Skeletal metastases are an increasing sequaelae for patients with a wide range of neoplastic lesions owing to the increasing incidences of cancer. The diagnosis of a skeletal metastasis is, however, at present a terminal diagnosis representing uncontrolled tumour dissemination. The metastatic destruction of the bone reduces its load bearing capabilities progressing to the principle orthopaedic complication, that of complete loss of cortical integrity.

Aim: We examine the population suffering a complication of skeletal metastasis in terms of their mortality and morbidity. We compare patients who underwent surgical stabilization as a result of a fracture through a metastatic lesion against those who underwent prophylactic stabilization.

This is a retrospective study of all patients within the Cardiff centre who underwent an operation for a metastatic bone lesion over a 10 year period (n=140). The patients were identified using pathological records created when samples were sent at the time of the operations. The patients were all followed up for a minimum of 24 months. The demographics of the patients were collected and a detailed analysis of the primary tumour, the surgical procedure, the mobility, and survival of the patients was undertaken. The patients data was then cross referenced with the database at the regional cancer centre and the post operative radiotherapy treatment regimen were collected.

Patients who underwent prophylactic surgical stabilization had a significant survival advantage compared to those stabilized following a fracture (p=0.002). The morbidity postoperatively, defined by the patients functional mobility, also shows the benefits of prophylactic stabilization with significantly improved mobility when compared to the mobility following fracture stabilization (p=0.033). It has also been shown that there is a significant postoperative survival benefit for those patients who were able to regain mobility (p< 0.01).

Our results show a significant survival benefit of prophylactic fixation rather than fixation following fracture which is in line with previous studies We have also, for the first time in a large number study, shown that there is a survival benefit for patients who are able to mobilize following surgery and if prophylactic stabilization was undertaken patients were significantly more mobile postoperatively.

Lumbar spinal surgery may be associated with considerable pain in the early postoperative period. This often leads to a delay in patient mobilisation and a consequent increase in the risk of developing perioperative complications. Several studies have demonstrated the efficacy of intrathecal opioids for analgesia following spinal surgery.^1–3 Morphine has been the most widely studied opioid and although improved analgesia has been reported with its use the risk of serious side effects such as respiratory depression has resulted in patients having to be nursed postoperatively in a high dependency unit.² Intrathecal diamorphine has been widely used for analgesia following lower limb joint replacement where it is an effective analgesic agent with a good safety profile.^4–5 Its use for analgesia following lumbar spinal surgery has never been reported.

We present our experience of using intrathecal diamorphine for analgesia following lumbar spinal surgery. Data were collected on all patients undergoing surgery who received intrathecal diamorphine and stored on a database (Microsoft Access).

Results: 194 patients received intrathecal diamorphine following spinal surgery over a 30 month period. All patients underwent lower lumbosacral decompressive and/or fusion surgery. Mean dose of diamorphine administered was 1.6mg (range 1–4mg or 20–50mcg/kg). In all cases intrathecal diamorphine was administered by the anaesthetist once the patient was anaesthetised. Only 9% of patients had a pain score of 2 or greater within the first 24 hours (using a verbal rating scale 0–10). No patients required rescue analgesia with intravenous opiates. All patients except one were nursed on a regular orthopaedic ward. Side effects were rare. Respiratory depression occurred in one patient necessitating supplemental oxygen and monitoring in a high dependency unit for 12 hours. Hypotension was an infrequent finding (3.5%) but was most common upon return to the ward and in the following 24 hours. It was easily treated with the administration of intravenous fluids and vasopressors were never required. Sedation occurred in 4 of the patients whilst in the recovery ward but the incidence was nil once patients had been discharged to the orthopaedic ward. The most common complication recorded was pruritis, occurring in 9% of patients within the first 12 hours.

Conclusion: Intrathecal diamorphine is an effective and safe method of providing analgesia following lumbar spinal surgery. High Dependency nursing care is not required as the incidence of serious side effects is low.