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The Journal of Bone and Joint Surgery 79:514-22 (1997)
© 1997 The Journal of Bone and Joint Surgery, Inc.

Posterior Decompression and Stabilization for Spinal Metastases. Analysis of Sixty-seven Consecutive Patients*

HENRIK C. F. BAUER, M.D., PH.D.{dagger}, STOCKHOLM, SWEDEN

Investigation performed at the Oncology Service, Department of Orthopedics, Karolinska Hospital, Stockholm


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
The neurological function, survival, and rehabilitation of sixty-seven consecutive patients who had been managed operatively for spinal metastases with epidural compression were assessed. The epidural compression was in the thoracic spine in forty-one patients and in the lumbar spine in twenty-six. According to the system of Frankel et al. for the assessment of neurological function, twenty-six patients had a major neurological deficit (grade B or C), thirty-two had a minor deficit (grade D), and nine had no deficit (grade E). None of the patients had an operation to treat a pathological vertebral fracture without epidural compression. The operative treatment included wide decompression through a posterior approach followed by stabilization without bone-grafting. A Cotrel-Dubousset device was used in thirty-two patients; an Olerud posterior fixator, in sixteen; an Isola device, in twelve; and another device, in seven. The most common complication was wound infection (eleven patients). There were no perioperative or immediate postoperative deaths (within fourteen days). The rate of survival was 51 per cent (thirty-four of sixty-seven) at six months and 22 per cent (fifteen of sixty-seven) at twelve months. Over-all, forty-four of the fifty-eight patients who had had a neurological deficit preoperatively had complete or partial neurological recovery within the first two weeks postoperatively. The nine patients who had not had a neurological deficit preoperatively retained normal neurological function postoperatively. Thirty-eight of the forty-four patients who were alive at three months and twenty-nine of the thirty-four who were alive at six months were still able to walk. Thirty-nine of the forty-nine patients who survived more than two months were able to return home for a median of seven months. Fourteen patients had a reoperation on the spine. Six of these patients had recurrent epidural compression at another level of the spine, and five had recurrent compression at the previously treated level. Three patients had a reoperation because of loosening of the implant. The results of this study suggest that neurological function can be maintained or improved by decompression and stabilization through a posterior approach as treatment for spinal metastases.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Anterior decompression and stabilization is the accepted method of treatment for patients who have vertebral metastases with neurological compromise due to epidural compression3,6,16,18. Harrington reported improved neurological function in forty-two of sixty-two patients who had been managed with this approach. In another study, sufficient neurological function for walking was retained or restored in 75 per cent (forty-one) of fifty-five patients17. The corresponding figure after treatment with posterior decompression alone has been reported to be approximately 30 per cent, and this technique has been largely abandoned3.

However, anterior decompression of the thoracic or lumbar spine is associated with a high rate of morbidity. The perioperative mortality rate has been reported to be about 10 per cent6,10,11,20. Although lower rates of morbidity have been reported7,17, patients who have extensive metastatic or cardiovascular disease are not ideal candidates for an anterior procedure. Posterior decompression combined with stabilization with segmental instrumentation has been proposed as an alternative2,5,8,12-15.

The aim of the present study was to assess neurological function, rehabilitation, and survival after posterior decompression and stabilization in patients who had thoracic or lumbar metastases with epidural compression.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Sixty-nine consecutive patients who were managed operatively from January 1990 to February 1994 for spinal metastases with epidural compression were followed prospectively. Two patients were lost to follow-up, leaving sixty-seven patients for analysis. There were forty-three men and twenty-four women, and the median age was sixty-four years (range, twenty-two to eighty-five years). Fourteen patients had not been diagnosed with cancer before the time of presentation. For the remaining fifty-three patients, a median interval of three years (range, one month to twenty years) had elapsed since the diagnosis of the primary tumor.

The most common primary tumors were cancer of the prostate (eighteen patients) and breast (twelve patients). Seven patients had a solitary tumor, forty had multiple skeletal metastases, and twenty had visceral or brain metastases. Preoperative assessment was based on magnetic resonance images for fifty patients, computed tomography scans for thirteen, and myelograms for four. Magnetic resonance imaging was not readily available during the first years of the study; computed tomography, with or without myelography, is now used only when magnetic resonance imaging is contraindicated. The epidural compression was located in the thoracic spine in forty-one patients and in the lumbar spine in twenty-six. A pathological compression fracture of the vertebral body was evident in thirty-six patients. Twenty-six patients had a major neurological deficit (grade B or C), thirty-two had a minor deficit (grade D), and nine had no deficit (grade E), according to the system of Frankel et al. There was no association between the severity of the neurological deficit and the presence of a pathological fracture. The indication for the operation was a neurological deficit due to epidural compression from a tumor or a pathological fracture, or both, in all but the nine patients who did not have a neurological deficit. These nine patients had symptoms and radiographic evidence of epidural compression. Hence, none of the patients were managed for a pathological fracture without compression of the spinal cord or cauda equina.

The operative treatment included wide decompression through a posterior approach, usually with removal of both pedicles of the affected vertebra as well as of the tumor or osseous fragments causing the epidural compression, followed by posterior stabilization without bone-grafting. Thirty-three patients were managed by me, and the remaining thirty-four were managed by senior orthopaedic surgeons in the same department. The decompressions were sometimes, but not routinely, performed in cooperation with a neurosurgeon. Two of six patients who had renal metastasis had preoperative embolization13. The spine was stabilized with a Cotrel-Dubousset device (Sofamor, Rang du Fliers, France) (Figs. 1-A and 1-B) in thirty-two patients, an Olerud posterior fixator (NordOpedic, Länna, Sweden) in sixteen, an Isola device (AcroMed, Cleveland, Ohio) in twelve, and another device in seven. Stabilization of two or three spinal segments was done with use of pedicle fixation and was more common in the lumbar spine than in the thoracic spine. Hook fixation was mostly used in the thoracic spine and for stabilization of longer segments. However, pedicle fixation was used in a few patients as far cephalad as the second thoracic vertebra.



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  		Figs. 1-A and 1-B: A sixty-nine-year-old woman who had a solitary skeletal metastasis of the fourth thoracic vertebra sixteen years after being diagnosed with cancer of the breast. The neurological function4 was grade D. Fig. 1-A: Preoperative magnetic resonance images. The sagittal section (left) shows a pathological fracture of the vertebral body and an abnormal marrow signal extending into the spinous process (arrow). The transverse section (right) shows the spinal cord (arrow) encircled by the soft-tissue metastatic mass.

 


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  		Postoperative radiographs showing stabilization with Cotrel-Dubousset hooks and pedicle screws. The patient had normal neurological function until the time of death from metastases to the brain two years after the index operation.

 
The median duration of the operation was three hours (range, one and a half to six hours), and the median blood loss was 1500 milliliters (range, 200 to 7800 milliliters). The duration of the operation and the operative blood loss increased with the number of segments stabilized (Table I). Postoperatively, all patients were allowed to walk without the use of braces. The median duration of hospitalization was seven days (range, three to twenty-eight days). Most of the patients were discharged to an oncology unit for additional treatment and rehabilitation. Thirteen patients received radiation therapy preoperatively, and thirty-five received it postoperatively.


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  		TABLE I DATA ACCORDING TO THE NUMBER OF SPINAL SEGMENTS STABILIZED

 
Neurological function was re-evaluated within two weeks after the operation and at approximately three-month intervals. Whether the patient was able to be discharged to home and how long that he or she had lived at home were determined. These factors were regarded as over-all assessments of the success of the rehabilitation effort. The hospital charts of patients who died during the follow-up period were reviewed. The duration of survival was considered to be the time between the date of the operation and death or the latest follow-up examination (in January 1996). Five patients were still alive at the time of the latest follow-up, at a median of thirty-nine months (range, twenty-six to forty-three months) after the operation.

Clinical data were compared with use of the chi-square test and the Wilcoxon rank-sum test. Survival estimates were calculated according to the method of Kaplan and Meier. Survival estimates for different subgroups were compared with use of the Mantel-Haenszel test.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 

Complications
There were no perioperative or immediate postoperative deaths (within fourteen days). A bleeding ulcer developed postoperatively in one patient and was treated without additional difficulty.

There were thirteen complications related to the wound, eleven of which were infections. Three of the eleven infected patients had débridement of the wound, and the remaining eight were managed with local wound care and antibiotics. One patient, a seventy-eight-year-old woman who had cancer of the kidney with metastasis to the fifth lumbar vertebra, died two months postoperatively partly because of a wound infection. The risk of infection increased with the duration of the operation; ten of the eleven infections developed after a procedure that lasted more than three hours. The rate of infection dropped to 7 per cent (three of forty-one) for patients who were managed in 1993 or 1994 from 31 per cent (eight of twenty-six) for those who were managed in 1990, 1991, or 1992. This is probably attributable to the learning curve and the shorter duration of the operation.

Survival
Fifteen of the sixty-seven patients survived for more than one year after the operation. The rate of survival was 51 per cent (thirty-four of sixty-seven) at six months, 22 per cent (fifteen) at one year, and 12 per cent (eight) at two years. Survival was closely related to the tumor burden (Fig. 2). None of the twenty patients who had visceral or brain metastases were alive at twelve months, compared with 32 per cent (fifteen) of the forty-seven patients who had skeletal metastases only. Survival was not related to the preoperative neurological function.



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  		Fig. 2: Kaplan-Meier curves showing the postoperative survival of the forty-seven patients who had only skeletal metastases (solid line) and the twenty who had visceral or brain metastases (open boxes) (p = 0.0004, Mantel-Haenszel log-rank test). The dotted lines represent the 95 per cent confidence intervals.

 

Neurological Function
Forty-four of the fifty-eight patients who had had a neurological deficit (grade B, C, or D) preoperatively had complete or partial neurological recovery at the time of discharge (Table II). Specifically, eighteen of the twenty-six patients who had not been able to walk (grade B or C) preoperatively recovered enough neurological function to walk (grade D or E). Of the thirty-two patients who had had grade-D function preoperatively, two had worsening of the deficit to grade C, four had no change, and twenty-six had grade-E function at the time of discharge. The nine patients who had not had a neurological deficit preoperatively retained normal neurological function postoperatively.


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  		TABLE II DATA ON THE NEUROLOGICAL GRADES4

 
The neurological recovery initiated by decompression and stabilization continued during the follow-up period. Three of the eight patients who had had grade-C function at the time of discharge had improvement to grade D, and eight of the eighteen who had had grade-D function at the time of discharge had grade-E function by the time of the latest follow-up. Over-all, thirty-eight of the forty-four patients who were still alive at three months, twenty-nine of the thirty-two patients who were still alive at six months, and all fifteen of the patients who were still alive at one year were able to walk. Of the sixty-two patients who died before the latest follow-up examination, eighteen had had grade-B or C function at the last neurological assessment before death, twelve had had grade-D function, and thirty-two had had grade-E function. Of the five patients who were still alive at the latest follow-up examination, four had grade-D and one had grade-E neurological function.

Rehabilitation
Twenty-three of the sixty-seven patients never returned home after the operation. Rehabilitation was clearly related to the neurological function at the time of discharge—that is, the proportion of patients who returned home increased with the neurological grade. Thirty-nine of the forty-nine patients who survived more than two months were able to return home. The median time at home for these patients was seven months (range, one to thirty-seven months).

Radiographic Follow-up
Radiographs were available for fourteen of the fifteen patients who survived more than one year. Loosening of the implant was seen in one patient. Another patient had compression of a vertebral body. This patient was a sixty-five-year-old woman with breast cancer and multiple metastases to the vertebral bodies who was managed in July 1992 because of compression of the spinal cord at the second thoracic vertebra with grade-C neurological function. After decompression and stabilization with Cotrel-Dubousset hooks and rods, the neurological function improved to grade D. Loosening of the cephalad hooks was seen in January 1993, and progressive spinal deformity developed because of additional collapse of the vertebral body. Because of a severe kyphosis, without additional neurological impairment, a reoperation was performed in May 1993, with repeat posterior Cotrel-Dubousset stabilization. At the time of the latest follow-up examination, almost three years after the last procedure, the patient was living at home and walked with a walker.

Reoperations
Fourteen patients had at least one reoperation (Table III): eleven because of progression of the primary disease, and three because of loosening of the implant. In the former group, six patients had recurrent epidural compression at a new spinal level and five had compression at the previously decompressed level. Three of the fourteen patients had anterior decompression and reconstruction, and eleven had repeat posterior decompression, with or without replacement of the fixator (Figs. 3-A, 3-B, 3-C, 3-D and 3-E). Eleven patients remained able to walk (grade D or E) after the reoperation. The median duration of survival after the reoperation was four months (range, two to thirty-four months), and ten patients were able to return home.


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  		TABLE III DATA ON THE FOURTEEN PATIENTS WHO HAD A REOPERATION

 


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  		Figs. 3-A through 3-E: Case 12, a forty-one-year-old man who had a metastasis of melanoma to the second lumbar vertebra. The patient had severe radicular pain and weakness in the left thigh. Fig. 3-A: Preoperative computed tomography scan showing destruction of the left side of the vertebral body and the tumor growing into the epidural space (arrow), dislocating the cauda equina posteriorly and to the right.

 


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  		Fig. 3-B Radiographs made after decompression and instrumentation with a Cotrel-Dubousset device.

 


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  		Fig. 3-C Radiographs showing severe compression of the vertebral body after the patient fell off his bicycle nine months postoperatively. Before the injury, he had been pain-free and had had no neurological deficit. At the time that these radiographs were made, he had mild pain and no neurological symptoms. Radiculopathy developed two months later.

 


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  		Fig 3-D Preoperative myelogram, made two months after the radiographs in Fig. 3-C, showing epidural compression and posterior dislocation of the cauda equina.

 


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  		Fig 3-E Radiographs made after repeat posterior decompression and stabilization with an Olerud posterior fixator device. The patient had normal neurological function until the time of death from visceral metastases two months after the reoperation.

 


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The results of this study show that posterior decompression and stabilization for metastatic spinal disease with epidural compression leads to improved neurological function. The rate of neurological improvement was of the same order as that after anterior procedures3,6,7,16-18. There were no perioperative deaths. The relatively low risk associated with posterior decompression and stabilization has also been reported in smaller series2,5,12,13,15.

Posterior decompression and stabilization should not be considered a minor procedure as the median duration of the operation in the present study was three hours and the median blood loss was 1500 milliliters. In fact, one major complication encountered was postoperative infection. The rate of infection decreased considerably, from 31 per cent at the beginning of this series to 7 per cent at the end, partly because the operative duration was reduced as fewer spinal segments were stabilized. The learning curve probably contributed to the reduction in complications as well. Attention to preparation of the skin preoperatively may also have influenced the rate of infection.

The initial strategy in the management of the patients in this series was to stabilize several segments cephalad and caudad to the level of the thoracic or lumbar epidural compression15. A shorter area of stabilization was not considered sufficient for a spine weakened by osseous destruction and decompression. However, Jónsson et al. reported long-term neurological recovery after decompression and posterior stabilization of two or three segments with the Olerud posterior fixator device in patients who had myeloma. Stabilization of fewer segments apparently does not jeopardize the results. With a reduction in the number of levels stabilized, a patient who otherwise may not have been considered a candidate for an extensive procedure may be able to have relief of pain and improved neurological function. With palliative operations on the spine, the issue is not how much can be done but how little, while still ensuring neurological function and reduction of pain during the remaining life span.

The improvement in neurological function that was obtained after the operation was retained during the follow-up period. Hence, the proportion of patients who remained able to walk at six and twelve months was approximately the same as that immediately postoperatively. This implies that the posterior stabilization was sufficient even though the affected vertebral body was not reconstructed. The rationale for anterior resection is that spinal instability commonly is secondary to destruction of the anterior and middle vertebral columns21. Nevertheless, it appears that the types of posterior implants that were used in the present study provided sufficient stability. Bone-grafting was not performed because osseous fusion was not considered possible in most of the patients, who were in poor general health, often were being managed with ongoing chemotherapy, and received postoperative local radiation therapy. The radiographic assessment showed that a spinal deformity developed in only two of the fourteen patients who survived more than one year and for whom radiographs were available, although an additional patient, who died after eleven months, had a reoperation because of failure of the implant due to progression of the disease.

The fact that fourteen (21 per cent) of the sixty-seven patients had a reoperation is worrisome, but this rate is not higher than that reported after anterior procedures6,10,16. In fact, Hosono et al. reported twenty-two local recurrences in eighty-four patients who had been managed with an anterior procedure. The risk of failure increased with the duration of survival. A similar association was reported between local failure and survival after operative treatment of metastases to long bones22. Preoperative identification of potential long-term survivors may be useful in the selection of candidates for more extensive procedures19. Among the important clinical features are the extent of the metastatic disease and the site of the primary tumor1. None of the patients in our series who had visceral or brain metastases survived for one year. It also appears that cancer of the breast or kidney as well as myeloma are favorable for long-term survival, while cancer of the prostate or lung is associated with a poor chance of surviving one year.

Six of the fourteen patients who had a reoperation had had epidural compression at a new level, which would not have been prevented by use of a different approach. Similarly, Harrington reported that six of seventy-two patients had a reoperation because of metastatic destruction at a new level of the spine. It is possible that an anterior approach could have been used for six of the remaining eight patients in the present series who had a reoperation. For example, one patient who had a solitary metastasis of melanoma to the vertebral body (Figs. 3-A, 3-B, 3-C, 3-D and 3-E) could have had an anterior procedure instead. However, corpectomies for spinal metastases are still intralesional procedures, which also entail a high risk of local recurrence5,7. Hence, it is still to be proved that anterior procedures have a lower rate of long-term failure. The postoperative improvement in neurological function and the ability to return home after the reoperation were similar to those after the index procedure.

Several criteria are now applied at our institution to choose the type of operative intervention. If the metastases involve one or two adjacent vertebral body segments and there is a good prognosis for one-year survival, anterior decompression and reconstruction is performed. If the metastases involve one or two adjacent vertebral body segments but there is a poor prognosis—that is, the patient has brain or visceral metastases or primary cancer of the lung—decompression, through a posterior approach, and fixation of a short segment is performed. If there is extensive spinal disease, fixation of a long segment with hooks or pedicle screws, or both, is performed. Only approximately 10 per cent of the patients seen at our institution fit into the first category.

The finding that one-third (twenty-three) of the sixty-seven patients died of cancer within three months after the operation may call into question the benefit of operative treatment of patients who have extensive disease. However, restoration of neurological function and reduction of pain are definitely beneficial even for only a short period of time. Furthermore, it is difficult to identify patients who have a poor prognosis in an emergency situation. This is especially true for patients in whom the epidural compression is the first sign of cancer. The proportion of patients who were able to return home increased with the degree of neurological recovery, reflecting the utility of prompt and adequate operative treatment of these patients. The degree of the preoperative neurological deficit was not related to the rate of survival, but those who could not walk postoperatively appeared to have a worse prognosis.

In conclusion, immediate and sustained neurological recovery can be achieved with posterior decompression and stabilization. The results were similar to those attained after anterior decompression but with less morbidity3,6,7,16-18. The rate of reoperation was fairly equal to that reported after anterior decompression6,10,16 and was more often attributable to new levels of epidural compression or local recurrence of the tumor than to failure of the posterior stabilization. Application of this approach for epidural compression often restores neurological function in patients with extensive metastatic disease for whom an anterior approach is considered too demanding.


   Footnotes
 

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding sources were the Karolinska Institute Research Funds and the Swedish Society of Medicine Research Funds.

{dagger}Oncology Service, Department of Orthopedics, Karolinska Hospital, S-171 76 Stockholm, Sweden. E-mail address: bauer@ort.ks.se.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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  8. Jónsson, B.; Sjöström, L.; Jónsson, H., Jr.; and Karlström, G.: Surgery for multiple myeloma of the spine. A retrospective analysis of 12 patients. Acta Orthop. Scandinavica, 63: 192-194, 1992.[Medline]

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