Surgical management of metastatic disease of the lumbar spine: experience with 139 patients

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Object. The surgical treatment of metastatic spinal tumors is an essential component of the comprehensive care of cancer patients. In most large series investigators have focused on the treatment of thoracic lesions because 70% of cases involve this region. The lumbar spine is less frequently involved (20% cases), and it is unclear whether its unique anatomical and biomechanical features affect surgery-related outcomes. The authors present a retrospective study of a large series of patients with lumbar metastatic lesions, assessing neurological and pain outcomes, complications, and survival.

Methods. The authors retrospectively reviewed data obtained in 139 patients who underwent 166 surgical procedures for lumbar metastatic disease between August 1994 and April 2001. The impact of operative approach on outcomes was also analyzed.

Among the wide variety of metastatic lesions, pain was the most common presenting symptom (96%), including local pain, radicular pain, and axial pain due to instability. Patients underwent anterior, posterior, and combined approaches depending on the anatomical distribution of disease. One month after surgery, complete or partial improvement in pain was demonstrated in 94% of the cases. The median survival duration for the entire population was 14.8 months.

Conclusions. The surgical treatment of metastatic lesions in the lumbar spine improved neurological and ambulatory function, significantly reducing axial spinal pain; results were comparable with those for other spinal regions. Analysis of results obtained in the present study suggests that outcomes are similar when the operative approach mirrors the anatomical distribution of disease. When lumbar vertebrectomy is necessary, however, anterior approaches minimize blood loss and wound-related complications.

Article Information

Address reprint requests to: Ziya L. Gokaslan, M.D., Department of Neurosurgery, The Johns Hopkins University, School of Medicine, Meyer Building 7-109, 600 North Wolfe Street, Baltimore, Maryland 21287. email: zgokasl1@jhmi.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Representative neuroimaging studies obtained in a patient with primarily posterior metastatic disease of unknown origin. The patient underwent L-3 laminectomy, foraminal decompression, and stabilization for radiculopathy and axial spinal pain. Preoperative sagittal T2-weighted (A) and axial T1-weighted (B) MR images are shown. C: Postoperative lateral radiograph demonstrating short-segment L2–4 pedicle fixation. The patient was wheelchair bound preoperatively and required multiple transdermal narcotic patches but was ambulating with a walker at the time of discharge and using only oral narcotic agents as necessary due to improved back and leg pain.

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    Representative neuroimaging obtained in a patient with metastatic RCC who underwent a retroperitoneal approach and L-3 vertebrectomy. Preoperative sagittal T1-weighted (A) and T2-weighted (B) MR images demonstrating isolated anterior column involvement that prompted an anterior-only approach for tumor resection and stabilization. Postoperative MR image (C) and lateral radiograph (D) revealing the effects of decompression and reconstruction/stabilization.

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    Artist's rendering of distractable-cage reconstruction of the lumbar spine following L-2 corpectomy and plate fixation. A = artery; v = vein.

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    Representative neuroimaging studies obtained in a patient with metastatic lung cancer. Sagittal (A) and axial (B) T1-weighted MR images revealing the tumor's involvement with the L-5 VB and left-sided posterior elements. The patient underwent L-5 transpedicular vertebrectomy, PMMA-augmented reconstruction, and pedicle fixation; postoperatively there was dramatic improvement in the VAS score. C: Postoperative lateral radiograph demonstrating the reconstructed L-5 VB and instrumentation.

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    Representative neuroimaging studies obtained in a patient, with circumferential involvement at the L-3 level due to metastatic prostate cancer, who underwent staged anterior—posterior decompression and stabilization. Preoperative sagittal T1-weighted (A) and T2-weighted (B) MR images revealing the extent of the disease. Postoperative anteroposterior (C) and lateral (D) radiographs demonstrating the results of a vertebrectomy, PMMA-augmented reconstruction at L-3, and anterior thoracolumbar locking plate and pedicle fixation.

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    Representative neuroimaging studies obtained in a patient with metastatic breast carcinoma in whom pathological collapse of L-1 VB occurred. Preoperative axial (A) and sagittal (B) T1-weighted MR images demonstrating cord compression and local kyphotic deformity. A simultaneous anterior—posterior L-1 vertebrectomy and thoracolumbar stabilization procedure was performed in the lateral decubitus position because of the patient's large body habitus. Intraoperatively, the T-12 vertebra was also seen to be compromised with tumor such that it was inadequate for inclusion in the PMMA—chest tube anterior reconstruction; thus, the rostral decompression was extended to the T-11 VB. C: Postoperative lateral postoperative radiograph revealing the reconstructed anterior column after pedicle fixation across the thoracolumbar junction to prevent instability.

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    Bar graph showing the change in Frankel grades at 1 month postoperatively for all patients and for patients categorized by initial operative approach (see Table 3).

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    Bar graph demonstrating pre- and postoperative median VAS scores obtained in 133 patients with pain as a significant presenting complaint. All postoperative scores were significantly reduced (p < 0.001; Wilcoxon signed-rank test).

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    Graphs depicting Kaplan—Meier survival curves. Upper Left: Overall survival curve for 139 patients who underwent surgery for metastatic lumbar disease. The median survival duration was 14.8 months. Upper Right: Survival estimates based on preoperative Frankel grade. Frankel Grade C status was associated with a significant decrease in survival compared with ambulatory groups (p = 0.02). Lower Left: Survival was significantly affected by preoperative weakness (p = 0.01). Lower Right: The presence of extraspinal metastatic disease strongly correlated with decreased survival (p = 0.002).

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    Graph demonstrating Kaplan—Meier survival curves for patients based on primary tumor histological composition: Group 1, breast, sarcoma, lymphoma, and myelodysplastic disorder; Group 2, RCC; and Group 3, melanoma, lung, prostate, unknown primary, esophageal, thyroid, colon cancer.

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