Clinical results of multidisciplinary therapy including palliative posterior spinal stabilization surgery and postoperative adjuvant therapy for metastatic spinal tumor

Abstract

BackgroundSurgeries performed for metastatic spinal tumor are mostly palliative and are controversial for patients with short life expectancy. We investigated whether palliative posterior spinal stabilization surgery with postoperative multidisciplinary therapy results in improvement of life prognosis and activities of daily living (ADL) in patients with metastatic spinal tumor.MethodsThe subjects were 55 patients who underwent palliative posterior-only instrumentation surgery for metastatic spinal tumor at our hospital between 2012 and 2015. Postoperative survival, early paralysis improvement, ADL improvement, and rate of discharge to home were examined.ResultsThe patients included 37 males and 18 females, and the mean age at the time of surgery was 66.8 years old. The mean Tokuhashi score was 7.1, the mean spinal instability neoplastic score (SINS) was 9.4, and the epidural spinal cord compression scale (ESCCS) was grade 3 in 20 patients (36.3%). The mean Barthel index for ADL was 48.7. The median postoperative survival time determined using the Kaplan-Meier method was 12.0 months (95% confidence interval 2.4–21.5). Regarding improvement of paralysis, the modified Frankel scale was improved by one grade or more or grade E was maintained in 35 patients (63.6%), whereas paralysis aggravated in 2 (3.6%). In surgery, conventional posterior decompression and fixation were applied in 31 patients (56.3%), and minimally invasive spine stabilization was applied in 24 (43.6%). Postoperative chemotherapy was performed in 31 patients (56.3%), radiotherapy was used in 38 (69.0%), and a bone-modifying agent was administered in 39 (70.2%). Regarding ADL, the mean Barthel index improved from 48.5 before surgery to 74.5 after surgery. Thirty-seven patients (67.2%) were discharged to home.ConclusionsADL improved and allowed discharge to home, and postoperative adjuvant therapy could be administered at a high rate in patients who received palliative posterior spinal stabilization surgery. Survival time extended beyond the preoperative life expectancy in many patients. Patients with a metastatic spinal tumor have short life expectancy and paralysis caused by spinal instability and spinal cord compression. However, multidisciplinary therapy including palliative posterior spinal stabilization surgery with reduced invasiveness and postoperative adjuvant therapy are effective in these patients.

Clinical Results of Minimally Invasive Spine Stabilization for the Management of Metastatic Spinal Tumors Based on the Epidural Spinal Cord Compression Scale

“…Therefore, surgical stress by palliative surgery has recently been minimized [ 12 – 21 ]. Compared with conventional posterior decompression fusion surgery, the surgical wound from MISt using PPS is small, the operative time is short, intraoperative blood loss is low, and the wound heals rapidly, facilitating adjuvant therapy early after surgery [ 15 , 16 , 23 ]. In the present study, the median survival time after surgery determined using the Kaplan-Meier method was 12.0 months in group A (95% CI: 9.1-14.8) and 15.0 months (95% CI: 3.9-26.0) in group B (P=0.60).…”

“…Most metastatic spinal tumors are cancer metastasis, a systemic disease for which treatment is limited [ 1 – 4 ]. Evaluation of the outcome of low-invasive palliative surgery for metastatic spinal tumors has focused only on the technical aspects, surgical stress, and short-term improvement of paralysis, and the postoperative survival time, ADL, and quality of life (QOL) were evaluated in only a few studies [ 15 , 16 , 18 , 19 , 23 ]. To maintain the QOL of cancer patients, it is important to continue adjuvant therapy, such as chemotherapy and radiotherapy, after surgery.…”

“…We performed a retrospective review using prospectively collected data from 100 consecutive patients who underwent palliative surgery for metastatic spinal tumors between January 2012 and December 2017 at our institution. MISt with PPS for metastatic spinal tumors [ 15 , 16 , 23 ] was indicated for intractable pain due to spinal instability or threat of instability defined by the spinal instability neoplastic score (SINS) [ 24 ], spinal paralysis, such as any change in the motor examination, or radiation-resistant cancer such as kidney cancer or thyroid cancer. We excluded patients for whom total en bloc spondylectomy was indicated for spinal levels at the occipital to the cervical region; it was impossible to confirm the pedicle of the vertebral arch under fluoroscopy or impossible to insert PPS who were treatable with balloon kyphoplasty, who were treatable with posterior decompression alone, or who had a life expectancy less than 6 months and were responsive to narcotic analgesics or markedly responsive to radiotherapy, poor general condition (Karnofsky performance status 3 or poorer), or a reduced will to live.…”

“…For surgical treatment for metastatic spinal tumor patients, minimization of surgical stress has been attempted, such as minimally invasive spine stabilization (MISt) using percutaneous pedicle screws (PPS) (Figures 1 – 3 ) [ 12 – 21 ] and balloon kyphoplasty [ 22 ]. Minimization of palliative surgery stress and multidisciplinary treatment has improved ADL, facilitated discharge to home, and enabled postoperative adjuvant therapy at a high rate [ 23 ]. MISt is more useful to minimize the stress of surgery for metastatic spinal tumors than for spinal degenerative disease, but no study has investigated the surgical outcomes of MISt in cases of different grades of spinal cord compression, although evaluation of the outcomes of conventional palliative surgical decompression (+/- stabilization) in cases of different grades of spinal cord compression has been reported [ 10 ].…”

Predictor of neurological function after surgical treatment of the metastatic epidural spinal cord compression

“…Therefore the number of surgical procedures performed in patients with MESCC has increased by 60% since 2000 and the annual rate of hospitalisation for spine tumor has increased from 3.8% to 4.9% [9]. Surgery can restore and preserve neurological function, spine stability and decrease mortality morbidity, pain and increase quality of life [10,11]. It should be emphasized that losing the ability to walk significantly decreases the patients quality of life and reduces their survival by 9-18 months [12].…”