Current concepts in the management of metastatic spinal disease

THE part OF MINIMALLY-INVASIVE APPROACHES

The spine is the greatest in quantity frequent location for skeletal metastases1 which come into view in up to 40% of patients with cancer.2,3 The greatest in quantity common primary sites are the breast, prostate and lung with involvement of 393% 235% and 199% respectively1 and with a slight male predominance.4 The thoracic spine is affected in up to 70% of cases, followed by the agency of the lumbar and cervical areas.3,5

Advances in imaging and instrumentation have allowed improvements in the techniques of excision of the tumour and spinal stabilisation. Despite this, the treatment of spinal metastases remains largely palliative. Surgical decision-making is composed of several elements with clear indications being symptomatic, radioresistant tumours (sarcoma, lung colon renal cell) spinal instability, neural compression secondary to retropuls bone deformity, intractable pain and failure of radiotherapy.6-9 smooth if the patient satisfies single or more of these indications, the nature and objective of surgery must be determined by dint of the ability of the patient to tolerate the manner of proceeding and, more importantly, by their estimated life expectancy.

Minimally-invasive techniques, namely percutaneous mortar augmentation, stereotactic radiosurgery and radiofrequency ablation have challenged the conventional management of metastatic spinal disease.10-13 These les invasive operations afford palliation, have a lower morbidity than conventional surgical operations and may alter our decision-making in the future14

Table I. Modified Frankel classification of neurological function24

In this review we have addressed classification schemes which assist in the management of metastatic spinal disease, the non-operative and operative management available, novel minimally-invasive techniques and the issue of treatment.

Classification a whole s

Metastatic lesions of the spine may involve the epidural space, the paravertebral yielding tissues and bone. Initially they usually involve the posterior vertebral elements615 Lesions may either be solitary or multiple and non-contigious in nature.6,16-22 Debilitating pain may or may not be associated with metastatic spinal disease and pathological fracture.6,15,23 Without intervention, the natural history of metastatic spinal disease is individual of symptomatic progression and the potential for consummate and irreversible paralysis. In the past, classification a whole s for patients with metastatic disease, of the like kind as that of Frankel24 have been largely based upon neurological function as it applied to horizontals of mobility (Table I). However, because of the heterogeneity of these lesions, various further a whole s have subsequently been proposed.

Table II. Harrington classification25 of metastatic disease of the spine

Table III. The scoring of Tokuhashi et al29

Table IV. The surgical strategy of Tomita et al30 for spinal metastases

The classification of Harrington. The five-category classification a whole of Harrington25 for metastatic spinal tumours is based upon the destruction of bone and neurological compromise (Table II). Patients in categories I, II and III are treated non-surgically with chemotherapy, hormonal manipulation and/or local irradiation. Patients in categories IV or V are approveed for surgical intervention. Category III lesions show a grey area regarding medical or surgical intervention. If the spinal cord is harshly compressed by an epidural tumour which is not radiosensitive, the patient may be at greater risk of neurological degradation during radiotherapy and should therefore be considered for initial surgical management. Patients with lesions that are unlikely to answer to radiation or chemotherapy, for example renal confined apartment tumours, are candidates for operative intervention irrespective of their Harrington category.26,27 Nonetheless, patients with a Harrington classification with neurological deficits and depressed Frankel grades24 (Tahle I) before and after surgical intervention are at increased risk of complications.28

The classification of Tokuhashi. The score of Tokuhashi et al29 determines the prognosis and life expectancy and is based upon six parameters (Table III). This combination of parts to form a whole was applied to 64 patients. Those with a score of ?‰? 9 points survived for a mean of 12 month or more, those with a score of ?‰¤ 8 for 12 month or les and those with a score of ?‰¤ 5 for les than three month The authors praiseed that patients with a score of ?‰? 9 should meet with an excisional procedure, whereas a palliative operation was moveed for those scoring ?‰¤ 5 No recommendations were made for patients with a score of 6 to 8 While this combination of parts to form a whole was the first to address prognosis as an important factor, sum of two units weaknesses were identified. First, no statistical assessment of the point values was assigned for each factor, and, secondly individual factors were not weighted as to their importance in determining the prognosis. As of that kind the value of this classification combination of parts to form a whole is in its ability to put in mind of the need for an excisional or palliative conduct