation can be used, is crucial for achieving fixation. There are strong supporters of posterior surgery over anterior surgery, whereas others favor combined approaches. New minimally invasive techniques, such as vertebroplasty, may also play a role for the prophylactic spinal fixation before significant vertebral collapse occurs.
The purpose of this paper is to present the current data concerning surgical treatment of spinal metastatic lesions. Relevant issues concerning evaluation, diagnostic work-up, adjunctive preoperative procedures, and surgical technique are discussed. Effective treatment decision making involves the cooperation of patient and family, medical and radiological oncologists, and the surgical team.
Abstract and Introduction
Abstract
Metastatic spinal tumors are the most common type of malignant lesions of the spine. Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors affect outcome including the nature of the primary cancer, the number of lesions, the presence of distant nonskeletal metastases, and the presence and/or severity of spinal cord compression. Initial management consists of chemotherapy, external beam radiotherapy, and external orthoses. Surgical intervention must be carefully considered in each case. Patients expected to live longer than 12 weeks should be considered as candidates for surgery. Indications for surgery include intractable pain, spinal cord compression, and the need for stabilization of impending pathological fractures. Whereas various surgical approaches have been advocated, anterior-approach surgery is the most accepted procedure for spinal cord decompression. Posterior approaches have also been used with success, but they require longer-length fusion. To obtain a stable fixation, the placement of instrumentation, in conjunction with judicious use of polymethylmethacrylate augmentation, is crucial. Preoperative embolization should be considered in patients with extremely vascular tumors such as renal cell carcinoma. Vertebroplasty, a newly described procedure in which the metastatic spinal lesions are treated via a percutaneous approach, may be indicated in selected cases of intractable pain caused by non-or minimally fractured vertebrae.
Introduction
Bone is the third most frequent metastatic site of distant spread of carcinoma. The vertebral column is the most common site of skeletal metastases. Improvements in oncological management have increased survival times in patients with skeletal metastases. Spine surgeons are frequently faced with decisions of how to treat patients with these lesions. Although not curative, resection and stabilization can have beneficial effects on neurological status, function, pain, and mobility. These are important issues, particularly in individuals in whom remaining life expectancy is no more than 1 to 2 years.
Metastatic disease of the spine can manifest in many ways. Pain is present in virtually all cases and can be severe enough that basic activities such as walking become nearly impossible. Significant bone destruction can lead to fracture, instability, and deformity. Perhaps the most dreaded complication, spinal cord compression, can result from pathological fractures, direct invasion of the spinal canal by the tumor, or osteoblastic bone reaction. Surgical treatment has a role in each of these scenarios; however, the decision to proceed with operative intervention is not always clear cut. Although various attempts have been made to devise methods for predicting life expectancy in this population, none exists. Regardless, most authors agree that patients in whom expected survival is at least 12 weeks should be considered for palliative surgery. Numerous other factors must be weighed, however, including overall health, nutrition, the aggressiveness of the primary tumor, and extent of preoperative neurological deficit(s).
Once the decision for surgery has been made, the goals can be more defined. If the neural elements are compressed, the first fundamental step is to undertake decompressive surgery, excising either the anterior or posterior elements. Resection of tumoral material is also effective for pain relief. With various methods available, reconstruction of the spine, in which cement augmentation, bone graft, and instrumentation can be used, is crucial for achieving fixation. There are strong supporters of posterior surgery over anterior surgery, whereas others favor combined approaches. New minimally invasive techniques, such as vertebroplasty, may also play a role for the prophylactic spinal fixation before significant vertebral collapse occurs.
The purpose of this paper is to present the current data concerning surgical treatment of spinal metastatic lesions. Relevant issues concerning evaluation, diagnostic work-up, adjunctive preoperative procedures, and surgical technique are discussed. Effective treatment decision making involves the cooperation of patient and family, medical and radiological oncologists, and the surgical team.
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