The spinal column is the
most frequent site of bony metastasis.[1,2] Metastatic spinal disease
is a significant problem for a large number of cancer patients.
Between 5% and 10% of all cancer patients develop spinal metastases
during the course of their disease. Approximately 40% of persons
dying of cancer will have autopsy evidence of spinal metastases,[3-5]
and 10% of these will develop spinal cord compression with subsequent
neurologic deficits.[6,7] The annual incidence of spinal cord
compression secondary to spinal metastases is estimated to be 20,000.
A recent autopsy study found metastatic involvement of the spine in
90% of patients with prostate carcinoma, 75% with breast carcinoma,
55% with melanoma, 45% with lung carcinoma, and 30% with renal
carcinoma.[9-11] Clinically significant (symptomatic) spinal cord
compression is observed in a higher percentage of patients with
certain carcinomas22% of patients with breast cancer, 15% with
lung cancer, and 10% with prostate carcinomas.
In almost 10% of cases of newly diagnosed spinal metastases, the
patient is not known to have cancer, and spinal cord compression is
the initial symptom of the malignancy. Half of these patients are
subsequently found to have lung cancer. The time between the original
diagnosis of cancer and the occurrence of spinal metastases varies widely.
There is a slight preponderance of metastatic spinal tumors in males
(60%) compared to females. This gender difference may reflect the
incidence of primary breast vs prostate tumors and the proclivity of
prostate cancer to metastasize to bone in published series. Spinal
metastases may occur in all age groups, but the period of highest
prevalence coincides with the relatively high cancer risk period of
40 to 65 years of age.
Metastatic spinal lesions involve the vertebral column (85% of
cases), paravertebral spaces (10% to 15%), or the epidural space (£
5%).[15,16] The vertebral body is usually the portion of the
vertebrae that is involved. Spinal metastases can also be noted
intradurally and within the spinal cord itself (intramedullary).[16,17]
Metastatic spread to bone may be related to osteotropism of the
malignant cells, direct spread, and/or the highly vascular supply of
bone marrow. Batson and others have demonstrated that the
vertebral venous plexus draining the thoracic, abdominal, and pelvic
viscera (Batsons plexus) is a route of metastases to the spine.
Most metastatic spinal lesions (70%) are found at the thoracic level,
20% in the lumbar region, and 10% in the cervical region. The
increased frequency of spinal metastases in the thoracic vertebrae
may be related to the greater number of thoracic vertebrae, compared
to vertebrae in the lumbar and cervical regions. Metastatic lesions
occur at multiple noncontiguous levels in 10% to 38% of cases.[15,19,20]
The incidence of metastatic spinal disease is likely to increase in
the future, due to several factors. Improvement in diagnostic
capabilities, especially the widespread availability and sensitivity
of magnetic resonance imaging (MRI), may increase the number of
metastatic lesions detected and patients evaluated. Progress in the
treatment of many cancers using multimodality regimens will
undoubtedly lead to a prolongation of patient survival, with the
resultant development of more spinal metastases. Finally, earlier
detection of malignant primary lesions as part of screening programs
and improved diagnostic tests will result in progressive increases in
the number of spinal metastases detected.
History and Physical Examination
Pain is the most common presenting symptom of patients with
metastatic spinal tumors.[15,21,22] The etiology of pain may be tumor
spread, spinal instability, nerve root or dural irritation, or direct
cauda equina or spinal cord compression. Pain may also be related to
bony destruction or invasion of paraspinous tissues, such as muscles
Patients with spinal metastases frequently describe the pain as a
dull, constant ache and often complain that the pain awakens them
from sleep. Occasionally, the pain will occur in a radicular
distribution, which may be caused by nerve root irritation.
Muscular weakness is frequently manifested by the progressive
inability to ambulate or the loss of limb function. The patients
ability to walk at the time of presentation is a sensitive predictor
of the ability to walk after surgery.
Difficulty with ambulation is often slowly progressive, and the
patient compensates for the difficulty by using a cane or other
assistive device, as well as reducing activities. Alternatively, an
ambulatory difficulty may occur rapidly and present as a neurologic
emergency. Occasionally, patients will relate difficulty in walking
to generalized weakness. Prognostically, the ability to walk, absence
of myelopathy, and £ 75% myelographic
block are all associated with preservation of the ability of a
patient to ambulate after treatment.
Sensory dysfunction, while frequently noted on physical examination,
is a rare presenting complaint, although paresthesias are often noted
by patients who are questioned carefully. Similarly, patients tend to
underestimate the loss of bladder and bowel control, or will relate
these difficulties to other medical problems, such as prostatic hypertrophy.
A complete medical history, including a treatment history, must be
obtained. Prior treatment may have included radiotherapy and
chemotherapy. The radiotherapy fields and dosage must be well
defined, as these factors may influence any decision to offer the
patient further radiation therapy for either local disease or for
treatment of metastatic spinal lesions. High skin dosages may
also affect decisions regarding surgical approach and timing.
Significant cardiac dysfunction may influence the decision to offer
surgery, the surgical procedure, or the use of preoperative surgical
adjuncts, such as tumor embolization. Pulmonary dysfunction also
increases perioperative morbidity and mortality. The presence of
disease in these major organ systems may represent contraindications
to surgery that would be expected to result in excessive blood loss
or further lung dysfunction (eg, transthoracic procedures).
An understanding of the rate of disease progression, response of the
tumor to prior treatments, and degree of tumor control is essential.
The patients desires and the degree of importance that the
patient places on the preservation of ambulatory function, bladder
and bowel control, and other neurologic functions should also be
considered. The patient and family must have realistic expectations
of the risks and potential benefits of the surgery so that they can
make an informed decision.
A detailed physical and neurologic examination is necessary to
determine the patients eligibility for surgery and to establish
a neurologic baseline against which responses to therapeutic
interventions can be compared. The spine is examined for tenderness
to palpation and paraspinous muscular spasm. A localized kyphotic
deformity is an important positive finding. Patient resistance to
active and passive movements is recorded. The neurologic examination
includes an evaluation of mental status and long tract and cerebellar
function to help determine whether intracranial lesions are present
Plain spinal radiography is relatively sensitive and
specific for metastatic disease. Plain radiographs may be obtained to
provide baseline information and intraoperative comparison and
can define spinal alignment, the presence of a fracture, and gross
areas of bone involvement by tumor. The majority of spinal
metastatic lesions are osteolytic, with only 5% being
osteoblastic; however, 30% to 60% of the bone must be destroyed
for a lytic lesion to be appreciated on plain radiographs.[9,28]
In one series comprising patients with clinical metastatic spinal
compression, 60% of patients had normal plain radiographs.[27,29]
Although radiographs are frequently employed in initial screening, a
negative plain radiograph does not necessarily indicate the absence
Flexion and extension studies may be required for lesions of the
cervical and lumbar spine where extensive bony destruction may be
associated with spinal stability. If instability is not felt to be
present, a nonoperative approach may be sufficient. However, movement
on flexion and extension studies may alone determine the need for
surgical spinal stabilization to prevent future neurologic injury.[30-32]
Magnetic resonance imaging is now the method of choice
to detect the presence and extent of spinal metastasis.[16,21,33-35]
It provides excellent visualization of soft-tissue involvement, bone
marrow replacement, ligamentous involvement, spinal cord edema, and
degree of canal compromise and cord compression. Magnetic
resonance imaging has the further advantage of being able to image
the entire spine; this may be especially helpful because multiple
lesions that are not suspected clinically are found in up to 30% of cases.
Due to the high sensitivity of MRI for the detection of early changes
in bone marrow, several reports have documented MRI detection of
spinal metastases that were not appreciated on plain radiographs,
radioisotope studies, or computed tomographic (CT) scans.[37-41]
However, false-positive MRI studies have been reported in which
signal characteristics suggestive of metastases were subsequently
found to be nonpathologic reactive tissue within vertebrae.[41,42]
Computed tomography remains an important imaging tool
in the evaluation of patients with spinal metastases. Axial CT
images provide excellent bony detail of the spinal canal and
vertebral bodies and can help determine whether canal compromise is
due to bone or soft tissue.[43,44] The integrity of vertebral
elements that may be required for internal fixation, such as pedicles
and lamina, can also be determined. Computed tomographic scanning
may be reserved for patients who cannot undergo MRI scanning for
reasons such as the presence of cardiac defibrillators.
Myelography, especially when combined with
postmyelographic CT studies, can provide an excellent analysis of
both the spinal cord and the vertebral column. In addition,
cerebrospinal fluid can be obtained for analysis during the
procedure. A possible risk associated with myelography is the
development of neurologic deficits in cases of high-grade block when
the lumbar puncture is performed below the level of
disease.[19,46-47] This complication may be avoided by gaining access
to the subarachnoid space via a high cervical cisternal puncture.
Radioisotope studies, most commonly using
technetium-99m pyrophosphate and diphosphonate compounds, are an
efficient means of detecting bone metastases.[26,48] These studies
identify areas of increased bone deposition, such as blastic-type
metastases but are less useful in detecting purely lytic-type lesions
unless sufficient bone repair is taking place.
Radioisotope studies are specific in only 60% to 80% of patients with
metastatic bone disease. Both CT and MRI imaging have been shown
to be more sensitive for the detection of cervical metastases than
1. Ratanatharathorn V, Powers WE: Epidural spinal cord compression
for metastatic tumor: Diagnosis and guidelines for management. Cancer
Treat Rev 18:55-71, 1991.
2. Aaron AD: The management of cancer metastatic to bone. JAMA
3. Barron KD, Hirano A, Araki S, et al: Experiences with metastatic
neoplasms involving the spinal cord. Neurology 9:91-106, 1959.
4. Abrams HL, Spiro R, Goldstein N: Metastases in carcinoma: Analysis
of 1,000 autopsied cases. Cancer 3:74-85, 1950.
5. Harrington KD: The use of methylmethacrylate for vertebral-body
replacement and anterior stabilization of pathological
fracture-dislocations of the spine due to metastatic malignant
disease. J Bone Joint Surg Am 63:36-46, 1981.
6. Schaberg J, Gainor BJ: A profile of metastatic carcinoma of the
spine. Spine 10:19-20, 1985.
7. Sundaresan N, Digiacinto GV, Hughes JEO, et al: Treatment of
neoplastic spinal cord compression: Results of a prospective study.
Neurosurgery 29:645-650, 1991.
8. Delaney TF, Oldfield EH: Spinal cord compression, in DeVita JC,
Hellman S, Rosenberg SA (eds): Cancer: Principles & Practice of
Oncology, pp 2118-2127. Philadelphia, JB Lippincott, 1993.
9. Wong DA, Fornasier VL, MacNab I: Spinal metastases: The obvious,
the occult, and the impostors. Spine 15:1-4, 1990.
10. Sundaresan N, Krol G, Digiacinto GV, et al: Metastatic tumors of
the spine, in Sundaresan N, Schmidek HH, Schiller AL, et al (eds):
Tumors of the Spine, pp 279-304. Philadelphia, WB Saunders, 1990.
11. Lenz M, Freid JR: Metastases to the skeleton, brain, and spinal
cord from cancer of the breast and the effect of radiotherapy. Ann
Surg 39:278-293, 1931.
12. Stark RJ, Henson RA, Evans SJ: Spinal metastases: A retrospective
survey from a general hospital. Brain 105:189-213, 1982.
13. Constans JP, Divitiis ED, Donzelli R, et al: Spinal metastases
with neurological manifestations: Review of 600 cases. J Neurosurg
14. Black P, Nair S, Giannakopoulos G: Spinal epidural tumors, in
Wilkins RH, Rengachary SS (eds): Neurosurgery, pp 1791-1804. New
York, McGraw-Hill, 1996.
15. Gilbert RW, Kim J-H, Posner JB: Epidural spinal cord compression
from metastatic tumor: Diagnosis and treatment. Ann Neurol 3:40-51, 1978.
16. Byrne TN: Spinal cord compression from epidural metastases. N
Engl J Med 327:614-619, 1992.
17. Posner JB: Management of central nervous system metastases. Semin
Oncol 4:81-91, 1977.
18. Batson OV: The function of vertebral veins and their role in the
spread of metastases. Ann Surg 112:138-149, 1940.
19. Ruff RL, Lanska DJ: Epidural metastases in prospectively
evaluated veterans with cancer and back pain. Cancer 63:2234-2241, 1989.
20. ORourke T, George CB, Redmond J, et al: Spinal computed
tomography and computed tomographic metrizamide myelography in the
early diagnosis of metastatic disease. J Clin Oncol 4:576-583, 1986.
21. Grant R, Papadopoulos SM, Sandler HM, et al: Metastatic epidural
cord compression: Current concepts and treatment. J Neurooncol
22. Elliot K, Foley KM: Neurologic pain syndromes in patients with
cancer. Neurol Clin 7:333-360, 1989.
23. Villavicencio H: Quality of life of patients with advanced
metastatic prostatic carcinoma. Eur Urol 24(S):118-121, 1993.
24. Sorensen PS, Borgesen SE, Rohde K, et al: Metastatic epidural
spinal cord compression: Results of treatment and survival. Cancer
25. Faul CM, Flickinger JC: The use of radiation in the management of
spinal metastases. J Neurooncol 23:149-161, 1995.
26. Porteno RK, Galer BS, Salamon O, et al: Identification of
epidural neoplasm: Radiography and bone scintigraphy in the
symptomatic and asymptomatic spine. Cancer 64:2207-2213, 1989.
27. Nazzaro JM: Metastatic spinal lesions, in Benzel EC (ed): Spine
Surgery: Techniques, Complication Avoidance, and Management, pp
679-695. New York, Churchill Livingstone, 1999.
28. Boland PJ, Lane JM, Sundaresan N: Metastatic disease of the
spine. Clin Orthop 169:95-102, 1982.
29. Greenberg HS, Kim J-H, Posner JB: Epidural spinal cord
compression from metastatic tumor: Results with a new treatment
protocol. Ann Neurol 8:361-366, 1980.
30. White AA, Punjabi MM: Clinical Biomechanics of the Spine, pp
277-378. Philadelphia, JB Lippincott, 1990.
31. Denis F: The three column spine and its significance in the
classification of acute thoracolumbar spine injuries. Spine 8:817-831,
32. Pope MH, Frymoyer J, Krag MH: Diagnosing instability. Clin Orthop
33. Harnsberger HR, Dillon WP: The radiologic role in diagnosis,
staging, and follow-up of neoplasia of the brain, spine, and head and
neck. Semin Ultrasound CT MR 10:431-452, 1989.
34. Jones JM, Schwartz RB, Mantello MT, et al: Fast spin-echo MR in
the detection of vertebral metastases: Comparison of three sequences.
Am J Neuroradiol 15:401-407, 1994.
35. Mehta RC, Marks MP, Hinks S, et al: MR evaluation of vertebral
metastases: T1-weighted short-inversion-time inversion recovery, fast
spin-echo, and inversion-recovery fast spin-echo sequences. Am J
Neuroradiol 16:281-288, 1995.
36. Smoker WRK, Godersky JC, Knutzon RK, et al: The role of MR
imaging in evaluating metastatic spinal disease. Am J Roetgenol
37. Sarpel S, Sarpel G, Yu E, et al: Early diagnosis of spinal
epidural metastases by magnetic resonance imaging. Cancer
38. Avrahami E, Tadmor R, Dally O, et al: Early MR demonstration of
spinal metastases in patients with normal radiographs and CT and
radionuclide bone scans. J Comput Assist Tomogr 13:598-602, 1989.
39. Chadwick DJ, Gillatt DA, Mukerjee A, et al: Magnetic resonance
imaging of spinal metastases. J R Soc Med 84:196-200, 1991.
40. Gosfield E III, Alvi A, Kneeland B: Comparison of radionuclide
bone scans and magnetic resonance imaging in detecting spinal
metastases. J Nucl Med 34:2191-2198, 1993.
41. Petren-Mallmin M: Clinical and experimental imaging of breast
cancer metastases in the spine. Acta Radiol 391(suppl):1-23, 1994.
42. Tan SB, Kozak JA, Mawad ME: The limitations of magnetic resonance
imaging in the diagnosis of pathologic vertebral fractures. Spine
43. McAfee PC, Bohlman HH, Hans JS, et al: Comparison of nuclear
magnetic resonance imaging and computed tomography in the diagnosis
of upper cervical spinal cord compression. Spine 11:295-304, 1986.
44. Vandermark RM, Shpall EJ, Affronti ML: Bone metastases from
breast cancer: Value of CT bone windows. J Comput Assist Tomogr
45. Welch WC, Jacobs GB: Surgery for metastatic spinal disease. J
Neurooncol 23:163-170, 1995.
46. Bruckman JE, Bloomer WD: Management of spinal cord compression.
Semin Oncol 5:135-140, 1978.
47. Hollis PH, Malis LI, Zappulla RA: Neurological deterioration
after lumbar puncture below complete spinal subarachnoid block. J
Neurosurg 64:253-256, 1986.
48. Hach A, Hahn K: The value of nuclear medicine for the diagnosis
of spine diseases. Neurosurg Rev 16:125-133, 1993.
49. Fuller BG, Heiss J, Oldfield EH: Spinal cord compression, in
DeVita VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and
Practice of Oncology, pp 2476-2486. Philadelphia, Lippincott-Raven, 1997.
50. Kim RY, Smith JW, Spencer SA, et al: Malignant epidural spinal
cord compression associated with a paravertebral mass: Its
radiotherapeutic outcome on radiosensitivity. Int J Radiat Oncol Biol
Phys 27:1079-1083, 1993.
51. Shapiro WR, Posner JB: Medical vs surgical treatment of
metastatic spinal cord tumors, in Thompson RA, Green JR (eds):
Controversies in Neurology, pp 57-65. New York, Raven Press, 1983.
52. Leviov M, Dale J, Stein M, et al: The management of metastatic
spinal cord compression: A radiotherapeutic success ceiling. Int J
Radiat Oncol Biol Phys 27:231-234, 1993.
53. Maranzano E, Latini P: Effectiveness of radiation therapy without
surgery in metastatic spinal cord compression: Final results from a
prospective trial. Int J Radiat Oncol Biol Phys 32:959-967, 1995.
54. Turner S, Marosszeky B, Timms I, et al: Malignant spinal cord
compression: A prospective evaluation. Int J Radiat Oncol Biol Phys
55. Ampil F: Epidural compression from metastatic tumor with
resultant paralysis. J Neurooncol 7:129-136, 1989.
56. Barcena AL, Lobato R: Spinal metastatic disease: Analysis of
factors determining functional outcome and the choice of treatment.
Neurosurgery 15:820-827, 1984.
57. Harrington KD: Metastatic disease of the spine. J Bone Joint Surg
Am 68:1110-1115, 1986.
58. Loblaw DA, Laperriere NJ: Emergency treatment of malignant
extradural spinal cord compression: An evidence-based guideline. J
Clin Oncol 16:1613-1624, 1998.
59. Black P: Spinal metastasis: Current status and recommended
guidelines for management. Neurosurgery 5:726-746, 1979.
60. Young RF, Post EM, King GA: Treatment of spinal epidural
metastases: Randomized prospective comparison of laminectomy and
radiotherapy. J Neurosurg 53:741-748, 1980.
61. Findlay GFG: Adverse effects of the management of malignant
spinal cord compression. J Neurol Neurosurg Psychiatry 47:761-768, 1984.
62. Siegal T, Siegal T: Current considerations in the management of
neoplastic spinal cord compression. Spine 14:223-228, 1989.
63. Miles J, Banks AJ, Noori Z: Stabilization of the spine affected
by malignancy. J Neurol Neurosurg Psychiatry 47:897-904, 1984.
64. Scarantino CW: Metastatic spinal cord compression: Criteria for
effective treatment. Int J Radiat Oncol Biol Phys 32:1259-1260, 1995.
65. Arbit E, Galicich JH: Vertebral body reconstruction with a
modified Harrington rod distraction system for stabilization of the
spine affected with metastatic disease. J Neurosurg 83:617-620, 1995.
66. Cooper PR, Errico TJ, Martin R, et al: A systematic approach to
spinal reconstruction after decompression for neoplastic disease of
the thoracic and lumbar spine. Neurosurgery 32:1-8, 1993.
67. Siegal T, Siegal T: The management of malignant epidural tumors
compressing the spinal cord, in Schmidek HH, Sweet WH (eds):
Operative Neurosurgical Techniques. Indications, Methods, and
Results, pp 1543-1544. Orlando, Florida, Grune & Stratton, 1988.
68. Posner JB: Back pain and epidural spinal cord compression. Med
Clin North Am 71:185-205, 1987.
69. Sundaresan N, Digiacinto GV, Hughes JEO: Surgical approaches to
primary and metastatic tumors of the spine, in Schmidek HH, Sweet WH
(eds): Operative Neurosurgical Techniques: Indications, Methods, and
Results, pp 1526-1527. Orlando, Florida, Grune & Stratton, 1988.
70. Shimizu K, Shikata J, Iida H, et al: Posterior decompression and
stabilization for multiple metastatic tumors of the spine. Spine
71. Wozney JM, Rosen V, Celeste AJ, et al: Novel regulators of bone
formation: Molecular clones and activities. Science 242:1528-1534, 1988.
72. Boden SD, Sumner DR: Biologic factors affecting spinal fusions
and bone regeneration. Spine 20:102S-112S, 1995.
73. Lesoin F, Kabbaj K, Debout J, et al: The use of Harrington rods
in metastatic tumours with spinal cord compression. Acta Neurochir
(Wien) 65:175-181, 1982.
74. Sundaresan N, Galicich JH, Lane JM, et al: Treatment of
neoplastic epidural cord compression by vertebral body resection and
stabilization. J Neurosurg 63:676-684, 1985.
75. Jackson RJ, Gokaslan ZL: Occipitocervicothoracic fixation for
spinal instability in patients with neoplastic processes. J Neurosurg
76. Caspar W, Pitzen T, Papavero L, et al: Anterior cervical plating
for the treatment of neoplasms in the cervical vertebrae. J Neurosurg
77. Sorensen S, Helweg-Larsen S, Mouridsen H, et al: Effect of
high-dose dexamethasone in carcinomatous metastatic spinal cord
compression treated with radiotherapy: A randomised trial. Eur J
Cancer 1:22-27, 1994.
78. Ushio Y, Posner R, Kim J-H, et al: Treatment of experimental
spinal cord compression caused by extradural neoplasms. J Neurosurg
79. Cantu RC: Corticosteroids for spinal metastases. Lancet 2:912, 1968.
80. Coleman RE: Glucocorticoids in cancer therapy. Biotherapy
81. Ikeda H, Ushio Y, Hayakawa T, et al: Edema and circulatory
disturbance in the spinal cord by epidural neoplasms in rabbits. J
Neurosurg 52:203-209, 1980.
82. Choi IS, Bernstein A: Spinal angiography and embolization of
tumors, in Sundaresan N, Scmidek HH, Schiller AL, et al (eds): Tumors
of the Spine. Diagnosis and Clinical Management, pp 52-62.
Philadelphia, WB Saunders, 1990.
83. Olerud C, Jonsson H, Jr, Lofberg AM, et al: Embolization of
spinal metastases reduces preoperative blood loss. Acta Orthop Scand
84. Broaddus WC, Grady MS, Delashaw JB, et al: Preoperative
superselective arteriolar embolization: A new approach to enhance
resectability of spinal tumors. Neurosurgery 27:755-759, 1990.
85. Sundaresan N, Choi IS, Hughes JEO, et al: Treatment of spinal
metastases from kidney cancer by presurgical embolization and
resection. J Neurosurg 73:548-554, 1990.
86. Chiras J, Cognard C, Rose M, et al: Percutaneous injection of an
alcoholic embolizing emulsion as an alternative preoperative
embolization for spine tumor. Am J Neuroradiol 14:1113-1117, 1993.
87. Stechison MT: Neurophysiologic monitoring in spinal surgery, in
Menezes AH, Sonntag VKH (eds): Principles of Spinal Surgery, pp
315-333. New York, McGraw-Hill, 1996.
88. Hosono N, Yonenobu K, Fuji T, et al: Vertebral body replacement
with a ceramic prosthesis for metastatic spinal tumors. Spine
89. Pollack IF, Welch WC, Jacobs GB, et al: Frameless stereotactic
guidance: An intraoperative adjunct in the transoral approach for
ventral cervicomedullary junction compression. Spine 20:216-220, 1995.
90. Sen CN, Sekhar LN: An extreme lateral approach to intradural
lesions of the cervical spine and foramen magnum. Neurosurgery
91. Henson RA, Urich H: Involvement of the vertebral column and
spinal cord, in Henson RA, Urich H (eds): Cancer and the Nervous
System, pp 120-154. St. Louis, Blackwell Scientific, 1982.
92. Cole SC, Godsick PA, Norman A: The value of laminectomy in benign
and malignant extradural spinal cord compression. Bull Hosp Jt Dis
93. Hall AJ, MacKay NNS: The results of laminectomy for compression
of the cord or cauda equina by extradural malignant tumors. J Bone
Joint Surg Br 55:497-505, 1973.
94. Bennett GJ: Surgical approaches to the thoracic spine. Clin
Neurosurg 38:234-251, 1992.
95. Lesoin F, Rousseaux M, Lozes G, et al: Posterolateral approach to
tumors of the dorsolumbar spine. Acta Neurochir (Wein) 81:40-44, 1986.
96. Weller SJ, Rossitch E: Unilateral posterolateral decompression
without stabilization for neurological palliation of symptomatic
spinal metastasis in debilitated patients. J Neurosurg 82:739-744, 1995.
97. Dickman CA, Rosenthal D, Karahalio DG, et al: Thoracic
verebrectomy and reconstruction using a microsurgical thoracoscopic
approach. Neurosurgery 38:279-293, 1996.
98. Rosenthal D, Marquardt G, Lorenz R, et al: Anterior decompression
and stabilization using a microsurgical endoscopic technique for
metastatic tumors of the thoracic spine. J Neurosurg 84:565-572, 1996.
99. Sundaresan N, Shah J, Foley KM, et al: An anterior surgical
approach to the upper thoracic vertebrae. J Neurosurg 61:686-690, 1984.
100. Dombrowski ET, Rezaian SM: Rezaian fixator in the anterior
stabilization of the unstable spine. Orthop Rev 15:30-65, 1986.
101. Overby MC, Rothman AS: Anterolateral decompression for
metastatic epidural spinal cord tumors. J Neurosurg 62:344-348, 1985.
102. Steffee AD: The variable screw placement system with posterior
lumbar interbody fusion, in Lin PM, Gill K (eds): Lumbar Interbody
Fusion: Principles and Techniques in Spine Surgery, pp 81-93.
Rockville, Maryland, Aspen Publishers, 1989.
103. Esses SI, Botsford DJ, Huler RJ, et al: Surgical anatomy of the
sacrum: A guide for rational screw fixation. Spine 16:S283-S288, 1991.
104. Harrington KD: Anterior cord decompression and spinal
stabilization for patients with metastatic lesions of the spine. J
Neurosurg 61:107-117, 1984.
105. Siegal T, Siegal T: Surgical decompression of anterior and
posterior malignant epidural tumors compressing the spinal cord: A
prospective study. Neurosurgery 17:424-432, 1985.
106. An HS: Surgical exposure and fusion techniques of the spine, in
An HS, Colter JM (eds): Spinal Instrumentation, pp 11-18. Baltimore,
Williams & Wilkins, 1992.
107. Goldner JL, Wood KE, Urbaniak JR: Anterior lumbar discectomy and
interbody fusion: Indications and technique, in Schmidek HH, Sweet WH
(eds): Operative Neurosurgical Techniques, pp 1421-1436. Orlando,
Florida, Grune & Stratton, 1988.
108. Rezaian SM: Rezaian spinal fixator for management of fractures
of the thoracolumbar spine. J Neurol Orthop Med Surg 12:307-314, 1991.
109. Moore AJ, Uttley D: Anterior decompression and stabilization of
the spine in malignant disease. Neurosurgery 24:713-717, 1989.
110. Landmann C, Hunig R, Gratzl O: The role of laminectomy in the
combined treatment of metastatic spinal cord compression. Int J
Radiat Oncol Biol Phys 24:627-631, 1992.
111. Bach F, Larsen BH, Rohde K, et al: Metastatic spinal cord
compression: Occurrence, symptoms, clinical presentations, and
prognosis in 398 patients with spinal cord compression. Acta
Neurochir (Wien) 107:37-43, 1990.
112. Cella DF: Quality of life outcomes: Measurement and validation.
Oncology 10:233S-246S, 1996.
113. Weeks J: Outcomes assessment, in Holland JF, Bast RC Jr, Morton
DL, et al (eds): Cancer Medicine, pp 1451-1457. Philadelphia,
Williams & Wilkins, 1997.