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Heary 2001
Heary 2001
Metastatic spinal tumors are the most common type of malignant lesions of the spine. Prompt diagnosis and iden-
tification 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 decom-
pression. Posterior approaches have also been used with success, but they require longer-length fusion. To obtain a sta-
ble fixation, the placement of instrumentation, in conjunction with judicious use of polymethylmethacrylate augmen-
tation, 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 tion is not always clear cut. Although various attempts
spread of carcinoma.4 The vertebral column is the most have been made to devise methods for predicting life ex-
common site of skeletal metastases.13 Improvements in pectancy in this population, none exists.10,31,33,37,39 Regard-
oncological management have increased survival times in less, most authors agree that patients in whom expected
patients with skeletal metastases. Spine surgeons are fre- survival is at least 12 weeks should be considered for pal-
quently faced with decisions of how to treat patients with liative surgery. Numerous other factors must be weighed,
these lesions. Although not curative, resection and stabi- however, including overall health, nutrition, the aggres-
lization can have beneficial effects on neurological status, siveness of the primary tumor, and extent of preoperative
function, pain, and mobility.14,17,18,24,25 These are important neurological deficit(s).31,33,37
issues, particularly in individuals in whom remaining life Once the decision for surgery has been made, the goals
expectancy is no more than 1 to 2 years.38 can be more defined. If the neural elements are com-
Metastatic disease of the spine can manifest in many pressed, the first fundamental step is to undertake decom-
ways. Pain is present in virtually all cases and can be se- pressive surgery, excising either the anterior or posterior
vere enough that basic activities such as walking become elements. Resection of tumoral material is also effective
nearly impossible.9 Significant bone destruction can lead for pain relief. With various methods available, recon-
to fracture, instability, and deformity. Perhaps the most struction of the spine, in which cement augmentation,
dreaded complication, spinal cord compression, can result bone graft, and instrumentation can be used, is crucial for
from pathological fractures, direct invasion of the spinal achieving fixation.5,17,24,25,36 There are strong supporters of
canal by the tumor, or osteoblastic bone reaction.16,20,29,35 posterior surgery over anterior surgery, whereas others
Surgical treatment has a role in each of these scenarios; favor combined approaches.5,9,30 New minimally invasive
however, the decision to proceed with operative interven- techniques, such as vertebroplasty, may also play a role
for the prophylactic spinal fixation before significant ver-
tebral collapse occurs.2,7,8
Abbreviations used in this paper: CT = computerized tomogra- The purpose of this paper is to present the current data
phy; GI = gastrointestinal; MMA = methylmethacrylate; MR = concerning surgical treatment of spinal metastatic lesions.
magnetic resonance; PMMA = polymethylmethacrylate; VB = ver- Relevant issues concerning evaluation, diagnostic work-
tebral body. up, adjunctive preoperative procedures, and surgical tech-
nique are discussed. Effective treatment decision making astatic prostate cancer, Yamashita, et al.,39 reported longer
involves the cooperation of patient and family, medical survival in patients with spinal or pelvic lesions (Group I)
and radiological oncologists, and the surgical team. compared with those in whom appendicular spread had
occurred (Group II). The mean survival time after initia-
tion of treatment (of primary cancer) in Group I was 5.7
PATHOPHYSIOLOGY OF METASTATIC years compared with 2.4 years in Group II. The authors
DISEASE hypothesized that axial metastasis was more likely in gen-
eral because of the proximity of the primary tumor to the
A primary carcinoma must undergo several steps before Batson venous plexus (vertebral venous system). The Bat-
producing a metastasis at a distant site. Common primary son plexus is a valveless venous system that has been fre-
cancers that spread to bone are lung, breast, renal, pros- quently implicated as a conduit for the metastatic spread
tate, and thyroid. Lung is the most common neoplasm in of prostate tumors. Thus, they found that patients who pre-
males, whereas breast is the most frequent in females. sented with vertebral lesions initially harbored the least
Despite the anatomical location, the tumor must grow be- aggressive tumor, whereas in those with appendicular le-
yond the bounds of the basement membrane of the cells at sions the metastasis had bypassed the Batson plexus. In-
the primary (extraspinal) site of the tumor. This process is terestingly, patients with both appendicular and axial met-
facilitated by enzymes known as matrix metalloproteinas- astases (Group III) an intermediate life expectancy (3.4
es causing degradation of this layer. Acting most specifi- years) was demonstrated, which was better than Group II
cally to break down the Type IV collagen in the basement but worse than Group I.39
membrane, the cancerous growth is then given access to Some investigators have addressed the question of sur-
surrounding blood vessels and lymph vessels. Tumor cells vival after surgery for spinal metastatic tumors. Tokuhashi
can then travel to distant tissues. For the cell to success- and coworkers37 have studied the results obtained in 64
fully metastasize, it must adhere to the second site and patients who underwent surgery for spinal metastases.
obligatorily stimulate the growth of new blood vessels. They included all primary diagnoses and operations per-
This is known as tumor angiogenesis. Unfortunately, a formed for a variety of indications including pain and pa-
well-vascularized metastasis will survive at the expense of ralysis. They formulated a score based on a number of
normal healthy tissue. parameters including general systemic condition, number
In the spinal column, metastatic carcinoma has a predil- of extraspinal bone metastases, number of spinal metasta-
ection for the well-vascularized cancellous bone of the ses, presence of lesions in other internal organs, location
VB. Less frequently, a lesion will develop only in the pos- of the primary lesion, and the severity of spinal cord in-
terior elements (that is, the neural arch). In some situa- jury. Although no single parameter was predictive, scores
tions, the tumor extends from the the anterior to posterior correlated with survival periods. Scores of 9 or higher
columns, making it more difficult to plan a surgical de- were predictive of at least 12 months of survival; scores of
bulking or resection of the tumor. 8 and lower indicated survival less than 12 months; and
scores of 5 or lower predicted survival of 3 months or less.
IMPORTANCE OF SURVIVAL PROGNOSIS Based on these data, it appears that the Tokuhashi sys-
tem would be a valuable tool in preoperative discussions
Patients with metastatic cancer have limited life expec- and decision making. Its value has been confirmed by
tancies. After primary lung cancer has spread to distant other authors. Enkaoua, et al.,10 found it predictive of sur-
organs, the mean survival time is 6 months. The mean sur- vival after surgery in patients with most metastatic tumors
vival after metastasis of breast, renal, or prostate carcino- to the spine. One exception was in cases of tumors of un-
ma is less dismal, averaging approximately 1.5 to 2 years. known primary origin. The investigators suggested ascrib-
Fewer than 10% of patients with metastatic renal cancer ing a lower score to patients in this group, because their
survive more than 2 years.35 Because of recent advances in outcomes were generally poorer than predicted. It has
the medical management of certain types of tumors, such been our experience that adenocarcinoma of unknown ori-
as breast and prostate carcinoma, longer survival periods gin has been particularly lethal and with survival periods
are being achieved, compared with those published in the frequently less than 3 months.
medical literature from prior decades. Surgical treatment Some authors have found preoperative neurological sta-
of skeletal disease must be considered in light of a pa- tus to be highly predictive of survival,33 whereas those
tient’s projected survival. Within the surgical oncological using the Tokuhashi system have not found it to be inde-
community, it is well accepted that a patient should be ex- pendently predictive. Perhaps this is related to the sim-
pected to live for at least a 6-week to 3-month period. plistic grading of the Tokuhashi system in which spinal
Typically it is the medical oncologist who makes this life cord deficits are divided into motor complete (Frankel
expectancy estimation, basing it on natural history of the Grade A or B), motor incomplete (Frankel Grade C or D),
disease itself. The surgeon, however, must consider the or intact (Frankel Grade E) groups. In subsequent studies,
attendant morbidity and negative effects that the surgery however, other authors10,38 have supported the findings re-
itself will have on the patient’s survival.31,37,38 It is in the ported by Tokuhashi, et al.36
surgeon’s best interest to be thoroughly familiar with all Other preoperative parameters have been analyzed. Si-
factors involved. outos and coworkers33 found that patients who were am-
Although a number of authors have attempted to iden- bulatory preoperatively and those in whom the disease
tify clinical predictors of survival in cases of metastatic involved only one vertebra survived statistically longer
disease, few have studied lesions of the spine specifical- than patients who were nonambulatory and those with
ly.10,33,37–39 In a retrospective series of patients with met- multilevel disease. Overall extent of disease, age, and tu-
mor location (that is, anterior or posterior elements of the Spinal cord or cauda equina injury is most effectively
spine) were not predictive. Not surprisingly, patients with treated by means of decompressive surgery.5,9,30,38 Radio-
metastatic renal carcinoma survived the longest, whereas therapy, although a useful adjuvant, does not produce
those with breast experienced longer life spans than indi- long-lasting results by itself.35 In a series of 43 patients,
viduals with lung metastases. Weigel, et al.,38 corroborat- Sundaresan, et al.,35 reported neurological improvement in
ed these findings, reporting that patients 60 years of age or 45% of patients in whom radiotherapy alone was per-
younger survived statistically longer than those older than formed, whereas surgery before or after radiotherapy re-
60 years of age, whereas tumor location was not statisti- sulted in 100 and 60% improvement, respectively. In the
cally significant. In contrast to the findings of Sioutos, et short term, radiotherapy may be more effective in patients
al., Weigel, et al., did not find preoperative neurological in whom no evidence of bone compression is present.27 In
function to be an important factor in survival. Similar to contrast, the use of high-dose corticosteroid therapy has
the Tokuhashi system, Weigel, et al., simplistically graded demonstrated beneficial effects on outcome in patients
neurological status as ambulatory or nonambulatory. In with metastatic spinal cord compression. In a prospective
actuality, ambulatory status is probably influenced by fac- randomized study of 57 patients, high-dose dexametha-
tors other than neural compression such as pain and gen- sone therapy resulted in 18% more patients becoming
eral systemic condition. ambulatory than those who had undergone radiotherapy.34
Side effects, such as GI or infectious complications, must
NEURAL COMPRESSION be considered, because they occur in approximately 11%
of cases. Although some may advocate moderate- or low-
Spinal cord compression, or more accurately, neurolog- dose steroid treatment to minimize these side effects, there
ical deficit is an unfortunately common sequela of spi- is little evidence that they have an impact on metastatic
nal metastatic tumors. Because of its perceived influence spinal cord compression.15 To our knowledge, the use of
on prognosis and its high incidence, this topic deserves steroids for cauda equina injury is not beneficial, because
particular discussion. The basic pathological feature caus- this is a lower motor neuron lesion.
ing spinal cord compression is encroachment of tumor
or bone into the spinal canal. In the cervical and thoracic
regions, this causes spinal cord compression, whereas le- Nonoperative Management
sions in the lumbar spine can cause stenosis and cauda This group of treatment modalities can be termed pal-
equina syndrome. The exact mechanism of disruption of liative care. Tokuhashi, et al.,37 reported that palliative
nerve function remains unclear. Commonly accepted the- treatment should be reserved for patients who are poor
ories include pressure-induced impedance of neural firing candidates for surgery. There are limited conservative op-
and cord ischemia secondary to compromise of the blood tions for the treatment of metastatic spinal tumors. Prac-
supply.29 The actual mechanism is likely a combination of titioners must keep in mind the goals of nonsurgical treat-
these two factors. ment. Pain relief is probably the most common indication.
Spinal metastases–induced canal compromise can be Radiation therapy localized to the area of the lesion can
caused by a number of factors. Most commonly, lytic le- successfully relieve pain and is probably a useful first-line
sions weaken the supporting bone of the VB, creating an modality in cases of most tumors. Some tumors are inher-
impending fracture. With little undue force, a pathological ently radioresistant, such as renal cell and GI tumors, with
fracture can ensue. The posterior VB can be retropulsed in fewer than half of cases responding. The benefit of radio-
a burstlike pattern, compressing the neural structures. therapy must be balanced against the potential harmful
Another mechanism occurs via direct extension of the le- side effects to the local tissue and skin. This can be an
sion beyond the confines of the posterior VB, which can, issue if surgery is planned in the near future. A minimum
by itself, compromise the spinal canal without a frank of 3 weeks should be allowed between the completion of
pathological fracture. The third mechanism is the rarest external-beam radiotherapy and surgery in the zone of
but an important one of which to be aware. Blastic tumors treatment.
can cause pathological bone overgrowth in the region of Spinal instability is not cured by radiotherapy, and in
the spinal canal. Hirschfeld, et al.,16 have reported two some cases, it can cause further bone weakening. Al-
such cases: one in a woman with metastatic breast cancer though there is little evidence in the literature to support
and another in a man with prostate carcinoma. In contrast their benefit in the long term, braces are commonly pre-
to renal cell or lung carcinomas, both breast and prostate scribed for patients with pathological spinal fractures.
cancers are well-known causes of blastic lesions. Usually, extension-type braces are most useful in the tho-
Neurological injury occurs in 5 to 10% of patients with racolumbar spine, because impending kyphotic deformi-
cancer.1,3,28 The mean survival after spinal cord compres- ties secondary to anterior column destruction are the fre-
sion–induced paraplegia is 3.4 months.38 Compression can quent presentation. Patients harboring cervical lesions may
occur at one or more sites. More than one site of com- receive some degree of comfort from wearing a hard or
pression is present in 23% of patients with spinal cord soft cervical collar. The collar’s effectiveness in prevent-
compression secondary to prostate metastasis. Although ing an impending pathological fracture is unknown. Le-
one site might be obvious, systemic clinical and radiolog- sions at the cervicothoracic junction may require a cus-
ical examination of the entire spine is essential to detect tom-made orthosis that includes both a cervical and upper
additional lesions. The most sensitive neurodiagnostic im- thoracic/chest component. In cases of lesions in the upper
aging studies for detecting additional lesions are MR im- cervical spine, a halo fixator can be a better option. In
aging, with and without intravenous contrast, or bone all situations, the patient’s comfort should be the pri-
scanning. mary goal.
TREATMENT-RELATED OUTCOMES
Pain relief is accomplished by partial or total excision
of the lesion from the vertebra. This lesion may be in the
anterior or posterior elements. The rate of pain relief after
surgery for metastatic tumors is generally high. Weigel, et
al.,38 have reported at least moderate pain relief in 89% of
patients after performing anterior decompressive surgery
and stabilization. Similarly, Rompe, et al.,30 and Hussein,
et al.,17 have documented pain relief in approximately
90% of their cases. Both Shimizu, et al.,32 and Cahill and
Kumar5 have reported 100% pain relief after undertaking
surgery via posterior approaches. The mechanism of pain
relief is not clearly understood but is most likely effected
after removal of the offending lesion in addition to the Fig. 1. A 54-year-old woman with known metastatic renal cell
increase in mechanical stability. carcinoma who was neurologically intact with back pain. Upper
Neurological deficits are common sequelae of metasta- Left: Sagittal T2-weighted MR image demonstrating involvement
tic spinal tumors. They can occur at the level of the spinal of the posterior elements of L-3 (arrow). Lower Left: Axial T1-
cord or cauda equina. Progressive deficits are an indica- weighted MR image revealing the L-3 spinous process and lami-
tion for surgical decompression, which can be effected by na infiltrated by tumor, with anterior structures intact (arrow).
anterior or posterior methods.5,17,18,38 Corpectomy at the Right: Bone scan demonstrating numerous additional sites of met-
astatic disease (ribs, skull, and scapula) in addition to L-3 (arrow).
site of the lesion is performed to decompress the anterior The patient underwent simple posterior decompression.
canal, whereas a posterior decompression is achieved via
laminectomy. The details of these procedures including
reconstruction will be discussed in greater detail below.
Although both methods have been used with success, the site at which laminectomy was performed in patients
most authors currently believe that in patients with better with significant loss of the anterior weight-bearing portion
prognoses restoration of the anterior weight-bearing por- of the spine. In more recent reports the authors have
tion of the spine may help prevent collapse of the involved placed elongated rigid posterior constructs after decom-
vertebral segment. This can be achieved using an anterior pressive laminectomy (Fig. 2). Despite these differences
corpectomy or posteriorly using a lateral extracavitary and trends, the rates of neurological improvement after
approach. surgery are comparable.
Laminectomy for decompression of spinal metastatic Rompe, et al.,30 undertook surgery via the posterior
tumors has fallen out of favor. Because the anterior col- approach in 50 patients with metastatic tumors of multi-
umn destruction was not treated, progressive kyphotic ple origins, they used long segmental hook stabilization
deformity was frequent. Removal of the posterior ele- alone. Twenty-six patients suffered a neurological deficit,
ments can further destabilize an already compromised of whom 14 (53%) improved at least one Frankel grade
spine. In some relatively rare cases in which a metastatic postoperatively. One patient (4%) became worse and 11
carcinoma predominantly invades the posterior elements (42%) remained unchanged. The authors recommended
of the spine, a laminectomy may be appropriate (Fig. 1). the posterior approach in cases of multi-level metastatic
Although the anterior resection and reconstruction more disease that would be difficult to manage via an anterior
directly address the typical site of spinal cord compression approach. Interestingly, the only two cases of hardware-
and vertebral column destruction, some surgeons believe related failure occurred in patients with single-level dis-
these procedures are associated with a high rate of mor- ease. Similar rates of neurological improvement were
bidity, which may not be justified in this patient popula- documented by Shimizu, et al.32 Of 11 patients with mul-
tion.23,30 The failures of earlier series involving simple tilevel metastatic disease, nine patients (82%) experienced
posterior decompression, without stabilization, were prob- neural improvement after undergoing posterior decom-
ably secondary to inadequate fixation above and below pression and stabilization.
Fig. 2. A 61-year-old man who underwent nephrectomy 16 years previously for renal cell carcinoma. He developed
severe back pain and paraparesis. He had a history of heavy smoking and recent 20-pound weight loss. The patient under-
went subtotal T-11 corpectomy and T8–L1 stabilization with pedicle screw/rod construct. The patient fractured his right
hip 5 days after spinal surgery and underwent an open reduction internal fixation procedure. A: Sagittal T1-weighted
MR image demonstrating significant collapse of T-11 with tumor extending anteriorly and posteriorly; the posterior
aspect of the tumor displaces the spinal cord (large arrow). Multiple lower lumbar vertebrae have small metastatic
deposits but no structural deficiencies (small arrow). B: Axial T1-weighted gadolinium-enhanced MR image demon-
strating near-total replacement of T-11 VB with tumor, minimal preservation of the right side of T-11 (arrow), and spinal
cord displacement on the left side. C: Angiogram demonstrating significant blush from tumor, which was successfully
embolized preoperatively. D: Intraoperative photograph obtained after subtotal T-11 corpectomy via a posterior ap-
proach. Stabilization was performed using pedicle screws (three levels above, two levels below) and rods. E: Postop-
erative plain anteroposterior radiograph revealing good coronal-plane alignment and screw placement. F: Postoperative
plain lateral radiograph demonstrating good sagittal-plane alignment and screw placement. G: Postoperative axial CT
scan revealing good pedicle screw positioning in T-9. H: Plain radiograph of right hip demonstrating good alignment
after open reduction internal fixation of the pathological hip fracture.
Weigel, et al.,38 used a variety of approaches in 45 cases rate of neurological improvement. There are no random-
of metastatic disease with a neural deficit. Sixty-two per- ized prospective studies currently available, however, in
cent of patients improved after anterior surgery whereas which the authors compare anterior and posterior ap-
50% improved after laminectomy. The investigation was proaches, and thus, nonuniform selection criteria likely
retrospective and there was no attempt to randomize pa- create a bias.
tients. King, et al.,18 reported a 50% rate of neurological
improvement of at least one Frankel grade in 20 patients
after anterior decompression combined with posterior sta- PREOPERATIVE EVALUATION
bilization without laminectomy. Based on these data, it is Obtaining a complete history and performing a physical
difficult to conclude that anterior surgery leads to a better examination are the initial steps in preoperative evalua-
Metastatic adenocarcinoma of the spine. Spine 17:427–430, for the preoperative evaluation of metastatic spine tumor prog-
1992 nosis. Spine 15:1110–1113, 1990
32. Shimizu K, Shikata J, Iida H, et al: Posterior decompression and 38. Weigel B, Maghsudi M, Neumann C, et al: Surgical manage-
stabilization for multiple metastatic tumors of the spine. Spine ment of symptomatic spinal metastases. Postoperative outcome
17:1400–1404, 1992 and quality of life. Spine 24:2240–2246, 1999
33. Sioutos PJ, Arbit E, Meshulam CF, et al: Spinal metastases 39. Yamashita K, Denno K, Ueda T, et al: Prognostic significance
from solid tumors. Analysis of factors affecting survival. Can- of bone metastases in patients with metastatic prostate cancer.
cer 76:1453–1459, 1995 Cancer 71:1297–1302, 1993
34. Sørensen S, Helweg-Larsen S, Mouridsen H, et al: Effect of
high-dose dexamethasone in carcinomatous metastatic spinal
cord compression treated with radiotherapy: a randomized trial.
Eur J Cancer 30A:22–27, 1994
35. Sundaresan N, Scher H, DiGiacinto GV, et al: Surgical treat-
ment of spinal cord compressionin kidney cancer. J Clin Oncol Manuscript received October 24, 2001.
4:1851–1856, 1986 Accepted in final form November 2, 2001.
36. Sundaresan N, Shah J, Foley KM, et al: An anterior surgical ap- Address reprint requests to: Robert F. Heary, M.D., The Spine
proach to the upper thoracic vertebrae. J Neurosurg 61: Center of New Jersey, New Jersey Medical School, 90 Bergen
686–690, 1984 Street, DOC Suite 7300, Newark, New Jersey 07103. email: heary
37. Tokuhashi Y, Matsuzaki H, Toriyama S, et al: Scoring system @umdnj.edu.