Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007

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Object

Opinions vary widely as to the role of surgery (from none to wide margin excision) in the management of spinal metastases. In this study the authors set out to ascertain if surgery improves the quality of remaining life in patients with spinal metastatic and tumor-related systemic disease.

Methods

The authors included 223 patients in this study who were referred by oncologists and physicians over a 2-year period. All underwent surgery. Surgery was classified according to extent of excision ranging from en bloc excision or debulking to palliative surgery. All patients had a histologically confirmed diagnosis of epithelial spinal metastasis, and an oncology specialist undertook appropriately indicated adjuvant therapy in almost half of the patients.

Results

The mean patient age was 61 years. Excisional en bloc or debulking surgery was performed in 74%; the rest had (minimal) palliative decompression. All patients considered for surgery were included in the study. Patients presented with pain in 92% of cases, paraparesis in 24%, and abnormal urinary sphincter function in 22% (5% were incontinent). Breast, renal, lung, and prostate accounted for 65% of the cancers, and in 60% of patients there were widespread spinal metastases (Tomita Type 6 or 7).

The incidence of perioperative death (within 30 days of surgery) was 5.8%. Postoperatively 71% of the entire group had improved pain control, 53% regained or maintained their independent mobility, and 39% regained urinary sphincter function. The median survival for the cohort was 352 days (11.7 months); those who underwent excision survived significantly longer than those in the palliative group (p = 0.003). As with survival results, functional improvement outcome was better in those who underwent excision.

Conclusions

Surgical treatment was effective in improving quality of life by providing better pain control, enabling patients to regain or maintain mobility, and offering improved sphincter control. Although not a treatment of the systemic cancer, surgery is feasible, has acceptably low mortality and morbidity rates, and for many will improve the quality of their remaining life.

Abbreviations used in this paper: ASA = American Society of Anesthesiologists; HR = hazard ratio; KPS = Karnofsky Performance Scale.

Article Information

Address correspondence to: Ahmed Ibrahim, M.R.C.S., The National Hospital for Neurology and Neurosurgery, Victor Horsley Department of Neurosurgery, Box 3, Queen Square, London, WC1N 3BG, United Kingdom. email: aibrahim@ion.ucl.ac.uk.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Diagram showing the 3 types of resection strategies: a) en bloc for total vertebrectomy; b) debulking intralesional excision; and c) palliative minimal surgical decompression.

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    Kaplan–Meier curve showing overall survival of all patients. A rapid decline in survival is seen up to the initial 180 days (6 months) following surgery, the decline rate becomes relatively slower between 180 and 400 days, and the least decline rate is seen after 400 days to end of follow-up.

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    Kaplan–Meier curves of the 3 different types of surgery showing that en bloc and debulking procedures have similar survival (p = 0.1357, log-rank test) but both have better survival than palliative surgery over the follow-up period (p < 0.001, log-rank test).

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