Quantifying the impact of surgical decompression on quality of life and identification of factors associated with outcomes in patients with symptomatic metastatic spinal cord compression

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  • 1 Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts;
  • 2 Faculty of Life Sciences and Medicine, King’s College, London, United Kingdom;
  • 3 Massachusetts College of Pharmacy and Health Science, Boston; and
  • 4 Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts
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OBJECTIVE

Metastatic spinal cord compression (MSCC) imposes significant impairment on patient quality of life and often requires immediate surgical intervention. In this study the authors sought to estimate the impact of surgical intervention on patient quality of life in the form of mean quality-adjusted life years (QALY) gained and identify factors associated with positive outcomes.

METHODS

The authors performed a retrospective chart review and collected data for patients who had neurological symptoms resulting from radiologically and histologically confirmed MSCC and were treated with surgical decompression during the last 12 years.

RESULTS

A total of 151 patients were included in this study (mean age 60.4 years, 57.6% males). The 5 most common metastatic tumor types were lung, multiple myeloma, renal, breast, and prostate cancer. The majority of patients had radioresistant tumors (82.7%) and had an active primary site at presentation (67.5%). The median time from tumor diagnosis to cord compression was 12 months and the median time from identification of cord compression to death was 4 months. Preoperative presenting symptoms included motor weakness (70.8%), pain (70.1%), sensory disturbances (47.6%), and bowel or bladder disturbance (31.1%). The median estimated blood loss was 500 mL and the average length of hospital stay was 10.3 days. About 18% of patients had postoperative complications and the mean follow-up was 7 months. The mean pre- and postoperative ECOG (Eastern Cooperative Oncology Group) performance status grades were 3.2 and 2.4, respectively. At follow-up, 58.3% of patients had improved status, 31.5% had no improvement, and 10.0% had worsening of functional status. The mean QALY gained per year in the entire cohort was 0.55. The mean QALY gained in the first 6 months was 0.1 and in the first year was 0.4. For patients who lived 1–2, 2–3, 3–4, or 4–5 years, the mean QALY gained were 0.8, 1.4, 1.7, and 2.3, respectively. Preoperative motor weakness, bowel dysfunction, bladder dysfunction, and ASA (American Society of Anesthesiologists) class were identified as independent predictors inversely associated with good outcome.

CONCLUSIONS

The mean QALY gained from surgical decompression in the first 6 months and first year equals 1.2 months and 5 months of life in perfect health, respectively. These findings suggest that surgery might also be beneficial to patients with life expectancy < 6 months.

ABBREVIATIONS ASA = American Society of Anesthesiologists; ASIA = American Spinal Injury Association; DVT = deep venous thrombosis; EBL = estimated blood loss; ECOG = Eastern Cooperative Oncology Group; LOS = length of hospital stay; MSCC = metastatic spinal cord compression; PE = pulmonary embolism; QALY = quality-adjusted life years; SINS = Spinal Instability Neoplastic Score.

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Contributor Notes

Correspondence Hasan A. Zaidi: Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. hzaidi1@bwh.harvard.edu.

INCLUDE WHEN CITING Published online April 3, 2020; DOI: 10.3171/2020.1.SPINE191326.

M.W.G. and H.A.Z. share senior authorship of this work.

Disclosures Dr. Groff reports receiving royalties from DePuy Spine, Biomet Spine, NuVasive, and SpineArt.

  • 1

    Klimo P Jr, Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol. 2005;7(1):6476.

    • Search Google Scholar
    • Export Citation
  • 2

    Patchell RA, Tibbs PA, Regine WF, Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643648.

    • Search Google Scholar
    • Export Citation
  • 3

    Bilsky M, Smith M. Surgical approach to epidural spinal cord compression. Hematol Oncol Clin North Am. 2006;20(6):13071317.

  • 4

    Hohenberger C, Schmidt C, Höhne J, Effect of surgical decompression of spinal metastases in acute treatment—predictors of neurological outcome. J Clin Neurosci. 2018;52:7479.

    • Search Google Scholar
    • Export Citation
  • 5

    Chaichana KL, Woodworth GF, Sciubba DM, Predictors of ambulatory function after decompressive surgery for metastatic epidural spinal cord compression. Neurosurgery. 2008;62(3):683692.

    • Search Google Scholar
    • Export Citation
  • 6

    de Ruiter GC, Nogarede CO, Wolfs JF, Arts MP. Quality of life after different surgical procedures for the treatment of spinal metastases: results of a single-center prospective case series. Neurosurg Focus. 2017;42(1):E17.

    • Search Google Scholar
    • Export Citation
  • 7

    Ghogawala Z, Mansfield FL, Borges LF. Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine (Phila Pa 1976). 2001;26(7):818824.

    • Search Google Scholar
    • Export Citation
  • 8

    Wang JC, Boland P, Mitra N, Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1(3):287298.

    • Search Google Scholar
    • Export Citation
  • 9

    de Borja MT, Chow E, Bovett G, The correlation among patients and health care professionals in assessing functional status using the Karnofsky and Eastern Cooperative Oncology Group performance status scales. Support Cancer Ther. 2004;2(1):5963.

    • Search Google Scholar
    • Export Citation
  • 10

    Roberts TT, Leonard GR, Cepela DJ. Classifications in brief: American Spinal Injury Association (ASIA) Impairment Scale. Clin Orthop Relat Res. 2017;475(5):14991504.

    • Search Google Scholar
    • Export Citation
  • 11

    The Cost-Effectiveness Analysis Registry. Center for the Evaluation of Value and Risk in Health. www.cearegistry.org. Accessed February 13, 2020.

    • Export Citation
  • 12

    Naglie G, Krahn MD, Naimark D, Primer on medical decision analysis: Part 3—Estimating probabilities and utilities. Med Decis Making. 1997;17(2):136141.

    • Search Google Scholar
    • Export Citation
  • 13

    Attema AE, Brouwer WBF, Claxton K. Discounting in economic evaluations. Pharmacoeconomics. 2018;36(7):745758.

  • 14

    Nater A, Tetreault LA, Kopjar B, Predictive factors of survival in a surgical series of metastatic epidural spinal cord compression and complete external validation of 8 multivariate models of survival in a prospective North American multicenter study. Cancer. 2018;124(17):35363550.

    • Search Google Scholar
    • Export Citation
  • 15

    Putz C, van Middendorp JJ, Pouw MH, Malignant cord compression: a critical appraisal of prognostic factors predicting functional outcome after surgical treatment. J Craniovertebr Junction Spine. 2010;1(2):6773.

    • Search Google Scholar
    • Export Citation
  • 16

    Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978;3(1):4051.

    • Search Google Scholar
    • Export Citation
  • 17

    Loblaw DA, Perry J, Chambers A, Laperriere NJ. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative’s Neuro-Oncology Disease Site Group. J Clin Oncol. 2005;23(9):20282037.

    • Search Google Scholar
    • Export Citation
  • 18

    Helweg-Larsen S, Sørensen PS, Kreiner S. Prognostic factors in metastatic spinal cord compression: a prospective study using multivariate analysis of variables influencing survival and gait function in 153 patients. Int J Radiat Oncol Biol Phys. 2000;46(5):11631169.

    • Search Google Scholar
    • Export Citation
  • 19

    Thomas N, Byrne ECB, Waxman SG. Diseases of the Spine and Spinal Cord. Oxford, England: Oxford University Press; 2000.

  • 20

    Skeers P, Battistuzzo CR, Clark JM, Acute thoracolumbar spinal cord injury: relationship of cord compression to neurological outcome. J Bone Joint Surg Am. 2018;100(4):305315.

    • Search Google Scholar
    • Export Citation
  • 21

    Morgen SS, Engelholm SA, Larsen CF, Health-related quality of life in patients with metastatic spinal cord compression. Orthop Surg. 2016;8(3):309315.

    • Search Google Scholar
    • Export Citation
  • 22

    Dea N, Versteeg AL, Sahgal A, Metastatic spine disease: should patients with short life expectancy be denied surgical care? An international retrospective cohort study [published online November 6, 2019]. Neurosurgery. doi:10.1093/neuros/nyz472

    • Search Google Scholar
    • Export Citation
  • 23

    Fürstenberg CH, Wiedenhöfer B, Gerner HJ, Putz C. The effect of early surgical treatment on recovery in patients with metastatic compression of the spinal cord. J Bone Joint Surg Br. 2009;91(2):240244.

    • Search Google Scholar
    • Export Citation
  • 24

    Quraishi NA, Rajagopal TS, Manoharan SR, Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression. Eur Spine J. 2013;22(6):13831388.

    • Search Google Scholar
    • Export Citation
  • 25

    American Society of Anesthesiologists. New classification of physical status. Anesthesiology. 1963;24:111.

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