Abstract
Introduction: Patients with malignant spinal disease who have neurologic symptoms are often considered poor surgical candidates. The aim of this paper is to review the effect on neurologic symptoms of surgical management of malignant spinal disease.
Methods: A retrospective review of patients treated from January 1993 to June 2003 was undertaken. Pain status was assessed using patient statements and recorded analgesic requirements. Neurologic symptoms were assessed using Frankel’s grading.
Results: There were 95 patients (32 females aged 26–83; 63 males aged 15–89). No patients were asymptomatic. 61 of 109 presentations were with multiple symptoms. The most common symptom was pain (99) – either localised (8), non-specific back (56) and/or radicular (57). The next most frequent symptom was weakness (54). The time course of onset varied from acute ward deterioration, with urgent surgery, to slow progression over weeks, prior to elective surgery. 8 cases had sphincteric dysfunction.
There were 98 tumours treated. In females, the most common tumours were breast (8) and renal (4) and in males, prostate (13), multiple myeloma (12) and lung (10). The thoracic spine was involved in 62, the lumbar in 18, cervical in 16 and sacral in 2. The vertebral body was involved in 76.
There were 109 operations. An instrumented fusion was performed in 82. Surgical approach was anterior in 17 (9 cervical, 8 thoracic) and posterior in 80 (5 cervical, 56 thoracic and 17 lumbar). Six patients had combined approaches (2 cervical, 3 thoracic and 1 lumbar). Two patients were treated for metachronous tumours. One patient had non-contiguous metastases treated separately. One patient was treated for local recurrence. One patient had revision for implant failure (anterior thoracic). One patient was explored after deterioration due to loss of autoregulation. Thoraco-abdominal approaches (12) were associated with ileus (2) and pneumonia (3). Of four cases with deep wound infections, three had received prior local irradiation. Two patients died of pulmonary embolus. 83 patients survived beyond three months.
All patients demonstrated improvement in pain status. Thirteen of 29 non-ambulatory cases were able to mobilise postoperatively. There were 32 whose Frankel grades improved. Seventeen of these returned to normal (15 from Grade 4 and 2 from Grade 3). One patient with complete motor and sensory loss improved to useful but subnormal status, three others improved to residual motor function. 11 other patients improved one grade. Of those whose scores did not change (76), 53 remained normal, eight maintained useful but subnormal status, five were stabilised with residual motor function, three kept some sensory perception and two had complete motor and sensory loss. One patient deteriorated from residual motor function to complete motor loss. The outcome for sphincter dysfunction (8) was not clear from the notes. In no case was a specific change in function documented.
Discussion: Surgical treatment of malignant spinal tumours is worthwhile. Posterior approaches are versatile and should be considered. Surgery is effective in the management of pain and preserves or may significantly improve neurologic function.
The abstracts were prepared by I. B. McPhee. Correspondence should be addressed to the Spine Society of Australia Secretariat, The Adelaide Centre for Spinal Research, Institute of Medical and Veterinary Science, PO Box 14, Rundle Mall, Adelaide SA 5000, Australia.
