SURGICAL APPROACH TO SPINAL PAIN DUE TO METASTATIC DISEASE: THE PERTH EXPERIENCE

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Peter Woodland
Spinal Unit, Department of Orthopaedic Surgery, Royal Perth Hospital, and Neuroscience Surgical Unit, St John of God Health Care, Perth, WA

A spinal surgery service is part of a multidisciplinary service managing cancer patients ('Centre of Excellence' Cancer Centre). Such a cancer centre may include specialist oncologists, pain medicine specialists/anaesthetists, palliative care specialists, radiotherapists and radiologists in addition to other support staff. Referral of a patient for spinal surgery assessment and opinion may also be initiated by a general practitioner and by an emergency department physician.

In very selected cases, surgical treatment may improve the pain management, function and quality of life of patients with spinal metastatic disease. Surgery may be adjunctive or alternative treatment to chemotherapy and/or radiotherapy. Surgery for spinal metastatic disease, in general terms, does not prolong life, rather the aim is to improve the quality of remaining life. (Some studies have demonstrated marginal improvements in survival).

Indications for surgery include:

1. Disabling spinal pain due to vertebral pathological fracture or tumour pain.
2. Impending neurological deficit due to pathological fracture or intracanal tumour extension.
3. Radicular pain due to tumour extension.
4. Failure to control the above, by non-surgical treatment methods.

Selection criteria for surgical management of spinal metastatic disease:

1. Patient's general condition; fitness for major surgery.
2. Neurological status; degree of paralysis.
3. Degree of metastatic spread.
4. Histology type.
5. Response to previous non-surgical treatment.
6. Anticipated survival; duration and quality.

In general terms, the best surgical candidate is a patient who is neurologically intact or with minimal neurological involvement, with few spinal metastases and without vertebral collapse. This may be analogous to surgical treatment of an isolated metastasis in a long bone not yet fractured. ('Prophylactic' surgical stabilisation).

In regard to the degree of metastatic spread, greater than two vertebral level contiguous tumour involvement is a relative contraindication, and an anticipated survival of less than six months is a relative contraindication.

In regard to histology type, 'breast is best', 'lung is worst'. Renal cell carcinoma lesions are notoriously and dangerously vascular in the context of planned spinal surgery. Pre-operative imaging and appropriate arterial embolisation may enable safe surgery.

Specific techniques of surgical treatment:

• Direction of surgical approach is generally determined by the site of most compression by cancer tissue.
• Anterior; vertebrectomy, spinal cord decompression, titanium/cement stabilisation.
• Posterior; laminectomy, transpedicular decompression, titanium pedicle screw stabilisation.
• Cement vertebroplasty/kyphoplasty.

Whatever technique is employed, again, the aim is to prevent neurological deficit, restore neurological function and control pain.

Time of Presentation
Sunday 2 May 2004 - 1030-1200