Abstract
The first part of the answer to this question is easy: when the risk benefit balance is negative !
How to determine elements to be taken in account and what is their specific weight is another question which is unsolved yet.
A first group is easy to determine: those whose problem can be solved with non surgical techniques, i.e. metastases responsive to radiotherapy and if too fragile accessible to vertebroplasty. This group underlines the interest of an early diagnosis through a wide use of MRI. By that mean, diagnosis of metastases is possible at the stage of cell penetration in the cancellous bone, before any kind of destruction. This would not be the case by the use of CT scan, where destruction only can be seen, bone scintigraphy where bone reconstruction is shown or even worse plain X rays where a wide range of destruction can only be shown.
On the contrary, MRI T1 hyposignal and even better STIR sequences allow a secured early diagnosis, opening all ways of treatment before surgery is indicated.
If the primary tumor is known as radio/chemo therapy resistant, surgery will done in better conditions than in emergency facing all major complications.
A second group is also easy to determine: those who won’t get any benefit from surgery. These have a complete thoracic paraplegia, lasting for one day with almost no pain. Hope for neurologic recovery is almost zero, risk for infection, skin problems major and the post op pain will be greater than the preop.
If the pain is important and resists to WHO grade 3 pain killers, fixation can be proposed, risks clearly explained.
For the others, the discussion between all members of the team is the only way to find the most suitable answer, knowing here again that nobody knows clearly what should be done “case by case”.
Each member of the team must give his techniques, risks and benefits and association of methods gives the lowest “price” accessible to the patient.
Oncologist: chemo, radio sensitivity, general situation of the patient, foreseeable life expectancy, other metastases with and without clinical significance,
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- Radiotherapist: area having already received radiation (classical situation in breast cancer), spinal cord acceptance for more, risk of increased weakness of the vertebrae just after the radiation.
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- Radiologist: completion of check up, risk for bleeding and possibilities of embolization, vertebroplasty possibilities, on which vertebrae and timing of these compared with surgery and radiotherapy.
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- General practitioner: he knows ( or should) the patient and his family and will be in charge of the immediate follow up
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- Anesthetist: responsible for the pain care of the patient and the anesthetical contraindications.
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- Spine surgeon: he knows the possibilities and risks.
Till now, no score exists to balance the Tokuashi score which is rather a score to foresee life expectancy. We need a score of the “cost” of surgery because a simple anterior cervical corpectomy is possible for any kind of patient and this is of course not the case for a long posterior instrumentation.
To us also, the level of denutrition is a good indicator of risk of complications and the value of surgery in these cases.
Conclusion No never, no always, just a discussion in which patient and family have to be included. It may happen that giving up surgery means acceptance of death. If serenity is achieved, it might be the best help we can offer rather than sending the patient for definitive intubation and no words.
Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.
