The article by Drs. Gerszten and Welch is a broad, general, and philosophic review of the surgical options that are currently available for the care of our unfortunate patients with metastatic spinal disease. The authors document the poor outcomes of surgery in this setting until recent advances, which have led to improvements in care over the use of radiation therapy alone.
Shortcomings of Laminectomy
“Decompressive laminectomy” was once inappropriately considered the standard of care for this incurable condition. For many years, this procedure was performed because it was the only operation the average surgical practitioner knew how to perform.
In fact, laminectomy was not decompressive, because most metastases to the spine initially occur in the vertebral body, thereby causing bony destruction and/or neural element compression from the anterior. Laminectomy actually increased instability and pain by removing the remaining intact spinal elements, thus rendering the spine unstable and often worsening neurologic and ambulatory status.[1] Kyphosis developed, as in trauma, due to tumor destruction anteriorly and iatrogenic loss of spinal integrity posteriorly. Ultimately, laminectomy failed as it was not based on sound biomechanical principles.[2]
Foremost Goal: Improving Quality of Life
The primary goal of any therapy for patients with metastatic spinal disease cannot be cure. Treatment must be aimed at improving the quality of remaining life by relieving pain, and, if possible, avoiding neural deficit and allowing useful mobility. Fortunately, the evolution of biomechanical principles learned in the treatment of fractures [3] has spurred the development of more efficient surgical procedures, as well as US Food and Drug Administration (FDA) approval of much-improved metallic instrumentation. This progress, combined with therapeutic advances in drug and radiation therapy, has improved the quality of remaining life for many patients.
In the erect posture, the center of gravity is anterior to the spine. Thus, in this position, the vertebral bodies and discs contribute to spinal stability by their ability to resist compression. The posterior elements and ligaments must resist distraction, while ligaments and facet articular anatomy resist rotational stresses. The object of surgery, then, is to remove any tumor that may compress neural elements, to correct deformity, and to create a stable construct by replacing needed structural elements that have been lost. This, in turn, will relieve pain and allow mobilization in an erect posture.
In summary, modern techniques and instrumentation—when applied using sound biomechanical principles—have substantially improved quality of life for most of the time remaining to patients with metastatic spinal disease.
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