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Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France
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Original article
Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France夽 Frédéric Sailhan a , Solène Prost b , Fahed Zairi c , Olivier Gille d , Hughes Pascal-Mousselard e , Saad Bennis f , Yann-Philippe Charles g , Benjamin Blondel b , Stéphane Fuentes b,∗ , the French Spine Society (SFCR)h a
Université Paris 5, hôpital Cochin, Paris, France Unité de chirurgie du rachis, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France c Neurochirurgie, université de Lille, Lille, France d Service de chirurgie vertébrale, université de Bordeaux, CHU Pellegrin, Bordeaux, France e Service de chirurgie vertébrale, université Pierre-et-Marie Curie, CHU la Pitié-Salpêtrière, Paris, France f Neurochirurgie, Suresnes, France g Service de chirurgie vertébrale, université de Strasbourg, Strasbourg, France h French Spine Society (SFCR), 56, rue Boissonade, 75014 Paris, France b
a r t i c l e
i n f o
Article history: Received 11 November 2017 Accepted 4 June 2018 Keywords: Spine Metastasis Surgery
a b s t r a c t Introduction: The occurrence of spinal metastasis is a turning point in the progression of cancer. The optimal management has not been well defined. The aim of this study was to identify the various treatments currently being used in France and to determine the benefits of surgical treatment. Material and methods: The records of patients treated between 2011 and 2015 at seven spine surgery centers in France were reviewed retrospectively. The pain level (VAS), McAfee scale, walking ability and Frankel Grade were evaluated at inclusion and at 6-months postoperative. The Tomita and Tokuhashi prognostic scores were also determined. Results: The cohort consisted of 319 patients. Preoperatively, 63.5% of patients could walk without assistance and 66% were Frankel Grade E. Twenty percent of patients were bed-ridden according to the Karnofsky Performance Status. According to the Tokuhashi criteria, 44% were predicted to have less than 6 months to live. The Tomita score recommended palliative surgery in 48% of cases. Potentially unstable lesions were present in 67% of patients. The surgical indication was made because of a neurological deficit in 40% of cases, to alleviate pain in 30% of cases, and for an instability in 30% of cases. Spinal cord decompression and posterior fixation were the most common procedures. The overall complication rate was 38.6%. At 6-months postoperative, 24 patients had died of the 245 available for review. Only 13 patients could not walk (5.3%), 69.4% of patients were Frankel Grade E and pain levels were significantly lower that preoperatively (2.4 vs. 4.6, p < 0.001). Discussion: This study’s findings are evidence of the difficulties encountered when treating spinal metastases. The main prognostic scores do not appear to be valid for these patients. A large number of patients were operated urgently because of a neurological deficit, before the treatment could be discussed in a multidisciplinary team (MDT) meeting. Nevertheless, the surgical treatment of these patients is associated with an acceptable complication rate and clinical improvement. Conclusion: Surgical treatment of spinal metastases is not well standardized; thus many different strategies are used. There is evidence that it improves the quality of life in most patients by reducing their pain and allowing them to walk again. However, this treatment must be discussed in the context of an MDT meeting before it is carried out. These patients should be evaluated early on by a spine surgeon to reduce the need for emergency surgery when a neurological deficit appears. © 2018 Published by Elsevier Masson SAS.
夽 Article issued from the French Spine Society (SFCR). ∗ Corresponding author. E-mail address: [email protected] (S. Fuentes). https://doi.org/10.1016/j.otsr.2018.06.006 1877-0568/© 2018 Published by Elsevier Masson SAS.
Please cite this article in press as: Sailhan F, et al. Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.006
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1. Introduction The spine is one of the most common locations for metastasis and the prevalence of spinal metastases continues to increase [1–3]. More than 60% of cancer patients will develop bone metastases during the progression of their disease. [1] The optimal care for these patients has not been well defined. While surgical treatment has been shown to be beneficial for patients with neurological deficits [4,5], the strategy for asymptomatic patients or those with pain but no associated deficit has not been defined. The occurrence of symptomatic spinal metastasis is a turning point in the disease progression. However, survival has improved thanks to advances in cancer treatment, in particular targeted therapies [6–8]. In parallel with these advances, the development of minimallyinvasive surgery offers the possibility of less aggressive procedures to these fragile patients, with earlier start or restart of adjuvant treatments [9–11]. The current objectives for these patients are to improve their quality of life by preserving their autonomy for activities of daily living with less pain and shorter hospital stays [12–14]. The numerous prognostic scores currently used to guide the care (surgical or not) of these patients during multidisciplinary team (MDT) meetings are not well suited to current technical advances. They do not allow standardization of the practices in terms of deciding on the surgical indication and the type of surgery [7,15–20]. This led the French Spine Society (SFCR) to conduct a multicenter retrospective study of patients who underwent surgical treatment for one or more spinal metastases in France. The primary aim was to identify the various treatments offered and to assess the outcomes.
2. Materials and methods 2.1. Patient inclusion The medical records at seven spine surgery centers in France (Marseille Timone, Paris [Foch/Cochin/Salpetrière], Lille, Bordeaux, Strasbourg) were reviewed systematically. This led to the inclusion of 319 patients operated between December 2011 and March 2015. Inclusion criteria were patients above 18 years of age with a diagnosis established based on clinical and radiological evidence of secondary spine localizations (whether the primary cancer was known or not), independent of the type of surgical procedure performed. Exclusion criteria were the presence of a surgical contraindication or the presence of a neurological deficit before the spinal metastasis was established.
Fig. 1. Type of primary cancer.
• in parallel, various prognostic indicators were determined preoperatively; • the Karnofsky scale [22] assesses the patient’s physical ability, where 100% represents normal health and 0% corresponds to death; • the Tokuhashi score [19], which is used to guide the surgical treatment according to the patient’s life expectancy by taking into consideration their general condition, the presence of neurological deficits, the nature of the primary tumor and the other secondary sites; • the Tomita score [7] is used to determine the treatment goal and surgical strategy; • the spinal instability neoplastic score (SINS) [23] is used to determine the spinal stability of patients with metastases based on the location of the lesion, mechanical pain, type of bone lesion, radiographic spinal alignment, loss of vertebral height, involvement of posterior elements. This assessment results in a description of “stable”, “potentially unstable” or “unstable” with the need for surgical treatment; • the Tomita Surgical Classification of Spinal Tumors (SCST) which classifies metastases based on their location. For each included patient, any preoperative treatment (embolization) and the type of strategy was recorded, along with the surgical approach, type of procedure, anterior instrumentation, or the need for two-phase surgery. During the follow-up period, general complications and those related to the surgical procedure were recorded.
3. Results 2.2. Data collection
3.1. Epidemiology
At inclusion, the patient’s age, sex, BMI, type of primary cancer, and delay between the diagnosis and metastasis was recorded. Various criteria were used to assess pain, neurological status and autonomy at inclusion:
The cohort consisted of 319 patients: 157 men (49.2%) and 162 women (50.8%) with a median age of 63 years [21–90] and a mean BMI of 24.8 [13.7–50.3]. The discovery of a metastasis was the first sign of cancer in 59 patients (18%). The primary tumor location was known in more than 80% of cases. The mean time elapsed between the diagnosis and the spinal metastasis was 33 months. The most common types of primary cancer (Fig. 1) were breast (19.7%) and lung (18.7%). The spine was the first metastasis location in 65.3% of cases, mainly the thoracic spine (56.2%) (Fig. 2).
• preoperative pain: visual analog scale (VAS) and McAfee scale; • preoperative autonomy: neurological status (using the Frankel Grade [21]) and walking ability, which was classified in five categories–normal walking without assistance, altered walking without assistance, walking with cane, walking with two canes or walker, cannot walk. These same criteria were reassessed at 6-months’ postoperative:
3.2. Preoperative data Various neurological, pain and autonomy indicators were determined preoperatively:
Please cite this article in press as: Sailhan F, et al. Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.006
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Fig. 2. Location of spinal metastasis.
Fig. 4. Preoperative McAfee scale for pain.
Fig. 5. Preoperative walking ability.
Fig. 3. Preoperative pain levels on visual analog scale.
• the average level of pain on VAS was 4.6/10, and the mean McAfee score was 2.9. (Figs. 3 and 4); • autonomy (Figs. 5 and 6): 64.6% of patients could walk without assistance; 19.4% had pyramidal syndrome and 17.1% had incontinence disorders; 66.1% of patients were Frankel Grade E and 4% were grade A or B; • only 13.5% of patients were considered as bed-ridden (Karnofsky < 30%) and 34.5% were considered in good general health (Karnofsky > 70%) (Fig. 7); • according to the Tokuhashi score, more than 43% of patients had an estimated life expectancy of less than 6 months (score 0 to 8)
while 18.8% had a life expectancy of more than 12 months (score 12 to 15) (Fig. 8); • the Tomita score recommended palliative surgery (score 6 to 10) in 48% of cases (Fig. 9); • potentially unstable lesions were present in 67.6% of patients while 13.4% of patients had stable lesions according to the SINS (Fig. 10); • lastly, more than 50% of patients were type 4, 5 or 6 based on the Tomita SCST classification (Fig. 11). 3.3. Surgical data Only 135 of the cases (41.3%) were discussed in an MDT meeting before the surgery. The surgical indication was made based on a neurological deficit in more than 40% of patients. The goal in 30% of
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Fig. 8. Tokuhashi score for preoperative evaluation of metastatic spine tumor prognosis.
(17 cases), lung (11 cases) and thyroid (5 cases) cancer. In the ideal case, the surgery was performed 24 to 72 hours after embolization. The following surgical procedures were performed (Fig. 12):
Fig. 6. Preoperative Frankel grade for neurological status.
• 184 patients underwent an open posterior procedure, typically laminectomy and instrumentation (110 cases); • 64 patients underwent an anterior procedure (corpectomy or tumor reduction), of which 41 were in the cervical spine; • 38 patients had a percutaneous procedure such as kyphoplasty (16 cases) or fixation (13 cases); • 19 patients underwent a two-approach procedure: posterior followed by completion of the corpectomy and instrumentation of the spine by the anterior route. This type of procedure was done during the same session or in two stages. The overall complication rate was 38.6%: • 27.9% general complications, mainly postoperative infections (8.9%) and anemia requiring a blood transfusion (6.7%); • 10.7% surgical procedure-related complications such as spinal cord hemorrhage (1.6%), poor fixation (1.6%), cement leakage (5.9%) and recurring dysphagia/palsy (0.3%).
3.4. 6-month postoperative data Fig. 7. Preoperative Karnofsky Performance Status.
patients was to relieve pain, while the others underwent surgery for unstable spinal lesions. The aim of surgery was curative in 1.6% of cases with the widest possible surgical excision. In the remainder of the cases, the aim of surgery was palliative, thus solely to relieve symptoms. Preoperative embolization was carried out in 48 cases for hypervascularized tumors as recommended by Robial et al. [24]: kidney
For the 6-month postoperative assessment, 52 patients were lost to follow-up (16.3%). Of the 267 patients who were reevaluated, 28 had died within 6 months of the surgery (8.8%), many of whom had lung cancer (9 patients). Only 18 patients could not walk, while 168 could walk without assistance, 18 used a cane and 35 used two canes or a walker. At 6-months postoperative, 69.4% of patients were Frankel Grade E (vs. 66.1% preoperatively), 26.5% were Grade C or D (vs. 31.6% preoperatively) and 4.1% were Grade A or B.
Fig. 9. Tomita score of surgical strategy for spinal metastases.
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Fig. 10. Spinal Instability Neoplastic Score (SINS).
Fig. 11. Tomita Surgical Classification of Spinal Tumors (SCST).
The pain level (VAS) was significantly lower on average than preoperatively (2.4 vs. 4.6, p < 0.001) and for the two main types of cancer (lung, breast). 4. Discussion This multicenter study is a survey of the various surgical practices used in France for spinal metastases. It reveals a lack of standardized strategies for spinal metastasis. Only 41.3% of cases were discussed in an MDT meeting preoperatively. This does not measure up to the recommendations of the French Health Authority (HAS) but could be due to the fact that
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many patients were operated urgently because of a neurological deficit. Thus, it is important to detect spinal metastases as early as possible in order to define a treatment strategy before this deficit occurs. The low mortality rate at 6 months in our study, which was much lower than in other published studies [7,8,15,17], must be weighed against the large number of patients lost to follow-up. Note that the Tokuhashi score for preoperative evaluation of metastatic spine tumor prognosis indicated that 45% of the cohort had a life expectancy of less than 6 months, while only 9.8% of patients actually died within this time frame. Despite the large number of patients lost to follow-up, this casts doubt on the validity of this scoring system, which was introduced in 1990 and revised later on [18,19], despite the results of Eap et al. [25]. If we were to assume a worst-case scenario in which all of the patients lost to follow-up had actually died, the mortality rate in our study would have been 25.1%, which is still lower than that predicted with the Tokuhashi scoring system. This mismatch between the prognosis based on this score and our findings is likely due to the recent advances in adjuvant and neo-adjuvant treatments. This also casts doubt on the validity of the various scores used to determine life expectancy that are used to support the decision to perform surgery on patients with cancer. Conversely, other factors were useful for evaluating the prognosis of patients with spinal metastases: ASA score, Karnofsky index and type of primary tumor [7,15,17]. At 6-months postoperative, more than 72% of patients had pain on VAS less than 3 (versus 34% preoperatively) and none had pain levels above 7, which is evidence of the major role that surgical treatment plays in reducing pain. The benefits of surgery extended to function also: more than 70% of patients could walk without assistance at 6-months postoperative versus 63.5% preoperatively, and 3% more patients were Frankel Grade E at 6-months postoperative. Improvement in function (Frankel), pain and walking is evidence of the importance and relevance of surgical treatment for these patients [3,11,13]. Within this population, quality of life is a basic tenet of the medical and surgical decision process. In terms of intraoperative and postoperative complications, the rate in our study was comparable to that of complex spine surgery studies with instrumentation outside the oncology context. When all the complications are pooled, our study had a 38.6% complication rate versus 55% in a cohort of adult patients operated for spinal deformity [26] or around 50% in studies of instrumented spine surgery [27,28]. The fact that the complication rate was not higher in our study is an additional argument in the favor of surgical care
Fig. 12. Surgical techniques used.
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Fig. 13. Preoperative CT scan, single L2 metastasis of lung cancer. Fig. 15. Postoperative CT scan after L2 instrumentation in two-stage surgery; percutaneous posterior fixation and additional anterior approach to complete tumor resection at L2 and implant a cage.
Fig. 16. Post-surgical scar after minimally invasive procedure. Fig. 14. T1-weighted MRI performed before surgery.
5. Conclusion for these patients, although it must be weighed against the large number of patients lost to follow-up. In addition, the continued advances in minimally invasive techniques for the treatment of tumors in the cervical or thoracolumbar spine [29] should help to further reduce the number of complications [9,12]. In our study, only 19% of patients underwent a minimally invasive procedure. These techniques provide pain relief and decompression that is equal to that of standard open surgery with less tissue damage, less blood loss, less postoperative pain and lower risk of perioperative infection (Figs. 13–16). These techniques also allow rehabilitation to start earlier, shorten the convalescence period, and should be favored whenever possible as they also allow faster access to adjuvant treatments, particularly radiation therapy, which can be initiated 2 to 3 weeks after surgery [9–11,13].
Surgical care for spinal metastases is currently not well standardized. Various strategies can be adopted. This study found improved quality of life (pain relief) and walking in most patients. The recent advances in cancer treatment have markedly increased the duration and quality of life of patients with spinal metastases. Thus spine surgeons are being increasingly called on to work with these fragile patients. Thus it is vital for the surgical strategy to be one component of the discussion by all the players involved in the patient’s care during MDT meetings. Disclosure of interest The authors declare that they have no competing interest.
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Funding None. Contribution of authors All authors contributed to data collection, to analyzing and multicentric writing. References [1] Choi D, Bilsky M, Fehlings M, Fisher C, Gokaslan Z. Spine oncology-metastatic spine tumors. Neurosurgery 2017;80:S131–7. [2] Osorio M, Moubayed SP, Su H, Urken ML. Systematic review of site distribution of bone metastases in differentiated thyroid cancer. Head Neck 2017;39: 812–8. [3] Yang J, Jia Q, Peng D, Wan W, Zhong N, Lou Y, et al. Surgical treatment of upper cervical spine metastases: a retrospective study of 39 cases. World J Surg Oncol 2017;15:21. [4] Conway R, Graham J, Kidd J, Levack P. Scottish cord compression group. What happens to people after malignant cord compression? Survival, function, quality of life, emotional well-being and place of care 1 month after diagnosis. Clin Oncol (R Coll Radiol) 2007;19:56–62. [5] 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 randomized trial. Lancet Lond Eng 2005;366: 643–8. [6] Chamberlain MC, Sloan A, Vrionis F, Cancer Care Ontario Practice Guidelines Initiative’s Neuro-oncology Disease Site Group. Systematic review of the diagnosis and management of malignant extradural spine cord compression: The Cancer Care Ontario Practice Guidelines Initiative’s Neuro-oncology Disease Site Group. J Clin Oncol 2005;23:7750–1 [author reply 7751-7752]. [7] Lee C-H, Chung CK, Jahng T-A, Kim K, Kim CH, Hyun S-J, et al. Which one is a valuable surrogate for predicting survival between Tomita and Tokuhashi scores in patients with spinal metastases? A meta-analysis for diagnostic test accuracy and individual participant data analysis. J Neurooncol 2015;123: 267–75. [8] Tabouret E, Gravis G, Cauvin C, Loundou A, Adetchessi T, Fuentes S. Long-term survivors after surgical management of metastatic spinal cord compression. Eur Spine J 2015;24:209–15. [9] Hamad A, Vachtsevanos L, Cattell A, Ockendon M, Balain B. Minimally-invasive spinal surgery for the management of symptomatic spinal metastasis. Br J Neurosurg 2017;31:526–30. [10] Toquart A, Graillon T, Mansouri N, Adetchessi T, Blondel B, Fuentes S. Management of spinal metastasis by minimal invasive surgery technique: Surgical principles, indications: a literature review. Neurochirurgie 2016;62: 157–64. [11] Zhang H-T, Chen G-D, Yang H-L, Luo Z-P. Percutaneous Kyphoplasty in the treatment of osteoblastic-related spinal metastases. Clin Spine Surg 2017;30:80–4. [12] Bernard F, Lemée J-M, Lucas O, Menei P. Postoperative quality of life assessment in patients with spine metastases treated with long-segment pedicle-screw fixation. J Neurosurg Spine 2017;26:725–35.
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[13] de Ruiter GCW, Nogarede CO, Wolfs JFC, Arts MP. Quality of life after different surgical procedures for the treatment of spinal metastases: results of a singlecenter prospective case series. Neurosurg Focus 2017;42:E17. [14] Ibrahim A, Crockard A, Antonietti P, Boriani S, Bünger C, Gasbarrini A, et al. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. J Neurosurg Spine 2008;8:271–8. [15] Papastefanou S, Alpantaki K, Akra G, Katonis P. Predictive value of Tokuhashi and Tomita scores in patients with metastatic spine disease. Acta Orthop Traumatol Turc 2012;46:50–6. [16] Pointillart V, Vital J-M, Salmi R, Diallo A, Quan GM. Survival prognostic factors and clinical outcomes in patients with spinal metastases. J Cancer Res Clin Oncol 2011;137:849–56. [17] Tabouret E, Cauvin C, Fuentes S, Esterni B, Adetchessi T, Salem N, et al. Reassessment of scoring systems and prognostic factors for metastatic spinal cord compression. Spine J 2015;15:944–50. [18] Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine 2005;30:2186–91. [19] Tokuhashi Y, Matsuzaki H, Toriyama S, Kawano H, Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine 1990;15:1110–3. [20] Ulmar B, Richter M, Cakir B, Muche R, Puhl W, Huch K. The Tokuhashi score: significant predictive value for the life expectancy of patients with breast cancer with spinal metastases. Spine 2005;30:2222–6. [21] Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia I. Paraplegia 1969;7:179–92. [22] Karnofsky DA, Burchenal JH. Present status of clinical cancer chemotherapy. Am J Med 1950;8:767–88. [23] Fisher CG, Schouten R, Versteeg AL, Boriani S, Varga PP, Rhines LD, et al. Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases. Radiat Oncol 2014;9:69. [24] Robial N, Charles Y-P, Bogorin I, Godet J, Beaujeux R, Boujan F, et al. Is preoperative embolization a prerequisite for spinal metastases surgical management? Orthop Traumatol Surg Res 2012;98:536–42. [25] Eap C, Tardieux E, Goasgen O, Bennis S, Mireau E, Delalande B, et al. Tokuhashi score and other prognostic factors in 260 patients with surgery for vertebral metastases. Orthop Traumatol Surg Res 2015;101:483–8. [26] Sciubba DM, Yurter A, Smith JS, Kelly MP, Scheer JK, Goodwin CR, et al. A comprehensive review of complication rates after surgery for adult deformity: a reference for informed consent. Spine 2015;3:575–94. [27] Campbell PG, Yadla S, Malone J, Maltenfort MG, Harrop JS, Sharan AD, et al. Complications related to instrumentation in spine surgery: a prospective analysis. Neurosurg Focus 2011;31:E10. [28] Smith JS, Klineberg E, Lafage V, Shaffrey CI, Schwab F, Lafage R, et al. Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 2016;25:1–14. [29] Blondel B, Adetchessi T, Demakakos J, Pech-Gourg G, Dufour H, Fuentes S. Anterolateral kyphoplasty in the management of cervical spinal metastasis. Orthop Traumatol Surg Res 2012;98:341–5.
Please cite this article in press as: Sailhan F, et al. Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.006
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Original article
Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France夽 Frédéric Sailhan a , Solène Prost b , Fahed Zairi c , Olivier Gille d , Hughes Pascal-Mousselard e , Saad Bennis f , Yann-Philippe Charles g , Benjamin Blondel b , Stéphane Fuentes b,∗ , the French Spine Society (SFCR)h a
Université Paris 5, hôpital Cochin, Paris, France Unité de chirurgie du rachis, université Aix-Marseille, CHU Timone, 264, rue Saint-Pierre, 13005 Marseille, France c Neurochirurgie, université de Lille, Lille, France d Service de chirurgie vertébrale, université de Bordeaux, CHU Pellegrin, Bordeaux, France e Service de chirurgie vertébrale, université Pierre-et-Marie Curie, CHU la Pitié-Salpêtrière, Paris, France f Neurochirurgie, Suresnes, France g Service de chirurgie vertébrale, université de Strasbourg, Strasbourg, France h French Spine Society (SFCR), 56, rue Boissonade, 75014 Paris, France b
a r t i c l e
i n f o
Article history: Received 11 November 2017 Accepted 4 June 2018 Keywords: Spine Metastasis Surgery
a b s t r a c t Introduction: The occurrence of spinal metastasis is a turning point in the progression of cancer. The optimal management has not been well defined. The aim of this study was to identify the various treatments currently being used in France and to determine the benefits of surgical treatment. Material and methods: The records of patients treated between 2011 and 2015 at seven spine surgery centers in France were reviewed retrospectively. The pain level (VAS), McAfee scale, walking ability and Frankel Grade were evaluated at inclusion and at 6-months postoperative. The Tomita and Tokuhashi prognostic scores were also determined. Results: The cohort consisted of 319 patients. Preoperatively, 63.5% of patients could walk without assistance and 66% were Frankel Grade E. Twenty percent of patients were bed-ridden according to the Karnofsky Performance Status. According to the Tokuhashi criteria, 44% were predicted to have less than 6 months to live. The Tomita score recommended palliative surgery in 48% of cases. Potentially unstable lesions were present in 67% of patients. The surgical indication was made because of a neurological deficit in 40% of cases, to alleviate pain in 30% of cases, and for an instability in 30% of cases. Spinal cord decompression and posterior fixation were the most common procedures. The overall complication rate was 38.6%. At 6-months postoperative, 24 patients had died of the 245 available for review. Only 13 patients could not walk (5.3%), 69.4% of patients were Frankel Grade E and pain levels were significantly lower that preoperatively (2.4 vs. 4.6, p < 0.001). Discussion: This study’s findings are evidence of the difficulties encountered when treating spinal metastases. The main prognostic scores do not appear to be valid for these patients. A large number of patients were operated urgently because of a neurological deficit, before the treatment could be discussed in a multidisciplinary team (MDT) meeting. Nevertheless, the surgical treatment of these patients is associated with an acceptable complication rate and clinical improvement. Conclusion: Surgical treatment of spinal metastases is not well standardized; thus many different strategies are used. There is evidence that it improves the quality of life in most patients by reducing their pain and allowing them to walk again. However, this treatment must be discussed in the context of an MDT meeting before it is carried out. These patients should be evaluated early on by a spine surgeon to reduce the need for emergency surgery when a neurological deficit appears. © 2018 Published by Elsevier Masson SAS.
夽 Article issued from the French Spine Society (SFCR). ∗ Corresponding author. E-mail address: [email protected] (S. Fuentes). https://doi.org/10.1016/j.otsr.2018.06.006 1877-0568/© 2018 Published by Elsevier Masson SAS.
Please cite this article in press as: Sailhan F, et al. Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.006
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1. Introduction The spine is one of the most common locations for metastasis and the prevalence of spinal metastases continues to increase [1–3]. More than 60% of cancer patients will develop bone metastases during the progression of their disease. [1] The optimal care for these patients has not been well defined. While surgical treatment has been shown to be beneficial for patients with neurological deficits [4,5], the strategy for asymptomatic patients or those with pain but no associated deficit has not been defined. The occurrence of symptomatic spinal metastasis is a turning point in the disease progression. However, survival has improved thanks to advances in cancer treatment, in particular targeted therapies [6–8]. In parallel with these advances, the development of minimallyinvasive surgery offers the possibility of less aggressive procedures to these fragile patients, with earlier start or restart of adjuvant treatments [9–11]. The current objectives for these patients are to improve their quality of life by preserving their autonomy for activities of daily living with less pain and shorter hospital stays [12–14]. The numerous prognostic scores currently used to guide the care (surgical or not) of these patients during multidisciplinary team (MDT) meetings are not well suited to current technical advances. They do not allow standardization of the practices in terms of deciding on the surgical indication and the type of surgery [7,15–20]. This led the French Spine Society (SFCR) to conduct a multicenter retrospective study of patients who underwent surgical treatment for one or more spinal metastases in France. The primary aim was to identify the various treatments offered and to assess the outcomes.
2. Materials and methods 2.1. Patient inclusion The medical records at seven spine surgery centers in France (Marseille Timone, Paris [Foch/Cochin/Salpetrière], Lille, Bordeaux, Strasbourg) were reviewed systematically. This led to the inclusion of 319 patients operated between December 2011 and March 2015. Inclusion criteria were patients above 18 years of age with a diagnosis established based on clinical and radiological evidence of secondary spine localizations (whether the primary cancer was known or not), independent of the type of surgical procedure performed. Exclusion criteria were the presence of a surgical contraindication or the presence of a neurological deficit before the spinal metastasis was established.
Fig. 1. Type of primary cancer.
• in parallel, various prognostic indicators were determined preoperatively; • the Karnofsky scale [22] assesses the patient’s physical ability, where 100% represents normal health and 0% corresponds to death; • the Tokuhashi score [19], which is used to guide the surgical treatment according to the patient’s life expectancy by taking into consideration their general condition, the presence of neurological deficits, the nature of the primary tumor and the other secondary sites; • the Tomita score [7] is used to determine the treatment goal and surgical strategy; • the spinal instability neoplastic score (SINS) [23] is used to determine the spinal stability of patients with metastases based on the location of the lesion, mechanical pain, type of bone lesion, radiographic spinal alignment, loss of vertebral height, involvement of posterior elements. This assessment results in a description of “stable”, “potentially unstable” or “unstable” with the need for surgical treatment; • the Tomita Surgical Classification of Spinal Tumors (SCST) which classifies metastases based on their location. For each included patient, any preoperative treatment (embolization) and the type of strategy was recorded, along with the surgical approach, type of procedure, anterior instrumentation, or the need for two-phase surgery. During the follow-up period, general complications and those related to the surgical procedure were recorded.
3. Results 2.2. Data collection
3.1. Epidemiology
At inclusion, the patient’s age, sex, BMI, type of primary cancer, and delay between the diagnosis and metastasis was recorded. Various criteria were used to assess pain, neurological status and autonomy at inclusion:
The cohort consisted of 319 patients: 157 men (49.2%) and 162 women (50.8%) with a median age of 63 years [21–90] and a mean BMI of 24.8 [13.7–50.3]. The discovery of a metastasis was the first sign of cancer in 59 patients (18%). The primary tumor location was known in more than 80% of cases. The mean time elapsed between the diagnosis and the spinal metastasis was 33 months. The most common types of primary cancer (Fig. 1) were breast (19.7%) and lung (18.7%). The spine was the first metastasis location in 65.3% of cases, mainly the thoracic spine (56.2%) (Fig. 2).
• preoperative pain: visual analog scale (VAS) and McAfee scale; • preoperative autonomy: neurological status (using the Frankel Grade [21]) and walking ability, which was classified in five categories–normal walking without assistance, altered walking without assistance, walking with cane, walking with two canes or walker, cannot walk. These same criteria were reassessed at 6-months’ postoperative:
3.2. Preoperative data Various neurological, pain and autonomy indicators were determined preoperatively:
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Fig. 2. Location of spinal metastasis.
Fig. 4. Preoperative McAfee scale for pain.
Fig. 5. Preoperative walking ability.
Fig. 3. Preoperative pain levels on visual analog scale.
• the average level of pain on VAS was 4.6/10, and the mean McAfee score was 2.9. (Figs. 3 and 4); • autonomy (Figs. 5 and 6): 64.6% of patients could walk without assistance; 19.4% had pyramidal syndrome and 17.1% had incontinence disorders; 66.1% of patients were Frankel Grade E and 4% were grade A or B; • only 13.5% of patients were considered as bed-ridden (Karnofsky < 30%) and 34.5% were considered in good general health (Karnofsky > 70%) (Fig. 7); • according to the Tokuhashi score, more than 43% of patients had an estimated life expectancy of less than 6 months (score 0 to 8)
while 18.8% had a life expectancy of more than 12 months (score 12 to 15) (Fig. 8); • the Tomita score recommended palliative surgery (score 6 to 10) in 48% of cases (Fig. 9); • potentially unstable lesions were present in 67.6% of patients while 13.4% of patients had stable lesions according to the SINS (Fig. 10); • lastly, more than 50% of patients were type 4, 5 or 6 based on the Tomita SCST classification (Fig. 11). 3.3. Surgical data Only 135 of the cases (41.3%) were discussed in an MDT meeting before the surgery. The surgical indication was made based on a neurological deficit in more than 40% of patients. The goal in 30% of
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Fig. 8. Tokuhashi score for preoperative evaluation of metastatic spine tumor prognosis.
(17 cases), lung (11 cases) and thyroid (5 cases) cancer. In the ideal case, the surgery was performed 24 to 72 hours after embolization. The following surgical procedures were performed (Fig. 12):
Fig. 6. Preoperative Frankel grade for neurological status.
• 184 patients underwent an open posterior procedure, typically laminectomy and instrumentation (110 cases); • 64 patients underwent an anterior procedure (corpectomy or tumor reduction), of which 41 were in the cervical spine; • 38 patients had a percutaneous procedure such as kyphoplasty (16 cases) or fixation (13 cases); • 19 patients underwent a two-approach procedure: posterior followed by completion of the corpectomy and instrumentation of the spine by the anterior route. This type of procedure was done during the same session or in two stages. The overall complication rate was 38.6%: • 27.9% general complications, mainly postoperative infections (8.9%) and anemia requiring a blood transfusion (6.7%); • 10.7% surgical procedure-related complications such as spinal cord hemorrhage (1.6%), poor fixation (1.6%), cement leakage (5.9%) and recurring dysphagia/palsy (0.3%).
3.4. 6-month postoperative data Fig. 7. Preoperative Karnofsky Performance Status.
patients was to relieve pain, while the others underwent surgery for unstable spinal lesions. The aim of surgery was curative in 1.6% of cases with the widest possible surgical excision. In the remainder of the cases, the aim of surgery was palliative, thus solely to relieve symptoms. Preoperative embolization was carried out in 48 cases for hypervascularized tumors as recommended by Robial et al. [24]: kidney
For the 6-month postoperative assessment, 52 patients were lost to follow-up (16.3%). Of the 267 patients who were reevaluated, 28 had died within 6 months of the surgery (8.8%), many of whom had lung cancer (9 patients). Only 18 patients could not walk, while 168 could walk without assistance, 18 used a cane and 35 used two canes or a walker. At 6-months postoperative, 69.4% of patients were Frankel Grade E (vs. 66.1% preoperatively), 26.5% were Grade C or D (vs. 31.6% preoperatively) and 4.1% were Grade A or B.
Fig. 9. Tomita score of surgical strategy for spinal metastases.
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Fig. 10. Spinal Instability Neoplastic Score (SINS).
Fig. 11. Tomita Surgical Classification of Spinal Tumors (SCST).
The pain level (VAS) was significantly lower on average than preoperatively (2.4 vs. 4.6, p < 0.001) and for the two main types of cancer (lung, breast). 4. Discussion This multicenter study is a survey of the various surgical practices used in France for spinal metastases. It reveals a lack of standardized strategies for spinal metastasis. Only 41.3% of cases were discussed in an MDT meeting preoperatively. This does not measure up to the recommendations of the French Health Authority (HAS) but could be due to the fact that
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many patients were operated urgently because of a neurological deficit. Thus, it is important to detect spinal metastases as early as possible in order to define a treatment strategy before this deficit occurs. The low mortality rate at 6 months in our study, which was much lower than in other published studies [7,8,15,17], must be weighed against the large number of patients lost to follow-up. Note that the Tokuhashi score for preoperative evaluation of metastatic spine tumor prognosis indicated that 45% of the cohort had a life expectancy of less than 6 months, while only 9.8% of patients actually died within this time frame. Despite the large number of patients lost to follow-up, this casts doubt on the validity of this scoring system, which was introduced in 1990 and revised later on [18,19], despite the results of Eap et al. [25]. If we were to assume a worst-case scenario in which all of the patients lost to follow-up had actually died, the mortality rate in our study would have been 25.1%, which is still lower than that predicted with the Tokuhashi scoring system. This mismatch between the prognosis based on this score and our findings is likely due to the recent advances in adjuvant and neo-adjuvant treatments. This also casts doubt on the validity of the various scores used to determine life expectancy that are used to support the decision to perform surgery on patients with cancer. Conversely, other factors were useful for evaluating the prognosis of patients with spinal metastases: ASA score, Karnofsky index and type of primary tumor [7,15,17]. At 6-months postoperative, more than 72% of patients had pain on VAS less than 3 (versus 34% preoperatively) and none had pain levels above 7, which is evidence of the major role that surgical treatment plays in reducing pain. The benefits of surgery extended to function also: more than 70% of patients could walk without assistance at 6-months postoperative versus 63.5% preoperatively, and 3% more patients were Frankel Grade E at 6-months postoperative. Improvement in function (Frankel), pain and walking is evidence of the importance and relevance of surgical treatment for these patients [3,11,13]. Within this population, quality of life is a basic tenet of the medical and surgical decision process. In terms of intraoperative and postoperative complications, the rate in our study was comparable to that of complex spine surgery studies with instrumentation outside the oncology context. When all the complications are pooled, our study had a 38.6% complication rate versus 55% in a cohort of adult patients operated for spinal deformity [26] or around 50% in studies of instrumented spine surgery [27,28]. The fact that the complication rate was not higher in our study is an additional argument in the favor of surgical care
Fig. 12. Surgical techniques used.
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Fig. 13. Preoperative CT scan, single L2 metastasis of lung cancer. Fig. 15. Postoperative CT scan after L2 instrumentation in two-stage surgery; percutaneous posterior fixation and additional anterior approach to complete tumor resection at L2 and implant a cage.
Fig. 16. Post-surgical scar after minimally invasive procedure. Fig. 14. T1-weighted MRI performed before surgery.
5. Conclusion for these patients, although it must be weighed against the large number of patients lost to follow-up. In addition, the continued advances in minimally invasive techniques for the treatment of tumors in the cervical or thoracolumbar spine [29] should help to further reduce the number of complications [9,12]. In our study, only 19% of patients underwent a minimally invasive procedure. These techniques provide pain relief and decompression that is equal to that of standard open surgery with less tissue damage, less blood loss, less postoperative pain and lower risk of perioperative infection (Figs. 13–16). These techniques also allow rehabilitation to start earlier, shorten the convalescence period, and should be favored whenever possible as they also allow faster access to adjuvant treatments, particularly radiation therapy, which can be initiated 2 to 3 weeks after surgery [9–11,13].
Surgical care for spinal metastases is currently not well standardized. Various strategies can be adopted. This study found improved quality of life (pain relief) and walking in most patients. The recent advances in cancer treatment have markedly increased the duration and quality of life of patients with spinal metastases. Thus spine surgeons are being increasingly called on to work with these fragile patients. Thus it is vital for the surgical strategy to be one component of the discussion by all the players involved in the patient’s care during MDT meetings. Disclosure of interest The authors declare that they have no competing interest.
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Please cite this article in press as: Sailhan F, et al. Retrospective multicenter study by the French Spine Society of surgical treatment for spinal metastasis in France. Orthop Traumatol Surg Res (2018), https://doi.org/10.1016/j.otsr.2018.06.006