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Metastatic spinal cord compression (MSCC) is a condition associated with high morbidity and mortality. It affects up to 5% of patients with cancer and continues to increase in prevalence with advances in cancer care. In certain cases, surgical management is required for management of pain, neurological decline, and mechanical instability. Various surgical approaches and techniques have been utilized with traditional open and minimally invasive surgery both shown to be effective in improving patients’ function and quality of life. Predictors of survival and functional outcomes following surgery for MSCC include primary tumor type, performance status, and preoperative neurological status. Several prognostic models have been created and validated to assist clinicians in appropriate patient selection. Complications following surgery for MSCC are varied, with wound infection and dehiscence being the most frequently reported. There remains considerable variation in reported outcomes and the decision to pursue surgery should be carefully considered in the context of the individual patient’s prognosis and goals of care.
Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
Steven Tominey
Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
Shabin Joshi
University Hospital of Coventry and Warwickshire NHS Trust, Coventry, UK
Rahim Hussain
University Hospital of Coventry and Warwickshire NHS Trust, Coventry, UK
Dheeraj Batheja
Center for Spinal Studies, Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire, UK
Birender Balain
Center for Spinal Studies, Robert Jones and Agnes Hunt Orthopaedic Hospital, Shropshire, UK
*Address all correspondence to: bhoresh.dhamija1@nhs.net
1. Introduction
Metastatic spinal cord compression (MSCC) infers significant morbidity and mortality in patients with cancer and represents a significant clinical challenge. The incidence of spinal metastatic disease continues to increase due to an aging population and improved overall cancer survival [1]. It affects up to 5% of patients with cancer [2]. Primary tumors that more commonly spread to the spine include breast, lung, kidney, and prostate cancers [3]. The mean survival for patients with MSCC is dependent on a variety of factors including primary pathology, baseline performance status, and the number of extraspinal organs affected [4, 5].
Spinal metastases can cause a range of symptoms, including pain, weakness, paralysis, bowel and bladder dysfunction, and mechanical instability. A multidisciplinary collaborative approach involving radiologists, oncologists, and spinal surgeons has been shown to be effective in improving neurological function and reducing pain in patients with MSCC [6]. In around one-third of cases, patients experience symptoms refractory to medical management require timely surgical intervention. This is influenced by the primary pathological mechanism of MSCC causing damage to the spinal cord through direct tumor compression, resulting edema, venous congestion, and resultant demyelination and secondary vascular injury. These effects can eventually become irreversible if not timely acted on [6]. Surgical decompression has the potential to offer prompt resolution of this compression, while radiotherapy requires days and longer to take effect. Multiple studies including meta-analysis and a randomized-controlled trial have demonstrated a combined approach of surgery with radiotherapy, compared with radiotherapy alone results in better outcomes [6, 7, 8]. In addition, surgical management through instrumented fixation and stabilization of the spinal column can negate the effects following bony infiltration/destruction, causing instability, fracture, or collapse.
In this chapter, we provide a review of surgical techniques, predictors of patient outcomes, and the complications reported in the literature over the past two decades. This information is intended to support and inform clinicians and patients in making the most appropriate treatment decisions for spinal metastases.
2. Patient population, demographics, and surgical selection
The patient population affected by MSCC is diverse. Studies have shown that the incidence of MSCC is higher in males than females, with a male to female ratio ranging from 1.2:1 to 2:1 [6]. The age at diagnosis varies widely, with a mean age of around 60 years. However, MSCC can also occur in younger patients, particularly those with hematologic malignancies. The most common primary tumors leading to MSCC are lung, breast, prostate, and renal cell carcinomas [9]. The incidence also varies depending on the primary tumor, with lung cancer being the most common implicated association [9].
Generally, surgery is opted for in patients with severe or rapidly progressing neurological deficits, as well as those with a single level of compression or lesions causing spinal instability. In patients with a poor performance status or multiple levels of compression, surgery may not be beneficial, and palliative care or radiotherapy alone may be more appropriate [6]. The timing of surgery is also important, with emergent surgery indicated in cases of impending neurological compromise, and urgent or elective surgery recommended for stable patients with less severe symptoms. Patients with spinal metastases are often at increased risk of operative morbidity and mortality compared to the general population [10]. Therefore, informed consent and shared decision making between the patient and clinician are essential.
The choice of surgical technique used is dependent on several variables that comprise both clinician and patient factors. These include the tumor location, size, and degree of spinal cord compression, surgeon experience, and expertise with the options for approach. A significant factor is the patient’s overall health status and expected survival.
Techniques can be categorized by approach (posterior, anterior, or combined) and exposure (open or minimally invasive surgery).
3.1 Posterior decompression
Posterior decompression techniques are the most common surgical approach used to treat MSCC. These techniques involve removal of the posterior elements of the vertebrae, to achieve decompression of the spinal cord and obtain a histological diagnosis. Simple decompression is a useful option for patients who require treatment to preserve neurology, while having significant frailty. However, additional instrumented fusion confers duration of benefit with mechanical stability.
Laminectomy involves removal of the laminae and spinous processes of the involved vertebrae; it provides direct access to the spinal cord and potentially allows for more extensive decompression but may result in spinal instability requiring additional fusion.
Laminoplasty involves making a hinge on one side of the laminae and opening it on the opposite side to create a channel facilitating decompression. Laminoplasty preserves the posterior spinal elements and can help maintain spinal stability, although it may not provide a sufficient channel for decompression in cases of extensive tumor involvement.
Surgical stabilization is achieved by use of rods fixed to pedicle screws commonly in unaffected vertebrae adjacent to the affected area of spine. This can involve use of inter-transverse grafts, metal cages, or bone grafts. Additional fusion in conjunction with decompression is preferred when there is significant anatomical instability, either due to the disease itself or created iatrogenically as a result of the necessary surgical decompression (Figure 1). Fusion allows reconstruction of the spinal column and mechanical stability, and confers longevity of surgical outcome. Surgical fusion is preferred in patients with good prognosis, and who are deemed medically fit for a more demanding surgical procedure.
Figure 1.
65-year-old female with metastatic spinal lung cancer. Pre-operative MRI images with 4 week post-operative x-rays.
3.2 Anterior decompression
Anterior decompression techniques involve removal of the anterior elements of the vertebrae to achieve spinal cord decompression. These techniques are particularly useful for tumors that are located anteriorly or for tumors that cause instability of the vertebral body. Anterior corpectomy, or vertebrectomy, involves removal of the vertebral body and adjacent disc. It is often combined with fusion and instrumentation to stabilize the spine and is often used for patients with large tumors that involve multiple spinal levels (Figure 2). Anterior decompression is usually more invasive and may be associated with a longer recovery time than posterior decompression. A lack of surgeon familiarity with the techniques required and requirements for access surgeon participation can make this a less appealing option for many spinal surgeons. Additionally, depending on the level of the spine involved, anterior approaches can carry a higher risk of complications such as damage to the great vessels, esophagus, and nerves.
Figure 2.
Intra-operative image showing an anterior vertebral body reconstruction with metal cage, cement, ceramic spacer device with allograft. Fixation achieved with rods and screws.
3.3 Traditional open surgery
The techniques described above represent in most cases a direct open approach, these being considered the recognized and more traditional methods to achieve MSCC decompression, with the posterior approach most used. The range of decompression can vary from a simple laminectomy to multi-level corpectomy depending on tumor involvement and desired operative outcome. Open surgery provides direct visualization of the tumor, allowing for improved and greater quantity of tumor resection, spinal reconstruction, and stabilization than minimally invasive techniques. Despite the advances in minimally invasive surgery, open surgery remains a valuable option for selected patients with MSCC, especially those with large, complex, or unstable tumors that require extensive decompression and reconstruction.
3.4 Minimally invasive surgery
Minimally invasive surgery (MIS) has gained popularity for the treatment of MSCC due to its potential benefits over traditional open surgery, including reduced surgical trauma and blood loss, and faster recovery time with shorter hospital stay with good patient selection. Several MIS techniques have been used in the treatment of MSCC, including percutaneous vertebroplasty (Figure 3), percutaneous kyphoplasty, and minimally invasive decompression with or without spinal stabilization (Figure 4). However, MIS techniques may be associated with insufficient decompression of the spinal cord in cases of extensive tumor involvement or significant spinal cord compression. Additionally, the smaller exposure used in MIS may limit the surgeon’s visualization and ability to fully resect tumor (Table 1).
Figure 3.
A. MRI of 75-year-old female with an undifferentiated cancer associated with spinal metastasis and L4 vertebral compression. Fluoro images B and C, creation of a void in the vertebral body using a radiofrequency wand prior to vertebral body augmentation with bone cement. D–F, post-op CT images, axial (D and E), sagittal (F).
Figure 4.
Intra-operative image showing the construct for MIS thoracolumbar fixation in a MSCC patient.
Description
Advantages
Disadvantages
Posterior
Removal, or opening of the posterior elements of the vertebrae. Commonly, laminectomy or laminoplasty.
Considered less technically challenging. Allows good exposure for spinal cord decompression. Less invasive.
Difficult access to anterior spine. Instability if not supplemented with fixation.
Anterior
Removal of the anterior elements of the vertebrae. Commonly, vertebrectomy or corpectomy.
Allows good exposure to anterior spine.
Often more technically challenging. Risk to anterior structures (aorta, esophagus, nerves). More invasive.
Open
Traditional open surgical access to the spine.
Better for extensive disease. Good visibility of affected areas. Allows for stabilization of the spine with direct open views of anatomical landmarks.
More invasive/traumatic.
Minimally invasive
Minimally invasive access to the spine.
Less invasive/traumatic. Potentially faster recovery time. Also allows for spinal stabilization using a percutaneous approach.
Reduced visibility of disease. Surgical skill set—additional training to perform.
Fixation
Additional intraoperative stabilization with a mechanical construct.
Provides added mechanical stability. Allows for prolonged duration of operative outcome.
Risk of construct failure. Risk to anterior structures (aorta, esophagus, nerves). More invasive.
Table 1.
Description of the surgical approaches used in MSCC along with advantages and disadvantages of each.
The prognosis for patients with MSCC can vary widely depending on several factors, including the patient’s overall health, the extent and location of the metastases, and the effectiveness of the treatment approach (Figure 5). The one-year survival of patients with MSCC is poor at around 20%, and surgical treatment is targeted to preserve the remaining quality of life [9]. Prognostic tools and identified predictors of survival may help clinicians make informed decisions about the best treatment strategies for individual patients, avoiding inappropriate referrals and treatment.
Figure 5.
Factors to consider when considering treatment options and outcomes for each MSCC patient.
4.1 Comprehensive scoring systems
The Tokuhashi scoring system is a widely used prognostic tool for predicting the survival time of patients with metastatic spinal tumors [11, 12, 13]. It was developed by Tokuhashi and colleagues in 1990 and has since been modified and validated by other researchers. The scoring system is based on six factors: primary tumor type, number of extraspinal bone metastases, number of spinal metastases, metastases to other organs, neurological deficit, and performance status. The system requires a bone scan to classify number of bony metastases and a CT/MRI to determine extraspinal metastases. The primary tumor type is scored based on its propensity to metastasize to bone, with lung and breast cancers receiving higher scores.
Each factor is assigned a point value ranging from 0 to 4, with a higher score indicating a more favorable prognosis. The total score ranges from 0 to 15. The scoring system is used to classify patients into one of three risk groups: A, B, and C. Group A patients have a poorer prognosis and are generally not considered candidates for aggressive surgical intervention. Group B patients have an intermediate prognosis and may benefit from surgery in some cases. Group C patients have the best prognosis and are generally considered candidates for surgical intervention.
Quraishi et al. conducted a semi-prospective study involving 201 patients to evaluate the usefulness of the Tokuhashi scoring system in predicting prognosis and decision making following surgery for MSCC [14]. The patients were divided into three groups based on their Tokuhashi score. Median survival was 93 days in Group A, 229 days in Group B, and 875 days in Group C. The predictive value of the Tokuhashi score using Cox regression for all groups was 66%. However, there was no significant difference in the neurological status between Group A and Group B or between Group B and Group C. However, Group C was found to have a significantly better neurological outcome than Group A patients.
The Katagiri scoring system was developed in 2005 and is based on the analysis of 1046 patients with spinal metastases [15]. The scoring system assigns points based on similar factors to the Tokuhashi system but utilizes degree of spinal cord compression in place of neurological status. Each factor is given a score ranging from 0 to 2, with a total possible score of 12.
Kobayashi et al. studied the merits of the Katagiri score in predicting survival outcomes in 201 patients with MSCC [16]. The authors concluded that faster rate of growth at the primary site, visceral metastases, and poorer performance status were the key significant independent prognostic factors showing correlation with decreased survival in patients.
4.2 Other scoring systems
The above scoring systems require comprehensive imaging and ideally multidisciplinary team discussion for proper functioning. Unfortunately, MSCC can present as a surgical emergency and require expedited decision-making in a patient’s best interests. Additional scoring systems exist and may be of use in these circumstances.
The Oswestry Spinal Risk Index (OSRI) is a system that was developed by utilizing the two most predictive factors of some recognized studies: performance index (by Karnofsky score) /General Condition and the assumed Primary Tumor Type [17]. This allows for an estimation of prognosis without the need for additional imaging. The OSRI has been validated for use in several studies involving patients with MSCC. It was created as a means of comparison of three recognized scoring systems (Tokuhashi, Tomita, and modified Bauer). Here, a prospective cohort of 199 patients with spinal metastases was treated with either surgery and/or radiotherapy and used to compare these three systems. Each system was found to be equally as good as the others in terms of overall prognostic performance. By utilizing their most predictive items the OSRI was formulated. Namely the OSRI is a simple summation of two elements: primary tumor pathology (PTP) and general condition (GC): OSRI = PTP + (2-GC). OSRI was found to have similar concordance albeit with a larger coefficient of determination than the three scoring systems. This had been further validated in national cohort studies with similar excellent results [18, 19].
The American Society of Anesthesiologists (ASA) classification is a widely used system for assessing the risk of morbidity and mortality in patients undergoing surgery [20]. The ASA classification system is based on a patient’s overall health status and helps guide the anesthetist and surgeon in making decisions about the type of anesthesia and surgical approach to use. The ASA classification system is divided into six categories depending on presence and generally perceived severity of disease.
The ASA classification system has been shown to be a useful tool in predicting surgical outcomes, as well as morbidity and mortality including in MSCC [21]. It is important to note, however, that the classification is based on a patient’s overall health status and does not consider other factors that may impact surgical outcomes, such as the surgery itself or pathology treated. It is also largely based on operator/anesthetist subjective assessment of illness severity and does not control for severity of disease (e.g., uncontrolled vs. well-controlled hypertension) (Table 2) [22].
Summary of prognostic indicators: An overview of the indicators used in discussed prognostic scoring systems and associated studies validating their use.
4.3 Other work examining survival
Out with these validation studies, one study found no significant difference in survival outcomes examining the surgical approaches (either anterior or posterior) in 282 patients who had surgery with overall survival rates of 63, 47, 30, and 16% at 3 months, 6 months, 1 year, and 2 years, respectively [23]. Neurological improvement in function was observed in most patients after surgery, but the complication rate was often high. Itshayek et al. identified a significant relation between duration of ambulation and both preoperative and post-operative ASIA grade, as well as a possible trend toward significance between preoperative ASIA grade and survival [24]. The importance of preoperative motor function was further highlighted by Lo et al. [25]. Patients who had an intact motor status preoperatively demonstrated improved survival compared to those with motor deficit. Survival was improved when surgery was performed within 7 days of the onset of motor deficit as opposed to when performed 7 days after onset.
Several studies have investigated the association between surgical intervention and post-operative motor function and ambulation. Rades et al. reviewed patients who underwent spinal surgery with radiotherapy versus radiotherapy alone [26]. The surgical technique was operator dependent, but was described as simple laminectomy or decompression with fixation. An improved motor score was found in 22 and 16% of patients after surgery with radiotherapy and after radiotherapy alone, respectively. Post-treatment ambulatory rates were 67 and 61%, respectively. Of note, for patients who were non-ambulatory pre-intervention, 29 and 19% regained ambulatory status. Individuals who had MSCC from more unfavorable, radioresistant primary tumors had an improved functional outcome with decompressive surgery, stabilization, and radiotherapy compared to when only laminectomy and radiotherapy were performed.
A retrospective cohort study by Younsi et al. reviewed 101 patients undergoing decompressive laminectomy for spinal metastases [27]. At discharge, 83 patients (82%) stated an overall improvement in their symptoms. It was noted that 51% of all non-ambulatory patients had regained ambulation after surgery. Overall, 61 patients (60%) were ambulatory at discharge compared to 20 patients (20%) prior to surgery. Tateiwa et al. also showed the benefit of a posterior approach for direct decompression with or without subsequent stabilization [28]. In this study, 21 patients (68%) improved by at least one Frankel grade, and 17 patients (55%) became ambulatory post-operatively.
In summary, factors that affect post-operative motor and ambulatory function for patients with MSCC include the type of surgery performed, preoperative neurological function, pre-operative ambulatory status, and post-operative oncological treatment.
5.2 Neurological function
Several studies have examined the effect of surgical intervention on neurological outcomes. Cofano and colleagues conducted a retrospective study to investigate the impact of decompression type on neurological outcomes in patients with spinal metastases [29]. The study included 84 patients, and decompression types were divided into anterior/anterior-lateral (AD), posterior/posterior-lateral (PD/PDL), and circumferential (CD). The results indicated that patients who underwent AD/CD decompression had higher rates of improved neurology and lower rates of deterioration compared to those who underwent PD/PLD decompression. These findings suggest the importance of removing the source of epidural metastatic compression and targeting CD/AD decompression in cases of circumferential or anterior/anterolateral compression for good neurological outcome.
In a retrospective study by Lida et al., the neurological outcomes of radiotherapy and surgery were compared in patients with MSCC presenting with myelopathy [30]. The study found that radiotherapy alone was less effective compared to surgery in these patients. Of patients treated surgically, 30 (88%) showed neurological improvement compared to 1 patient (8%) in the radiotherapy group. In addition, ambulation and survival rates were significantly improved by surgery. Lak et al. also aimed to quantify the results of decompressive surgery on patients’ quality of life in symptomatic metastatic spinal disease [21]. They reviewed 151 patients, where most patients had a posterior approach for their spinal metastases. The authors identified that surgical decompression provides considerable chances of neurological recovery and good functional performance in patients presenting with neurological deficits from MSCC. About 58.3% of patients improved, 31.5% had no improvement, and 10.0% had worsening of functional status. The findings also give support to surgical intervention in situations where life expectancy is less than 6 months, as significant QALY was gained at both 6 months and 1-year time points.
Walter et al. reported on the outcomes of patients with metastatic spinal disease treated with palliative considerations using the techniques of spinal decompression and posterior instrumentation [31]. In this study, 57 individuals underwent a posterolateral approach for decompression and posterior instrumentation, and the authors described excellent clinical outcomes with 13 (22.8%) patients demonstrating neurological improvement and 43 (75.5%) remaining stable at follow-up. In another study, nerve root palsies showed good recovery following decompressive laminectomy, and pain relief was provided in most cases [27]. Pre-operatively impaired neurological function had improved by at least one grade in 61% of patients at discharge. However, sensory deficits and bladder/bowel dysfunction were often persistent.
A subgroup analysis by the global spine tumor study group suggested that post-operative improvement in neurological function may not always be sustained, and long-term follow-up is required [32]. This review of 914 patients undergoing decompressive debulking surgery with fixation demonstrated an initial improvement in post-operative Frankel scores in 25% of patients; however, it was found that approximately 20% of patients had deteriorated between 6 and 12 months post-op.
Complications following surgical treatment of MSCC have been reported in the literature and can be defined broadly as surgical and non-surgical (Table 3).
Summary of reported complications: An overview of surgical and medical complications following operative treatment of MSCC as reported in the literature. Total number reported (percentage of cohort) [study]: N (%) [Author Year].
6.1 Surgical complications
Across the literature, multiple surgical complications have been reported including worsening pain or neurology, wound infection, dural tears/CSF leak, significant operative hemorrhage, and construct failure. Wrong level surgery has also been recognized in this setting. Wound infection or wound dehiscence were the most frequently reported complication in the studies reviewed. In one study, rates of wound infection were found to be significantly higher in open compared with MIS surgery [41].
The loosening rate of implants was also studied with an overall loosening rate of 44% [46]. Luque rods and sublaminar wire system were the most affected systems (70%). Despite this, no cases needed revisional surgery or implant removal at 1 year post-operatively. The authors postulated that the loosening rate of implants was high and would be expected to grow even higher as oncological patients continue to show improved level of survivorship with medical advances, for example, target therapy. However, there remain no definitive studies on how the loosening of implants would impact patients’ quality of life and clinical performance.
6.2 Medical complications
Where documented in these studies, systemic/medical complications tended to concentrate on cardiorespiratory events particularly venous thromboembolism and post-operative pneumonia.
Surgical treatment for MSCC typically involves decompression with or without spinal stabilization with various approaches used to address this condition. Minimally invasive surgery has been shown to be non-inferior to open surgery in improving patients’ motor and neurological function. Multiple validated prognostic scoring systems exist to assist surgical decision making and patient selection. Wound infection and dehiscence are the most common complications of surgical management. However, there is a notable incidence of construct/implant failure, epidural hematoma, incidental durotomy, and venous thromboembolism. Further research is required directly comparing surgical approaches and techniques for MSCC along with the adjunctive treatment measures used. This needs to be tailored to the tumor type, extent, and levels of spinal involvement and consideration given to the goals for patient care.
1.Boussios S, Cooke D, Hayward C, Kanellos FS, Tsiouris AK, Chatziantoniou AA, et al. Metastatic spinal cord compression: Unraveling the diagnostic and therapeutic challenges. Anticancer Research. 2018;38(9):4987-4997
2.Robson P. Metastatic spinal cord compression: A rare but important complication of cancer. Clinical Medicine (London, England). 2014;14(5):542-545
3.Loblaw DA, Laperriere NJ, Mackillop WJ. A population-based study of malignant spinal cord compression in Ontario. Clinical oncology (Royal College of Radiologists (Great Britain)). 2003;15(4):211-217
4.Lei M, Liu Y, Tang C, Yang S, Liu S, Zhou S. Prediction of survival prognosis after surgery in patients with symptomatic metastatic spinal cord compression from non-small cell lung cancer. BMC Cancer. 2015;15(1):853
5.Weber A, Bartscht T, Karstens JH, Schild SE, Rades D. Survival in patients with metastatic spinal cord compression from prostate cancer is associated with the number of extra-spinal organs involved. Anticancer Research. 2013;33(10):4505-4507
6.Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: A randomised trial. Lancet (London, England). 2005;366(9486):643-648
7.Sarri G, Patorno E, Yuan H, Guo JJ, Bennett D, Wen X, et al. Framework for the synthesis of non-randomised studies and randomised controlled trials: A guidance on conducting a systematic review and meta-analysis for healthcare decision making. BMJ Evidence-based Medicine. 2022;27(2):109-119
8.Klimo P, Thompson CJ, Kestle JRW, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro-Oncology. 2005;7(1):64-76
9.Cardiff (UK): National Collaborating Centre for cancer (UK). NICE clinical guidelines 75: Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compression. [Internet]. NICE Clinical Guidelines; 2008. Available from: https://www.ncbi.nlm.nih.gov/books/NBK55011/
10.de Araujo BLC, Theobald D. Letter to the editor: ASA physical status classification in surgical oncology and the importance of improving inter-rater reliability. Journal of Korean Medical Science. 2017;32(7):1211
11.Tokuhashi Y, Kawano H, Ohsaka S, Matsuzaki H, Toriyama S. A scoring system for preoperative evaluation of the prognosis of metastatic spine tumor (a preliminary report). Nihon Seikeigeka Gakkai Zasshi. 1989;63(5):482-489
12.Tokuhashi Y, Matsuzaki H, Toriyama S, Kawano H, Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine. 1990;15(11):1110-1113
13.Tokuhashi Y, Matsuzaki H, Kawano H, Sano S. The indication of operative procedure for a metastatic spine tumor: A scoring system for the preoperative evaluation of the prognosis. Nihon Seikeigeka Gakkai Zasshi. 1994;68(5):379-389
14.Quraishi NA, Manoharan SR, Arealis G, Khurana A, Elsayed S, Edwards KL, et al. Accuracy of the revised Tokuhashi score in predicting survival in patients with metastatic spinal cord compression (MSCC). European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2013;22(Suppl. 1):S21-S26
15.Katagiri H, Okada R, Takagi T, Takahashi M, Murata H, Harada H, et al. New prognostic factors and scoring system for patients with skeletal metastasis. Cancer Medicine. 2014;3(5):1359-1367
16.Kobayashi K, Ando K, Nakashima H, Sato K, Kanemura T, Yoshihara H, et al. Prognostic factors in the new Katagiri scoring system after palliative surgery for spinal metastasis. Spine. 2020;45(13):E813-E819
17.Balain B, Jaiswal A, Trivedi JM, Eisenstein SM, Kuiper JH, Jaffray DC. The Oswestry risk index: An aid in the treatment of metastatic disease of the spine. The Bone & Joint Journal. 2013;95-B(2):210-216
18.Fleming C, Baker JF, O’Neill SC, Rowan FE, Byrne DP, Synnott K. The Oswestry spinal risk index (OSRI): An external validation study. European Spine Journal. 2016;25(1):252-256
19.Kramer A, Coßmann T, Jägersberg M, Preuß A, Meyer B, Ringel F. The Oswestry spinal risk index (OSRI) in assessing prognosis of patients with spinal metastases. Brain Spine. 2022;2:100875
20.Hurwitz EE, Simon M, Vinta SR, Zehm CF, Shabot SM, Minhajuddin A, et al. Adding examples to the ASA-physical status classification improves correct assignment to patients. Anesthesiology. 2017;126(4):614-622
21.Lak AM, Rahimi A, Abunimer AM, Tafel I, Devi S, Premkumar A, et al. Quantifying the impact of surgical decompression on quality of life and identification of factors associated with outcomes in patients with symptomatic metastatic spinal cord compression. Journal of Neurosurgery. Spine. 2020;33(2):237-244
22.Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status - historical perspectives and modern developments. Anaesthesia. 2019;74(3):373-379
23.Jansson KÅ, Bauer HCF. Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases. European Spine Journal. 2006;15(2):196-202
24.Itshayek E, Candanedo C, Fraifeld S, Hasharoni A, Kaplan L, Schroeder JE, et al. Ambulation and survival following surgery in elderly patients with metastatic epidural spinal cord compression. The Spine Journal. 2018;18(7):1211-1221
25.Lo WY, Yang SH. Metastatic spinal cord compression (MSCC) treated with palliative decompression: Surgical timing and survival rate. PLoS One. 2017;12(12):e0190342
26.Rades D, Huttenlocher S, Bajrovic A, Karstens JH, Adamietz IA, Kazic N, et al. Surgery followed by radiotherapy versus radiotherapy alone for metastatic spinal cord compression from unfavorable tumors. International Journal of Radiation Oncology, Biology, Physics. 2011;81(5):e861-e868
27.Younsi A, Riemann L, Scherer M, Unterberg A, Zweckberger K. Impact of decompressive laminectomy on the functional outcome of patients with metastatic spinal cord compression and neurological impairment. Clinical & Experimental Metastasis. 2020;37(2):377-390
28.Tateiwa D, Oshima K, Nakai T, Imura Y, Tanaka T, Outani H, et al. Clinical outcomes and significant factors in the survival rate after decompression surgery for patients who were non-ambulatory due to spinal metastases. Journal of Orthopaedic Science. 2019;24(2):347-352
29.Cofano F, Di Perna G, Alberti A, Baldassarre BM, Ajello M, Marengo N, et al. Neurological outcomes after surgery for spinal metastases in symptomatic patients: Does the type of decompression play a role? A comparison between different strategies in a 10-year experience. Journal of Bone Oncology. 2021;26:100340
30.Iida K, Matsumoto Y, Setsu N, Harimaya K, Kawaguchi K, Hayashida M, et al. The neurological outcome of radiotherapy versus surgery in patients with metastatic spinal cord compression presenting with myelopathy. Archives of Orthopaedic and Trauma Surgery. 2018;138(1):7-12
31.Walter J, Reichart R, Waschke A, Kalff R, Ewald C. Palliative considerations in the surgical treatment of spinal metastases: Evaluation of posterolateral decompression combined with posterior instrumentation. Journal of Cancer Research and Clinical Oncology. 2012;138(2):301-310
32.Depreitere B, Ricciardi F, Arts M, Balabaud L, Bunger C, Buchowski JM, et al. How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database. Acta Neurochirurgica. 2020;162(4):943-950
33.Vanek P, Bradac O, Trebicky F, Saur K, de Lacy P, Benes V. Influence of the preoperative neurological status on survival after the surgical treatment of symptomatic spinal metastases with spinal cord compression. Spine. 2015;40(23):1824-1830
34.Uei H, Tokuhashi Y, Maseda M, Nakahashi M, Sawada H, Nakayama E, et al. Clinical results of multidisciplinary therapy including palliative posterior spinal stabilization surgery and postoperative adjuvant therapy for metastatic spinal tumor. Journal of Orthopaedic Surgery. 2018;13(1):30
35.Li Z, Long H, Guo R, Xu J, Wang X, Cheng X, et al. Surgical treatment indications and outcomes in patients with spinal metastases in the cervicothoracic junction (CTJ). Journal of Orthopaedic Surgery. 2018;13(1):20
36.Pessina F, Navarria P, Carta GA, D’Agostino GR, Clerici E, Nibali MC, et al. Long-term follow-up of patients with metastatic epidural spinal cord compression from solid tumors submitted for surgery followed by radiation therapy. World Neurosurgery. 2018;115:e681-e687
37.Gallazzi E, Cannavò L, Perrucchini GG, Morelli I, Luzzati AD, Zoccali C, et al. Is the posterior-only approach sufficient for treating cervical spine metastases? The evidence from a case series. World Neurosurgery. 2019;122:e783-e789
38.Chen LH, Chen WJ, Niu CC, Shih CH. Anterior reconstructive spinal surgery with Zielke instrumentation for metastatic malignancies of the spine. Archives of Orthopaedic and Trauma Surgery. 2000;120(1-2):27-31
39.Xiaozhou L, Xing Z, Xin S, Chengjun L, Lei Z, Guangxin Z, et al. Efficacy analysis of separation surgery combined with SBRT for spinal metastases—A long-term follow-up study based on patients with spinal metastatic tumor in a single-center. Orthopaedic Surgery. 2020;12(2):404-420
40.Colangeli S, Capanna R, Bandiera S, Ghermandi R, Girolami M, Parchi PD, et al. Is minimally-invasive spinal surgery a reliable treatment option in symptomatic spinal metastasis? European Review for Medical and Pharmacological Sciences. 2020;24(12):6526-6532
41.Zhu X, Lu J, Xu H, Tang Q , Song G, Deng C, et al. A comparative study between minimally invasive spine surgery and traditional open surgery for patients with spinal metastasis. Spine. 2021;46(1):62-68
42.Hohenberger C, Schmidt C, Höhne J, Brawanski A, Zeman F, Schebesch KM. Effect of surgical decompression of spinal metastases in acute treatment – Predictors of neurological outcome. Journal of Clinical Neuroscience. 2018;52:74-79
43.Gao X, Zhang K, Cao S, Hou S, Wang T, Guo W, et al. Surgical treatment of spinal cord compression caused by metastatic small cell lung cancer: Ten years of experience in a single center. Cancer Management and Research. 2020;12:3571-3578
44.Rustagi T, Mashaly H, Ganguly R, Akhter A, Mendel E. Transpedicular Vertebrectomy with circumferential spinal cord decompression and reconstruction for thoracic spine metastasis: A consecutive case series. Spine. 2020;45(14):E820-E828
45.Hamad A, Vachtsevanos L, Cattell A, Ockendon M, Balain B. Minimally invasive spinal surgery for the management of symptomatic spinal metastasis. British Journal of Neurosurgery. 2017;31(5):526-530
46.Chong-chung C, Martin WC t, Eleanor W, Wing-ngai Y, Hung-on C, Ka-kin C. Decompression and instrumentation without fusion for spinal metastases: Loosening rate and consequences. Journal of Orthopaedics, Trauma and Rehabilitation. 2018;25(1):82-86
Written By
Bhoresh Dhamija, Steven Tominey, Shabin Joshi, Rahim Hussain, Dheeraj Batheja and Birender Balain
Submitted: 23 February 2023Reviewed: 23 February 2023Published: 11 April 2023
Open access peer-reviewed chapter
