Preoperative embolization in patients with metastatic spinal cord compression: mandatory or optional?

Abstract

BackgroundThe contribution of preoperative embolization in reducing intraoperative blood loss and its clinical importance are unclear. So, we aimed to compare the perioperative clinical outcomes based on whether preoperative embolization was performed and assess the role and safety of preoperative embolization in metastatic spinal cord compression (MSCC) patients.MethodsWe enrolled 52 patients (men, 37; women, 15) who underwent palliative decompression for MSCC. Demographic data, neurologic status, surgery-related data (operation time, estimated blood loss, and transfusion), complications, and survival time were recorded. Patients were categorized based on whether they received preoperative embolization: groups E (embolization) (n = 18) and NE (non-embolization) (n = 34) and the clinical parameters were compared. Subgroup analysis was performed specifically for cases of hypervascular tumors (23/52, 44%).ResultsThe transfusion degree was greater in the NE group (4.6 pints) than in the E group (2.5 pints, P = 0.025); the other parameters did not differ between the groups. However, massive bleeding (>2000 mL) was more frequent in the NE group (10/34) than in the E group (0/18, P = 0.010). Subgroup analysis indicated that intraoperative blood loss was greater in the NE group (1988 mL) than in the E group (1095 mL, P = 0.042) in hypervascular tumor patients. Although massive bleeding was more frequent among hypervascular tumor patients, 3 patients with non-hypervascularized tumors also exhibited massive bleeding (P = 0.087).ConclusionsIntraoperative blood loss and perioperative transfusion can be reduced by preoperative embolization in MSCC patients. Neurologic recovery, operation time, and complications did not differ according to the application of embolization. As preoperative embolization is relatively safe and effective for controlling intraoperative bleeding without any neurologic deterioration, it is highly recommended for hypervascular tumors. Moreover, it may also be effective for non-hypervascular tumors as massive bleeding may be noted in some cases.

Update on Preoperative Embolization of Bone Metastases

“…However, massive bleeding (>2,000 mL) was significantly more frequent in the nonembolization group than in the embolization group. 6 Moreover, Rehák et al reported conflicting results as the embolized group presented with a significantly higher blood loss of 4,750 mL compared with 1,786 mL for the nonembolized group. Selection bias was likely present in this study, as tumor volume in the embolization wing was 2.5 times higher than that in the nonembolized group.…”

“…Many studies report preoperative TAE can significantly reduce IBL and transfusion requirements. 6,34,35 In a recent case-control study, which matched patients with respect to age, surgery type, and tumor size, patients of the embolization group had less mean IBL (0.90 vs. 1.77L; p ¼ 0.002) and less packed red blood cell transfusion volume (2.15 vs. 3.56U; p ¼ 0.020), respectively, compared with those without preoperative embolization. 7 Conversely, other studies reported that IBL did not differ between the embolization and control groups.…”

“…8 In cases of hypervascular tumors, the mean IBL was greater in the nonembolization group (1,988 vs. 1,095 mL, p ¼ 0.042) than in the embolization group. 6…”

“…Few reports focus on overall survival of patients with preoperative TAE, and limited data show survival did not significantly differ between the embolization group and nonembolization group. 6,49 Complications Preoperative embolization of bone metastases is a relatively safe procedure and has been associated with low complication rates. 12,14,36,50 The most common complication of TAE is postembolization syndrome, due to vessels occlusion and tumor necrosis which can occur with symptoms such as pain and fever.…”

Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review

“…Previous studies have verified the effectiveness of preoperative embolization in reducing intraoperative bleeding in spinal metastasis surgeries [ 85 - 87 ]. Surgery should be performed within 24 hours following embolization to avoid the diminished effect of preoperative embolization [ 88 ].…”