Spine stability, direct decompression play key roles in metastases management

The decision to perform surgery for spinal metastases and the type of treatment depends on a number of factors, including the patient’s cancer diagnosis and whether the spinal cord is compressed by a tumor, according to a presenter.

Identifying what type of cancer a patient is diagnosed with and if the tumor is resistant to traditional chemotherapy and radiation are the first steps in determining if surgery is necessary or will even be effective, Ziya L. Gokaslan, MD, FACS, FAANS, said during a consensus session on the management of metastatic spine tumors at the Congress of Neurosurgeons Annual Meeting.

“I would make the argument that there are two clear cut indications when you are dealing with patients with a metastatic disease. If you have a solid tumor, the tumor is going to be resistant, and if you have a high degree of spinal cord compression, that is when you really have to go to surgery to decompress the spinal column and stabilize,” Gokaslan said. “Of course, when the patient has gross instability of the spinal column, nothing else will help except for stabilization of the spine and achieving stability of the spinal column through surgery.”

The diagnosis is key

Determining a patient’s cancer diagnosis is the first thing a surgeon must do to establish a course of action. Basically, this will tell a surgeon “how long a patient will be around” and if the particular tumor will respond to radiation therapy treatment.

For instance, patients who present with lymphoma will most likely respond to radiation therapy and will survive their disease, according to Gokaslan. If a tumor is radiosensitive, it is extremely beneficial for a patient to undergo a combination of surgery and radiation therapy at the same time. However, if the tumor is touching the spine, the tumor may not receive a full dose of radiation and could later recur, he said.

“The surgery is a highly effective tool and can control the tumor, but you have to administer enough radiation to achieve that objective. If the tumor is making contact with the spinal cord, you will end up underdoing the radiation therapy and that is exactly when the tumor comes back and bites you and you have to take the patient back to the OR at a later time,” Gokaslan said.

Stability and decompression

Spinal cord decompression is a critical first step when a patient presents with a tumor pressing against the spinal cord, according to Gokaslan, who said this approach helps create enough room for the radiation to affect the entire tumor. Afterwards, the spine should then be surgically stabilized, if necessary, to address instability.

“If you look at this with retrospective experience, we have learned several things. Number one, laminectomy is not the operation you should be doing for metastatic disease. The stabilization of the spinal column is an integral part of your surgical procedure, and the third, the more direct the decompression is, the more effective it is to enhance the neurological outcomes,” Gokaslan said. – by Robert Linnehan

Reference:

Gokaslan ZL. Surgery for spinal metastases. Presented at: Congress of Neurological Surgeons Annual Meeting; Oct. 18-22, 2014; Boston.

For more information:

Ziya L. Gokaslan, MD, FACS, FAANS, can be reached at Johns Hopkins University, Department of Neurological Surgery, Meyer 7-109, 600 N. Wolfe St., Baltimore, MD 21287; email: zgokas11@jhmi.edu.

Disclosure: Gokaslan reports he received grants from DePuy Spine, AO Spine North America, Medtronic, NREF, Integra LifeSciences and K2M and has ownership interest in Spinal Kinetics and US Spine.