Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery!

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The Spine Journal ■■ (2015) ■■–■■

Clinical Study

Surgery for metastatic spine tumors in the elderly. Advanced age is not a contraindication to surgery! A. Amelot, MD, PhDa,*, L. Balabaud, MDa, D. Choi, MDb, Z. Fox, MD, PhDb, H.A. Crockard, MDb, T. Albert, MDc, C.M. Arts, MDd, J.M. Buchowski, MDe, C. Bunger, MDf, C.K. Chung, MDg, M.H. Coppes, MDh, B. Depreitere, MDi, M.G. Fehlings, MDj, J. Harrop, MDc, N. Kawahara, MDk, E.S. Kim, MDl, C.S. Lee, MDl, Y. Leung, MDm, Z.J. Liu, MDn, J.A. Martin-Benlloch, MDo, E.M. Massicotte, MDj, B. Meyer, MDp, F.C. Oner, MDq, W. Peul, MDr, N. Quraishi, MDs, Y. Tokuhashi, MDt, K. Tomita, MDu, C. Ulbricht, MDv, J.J. Verlaan, MDq, M. Wang, MDw, C. Mazel, MDa a Department of Orthopedic Surgery, L’Institut Mutualiste Montsouris, Paris, France Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London, London, UK c Departments of Neurosurgery and Orthopedic Surgery, Thomas Jefferson University and Hospitals, Philadelphia, PA, USA d Department of Neurosurgery, Medical Center Haaglanden, Haaglanden, The Netherlands e Departments of Orthopedic and Neurological Surgery, Washington University, MO, USA f Department of Orthopedic Surgery, University Hospital of Aarhus, Aarhus, Denmark g Department of Neurosurgery, Seoul National University, Seoul, South Korea h Department of Neurosurgery, Groningen, The Netherlands i Division of Neurosurgery, University Hospital Leuven, Leuven, Belgium j Department of Neurosurgery, Toronto Western Hospital, Toronto, Canada k Department of Orthopedic Surgery, Kanazawa Medical University Hospital, Kanazawa, Japan l Departments of Orthopedic Surgery and Neurosurgery, Samsung Medical Center, Seoul, South Korea m Department of Orthopaedic Surgery, Musgrove Park Hospital, Taunton, UK n Department of Orthopedics, Peking University Hospital, Beijing, China o Spinal Unit, Hospital Universitario Dr Peset, Valencia, Spain p Department of Neurosurgery, Technical University of Munich, Munich, Germany q Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands r Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands s Centre for Spine Studies and Surgery, Queens Medical Centre, Nottingham, UK t Department of Orthopaedic Surgery, Nihon University School of Medicine, Japan u Department of Orthopedic Surgery, Kanazawa University, Kanazawa, Japan v Department of Neurosurgery, Charing Cross Hospital, London, UK w Department of Neurosurgery, Jackson Memorial Hospital, University of Miami, Miami, FL, USA Received 20 February 2015; revised 31 May 2015; accepted 13 July 2015

b

Abstract

BACKGROUND: With recent advances in oncologic treatments, there has been an increase in patient survival rates and concurrently an increase in the number of incidence of symptomatic spinal metastases. Because elderly patients are a substantial part of the oncology population, their types of treatment as well as the possible impact their treatment will have on healthcare resources need to be further examined.

FDA device/drug status: Not applicable. Author disclosures: AA: Nothing to disclose. LB: Nothing to disclose. DC: Nothing to disclose. ZF: Nothing to disclose. HAC: Nothing to disclose. TA: Nothing to disclose. CMA: Nothing to disclose. JMB: Nothing to disclose. CB: Nothing to disclose. CKC: Nothing to disclose. MHC: Nothing to disclose. BD: Nothing to disclose. MGF: Nothing to disclose. JH: Nothing to disclose. NK: Nothing to disclose. ESK: Nothing to disclose. CSL: Nothing to disclose. YL: Nothing to disclose. ZJL: Nothing to disclose. JAMB: Nothing to disclose. EMM: Nothing to disclose. BM: Nothing to disclose. FCO: Nothing to disclose. WP: Nothing to disclose. NQ: Nothing to disclose. YT: Nothing to disclose. KT: Nothing to dishttp://dx.doi.org/10.1016/j.spinee.2015.07.440 1529-9430/© 2015 Elsevier Inc. All rights reserved.

close. CU: Nothing to disclose. JJV: Nothing to disclose. MW: Nothing to disclose. CM: Nothing to disclose. The authors declare no conflicts of interest associated with this study. Funding: This work was funded by the Global Spine Tumour Study Group, a registered charity of England and Wales, Charity Commission number 1134934 and DePuy Synthes. * Corresponding author. Orthopedy Department, Institut Mutualiste Montsouris, Jourdan boulevard, 42, 75014 Paris, France. Tel.: +33 1 56 61 63 63; fax: +33 1 45 80 60 41. E-mail address: [email protected] (A. Amelot).

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PURPOSE: We studied whether age has a significant influence on quality of life and survival in surgical interventions for spinal metastases. STUDY DESIGN: We used data from a multicenter prospective study by the Global Spine Tumor Study Group (GSTSG). This GSTSG study involved 1,266 patients who were admitted for surgical treatments of symptomatic spinal metastases at 22 spinal centers from different countries and followed up for 2 years after surgery. PATIENT SAMPLE: There were 1,266 patients recruited between March 2001 and October 2014. OUTCOME MEASURES: Patient demographics were collected along with outcome measures, including European Quality of Life-5 Dimensions (EQ-5D), neurologic functions, complications, and survival rates. METHODS: We realized a multicenter prospective study of 1,266 patients admitted for surgical treatment of symptomatic spinal metastases. They were divided and studied into three different age groups: <70, 70–80, and >80 years. RESULTS: Despite a lack of statistical difference in American Society of Anesthesiologists (ASA) score, Frankel neurologic score, or Karnofsky functional score at presentation, patients >80 years were more likely to undergo emergency surgery and palliative procedures compared with younger patients. Postoperative complications were more common in the oldest age group (33.3% in the >80, 23.9% in the 70–80, and 17.9% for patients <70 years, p=.004). EQ-5D improved in all groups, but survival expectancy was significantly longer in patients <70 years old (p=.02). Furthermore, neurologic recovery after surgery was lower in patients >80 years old. CONCLUSIONS: Surgeons should not be biased against operating elderly patients. Although survival rates and neurologic improvements in the elderly patients are lower than for younger patients, operating the elderly is compounded by the fact that they undergo more emergency and palliative procedures, despite good ASA scores and functional status. Age in itself should not be a determinant of whether to operate or not, and operations should not be avoided in the elderly when indicated. © 2015 Elsevier Inc. All rights reserved. Keywords:

Elderly; Emergency; Neurologic prognosis; Quality of life; Scheduled surgery; Spine compression; Spine metastasis

Introduction Cancer treatments have continuously improved, resulting in higher patient survival rates. Therefore, patients with advanced stage cancer live longer, but the number of incidence of spinal metastases increases [1,2]. Furthermore, the “elderly” are a steadily growing population group in high-income countries. Spinal metastasis with or without cord compression are a debilitating and common complication of cancer. More than 20,000 new cases are reported every year in the United States [3–5]. In 5–14% of patients, cancer metastasizes commonly to the spine and leads to spinal cord compression, cauda equina syndrome, and paraparesis [3], but the incidence of spinal metastases in patients with cancer at postmortem examination is much higher [6]. To demonstrate the effect of age on outcomes and complications, we analyzed data from a large multicenter international prospective cohort study of 1,266 patients undergoing surgery for spinal metastases. This study was conducted by the “Global Spine Tumor Study Group” (GSTSG), an international group of spinal surgeons [6].

neurosurgical spinal units. Data were collected on a secure Internet database designed by the GSTSG. The centers were in Belgium, Canada, China, Denmark, France, Germany, Japan, The Netherlands, South Korea, Spain, the United Kingdom, and the United States of America. The database was hosted on computer servers managed by the data-management company, Giant Systems Limited (Leeds, UK), with secure socket layer encryptions. Anonymized data were prospectively entered when patients were admitted to the hospital, and at subsequent follow-up visits. Local institutional ethical regulatory approval was granted for all centers. The patients were recruited between March 2001 and October 2014. Patient details were locked 4 weeks after initial data entry, and data were downloaded for analysis in October 2014. For this study, follow-up was from recruitment up to death or 2 years after surgery. Research participants’ consents were required to allow anonymized data collection and storage, but otherwise treatment and follow-up did not vary from the standard provided at each center. Patients were excluded if they were unable to consent because of learning disabilities, unconsciousness, mental illness, or age <18 years.

Methods

Variables

The GSTSG conducted an international multicenter study of 1,266 patients who were admitted for surgery to treat symptomatic spinal metastases at 22 international orthopedic and

Preoperative data The preoperative data for this study were type of tumor, neurologic status, functional status, pain, Karnofsky score,

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Fig. 1. (Top) Frankel score and (Bottom) classification of surgical strategies as determined by the Global Spine Tumor Study Group.

American Society of Anesthesiologists (ASA) score, number of spinal levels affected by tumor, Tomita score, and European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Frankel score The Frankel Classification defines the extent of spine injury according to the following grading system: A, complete motor and sensory loss below level of spinal cord dysfunction; B, sensation spared, but no motor activity; C, non-functional motor preservation; D, useful motor preservation; and E, normal motor function [7] (Fig. 1A). Karnofsky score The Karnofsky score assesses changes in a patient’s condition, attributing grades in a patient’s ability to perform certain tasks according to the following scores: 100, a normal state,

no complaints; 70, an inability to carry out daily life activities; 50, a condition requiring significant assistance; 40, a disability; 30, a mandatory hospitalization; and 0, if deceased [8]. Tomita score The Tomita score is a classification system which estimates prognosis in patients with spinal metastases, taking into account the type of tumor, number of spinal metastases, and presence of visceral metastases [9] (Fig. 2). Surgery data Surgical approach, type of surgery, levels of tumor resection and fixation, and intra-operative complications comprise surgery data.

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Fig. 2. Tomita prognostic score: For each category (primary tumor, visceral and bone metastases) a score of 1, 2, or 4 is allocated accordingly; these scores are added to provide up to a maximum total score of 10 [9].

Data at the time of discharge from the spinal center These data consist of postoperative complications, neurologic status, Frankel score, and functional status. Operations for spinal metastases Operations were classified into five grades, from palliative decompression or stabilization (grade 1) and debulking surgery (grade 2) to complete excisional surgery (grades 3–5) according to the GSTSG classification of tumor excision (grade 6) (Fig. 1B). Statistical analysis All patients were included in the analysis provided that information was logged for the date of surgery and secondary tumor type. Data distributions were reviewed for skew deviation before descriptive analysis and means or medians were presented accordingly. Kaplan-Meier plots were produced to assess survival rate in the different age groups. In this analysis, patients were included from the date of surgery until their last follow-up visit, time of death, or 2 years following surgery. Differences in baseline trends were researched using t tests and variance analysis. Differences in outcomes, complications, and quality of life were also investigated by variance analysis; p-values of less than .05 were considered significant. Data were analyzed by encrypted download to the GSTSG Trustees. Data handling and statistical tests were performed with Stata 13.1 software (StataCorp LP, TX, USA). Results From a total of 1,435 patients in our series, 1,266 fulfilled the inclusion criteria for analysis. Because of inconsistencies in data entry, such as failing to establish the date of surgery or details of surgery from that of the database, 169 patients were excluded from analysis. Exclusion of these patients did not bias our interpretation of the results,

and we felt that including these data would have likely led to inaccuracies. We divided our cohort into three age categories: <70 years old (n=951, median age 55.8); 70–80 years old (n=264, median age 74.1); and >80 years old (n=51, median age 82.3). The oldest patient in our series was 90 years old. Patients were followed up prospectively at 3, 6, 12, and 24 months post surgery. The number of patients completing follow-up (or dying before follow-up) was 880 at 3 months (of whom 27.4% had died), 868 at 6 months (of whom 37.0% had died), 767 at 12 months (of whom 67.4% had died), and 638 at 24 months (of whom 83.5% had died). The demographic characteristics of the three groups are shown in Table 1. There was a trend for more emergency surgeries (within 24 hours of presentation) in patients >80 years old compared to the other two groups: 27.8% versus 16% (p=.105) for 70–80 years old and versus 17.1% (p=.17) for <70 years old. However, scheduled surgeries (greater than 3 days from presentation) were significantly less common, compared to younger patients (p=.043). The incidence of urgent operations (within 1–3 days of presentation) was similar in the three groups: 30–36% (Table 1). Palliative tumor surgeries (stabilization or minimal debulking) were less common in younger patients (31.4% for the <70-year-old group) compared with 50% for the 70- to 80-year-old group (p<.0005) and 52.2% in the >80-year-old group (p=.002). No significant difference was seen between the three groups for piecemeal debulking or vertebrectomies. The median number of affected spinal vertebral levels was 1 (range 1–3) for the two younger age categories, and 2 (range 1–4) for the oldest patient category (>80 years old) (p=.006; Table 2). Older patients tended to present with more extensive disease. Assessment of preoperative quality of life revealed no significant difference in the Karnofsky Performance Status (KPS) between groups >80 years old (KPS 55, SD=19.8) and 70– 80 years old (KPS 57, SD=18.4). However, there was a significant difference between the >80-year-old and <70year-old groups, with the younger age group having better functional scores (KPS 61.5, SD=21.0, p=.003). When looking at other preoperative factors, which may influence the postoperative patient survival, we noticed there was no significant difference between the three groups in preoperative EQ-5D (0.40 in the <70-year-old group, 0.33 in the 70- to 80-year-old group, and 0.33 in the >80-year-old group, p=.56) or ASA score (p=.08). There was also no difference

Table 1 Patient demographics

Age at surgery; mean (SD) Gender; n male (%) First surgery type; n (%) Emergency Scheduled Urgent

<70 Years (N=951)

70–79 Years (N=264)

≥80 Years (N=51)

p-Value

55.8 (9.9) years 504 (53.1%)

74.1 (2.6) years 173 (66.3%)

82.3 (2.2) years 33 (64.7%)

<.0001 <.0001

30 (16.0%) 98 (52.4%) 59 (31.6%)

10 (27.8%) 13 (36.1%) 13 (36.1%)

.105 .043

123 (17.1%) 373 (52.0%) 222 (30.9%)

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Table 2 Characteristics of surgery according to age at surgery

Tumour excision; n (%) Palliative Piecemeal debulking Piecemeal vertebrectomy En bloc intralesional En bloc extralesional Number of levels affected; median Interquartile Range (IQR)

<70 Years (N=951)

70–79 Years (N=264)

≥80 Years (N=51)

263 (31.4%) 324 (38.6%) 101 (12.0%) 60 (7.2%) 91 (10.9%) 1 (1–3)

116 (50.0%) 72 (31.0%) 23 (9.9%) 7 (3.0%) 14 (6.0%) 1 (1–3)

24 (52.2%) 16 (34.8%) 4 (8.7%) 0 (0.0%) 2 (4.4%) 2 (1–4)

P-value <.0005

.006

IQR, interquartile range.

in the proportions of patients with preoperative Frankel A (p=.6) or B (p=.5) score. However, there was a significantly larger proportion presenting with Frankel C (p<.001) or E (p=.005) score in the >80-year-old group. Additionally, significant differences were noticed in the preoperative Frankel B (p=.008) and E categories (p=.0025) between the >70year-old and <80-year-old groups (Table 3). We studied the metastatic tumor types in our series (Table 4). The most recurrent origin for bone metastasis was breast cancer (18.5%), prostate cancer (13.3%), lung cancer (12.8%), kidney cancer (12.8%), and multiple myeloma (6.7%). We observed a high incidence of gastric metastasis in the >80-year-old group (35.3%) compared to the two other groups (p<.001). As previously reported [10–12], the primary tumor type was unknown at presentation in 183 cases (14.5%). Breast metastases were similar in the >70-year-old and >80-year-old age groups, and there were only 6 lung cancers in the >80-year-old group. There was no significant difference in the Tomita score between the three groups, with almost half of the >80-year-old patients (42%) presenting with a Tomita score of 3 or less. Postoperative complications were more common in the elderly (33.3% of the >80-year-old group, p=.004) compared with 23.9% in 70–79-year-old group and 17.9% in <70-year-old groups. There were primarily wound complications (p=.03) or chest infections (p=.04) (Table 5A and B).

Overall median postoperative survival was 13.9 months. Survival was significantly higher for the <70-year-old group compared with the 70- to 80-year-old group (p=.02), but there was no difference between the 70- to80-year-old and >80year-old groups (Fig. 3). Throughout the 24 months of followup, the Kaplan-Meier curves were similar in these latter two groups. Surgery even in the >80-year-old group was not associated with increased patient mortality rate compared with 70–79-year-old group (green and red curves), and overall there wasn’t a great difference between the three age categories. Improvements in Frankel scores were recorded in all age groups after surgery. However, a greater proportion in the younger age groups saw improvements compared with the >80-year-old group. In the <70-year-old group, 41% of patients presenting with grades C and D motor weakness improved at least one grade after surgery (Table 6A), and 42% improved in the 70- to 80-year-old age group (Table 6B). However, in the >80-year-old group, only 29% of patients presenting with Frankel grades C and D improved at least one grade (Table 6C). Discussion In this multicenter international series there were insufficient numbers of patients to reliably evaluate the >90 years age group. Our findings are therefore limited to the age groups

Table 3 Preoperative quality of life parameters according to age at surgery

Pre-Op Karnofsky score; mean (SD) Pre-Op EQ index; median (IQR) Pre-Op Frankel category; n (%) A B C D E ASA; n (%) 1 2 3 >3

<70 Years (N=951)

70–79 Years (N=264)

≥80 Years (N=51)

p-Value

61.5 (21.0) 0.40 (0.17–0.69)

57.0 (18.4) 0.33 (0.12–0.69)

55.0 (19.8) 0.33 (0.12–0.60)

.003 .56

11 (1.2%) 23 (2.5%) 176 (19.0%) 326 (35.1%) 393 (42.3%)

6 (2.3%) 17 (6.6%) 57 (22.0%) 90 (34.8%) 89 (34.4%)

1 (2.0%) 2 (3.9%) 21 (41.2%) 16 (31.4%) 11 (21.6%)

107 (13.7%) 337 (43.0%) 304 (38.8%) 35 (4.5%)

14 (6.7%) 104 (49.8%) 80 (38.3%) 11 (5.3%)

2 (5.1%) 16 (41.0%) 19 (48.7%) 2 (5.1%)

.6 .008 .0007 .0008 .08

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Table 4 Oncologic characteristic according to age at surgery

Metastatic tumor diagnosis; n (%) Breast Colorectal Renal Lung (any) Prostate Myeloma Gastric Liver Bladder Lymphoma Melanoma Sarcoma Thyroid Other specified Other unknown Tomita score n (%) ≤3 4/5 6/7 ≥8

<70 Years (N=951)

70–79 Years (N=264)

≥80 Years (N=51)

197 (20.7%) 42 (4.4%) 126 (13.3%) 127 (13.4%) 84 (8.8%) 61 (6.4%) 12 (1.3%) 17 (1.8%) 10 (1.1%) 13 (1.4%) 21 (2.2%) 17 (1.8%) 29 (3.1%) 47 (4.9%) 148 (15.6%)

31 (11.7%) 10 (3.8%) 32 (12.1%) 34 (12.9%) 66 (25.0%) 22 (8.3%) 6 (2.3%) 3 (1.1%) 5 (1.9%) 7 (2.7%) 5 (1.9%) 1 (0.4%) 7 (2.7%) 9 (3.4%) 26 (9.9%)

6 (11.8%) 2 (3.9%) 5 (9.8%) 2 (3.9%) 18 (35.3%) 2 (3.9%) 18 (35.3%) 2 (3.9%) 0 (0.0%) 1 (2.0%) 1 (2.0%) 0 (0.0%) 1 (2.0%) 3 (5.9%) 9 (17.7%)

265 (31.6%) 195 (23.2%) 191 (22.7%) 189 (22.5%)

90 (39.5%) 47 (20.6%) 52 (22.8%) 39 (17.1%)

18 (42.9%) 6 (14.3%) 8 (19.1%) 10 (23.8%)

p-Value .0001

studied, but the aging population is a trend which is increasing, and in general, our findings can be applied in principle. The size of the samples was not large enough to determine possible regional differences in practice. All the centers participating in this prospective work were highly specialized in spine surgery, with acceptable technical ability and outcomes. We did not compare outcomes to a control group undergoing radiotherapy alone, and therefore our findings are limited to patients who are being considered for surgery. The main treatment options for patients with spinal metastasis are analgesics, corticosteroids, chemotherapy, radiotherapy, and surgery. The aim of these treatments is generally palliative. They improve life quality rather than cure the patient. A specific targeted treatment needs to be planned for each patient to give the maximum palliative effects: pain reduction, stability restoration, or neurologic functions by

.17

removal of spinal cord compression. Treatment strategy was tailored to the individual patient, after multidisciplinary team discussion, including patient and family. The role of surgery for spinal metastasis is becoming more significant [13]. Patchell et al. demonstrated the results of surgery for symptomatic nonradiation sensitive metastatic spinal cord compression were better than those of radiotherapy alone [14]. Additionally, improvements in surgical fixation techniques have resulted in better outcome in terms of pain, ambulation, and survival rates [15]. Patchell et al. concluded that, if operable, patients with metastatic extradural spinal cord compression (MSCC) should undergo tumor resection and stabilization, often followed by postoperative radiotherapy [16]. Even for specific radiosensitive tumors, surgery can be useful to provide mechanical stability. Conversely, for patients with inoperable tumors, definitive radiotherapy still remains a treatment option.

Table 5 (A) Intra- and postoperative complication breakdown according to age at surgery; (B) Postoperative complication localization according to age at surgery

(A) Intra-operative complications; N Y (%) Postoperative complications; N Y (%) (B) Implant failure Urinary tract infection Chest infection Pulmonary embolism and Deep vein thrombosis (PE/DVT) Wound complication Neurologic Other medical PE/DVT, pulmonary embolism and deep vein thrombosis.

<70 Years (N=951)

70–79 Years (N=264)

≥80 Years (N=51)

p-Value

64 (6.7%) 170 (17.9%)

19 (7.2%) 63 (23.9%)

3 (5.9%) 17 (33.3%)

.93 .004

19 (2.0%) 8 (0.8%) 13 (1.4%) 13 (1.4%) 48 (5.1%) 25 (2.6%) 64 (6.7%)

4 (1.5%) 5 (1.9%) 6 (2.3%) 6 (2.3%) 8 (3.0%) 7 (2.7%) 29 (11.0%)

0 (0.0%) 1 (2.0%) 3 (5.9%) 1 (2.0%) 6 (11.8%) 2 (3.9%) 5 (9.8%)

.53 .29 .04 .57 .03 .86 .06

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Fig. 3. Time to death according to age at surgery (log-rank test p=.02).

The role of surgery in the management of spinal metastasis is to restore or preserve fundamental motor functions, especially ambulation. In a prospective study of 98 patients with spinal metastasis, Rades et al. concluded that the best predictor for ambulatory status after radiotherapy was the duration between the onset of symptoms and the development of a motor deficit [17–19]. In the elderly population, the main goal of surgery for MSCC is to prevent neurologic deterioration by spinal cord compression. We demonstrated in this study that the elderly patients present with a worse neurologic function (Frankel score), and there was a trend for fewer scheduled surgeries and greater requirement for urgent operations, although this

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was not statistically significant perhaps because the number of patients >80 years was small. This perhaps resulted in higher complication rates and lower survival rate in the >80-yearold group, which might also be associated with a trend toward worse ASA and functional status in older patients. Nevertheless, the survival curves for the elderly patient groups were not too dissimilar from the survival function for patients <70 years of age (Fig. 3). These results suggest that operative treatment for the elderly improve their quality of life, and it might be potentially detrimental to delay a surgical option simply on the basis of age. Our results suggest that with older age, more spinal levels are affected (p=.006). This might explain the growing complication rates in this subgroup owing to longer and more extensive operative treatments. Similarly, more elderly patients have a worse preoperative Frankel score (p<.0001), yet 42% of patients >80 years old had a favorable Tomita prognostic score <3, with long-term local control and survival expectancy of 50 months, making those patients suitable candidates for surgery. Furthermore, life quality is improved by surgery in all age groups, without a significantly different outcome for the elderly (Fig. 4). Several studies have shown that the primary tumor histology in MSCC patients is the most important prognostic factor for survival [9,20,21]. For instance, prostate cancer is a common cause of spinal metastasis in men >80, and the mean survival is greater than 10 years [22]. In addition, lung cancer metastasis often occurs in the younger age group (13.4%). The larger number of gastric cancers in the >80year-old group may be due to recruitment of patients from

Table 6 (A) Frankel scores before and after surgery, for patients less than 70 years of age; (B) Frankel scores before and after surgery, for patients aged 70–80 years; (C) Frankel scores before and after surgery, for patients over 80 years of age Frankel at discharge (number, percentage) Frankel before surgery (A) A B C D E Total (B) A B C D E Total (C) A B C D E Total

A

B

C

D

E

Total

4 (44%) 2 (9%) 2 (1%) 2 (1%) 0 (0%) 10 (1%)

1 (11%) 7 (30%) 13 (8%) 4 (1%) 0 (0%) 25 (3%)

3 (33%) 7 (30%) 68 (40%) 12 (4%) 3 (1%) 93 (11%)

1 (11%) 6 (26%) 59 (35%) 180 (87%) 38 (10%) 284 (32%)

0 (0%) 1 (4%) 26 (15%) 109 (36%) 332 (89%) 468 (53%)

9 23 168 307 373 880

3 (60%) 0 (0%) 2 (4%) 0 (0%) 1 (1%) 6 (2%)

0 (0%) 5 (31%) 1 (2%) 0 (0%) 0 (0%) 6 (2%)

1 (20%) 7 (44%) 19 (35%) 7 (8%) 3 (4%) 37 (15%)

1 (20%) 4 (25%) 27 (49%) 53 (62%) 8 (9%) 93 (38%)

0 (0%) 0 (0%) 6 (11%) 26 (30%) 73 (86%) 105 (43%)

5 16 55 86 85 247

0 (0%) 0 (0%) 1 (5%) 0 (0%) 0 (0%) 1 (2%)

0 (0%) 1 (50%) 0 (0%) 0 (0%) 0 (0%) 1 (2%)

0 (0%) 0 (0%) 11 (55%) 0 (0%) 1 (10%) 12 (26%)

0 (0%) 1 (50%) 8 (40%) 13 (87%) 3 (30%) 25 (53%)

0 (0%) 0 (0%) 0 (0%) 2 (13%) 6 (60%) 8 (17%)

0 2 20 15 10 47

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Fig. 4. Quality of life was improved by surgery in all age groups. There was no statistically significant difference between the groups, but the improvement was not as sustained in the older age group, and with higher variation.

Japanese centers, thus overrepresenting these tumors that are predominantly found in East Asian populations. A relatively large number of patients were registered with an unknown primary cancer diagnosis compared to other studies [23,24], which might reflect local referral pathways directly to spinal centers when patients present with spinal metastasis as the first manifestation of the disease. In the past, surgeons were reluctant to operate on elderly patients >80. The potential for postoperative medical complications after spine surgery undoubtedly plays a major role in the decision-making process; higher risk patients are evaluated before undergoing extensive spinal surgery. Our results suggest that the preoperative evaluation of patients over 70 years of age should include the Karnofsky score (KPS), which is less subjective than the ASA score. The KPS was more likely to be lower in patients above the age of 70 years compared with below 70 years, perhaps owing to the association with worse preoperative Frankel scores in the elderly. Based on the results of our study, we believe the use of the Karnofsky score (KPS) should be highlighted and recommended. ASA score is known to be a better prognosis factor than KPS in certain diseases such as meningiomas [25]. However, KPS has been shown to be equally as good a prognosis factor as ASA in previous metastatic spinal cord compression studies [26]. Recently, KPS showed to be the strongest support in the literature for predicting brain surgery-related outcomes [27]. In surgical oncology, the KPS has already been recognized as a quality prognostic factor in many tumor entities such as brain metastasis, glioblastomas, urological, and gastrointestinal tumors [28,29]. Assuredly, many products use ASA because it is readily available in electronic database, and it is well established. The determination of KPS score remains very fast, easy, and appropriate to assess therapeutic efficacy, which could make it very useful and preferable. The postoperative complication rate in the >80 age group was higher (33.3%, p=.004) compared with other groups, mainly due to increased wound complications. Our data

suggest that these patients have a more unpredictable outcome even after straightforward surgery. Accordingly, surgery and postoperative management should be planned and anticipated to be more complicated in the >80 age group than with younger patients. However, despite these higher complication rates, these patients still had significant improvements in their quality of life based on the EQ-5D. Therefore, it is important not to base surgical decision making solely on patient age. In a retrospective cohort study from a National Inpatient Database, Li et al. found a 12.17% complication rate and a 0.17% mortality rate after lumbar laminectomy [30]. But in patients older than 85 years, these rates increased up to an 18.9% complication rate, and 1.4% mortality rate, depending on co-morbidities. In a similar study, Deyo et al. identified in the State of Washington hospital discharge registry an 18% complication rate and a 0.6% mortality rate for patients older than 75 years [31]. Reindl et al. compared the complication rates between lumbar spine surgery with or without instrumentation and total hip arthroplasty in the elderly group, and found no significant difference [32]. Raffo and Lauerman reported a 35% major complication rate for patients older than 80 years with instrumented surgery [33], whereas Mazel et al., in their series of lumbar spine surgery in patients 80 years of age or older, reported only 13% major complications and 29.7% minor complications rates [34]. Conclusions It is important to educate general practitioners, oncologists, and spinal surgeons to improve patient pathways, minimize delays, and ensure prompt multidisciplinary consultation for patients with MSCC. Age should not be a contraindication to spine surgery. We also suggest, regardless of age, that surgery should not be delayed if there is a clear indication to operate. However, elderly patients may also present later, with more advanced disease requiring urgent surgery, which may influence the outcome. Patients with spinal metastases may have a relatively short survival, but good functional outcomes and quality of life can be achieved in elderly patients by prompt assessment and early surgery when indicated. References [1] Akram H, Allibone J. Spinal surgery for palliation in malignant spinal cord compression. Clin Oncol (R Coll Radiol) 2010;22:792–800. [2] Choi D, Crockard A, Bunger C, Harms J, Kawahara N, Mazel C, et al. Review of metastatic spine tumor classification and indications for surgery: the consensus statement of the Global Spine Tumor Study Group. Eur Spine J 2010;19:215–22. [3] Byrne TN, Benzel EC, Waxman SG. Epidural tumors. Diseases of the spine and spinal cord. 2000:166–205. [4] Byrne TN. Spinal cord compression from epidural metastases. N Engl J Med 1992;327:614–9. [5] Quinn JA, DeAngelis LM. Neurologic emergencies in the cancer patient. Semin Oncol 2000;27:311–21. [6] Hatrick NC, Lucas JD, Timothy AR, Smith MA. The surgical treatment of metastatic disease of the spine. Radiother Oncol 2000;56:335–9.

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