The article entitled The Current Surgical Management of
Metastatic Spinal Disease, by Drs. Peter C. Gerszten and
William C. Welch, is a timely, comprehensive review of the current
state of the art in the diagnosis and surgical management of spinal
metastatic disease. The authors begin by describing the clinical
problem and noting the high prevalence of spinal column metastases
and cord compression associated with breast, bronchogenic, prostatic,
and other types of primary malignancies. They also note that this
will likely become an even more common clinical challenge as
diagnostic and oncologic treatment modalities continue to improve.
The authors proceed to describe an accepted clinical approach to the
evaluation and diagnosis of these patients. The clinical presentation
is reviewed, and diagnostic imaging modalities are discussed.
Although plain films are an excellent screening tool, the authors
emphasize the utility of magnetic resonance imaging (MRI) in the
evaluation of metastatic disease. The advantages of MRI include
increased sensitivity (eg, for noncontiguous lesions, which often are
missed) and the ability to evaluate both cord impingement and
soft-tissue extension. Thus, MRI has become the imaging modality of
choice in the evaluation of spinal metastatic disease. The roles of
computed tomography (CT) and nuclear studies are also discussed.
The authors then review the treatment options for spinal metastatic
disease and the role of surgery in treatment. Indications for surgery
can include a need for biopsy tissue, radioresistant tumors, spinal
instability due to destruction of the bony elements, canal
compromise, poor response to radiotherapy, tumor recurrence, and pain
In discussing surgical indications, the authors make an important
distinction. Radiotherapy was previously the universally accepted
primary treatment for spinal metastatic disease, and this was due, in
part, to the somewhat disappointing results of surgical treatment.
However, many older series were based on the results of laminectomy
to decompress the neural elements.
Laminectomy is a posterior procedure that was performed in the hopes
of obtaining an indirect decompression of the neural elements.
Because neural element compression with metastatic disease occurs
most often ventrally (ie, tumors are most commonly found in the
vertebral body), prior surgical treatment often did not produce an
Modern surgical techniques have allowed direct anterior
decompression. Spinal stability can then be effectively restored with
bone graft or methylmethacrylate, and appropriate spinal
instrumentation (cages, plates, and rods) can be applied both
anteriorly and posteriorly. In most cases, surgical decompression and
stabilization of the involved spinal segment should precede
radiotherapy to avoid possible wound healing complications.
These modern techniques have led to a significant improvement in
results compared to the historical results of laminectomy alone.
Thus, surgery has become the treatment of choice in selected cases,
and early surgical consultation can, at times, prevent unnecessary
prolonged pain and neurologic deterioration. The authors emphasize
the need for a multidisciplinary approach to these patients,
including an in-depth discussion with the patient, his or her family,
and other caregivers. The decision to intervene surgically must
always be made in light of the patients prognosis and expected
Surgical options in the anatomic regions of the spine are then
explored. In the cervical spine, anterior corpectomy and
reconstruction with autograft, allograft, or methylmethacrylate can
be used when the tumor mass is primarily in the vertebral body and
compression is occurring anteriorly. However, the anterior approach
provides limited ability to approach posterolateral tumor masses. In
these cases, a posterior laminectomy approach is best, but as the
authors point out, there is the danger of possible posterior cord
displacement if the cord is compressed anteriorly.
Thoracic tumors are then discussed, beginning with the problems
associated with traditional laminectomy techniques, including
progressive kyphosis and continued neurologic deterioration. Anterior
approachesor in selected patients, posterolateral approaches
(for example, costotransversectomy)are generally preferred.
Minimally invasive tools such as thoracoscopy are exciting adjunctive
options, which hold much promise for the future. Decompression and
fusion techniques in the lumbar spine can be performed anteriorly,
posteriorly, or with a combination of both approaches.
Finally, prognosis and complications are reviewed. The authors point
out the high rate of neurologic recovery, with over 65% of previously
paraplegic patients regaining functional ambulation. Neurologic
outcome tends to be better in patients with incomplete deficits and
those with a more gradual onset of symptoms.
Overall, the authors give an excellent, comprehensive review of the
surgical treatment of metastatic spine disease, which is accessible
and relevant to surgeon and nonsurgeon alike. The role of surgery
continues to evolve but clearly is increasingly important. Timely
reviews of the literature such as this one can help to better define
that role and ensure that surgical modalities will be applied most
appropriately to patients who will benefit most from them.
Christopher Michelsen, md