Evaluation of Postoperative Spine Radiosurgery Following Separation Surgery for Spinal Metastases With High Grade Epidural Spinal Cord Compression

Object In this paper, the authors' goal was to determine the outcome of reoperation for recurrent epidural spinal cord compression in patients with metastatic spine disease. Methods A retrospective chart review was conducted of all patients who underwent spine surgery at the Memorial Sloan-Kettering Cancer Center between 1996 and 2007. Thirty-nine patients who underwent reoperation of the spine at the level previously treated with surgery were identified. Only patients whose reoperation was performed because of tumor recurrence leading to high-grade epidural spinal cord compression or recurrence with no further radiation options were included in the study. Patients who underwent reoperations exclusively for instrumentation failure were excluded. All patients underwent additional decompression via a posterolateral approach without removal of the spinal instrumentation. Results Patients underwent 1–4 reoperations at the same level. A median survival time of 12.4 months was noted after the first reoperation, and a median survival time of 9.1 months was noted after the last reoperation. At last follow-up 22 (65%) of 34 patients were ambulatory at the time of last follow-up or death, and the median time between loss-of-ambulation and death was 1 month. Functional status was maintained or improved by one Eastern Cooperative Oncology Group grade in 97% of patients. A major surgical complication rate of 5% was noted. Conclusions Reoperation represents a viable option in patients with high-grade epidural spinal cord compression who have recurrent metastatic tumors at previously operated spinal levels. In carefully selected patients, reoperation can prolong ambulation and result in good functional and neurological outcomes.

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Neurological Outcome and Survival after Radiosurgery of High-Grade Epidural Spinal Cord Compression

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2013.06.264 ◽

2013 ◽

Vol 87 (2) ◽

pp. S102

Author(s):

S. Ryu ◽

I. Lee ◽

J. Rock

Keyword(s):

Spinal Cord ◽

Spinal Cord Compression ◽

Neurological Outcome ◽

Cord Compression ◽

High Grade

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Radiation-Sensitive Spine Tumor

Spinal Neurosurgery ◽

10.1093/med/9780190887773.003.0017 ◽

2018 ◽

pp. 159-174

Author(s):

Adam M. Robin ◽

Ilya Laufer

Keyword(s):

Spinal Cord ◽

Multiple Myeloma ◽

Spinal Cord Compression ◽

Cauda Equina ◽

Spinal Metastases ◽

Cord Compression ◽

External Beam Radiation ◽

Spinal Instability ◽

Mechanical Instability

A decision-making framework called NOMS (neurologic, oncologic, mechanical and systemic) facilitates and guides therapeutic decisions for patients with spinal metastases. Patients should be evaluated for signs of myelopathy or cauda equina syndrome. The Epidural Spinal Cord Compression (ESCC) scale facilitates reporting of the degree of radiographic spinal cord compression. A determination of the expected histology-specific tumor response to conventionally fractionated external beam radiation (cEBRT) and systemic therapy should be made. Radiation therapy effectively treats biologic pain for radiosensitive tumors such as multiple myeloma. Patients should undergo a careful evaluation of movement-associated pain as tumor-induced spinal instability is an independent indication for surgery. Determination of tumor-associated mechanical instability can be facilitated by the Spinal Instability Neoplastic Score (SINS). Herein, the authors present a case of spinal multiple myeloma managed using the NOMS framework and in consideration of current evidence and treatment paradigms.

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Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice

Global Spine Journal ◽

10.1177/2192568219830323 ◽

2019 ◽

Vol 9 (1_suppl) ◽

pp. 98S-107S ◽

Cited By ~ 12

Author(s):

Ori Barzilai ◽

Stefano Boriani ◽

Charles G. Fisher ◽

Arjun Sahgal ◽

Jorrit Jan Verlaan ◽

...

Keyword(s):

Quality Of Life ◽

Spinal Cord ◽

Literature Review ◽

Functional Status ◽

Local Control ◽

Spinal Cord Compression ◽

Spinal Metastases ◽

Cord Compression ◽

Tumor Histology

Study Design: Literature review. Objective: To provide an overview of the recent advances in spinal oncology, emphasizing the key role of the surgeon in the treatment of patients with spinal metastatic tumors. Methods: Literature review. Results: Therapeutic advances led to longer survival times among cancer patients, placing significant emphasis on durable local control, optimization of quality of life, and daily function for patients with spinal metastatic tumors. Recent integration of modern diagnostic tools, precision oncologic treatment, and widespread use of new technologies has transformed the treatment of spinal metastases. Currently, multidisciplinary spinal oncology teams include spinal surgeons, radiation and medical oncologists, pain and rehabilitation specialists, and interventional radiologists. Consistent use of common language facilitates communication, definition of treatment indications and outcomes, alongside comparative clinical research. The main parameters used to characterize patients with spinal metastases include functional status and health-related quality of life, the spinal instability neoplastic score, the epidural spinal cord compression scale, tumor histology, and genomic profile. Conclusions: Stereotactic body radiotherapy revolutionized spinal oncology through delivery of durable local tumor control regardless of tumor histology. Currently, the major surgical indications include mechanical instability and high-grade spinal cord compression, when applicable, with surgery providing notable improvement in the quality of life and functional status for appropriately selected patients. Surgical trends include less invasive surgery with emphasis on durable local control and spinal stabilization.

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Conventional Radiotherapy and Stereotactic Radiosurgery in the Management of Metastatic Spine Disease

Technology in Cancer Research & Treatment ◽

10.1177/1533033820945798 ◽

2020 ◽

Vol 19 ◽

pp. 153303382094579

Author(s):

Hao-ran Zhang ◽

Ji-kai Li ◽

Xiong-gang Yang ◽

Rui-qi Qiao ◽

Yong-Cheng Hu

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Life Expectancy ◽

Stereotactic Radiosurgery ◽

Spinal Cord Compression ◽

Spinal Metastases ◽

Scoring Systems ◽

Cord Compression ◽

Conventional Radiotherapy ◽

Radiation Induced

Spinal metastases are a common manifestation of malignant tumors that can cause severe pain, spinal cord compression, pathological fractures, and hypercalcemia, and these clinical manifestations will ultimately reduce the health-related quality of life and even shorten life expectancy in patient with cancer. Effective management of spinal bone metastases requires multidisciplinary collaboration, including radiologists, surgeons, radiation oncologists, medical oncologists, and pain specialists. In the past few decades, conventional radiotherapy has been the most common form of radiotherapy, which can achieve favorable local control and pain relief; however, it lacks precise methods of delivering radiation and thus cannot provide sufficient tumoricidal dose. The advent of stereotactic radiosurgery has changed this situation by using highly focused radiation beams guided by 3-dimensional imaging to deliver a high biologic equivalent dose to the target region, and the spinal cord can be identified and excluded from the target volume to reduce the risk of radiation-induced myelopathy. Separation surgery can provide a 2- to 3-mm safe separation of tumor and spinal cord to avoid radiation-induced damage to the spinal cord. Targets for separation surgery include decompression of metastatic epidural spinal cord compression and spinal stabilization without partial or en bloc tumor resection. Combined with conventional radiotherapy, stereotactic radiosurgery can provide better local tumor control and pain relief. Several scoring systems have been developed to estimate the life expectancy of patients with spinal metastases treated with radiotherapy. Thorough understanding of radiotherapy-related knowledge including the dose-fractionation schedule, separation surgery, efficacy and safety, scoring systems, and feasibility of combination with other treatment methods is critical to providing optimal patient care.

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Surgical Decompression of High-Grade Spinal Cord Compression from Hormone Refractory Metastatic Prostate Cancer

Neurosurgery ◽

10.1093/neuros/nyx292 ◽

2017 ◽

Vol 82 (5) ◽

pp. 670-677

Author(s):

Muhammad Omar Chohan ◽

Sweena Kahn ◽

Gustav Cederquist ◽

Anne S Reiner ◽

Joseph Schwab ◽

...

Keyword(s):

Prostate Cancer ◽

Spinal Cord ◽

Spinal Cord Compression ◽

Median Overall Survival ◽

Cord Compression ◽

Spinal Instability ◽

High Grade ◽

Hormone Sensitive ◽

Hormone Refractory ◽

Spine Disease

Abstract BACKGROUND Spine and nonspine skeletal metastases occur in more than 80% of patients with prostate cancer. OBJECTIVE To examine the characteristics of the patient population undergoing surgery for the treatment of prostate cancer metastatic to the spine. METHODS A retrospective chart review was performed on all patients treated at our institution from June 1993 to August 2014 for surgical management of metastatic spine disease from prostate cancer. RESULTS During the study period, 139 patients with 157 surgical lesions underwent surgery for metastatic spine disease. Decompression for high-grade epidural spinal cord compression was required for 126 patients with 143 lesions. Preoperatively, 69% had a motor deficit and 21% were nonambulatory, with 32% due to motor weakness. At surgery, 87% of patients had hormone-refractory prostate cancer (HRPC) and 61% failed prior radiation. Median overall survival for HRPC patients was 6.6 mo (95% confidence interval [CI]: 5.6-8.6) while the median overall survival for hormone-sensitive patients was 16.3 mo (95% CI: 4.0-26.6). CONCLUSION The majority of patients undergoing surgery for prostate cancer metastases to the spine were refractory to hormone therapy, indicating that patients with hormone-sensitive prostate cancer are unlikely to develop symptomatic spinal cord compression or spinal instability. A significant number of HRPC patients presented with neurological deficits attributable to spinal cord compression. Vigilant monitoring for the development of signs and symptoms of epidural spinal cord compression and spinal instability in hormone-refractory patients is recommended. Surgical decision making may be affected by the much shorter postoperative survival for HRPC patients as compared to patients with hormone-sensitive cancer.

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