Spinal metastases constitute two-third of all cases of bone metastases. Surgical intervention in these tumours has been recommended in highly selective cases, for confirming diagnosis, stabilizing the spine, and decompressing nerves or spinal cord for alleviation of pain and preservation of function.In this article,the authors have reviewed available evidence on role of surgery in spinal metastases and have presented results of selected papers on this vast topic

Laghari, Altaf Ali

Shamim, Muhammad Shahzad

Siddiqui, Humza Faisal

English

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eCommons@AKUSection of Cardiology Department of MedicineApril 2019Role of Surgery in Spinal MetastasesAltaf Ali LaghariAga Khan University, altaf.alilaghari@aku.eduHumza Faisal SiddiquiAga Khan UniversityMuhammad Shahzad ShamimAga Khan University, shahzad.shamim@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiolPart of the Cardiology Commons, and the Neurology CommonsRecommended CitationLaghari, A., Siddiqui, H. F., Shamim, M. (2019). Role of Surgery in Spinal Metastases. JPMA. The Journal of the Pakistan MedicalAssociation., 69(4), 598-599.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/110AbstractSpinal metastases constitute two-third of all cases of bonemetastases. Surgical intervention in these tumours hasbeen recommended in highly selective cases, forconfirming diagnosis, stabilizing the spine, anddecompressing nerves or spinal cord for alleviation ofpain and preservation of function.In this article,the authorshave reviewed available evidence on role of surgery inspinal metastases and have presented results of selectedpapers on this vast topic.Keywords: Spinal metastases, microsurgery, radiationtherapy, radiosurgery.IntroductionSpinal metastases is found in about 10% of all patientssuffering from malignant tumours at some point duringthe course of their disease, most common primary sitesbeing prostrate, lung and breast.1 Treatment optionsinclude excision, debulking, chemotherapy, conventionalradiotherapy, stereotactic radiosurgery; and in certaincases, supportive treatment of pain management,prevention of deformity and loss of function. Minimallyinvasive techniques have recently been introduced butso far there is limited data supporting it.2 For patientspresenting with established or impending spinal instability,surgery plays an important role to prevent furtherdeformity and to control pain refractory to non-operativetreatment options. The objective of this review is to discussthe role of surgery in spinal metastasis, other than for theestablishment of diagnosis. Although there is substantialliterature available, for the purpose of brevity, we havementioned only a few key articles.Review of EvidenceSundaresan et al., in their retrospective review ofmanagement of patients with solitary spinal metastasesfrom solid tumours concluded that these patients showedbetter potential for long-term survival; and in selectivecases, total surgical removal prior to radiation improvedpossibility of cure, as well as long-term palliation. Patientswho received radiation prior to surgery had remarkablyhigher rates of surgical morbidity and local recurrences.3Patchell et al.4 in a landmark randomized trial, reportedlonger median survival and better quality of life(ambulation and continence) for patients with metastaticepidural masses, after surgical decompression withradiation therapy, compared to radiation therapy alone.In another prospective study on patients undergoingRole of Surgery in Spinal MetastasesAltaf Ali Laghari, Humza Faisal Siddiqui, Muhammad Shahzad Shamim598Aga Khan University, Karachi, Pakistan.Correspondence:  M. Shahzad Shamim. e-mail :shahzad.shamim@aku.eduVol. 69, No. 04, April 2019Image (a,b):      MRI TIWI mid sagittal cuts, with and without contrast of a 60 yearold male patient, with spinal metastases involving T10 vertebralbody, secondary to sarcoma of left femur. The lesion shows typicalfeatures of vertebral body involvement sparing the disc spaces, anda significant epidural component compressing the cord.a)b)spinal surgery for symptomatic spinal metastases, Quanet al.5 concluded that surgery lead to immediate andmarked improvement in both pain and quality of life.Laufer et al.6 in an analysis of patients who underwentsurgical decompression and adjuvant stereotacticradiosurgery (SRS) suffering from metastatic epiduralspinal cord compression also concluded that surgery withSRS resulted in longer local tumour control rate. Choi etal.7 in a large prospective cohort, reported improvementin pain, quality of  life and ambulation in  patients withepidural  spinal metastases who underwent surgery, eventhough they observed significant postoperative systemiccomplications, largely attributed to their disseminateddisease process. Xinghuo Wu et al.8 also concluded thatsurgery for symptomatic cervical spine metastases,including tumour resection and stabilization, resulted inremission of pain in 93.3% of the patients as well as markedimprovement in pre-operative myelopathy in majority.Pessina et al.9 in an article published in 2018, alsoconcluded that surgery with radiotherapy in patients withmetastatic epidural spinal cord compression from breastcancer results in limited morbidity and recommendedthat surgical intervention in selective cases, should beoffered early in the disease. Hohenberger et al.10 in anotherpaper published in 2018, also concluded that tumourremoval and mass reduction results in improvement inboth motor and sensory deficits, as well as pain remission,in patients with space-occupying spinal metastases.With the recent trend towards 'minimally invasive spinesurgery'(MISS) for most spine procedures, it isunderstandable that it is also considered for surgery forspinal metastases. In one of the first direct comparisons,Miscusi et al.11 compared MISS with open surgery onpatients with acute myelopathy due to vertebral thoracicmetastases in a study limited by small sample size (23patients in MISS group and 19 patients who underwentlaminectomy and stabilization with standard opensurgery). It was argued that MISS should be consideredas first choice of treatment as blood loss and recoverytime was markedly less and need for post-operativeopioids was significantly reduced, although neurologicaloutcome and complications had no significant difference. A more recent meta-analysis by Lu VM et al.12 also reportedreduced hospital stay and blood loss, and improved post-operative function and pain in MISS compared to opensurgery, also showing better complication rates in MISS(14%) than open surgery (27%).ConclusionFor selected patients with spinal metastases, surgicalresection or debulking, with or without stabilization is aviable option as it improves quality of life (sensory andmotor function, pain control, continence) and may alsoimprove life expectancy. Even radiotherapy, whenindicated, has shown better outcomes, when combinedwith surgical resection (with or without stabilization)compared to radiotherapy alone. Patient selection remainsthe most important aspect of management and theauthors strongly recommend multi-disciplinary teammeetings for collaborative approach for all such cases.References1. Delank K-S, Wendtner C, Eich HT, Eysel P. The treatment of spinalmetastases. Dtsch Arztebl Int.. 2011;108:71.2. Kaloostian P, Yurter A, Zadnik P, Sciubba D, Gokaslan Z. Currentparadigms for metastatic spinal disease: an evidence-based review.Ann Surg Oncol 2014;21:248-62.3. Sundaresan N, Rothman A, Manhart K, Kelliher K. Surgery for solitarymetastases of the spine: rationale and results of treatment. Spine.2002;27:1802-6.4. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al.Direct decompressive surgical resection in the treatment of spinalcord compression caused by metastatic cancer: a randomised trial.The Lancet. 2005;366:643-8.5. Quan GM, Vital J-M, Aurouer N, Obeid I, Palussiere J, Diallo A, et al.Surgery improves pain, function and quality of life in patients withspinal metastases: a prospective study on 118 patients. Eur SpineJ. 2011;20:1970-8.6. Laufer I, Iorgulescu JB, Chapman T, Lis E, Shi W, Zhang Z, et al. Localdisease control for spinal metastases following "separation surgery"and adjuvant hypofractionated or high-dose single-fractionstereotactic radiosurgery: outcome analysis in 186 patients. JNeurosurg Spine. 2013;18:207-14.7. Choi D, Fox Z, Albert T, Arts M, Balabaud L, Bunger C, et al. Rapidimprovements in pain and quality of life are sustained after surgeryfor spinal metastases in a large prospective cohort. BRIT JNEUROSURG 2016;30:337-44.8. Wu X, Ye Z, Pu F, Chen S, Wang B, Zhang Z, et al. Palliative surgeryin treating painful metastases of the upper cervical spine: casereport and review of the literature. Medicine. 2016;95: e35589. Pessina F, Navarria P, Riva M, Franceschini D, Nibali MC, Fornari M,et al. Long-Term Follow-Up of Patients with Metastatic EpiduralSpinal Cord Compression from Breast Cancer Treated with SurgeryFollowed by Radiotherapy. World Neurosurg. 2018;110:e281-e6.10. Hohenberger C, Schmidt C, Höhne J, Brawanski A, Zeman F,Schebesch K-M. Effect of surgical decompression of spinalmetastases in acute treatment-Predictors of neurological outcome.J Clin Neurosci. 2018; 52:74-7911. Miscusi M, Polli FM, Forcato S, Ricciardi L, Frati A, Cimatti M, et al.Comparison of minimally invasive surgery with standard open surgeryfor vertebral thoracic metastases causing acute myelopathy in patientswith short-or mid-term life expectancy: surgical technique and earlyclinical results. J Neurosurg Spine 2015;22:518-25.12. Lu VM, Alvi MA, Goyal A, Kerezoudis P, Bydon M. The Potential ofMinimally Invasive Surgery to Treat Metastatic Spinal Disease versusOpen Surgery: A Systematic Review and Meta-Analysis. WorldNeurosurg. 2018;112:e859-e68.599J Pak Med AssocA.A. Laghari, H.F. Siddiqui, M.S. Shamim

Role of Surgery in Spinal Metastases

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Role of Surgery in Spinal Metastases

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