- Options
- Circumferential decompression of the spinal cord/nerve roots
- 1cm circumferentially from the cord
- Aim
- Decompression
- A safe distance between the tumor and the spinal cord, allowing SRS on target lesion
- Notes
- RT can start from post op 4 weeks
- Surgery can be done within 2 week post radiotherapy
- Surgery (north American society has a pathway & lancet 2017 MNOP algorithm)
- General
- Not to improve overall survival
- To improve quality of life
- Aim
- Stabilize spine
- Histopathology diagnosis
- Decompress cord and neuronal structure
- Indication
- Instability
- NICE
- Consider patients with spinal metastases and mechanical pain resistant to conventional analgesia for spinal stabilisation surgery even if completely paralysed.
- Consider patients with MSCC who have severe mechanical pain and/or imaging evidence of spinal instability, but who are unsuitable for surgery, for external spinal support (for example, a halo vest or cervico-thoraco-lumbar orthosis).
- Patients with spinal metastases without pain or instability should not be offered surgery with the intention of preventing MSCC except as part of a randomised controlled trial.
- Good prognosis
- For those patients with prognoses at or close to the anticipated rehabilitation period for the procedure, surgery is extremely unlikely to be of benefit
- Surgery only if expected survival >3 months
- Single site
- Solitary lesion
- Acute neurological deterioration
- If paraplegic less than 24 hrs
- If patient paraplegic for >24 hours only stabilize for pain relief
- Generally do no surgery if deficit for more than 24 hrs unless pain is uncontrollable
- For tissue diagnosis
- Rarely, radiological appearances may strongly suggest lymphoma, and needle biopsy, rather than immediate surgery is occasionally warranted, in which case immediate radiotherapy, rather than chemotherapy is given, as a provisional diagnosis can be obtained in an emergency within 24 h, and the correct chemotherapy usually requires a more detailed pathological diagnosis, which takes longer.
- Radioresistant
- Previous RT at site
- Surgical options
- Anterior vs posterior
- Posterior decompression
- only for
- Isolated epidural tumour
- Neuro arch mets
- Options
- Laminoplasty
- This preserves the posterior spinal elements and helps maintain spinal stability
- Might not provide sufficient decompression in cases of widespread tumour involvement
- Laminectomy
- Standard of care
- may lead to spinal instability, potentially requiring additional fusion
- Post decompression with instrumented stabilisation is recommended for vertebral body involvement
- Anterior decompression
- Dunning et al., 2012
- Anterior thoracolumbar spinal decompression and reconstruction for spinal mets complication rates as 52% and mortality as high as 13%
- Recovery from anterior spinal surgery can be expected to last 3 months with persistent restriction of physical activity advised for as long as 6 months and symptomatic improvement possible over 18 months postoperatively (RNOH, 2018).
- Taken as a whole, patients with MSCC have a poor prognosis and in a population- based study, 74% had died within 3 months of admission (McLinton and Hutchison, 2006).
- For those patients with prognoses at or close to the anticipated rehabilitation period for the procedure, surgery is extremely unlikely to be of benefit. It is also worth noting that a subgroup analysis of the
- Anterior support
- Consider cement augmentation for expected survival <1 yr
- this is odd because if the decompression is done then the cement leaks
- Consider anterior support (bone grafts for expected survival >1 yr
- Options
- Anterior Corpectomy (or Vertebrectomy):
- Involves the removal of the vertebral body and the adjacent disc.
- It is frequently combined with fusion and instrumentation to stabilise the spine and is used for large tumours affecting multiple spinal levels
- Open vs MIS
- MIS
- Techniques:
- Percutaneous vertebroplasty
- Percutaneous kyphoplasty
- Minimally invasive decompression
- With or without spinal stabilisation
- En bloc excisional surgery
- not done normally due to high morbidity >40%
- only in rare circumstances
- Confirmed solitary renal
- Thyroid met
- For functional tumour (hormone producing)
- Separation surgery
Surgical complications
Complication | Range of Rates (%) |
Worsening neurology | 1.9–4.0 |
Wound problem (infection/dehiscence) | 1.9–21 |
CSF leak | 1.9–12.1 |
Significant hemorrhage | 1.9–9.0 |
Epidural hematoma | 1.9–3.7 |
Gastric perforation | 1.9 |
Construct failure | 0.8–5.9 |
Wrong level surgery | 0.7 |
Pulmonary embolism | 3.3–4.3 |
Deep vein thrombosis | 3.1 |
Post-operative pneumonia | 3.7–8.0 |
Medical unspecified | 1.9–7.6 |
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