MANAGEMENT OF METASTATIC DISEASE OF THE SPINE

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Surgery for metastatic disease of the spine is indicated to preserve function, to maintain quality of life, and to control pain. Because of anatomic considerations, local control may be the only feasible goal. Prior studies have suggested that 70% of patients with primary neoplasia have spinal involvement; current studies dispute this. Wong et al65 found metastatic disease in 36% of patients who died from neoplasia. Their group discovered that 26% of the specimens with confirmed metastases had lesions that could not be visualized on radiographic studies (occult lesions). Vertebral collapse, commonly believed to be a reliable indicator of metastatic disease, was not found not to be so: 22% of the fractures in this series were not caused by metastases.

The vascular sinusoidal system in the red marrow of the vertebral bodies is particularly susceptible to invasion by neoplastic cells as a result of the anatomic arrangement of the paravertebral plexus of Batson. Drainage of the breast through the azygos vein and the prostate through the pelvic venous plexus commonly results in thoracic and lumbar metastases. Drainage of the lung through the pulmonary vein and colon and rectum through the portal system tends to result in more diffuse embolic patterns. Colorectal cancers frequently seed the lung and liver before the spine. Most metastatic involvement in the spine is by definition anterior, involving the vertebral body.

The management of spinal metastasis hinges on three determinations: stability, neurologic status, and pain. The most widely used classifications scheme is that of Harrington.23, 24 The Harrington classification is as follows:

  • Class I—no significant neurologic involvement

  • Class II—bone involvement without collapse

  • Class III—neurologic impairment in the absence of body involvement

  • Class IV—vertebral collapse or instability without significant neurologic involvement

  • Class V—vertebral collapse with major neurologic impairment

This classification scheme is useful to formulate treatment. In patients without evidence of instability and who are neurologically intact (class I or II), chemotherapy or local radiation usually is appropriate for local control. Neurologic impairment without structural compromise (class III) frequently responds to radiation alone. Boland et al6 have recommended steroid administration and radiation therapy in neurologic compromise of acute onset; others, however, have reported that radiation therapy alone is as efficacious as laminectomy in relieving epidural compression.

In patients who have shown mechanical instability or progressive deformity, with or without neurologic involvement (class IV and V), surgical intervention is indicated. In all of these patients, disruption of the anterior and middle biomechanical columns has occurred. Reconstructive surgery in these patients should be directed anteriorly. In cases of severe collapse with disruption of the posterior elements, posterior surgery may be required as well.

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DIAGNOSTIC APPROACH

Spinal lesions seldom should be biopsied; attention should be directed toward discovery of the primary tumor. Needle biopsies produce small specimens and are prone to sampling error. The proper role of the spinal biopsy is confirmation of a suspected diagnosis of metastases or infection. Ghelman et al20 reported an 86% success rate in their series of 75 patients with thoracic and lumbar lesions. Of 75 patients, 45 were diagnosed as having metastatic lesions. Thirty-four lesions were lytic, and

SURGICAL APPROACH

Surgical treatment of metastatic disease has increased significantly, as survival has improved. Siegal et al51 outlined a comprehensive surgical approach to spinal neoplasm, reviewing anterior and posterior approaches. As noted earlier, the mainstay of surgical treatment for metastatic disease is anterior decompression and reconstruction. The results of laminectomy alone are disappointing, with neurologic improvement rates of 23%.42 Weinstein and McLain60 performed a comprehensive review of the

Anterior Approach

The basiocciput and upper vertebrae are accessible anteriorly through the pharynx by dividing the soft palate and part of the hard palate. A significant disadvantage of this exposure is a high rate of infection, approaching 50%. Anesthesia must be administered through a tracheostomy, distal to the surgical site. Insertion of a nasogastric tube to which the soft palate is sutured also is recommended. The soft palate is retracted by pulling back on the tube; with significant edema, the palate may

LOWER CERVICAL SPINE

The anterior bodies of C2 through C7 are exposed easily by the anterior approach of Southwick and Robinson,54 with dissection anterior and medial to the carotid sheath. Lower cervical and upper thoracic levels may be reached through a transverse supraclavicular approach, which permits exposure as far distally as T3. After appropriate stabilization in head halter traction or Gardner-Wells tongs, the cervical spine is extended gently, with the chin raised from the chest to facilitate anterior

CERVICOTHORACIC SPINE

The cervicothoracic area is one of the most difficult to approach because of the transition from cervical lordosis to thoracic kyphosis. The arch of the aorta and the great veins also make anterior access difficult. Perry45 has summarized three approaches to this area: a high transthoracic, a low anterior cervical, and a sternal splitting technique. In cases of kyphosis, the lateral transthoracic approach is recommended; for equal exposure of thoracic and cervical spines, a sternal splitting

THORACIC SPINE

As noted previously, the role of posterior decompression and stabilization alone is extremely limited. Decompression can be achieved through a posterior transpedicular approach; however, this approach provides limited access to the body and mitigates in favor of bilateral transpedicular decompression in cases of extensive involvement. This approach compromises the surface available for posterior fusion and precludes adequate access to the anterior and middle columns for the purposes of

LUMBAR SPINE

Posterior techniques to decompress the lumbar spine suffer from the same limitations (i.e., anterior access) as the previously described techniques in the thoracic spine. As such, their utility is extremely limited in management of metastatic disease in the lumbar region. Posterior techniques for stabilization involving bone screws and hook techniques have been described.

The cranial lumbar vertebrae, L1 to L4, may be accessed anteriorly through a lateral retroperitoneal approach. This approach

DIFFUSE DISEASE

Diffuse spinal metastasis remains problematic. Extensive anterior and posterior reconstruction may be indicated to preserve neurologic function and control pain, but feasibility may be limited by concerns of morbidity, prolonged hospitalization, and technical factors. In the occasional case with multilevel involvement and life expectancy greater than 2 years, more aggressive intervention may be considered. Some cases are not reconstructible, however. There are no absolute anatomic limits, but

SUMMARY

Accurate assessment of spinal cord stability, pain, and neurologic function is essential to any rational approach to metastatic disease of the spine. The Harrington classification is useful in terms of selecting treatment options and planning appropriate interventional and adjuvant therapy. For milder cases, with bone involvement in the absence of structural deformity, adjuvant therapy usually is appropriate. In cases of bone collapse, with or without neurologic compromise, surgical

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    Reprint Requests: F. Todd Wetzel, MD, Section of Orthopaedic Surgery and Rehabilitation, The University of Chicago Spine Center, 4646 North Marine Drive–8th NW, Chicago, IL 60640

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