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Neuro-Oncology
Surgical Management of Spinal Metastases
PAUL KLIMO, JR., MEIC H. SCHMIDT
Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
Key Words. Spine · Metastases · Surgery · Radiosurgery · Outcomes
ABSTRACT
Metastatic spread to the spinal column is a growing while reconstructing and immediately stabilizing the
problem in patients with cancer. It can cause a number of spinal column. This has been made possible by the use of
sequelae including pain, instability, and neurologic deficit. different surgical approaches and the exploitation of a
If left untreated, progressive myelopathy results in the loss burgeoning array of internal fixation devices. More
of motor, sensory, and autonomic functions. Except in rare recently, minimally invasive surgical techniques, such
circumstances, treatment is palliative. Traditionally, con- as endoscopy, kyphoplasty/vertebroplasty, and stereo-
ventional fractionated external beam radiotherapy has tactic radiosurgery, have been added to the surgeon s
been the treatment of choice. Surgery for metastatic armamentarium. As the number of treatment options for
spinal disease was, and generally continues to be, equated metastatic spinal disease grows, it has become clear that
with laminectomy by many physicians. However, there has effective implementation of treatment can only be achieved
been a remarkable evolution in surgical techniques over by a multidisciplinary approach. This will provide the
the last 20 years. Today, the goal of surgery is to achieve surest means of maximizing the quality of the remainder
circumferential decompression of the neural elements of the patient s life. The Oncologist 2004;9:188-196
INTRODUCTION from one of three locations (Fig. 2): the vertebral column
Approximately 70% of patients with cancer have evi- (85%), the paravertebral region (10%-15%), and, rarely, the
dence of metastatic disease at the time of their deaths [1] (Fig. epidural or subarachnoid/intramedullary space itself (<5%)
1). The spinal column is the most common location among [6, 7, 11]. The posterior half of the vertebral body is usually
osseous sites for metastatic deposits [2]. Spinal involvement involved first, with the anterior body, lamina, and pedicles
may occur in up to 40% of patients with cancer. Of 832 autop- invaded later [12]. Intradural metastases, including those that
sies performed by Wong et al. [3] on patients who had died of are intramedullary, are extremely rare but have been reported
cancer, 300 (36%) had spinal metastases. However, not all [13, 14]. Multiple lesions at noncontiguous levels occur in
spinal metastases lead to neurologic compromise. Spinal cord 10%-40% of cases [6, 7, 11, 15].
compression from epidural metastases occurs in 5%-10% of Approximately 50% of metastases arise from one of three
cancer patients and in up to 40% of patients with preexisting primary types of cancer: breast, lung, or prostate [6]. These
nonspinal bone metastases [3-8]. Of those with bony spinal are followed by renal cancer, gastrointestinal cancer, thyroid
disease, 10%-20% develop symptomatic spinal cord com- cancer, sarcoma, and the lymphoreticular malignancies: lym-
pression, resulting in over 25,000 cases per year, and the num- phoma and multiple myeloma. Metastases from prostate can-
ber is expected to grow [7, 9, 10]. cer, breast cancer, melanoma, and lung cancer commonly
The thoracic spine is the most common site of disease cause spinal metastases in 90.5%, 74.3%, 54.5%, and 44.9%
(70%), followed by the lumbar spine (20%), and cervical of patients, respectively [3]. However, the frequency of neu-
spine (10%) [6, 7, 11]. Metastatic spinal disease can arise rologic deficit as a result of epidural spinal cord compression
Correspondence: Meic H. Schmidt, M.D., University of Utah, Department of Neurosurgery, 30 North 1900 East Suite #3B-409
SOM, Salt Lake City, Utah 84132-2303, USA. Telephone: 801-581-6908; Fax 801-581-4385; e-mail: meic.schmidt@hsc.utah.edu
Received July 30, 2003; accepted for publication December 12, 2003. ©AlphaMed Press 1083-7159/2004/$12.00/0
The Oncologist 2004;9:188-196 www.TheOncologist.com
189 Spinal Metastases
All cancer patients
70% of all patients
develop metastatic
disease
40% of all patients
develop metastatic
spinal disease
10%-20% of these patients
will develop epidural
Figure 2. Locations of metastases to the spine. Most tumor emboli are found
spinal cord compression
in the vertebral column surrounding the spinal cord, with the posterior half of
(~25,000 cases/year)
the vertebral body being the most common initial focus (upper left inset).
Tumor can also originate in a paravertebral location and track along the
spinal nerves to enter the spinal column by way of the neural foramina (lower
right inset). Both of these mechanisms can lead to epidural spinal cord com-
pression. Intramedullary and subdural/leptomeningeal metastatic deposits
are rarely encountered (middle inset).
Location:
Thoracic 70%
cure be the goal if the spine is the only known site of metas-
Lumbar 20%
tasis [20]. Treatment can involve chemotherapy, radiation
Cervical 10%
therapy, and surgery. The decision to pursue radical surgi-
cal treatment is complex, but the indications are becoming
clearer. These include radioresistant tumors (sarcoma, lung,
colon, renal cell), obvious spinal instability, clinically sig-
Figure 1. Diagram depicting the proportion of cancer patients
nificant neural compression secondary to retropulsed bone
affected by spinal metastases and epidural spinal cord compression
or from spinal deformity, intractable pain unresponsive to
and the distribution of involvement within regions of the spine.
nonoperative measures, and radiation failure (progression
of deficit during treatment or spinal cord tolerance
varies with the site of primary disease as follows: 22% with reached). Even if the patient satisfies one or more of the
breast cancer, 15% with lung cancer, and 10% with prostate above indications, the type and goals of surgery must be
cancer [7]. Some patients present with neurologic dysfunction determined by the patient s ability to tolerate the procedure
and spinal pain without a known history of cancer. In some of (i.e., the patient s general medical condition) and, more
the older surgical literature, this group accounted for up to importantly, by their estimated life expectancy. The latter is
70% of the study population [16-19]. Of these cases, lung was primarily based on the extent and aggressiveness of the can-
the primary source more than 50% of the time [7, 18]. cer and its response to previous therapies. In general, the
goals of surgery are to correct and prevent any further
SURGICAL INDICATIONS deformity by stabilizing the spine, decompressing neural
Treatment for spinal metastases is largely palliative. structures (spinal cord and nerves), obtaining a diagnosis if
Only in rare cases, usually with renal cell carcinoma, can the primary is unknown, and preventing local recurrence.
Klimo, Schmidt 190
In general, most surgeons agree that excisional surgery
Table 1. Tokuhashi score [24]
should only be offered to those patients with an estimated life
expectancy of greater than 3 months [21-23]. However, 1. General condition (Karnofsky) Score
determining this estimate is difficult and is usually left to the Poor (10%-40%) 0
Moderate (50%-70%) 1
expertise of the individual oncologist. In an effort to more
Good (80%-100%) 2
accurately predict survival, Tokuhashi et al. [24] proposed a
2. Number of extraspinal bone metastases
preoperative prognostic scoring system. Their model takes
into account six variables: general medical condition, num- e"3 0
1-2 1
ber of extraspinal metastases, number of vertebral metas-
02
tases, status of metastases to the major internal organs,
3. Number of metastases in the spine
primary tumor type, and presence of a neurologic deficit
e"3 0
(Table 1). Patients who have scores d"5 generally die within
21
3 months whereas those with total scores e"9 survive an aver-
12
age of 12 months or more. Several others, including the
4. Metastases to major internal organs
authors, have used this scoring system and have found it
Irremovable 0
useful in making decisions regarding treatment [25-27].
Removable 1
No metastases 2
SURGERY IN THE OLD ERA
5. Primary site of cancer
For years, posterior decompressive laminectomy was the
Lung, stomach 0
only surgical treatment offered for metastatic spinal cord
Kidney, liver, uterus, other, unidentified 1
compression. It is a relatively quick and simple procedure
Thyroid, prostate, breast, rectum 2
that enlarges the space for the spinal cord by removing the
6. Myelopathy
roof of the spinal canal (Fig. 3). Surgeons at that time real-
Complete 0
ized that the operation was of limited value in regaining neu-
Incomplete 1
rologic function, and some stated that the goal of surgery
None 2
should be pain control rather than neurologic rescue [8, 28-
32]. A number of retrospective reports found that laminec-
tomy with adjuvant radiation was no more effective than circumferential spinal cord decompression. This requires
radiation alone in retaining or restoring ambulatory function removing the tumor at the site of spinal cord compression,
[29, 33, 34]. Furthermore, significant complications were a philosophy diametrically opposite to that of the days of
associated with laminectomies, most notably the acceleration decompressive laminectomies.
of preexisting spinal instability and wound complications. Sundaresan et al. [35] reported their results in 80 patients
Thus, conventional external beam radiotherapy became and with solitary metastatic spinal lesions. Depending on the
continues to be the first-line treatment in the majority of anatomic and radiologic extent of the tumor, they used a vari-
patients with newly diagnosed metastatic spinal disease. ety of approaches: an anterior approach was used in 32
patients, a strictly posterior or posterolateral approach was
SURGERY IN THE NEW ERA used in eight patients, and a combined anteroposterior
With the failure of the indiscriminant use of laminec- approach was used in 40 patients. Preoperatively, 48 patients
tomies, the surgical treatment of spinal metastases (60%) were ambulatory and 55 (69%) had a significant
remained dormant until the emergence and acceptance of amount of pain. Postoperatively, 78 (98%) were ambulatory,
approaches that were tailored to the exact anatomic location including 94% of those who were initially nonambulatory.
of the disease. This marked the beginning of a new era in Pain was improved in 95% of patients with 76% having com-
the surgical management of spinal metastases. For example, plete relief. Although the overall survival time was 30
transthoracic and posterolateral trajectories give the surgeon months, there was a considerable range with the various
access to the thoracic vertebral bodies, the most common tumor types. Patients with breast and renal cell carcinoma
site of metastatic disease (Fig. 3). Currently, any part of the both had median survival times of 36 months, compared with
spine can be reached by the surgeon s hand. Using one 15 months and 12 months for gastrointestinal and unknown
approach or a combination of approaches allows the surgeon primary carcinomas, respectively.
to excise the tumor, reconstruct the spinal column, and place Neurologic recovery is dependent on the rapidity of neu-
internal fixation devices to achieve immediate stabilization. rologic decline, duration of neurologic decline, and, most
The goal of surgery in these patients today is to achieve importantly, neurologic status before treatment. Use of these
191 Spinal Metastases
rate of 29% in the most recent conventional radiation reports
[46-51]. Furthermore, appropriate patient and surgical man-
agement seems to produce a positive effect on overall quality
of life, especially in the reduction of pain [52]. For further
details on the effectiveness of different treatment modalities
for metastastic spinal disease, we direct readers to our recently
published comprehensive literature review [53].
Given the seemingly superior results with surgery com-
pared with conventional radiation therapy, it was clear to sev-
eral investigators that the best way to compare these two
treatment options was with a well-designed, randomized, con-
trolled trial (RCT) [18, 33, 54]. Until recently, only one RCT
had been attempted in the area of metastatic spinal disease,
but it compared laminectomy with radiation and suffered
from a lack of power [33]. However, at the most recent annual
meeting of the American Society of Clinical Oncology
(Chicago, 2003), Patchell et al. [55] presented results from
their RCT comparing direct decompressive surgical resection
followed by adjuvant radiation with conventional radiation
alone. Both groups were treated with the same steroid proto-
col and both received the same total radiation dose (30 Gy).
There were 50 patients in the surgical arm and 51 in the radi-
ation arm. Patients treated with surgery retained ambulatory
and sphincter function significantly longer than patients in the
radiation group. Also, 56% of nonambulators in the surgical
group regained the ability to walk, compared with 19% in the
radiation group. As expected, length of survival was not sig-
nificantly different between the two groups. This landmark
study clearly shows, for the first time, an undisputed advan-
Figure 3. Surgical approaches to the spine. The shaded areas indicate the bone
tage for surgery, where the goal is to achieve complete spinal
removed in each of the approaches. A) Laminectomy. The spinous process and the
cord decompression, over radiation therapy, which has been
adjacent lamina are removed up to the junction of the pedicles. This was the stan-
the treatment of choice for the last 25 years.
dard surgical procedure for many years regardless of where the tumor was actu-
ally located within the vertebra. It can still be used for disease isolated to the
However, there are substantial potential complications
posterior elements. B) Transthoracic or retroperitoneal. These anterior
associated with this more aggressive surgical philosophy.
approaches provide direct access to the vertebral body in the thoracic (transtho-
Complications can be classified as surgical (e.g., wound
racic) and thoracolumbar/lumbar regions (retroperitoneal). C) Posterolateral.
infections, cerebrospinal fluid fistulas), hardware related
For patients who cannot tolerate an anterior approach or who have significant
posterior extension of their disease, a posterolateral approach provides excellent
(broken, misplaced, migrated), medical (e.g., pneumonia),
access to both the anterior and posterior elements. The inset shows the skin inci-
and neurologic (i.e., new deficit). For example, in the series
sions for each of the approaches. The laminectomy (A) and posterolateral (B)
of 80 patients reported by Sundaresan et al. [35], 16 patients
approaches can be performed through a midline incision. The transthoracic
suffered surgical complications such as wound breakdowns
(upper B line) and retroperitoneal approaches (lower B line) require flank
incisions. and hematomas, four had hardware complications, two had
medical complications, one had a neurologic complication,
and one died from respiratory failure. Gokaslan et al. [40]
surgical techniques, usually followed by standard radiation
therapy, seems to have dramatically improved neurologic out- performed transthoracic vertebrectomies on 72 patients.
Complications, ranging from minor atelectasis to pulmonary
come. In a review of the recent surgical literature, the average
success rate was 85%, with success defined as the per- embolism, occurred in 21 patients, with a 30-day mortality
rate of 3%. One of the most problematic surgical complica-
centage of patients retaining or regaining ambulatory function
tions is wound infection. Factors associated with wound
after treatment [19, 21-23, 35-45]. More importantly, the
average rescue rate from the same series, defined as the per- infection include postoperative incontinence, posterior
approach, surgery for tumor resection, and morbid obesity
centage of patients who regained ambulatory function, was
[56]. In metastatic spinal patients, preoperative radiation
60%. This compares with a success rate of 73% and a rescue
Klimo, Schmidt 192
(especially within 7 days), malnutrition, and steroid use are
also risk factors [21, 35, 42, 57, 58]. The risk of developing
complications is dependent on both the characteristics of
the operation and the preoperative medical status of the
patient. Both must be carefully considered when deciding
the appropriate treatment.
In an attempt to reduce surgical morbidity and decrease
recovery time, a new field called minimally invasive spinal
surgery (MISS) has developed and is rapidly flourishing.
MISS refers to a variety of techniques in which the primary
objective is to minimize trauma to the surrounding anatomic
structures during the approach to the surgical site. Many
common spinal surgeries, such as microdiscectomy, inter-
body fusion, and pedicle screw/rod fixation, have been trans-
formed with these new techniques [59]. Proponents of MISS
cite shorter operative times, less blood loss, less postopera-
tive pain, lower medication use, shorter hospital stays, and
lower overall costs. Although much of the literature regard-
ing MISS involves its use in degenerative disorders, there is
a small, but growing, body of literature on its application in
patients with spinal metastases.
Figure 4. Schematic diagram depicting the positioning and placement of instru-
One area that has received much attention recently is the
ments for MISS. The patient is placed in a decubitus position and the lung is
use of endoscopes in the resection of metastatic tumors in the
deflated. Multiple small incisions (A-D) are made in the chest wall through which
thoracic spine [60-64]. Although an endoscope can be used
instruments and a camera can be inserted. All stages of the more traditional open
approach, including instrumentation, can be achieved through these access ports.
with open approaches, it is most often used in conjunction
with a minimally invasive anterior transthoracic approach.
Transthoracic endoscopic techniques were pioneered in the [70] performed 97 procedures (65 vertebroplasties and 32
treatment of thoracic disc herniations and traumatic fractures kyphoplasties) during 58 treatment sessions in 56 patients
but have also found a role in metastatic patients. Access to the with intractable spinal pain caused by pathologic vertebral
diseased level is achieved by making 3-4 strategically placed body fractures. Using visual analog scale pain scores, there
1-cm incisions in the lateral chest wall through which instru- was improvement or complete relief of pain after 49 sessions
ments are inserted (Fig. 4). The three phases of the surgery (84%). None of the patients were made worse by the proce-
vertebrectomy, reconstruction, and stabilization can be dures. There was a significant decrease in analgesic usage at
performed entirely by endoscopic techniques. 1 month postprocedure, and the pain reduction remained
Other minimally invasive spinal procedures that deserve significant at each follow-up interval for 1 year.
special mention are percutaneous vertebroplasty and kypho- Although preliminary reports using the various MISS
plasty. Both procedures involve the percutaneous injection of techniques appear promising, most metastatic spinal surgery
polymethylmethacrylate bone cement (PMMA) into a col- is still performed via the more traditional open approaches.
lapsed vertebral body. In vertebroplasty, the vertebral body is As with any new surgical procedure, there is a learning curve
not re-expanded, whereas in kyphoplasty, a balloon is first associated with MISS. Initially, MISS procedures can be
inflated, thereby restoring the vertebral body height and more technically demanding, leading to longer operative
reducing kyphosis, followed by injection of PMMA (Fig. 5). times and higher complication rates. These drawbacks will,
Currently, the most common indication for vertebroplasty or hopefully, diminish as MISS becomes more prevalent
kyphoplasty is osteoporotic fracture; however, it is also a among spine surgeons.
well-recognized therapeutic option for cancer patients [65-
71]. Poor surgical candidates with disabling pain secondary SPINAL RADIOSURGERY
to a pathologic thoracic or lumbar vertebral body fracture Conventional external beam radiotherapy typically
without epidural compression are ideal candidates for the delivers a total dose of 2,500-4,000 cGy of radiation over
procedure. The procedure is quick, performed on an outpa- 8-20 daily fractions. Generous margins are used within the
tient basis, rarely associated with complications, and highly radiation field, typically one or two vertebral segments, to
effective in reducing axial spinal pain [70]. Fourney et al. compensate for internal organ motion as well as patient
193 Spinal Metastases
Figure 5. Vertebroplasty and kypho-
plasty. A) The collapsed vertebral body
is accessed through a transpedicular
route. In kyphoplasty, a balloon at the
end of the instrument is inflated, thus
restoring the height of the body. This
step is not performed in vertebroplasty.
B and C) The balloon is removed and
the defect is filled with bone cement
(PMMA), which reestablishes the struc-
tural integrity of the vertebral body.
motion during the treatment.
Thus, a substantial amount of nor-
mal tissue, including the spinal
cord, is subjected to radiation [72-
74]. Fractionating the treatment is
done to optimize the tolerance of
The existing data on these modalities are, however,
normal tissue to radiation. If radiation could be delivered to
limited to small case series. Follow-up times have been short,
the target while decreasing the amount delivered to normal
and outcome measures, such as neurologic function, are rarely
tissue, injury to the spinal cord would, theoretically, be
discussed. The research to date has shown image-guided SRS
reduced.
Nonconventional radiotherapy, which includes stereotac- to be a safe intervention; however, its effectiveness has not
been rigorously tested against other current therapies (surgery
tic radiosurgery (SRS) and intensity-modulated radiotherapy
or conventional radiotherapy). Such data are needed before a
(IMRT), can do just that. SRS combines the principle of
treatment recommendation can be rendered. At this time, the
stereotactic localization to achieve accurate targeting with
application of spinal SRS is usually limited to patients who
multiple radiation beams of equal intensity to deliver a high
are poor surgical candidates with recurrent disease, and by the
dose of radiation to a treatment site while minimizing exposure
availability of the technology. Therefore, it should still be
of normal tissue. In IMRT, multiple beams are also used, but
the intensity of each individual beam can be modified to min- considered experimental therapy.
imize radiation exposure to surrounding structures (Fig. 6). In
CONCLUSION
SRS, treatment is usually delivered in one or two sessions,
Spine surgeons are playing greater roles in the manage-
with total doses ranging from 800-1,800 cGy. Because spine
lesions generally have a fixed relationship to the bony struc- ment of patients with metastatic disease. They are able to
offer a wide array of effective treatment options ranging from
tures of the spinal column and the spine is the extracranial
radical, open excisional surgery to minimally invasive
organ with the least breathing-related movement, SRS to the
spine is particularly feasible. Early versions of spinal radio- surgery, such as endoscopy and vertebroplasty, to ultramini-
mal/noninvasive spinal radiosurgery. However, many cancer
surgery using a linear accelerator required multiple 1- to 2- cm
centers do not employ a multidisciplinary, upfront approach
incisions to fixate a frame to the spinous processes [75, 76].
to patients with newly diagnosed metastatic spinal disease.
Although the results were encouraging, the fixation process
The vast majority of patients are sent directly to radiation
was cumbersome, resulting in long procedures and making
repeat treatments difficult for the patient. Current image- oncology for conventional external therapy. Most surgeons
only see patients after they have failed their primary treat-
guided SRS systems, such as the Novalis® system (BrainLAB
ment. This will, hopefully, change in the near future based on
Inc.; Munich, Germany) and CyberKnife® (Accuray Inc.;
the evidence of more recent reports, in particular, a random-
Sunnyvale, CA), differ from earlier frame-based systems in
ized clinical trial that clearly shows a benefit for surgery as the
four ways: A) referencing is based on internal skeletal
primary mode of treatment. Multidisciplinary strategic treat-
anatomy, implanted fiducials, or infrared surface markers;
ment planning and a continuation of well-designed clinical
B) near real-time images are acquired to correct for motion;
research trials are needed in the future to fully evaluate and
C) fixed isocenters are not required, allowing irregular dose
synthesize individualized therapy for patients with metastatic
shapes, and D) intensity modulation of radiation increases the
spinal disease with the ultimate goal of maximizing function
conformality of radiation to the tumor while minimizing the
and quality of life.
dose of radiation to normal tissue [77-80].
Klimo, Schmidt 194
Figure 6. IMRT. This 56-year-old male has metastatic lung cancer to the left paraspinal region in the midthoracic area. A) Axial model of the patient showing the
location of his tumor with respect to the spinal cord and lungs and the radial arrangement of the beams. B) Axial, C) coronal, and D) sagittal images of the planned
treatment showing the isodose lines: 100% (yellow), 90% (dark blue), 80% (light blue), 50% (green), 30% (purple), and 20% (orange). The spinal cord is outlined in
yellow. Note how the beams are contoured to avoid the spinal cord.
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