Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Minimally Invasive Surgery without Decompression for Hepatocellular Carcinoma Spinal Metastasis with Epidural Spinal Cord Compression Grade 2

  • Jung, Jong-myung (Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital) ;
  • Chung, Chun Kee (Department of Neurosurgery, Seoul National University College of Medicine) ;
  • Kim, Chi Heon (Department of Neurosurgery, Seoul National University College of Medicine) ;
  • Yang, Seung Heon (Department of Neurosurgery, Seoul National University College of Medicine)
  • Received : 2018.10.18
  • Accepted : 2018.11.20
  • Published : 2019.07.01
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Abstract

Objective : There is a lack of knowledge regarding whether decompression is necessary in treating patients with epidural spinal cord compression (ESCC) grade 2. The purpose of this study was to compare the outcomes of minimally invasive surgery (MIS) without decompression and conventional open surgery (palliative laminectomy) for patients with hepatocellular carcinoma (HCC) spinal metastasis of ESCC grade 2. Methods : Patients with HCC spinal metastasis requiring surgery were retrospectively reviewed. Patients with ESCC grade 2, medically intractable mechanical back pain, a Nurick grade better than 3, 3-6 months of life expectancy, Tomita score ${\geq}5$, and Spinal Instability Neoplastic Score ${\geq}7$ were included. Patients with neurological deficits, other systemic illnesses and less than 1 month of life expectancy were excluded. Thirty patients were included in the study, including 17 in the open surgery group (until 2008) and 13 in the MIS group (since 2009). Results : The MIS group had a significantly shorter operative time ($94.2{\pm}48.2minutes$ vs. $162.9{\pm}52.3minutes$, p=0.001), less blood loss ($140.0{\pm}182.9mL$ vs. $1534.4{\pm}1484.2mL$, p=0.002), and less post-operative intensive care unit transfer (one patient vs. eight patients, p=0.042) than the open surgery group. The visual analogue scale for back pain at 3 months post-operation was significantly improved in the MIS group than in the open surgery group ($3.0{\pm}1.2$ vs. $4.3{\pm}1.2$, p=0.042). The MIS group had longer ambulation time ($183{\pm}33days$ vs. $166{\pm}36days$) and survival time ($216{\pm}38days$ vs. $204{\pm}43days$) than the open surgery group without significant difference (p=0.814 and 0.959, respectively). Conclusion : MIS without decompression would be a good choice for patients with HCC spinal metastasis of ESCC grade 2, especially those with limited prognosis, mechanical instability and no neurologic deficit.

Keywords

References

  1. Abrahm JL, Banffy MB, Harris MB : Spinal cord compression in patients with advanced metastatic cancer: "all I care about is walking and living my life". JAMA 299 : 937-946, 2008 https://doi.org/10.1001/jama.299.8.937
  2. Bartels RH, van der Linden YM, van der Graaf WT : Spinal extradural metastasis: review of current treatment options. CA Cancer J Clin 58 : 245-259, 2008 https://doi.org/10.3322/CA.2007.0016
  3. Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, et al. : Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine 13 : 324-328, 2010 https://doi.org/10.3171/2010.3.SPINE09459
  4. Bruix J, Llovet JM : Prognostic prediction and treatment strategy in hepatocellular carcinoma. Hepatology 35 : 519-524, 2002 https://doi.org/10.1053/jhep.2002.32089
  5. Chang UK, Kim MS, Han CJ, Lee DH : Clinical result of stereotactic radiosurgery for spinal metastasis from hepatocellular carcinoma: comparison with conventional radiation therapy. J Neurooncol 119 : 141-148, 2014 https://doi.org/10.1007/s11060-014-1463-9
  6. Cho DC, Sung JK : Palliative surgery for metastatic thoracic and lumbar tumors using posterolateral transpedicular approach with posterior instrumentation. Surg Neurol 71 : 424-433, 2009 https://doi.org/10.1016/j.surneu.2008.02.049
  7. Choi D, Crockard A, Bunger C, Harms J, Kawahara N, Mazel C, et al. : Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group. Eur Spine J 19 : 215-222, 2010 https://doi.org/10.1007/s00586-009-1252-x
  8. Dittmer DK, Teasell R : Complications of immobilization and bed rest. Part 1: musculoskeletal and cardiovascular complications. Can Fam Physician 39 : 1428-1432, 1435-1437, 1993
  9. Falicov A, Fisher CG, Sparkes J, Boyd MC, Wing PC, Dvorak MF : Impact of surgical intervention on quality of life in patients with spinal metastases. Spine (Phila Pa 1976) 31 : 2849-2856, 2006 https://doi.org/10.1097/01.brs.0000245838.37817.40
  10. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC : Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 32 : 193-199, 2007 https://doi.org/10.1097/01.brs.0000251863.76595.a2
  11. Gerszten PC, Germanwala A, Burton SA, Welch WC, Ozhasoglu C, Vogel WJ : Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures. J Neurosurg Spine 3 : 296-301, 2005 https://doi.org/10.3171/spi.2005.3.4.0296
  12. Gerszten PC, Monaco EA 3rd : Complete percutaneous treatment of vertebral body tumors causing spinal canal compromise using a transpedicular cavitation, cement augmentation, and radiosurgical technique. Neurosurg Focus 27 : E9, 2009 https://doi.org/10.3171/2009.9.FOCUS09184
  13. Gerszten PC, Welch WC : Spine: minimally invasive techniques. Prog Neurol Surg 19 : 135-151, 2006 https://doi.org/10.1159/000095188
  14. Goodwin CR, Yanamadala V, Ruiz-Valls A, Abu-Bonsrah N, Shankar G, Sankey EW, et al. : A systematic review of metastatic hepatocellular carcinoma to the spine. World Neurosurg 91 : 510-517.e4, 2016 https://doi.org/10.1016/j.wneu.2016.04.026
  15. Halpin RJ, Bendok BR, Liu JC : Minimally invasive treatments for spinal metastases: vertebroplasty, kyphoplasty, and radiofrequency ablation. J Support Oncol 2 : 339-351; discussion 352-355, 2004
  16. Hansen-Algenstaedt N, Algenstaedt P, Bottcher A, Joscheck C, Schwarzloh B, Schaefer C, et al. : Bilaterally increased VEGF-levels in muscles during experimental unilateral callus distraction. J Orthop Res 21 : 805-812, 2003 https://doi.org/10.1016/S0736-0266(03)00060-3
  17. Hayat MJ, Howlader N, Reichman ME, Edwards BK : Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) program. Oncologist 12 : 20-37, 2007 https://doi.org/10.1634/theoncologist.12-1-20
  18. Itshayek E, Yamada J, Bilsky M, Schmidt M, Shaffrey C, Gerszten P, et al. : Timing of surgery and radiotherapy in the management of metastatic spine disease: a systematic review. Int J Oncol 36 : 533-544, 2010
  19. Jansson KA, Bauer HC : Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases. Eur Spine J 15 : 196-202, 2006 https://doi.org/10.1007/s00586-004-0870-6
  20. Jonsson B, Sjostrom L, Olerud C, Andreasson I, Bring J, Rauschning W : Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 5 : 36-44, 1996 https://doi.org/10.1007/BF00307825
  21. Kim CH, Chung CK, Jahng TA, Kim HJ : Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis. Spine J 11 : 1015-1023, 2011 https://doi.org/10.1016/j.spinee.2011.09.007
  22. Kim CH, Chung CK, Jahng TA, Kim HJ : Surgical outcome of spinal hepatocellular carcinoma metastases. Neurosurgery 68 : 888-896, 2011 https://doi.org/10.1227/NEU.0b013e3182098c18
  23. Kim CH, Chung CK, Sohn S, Lee S, Park SB : Less invasive palliative surgery for spinal metastases. J Surg Oncol 108 : 499-503, 2013 https://doi.org/10.1002/jso.23418
  24. Kim CW : Scientific basis of minimally invasive spine surgery: prevention of multifidus muscle injury during posterior lumbar surgery. Spine (Phila Pa 1976) 35 : S281-S286, 2010 https://doi.org/10.1097/BRS.0b013e3182022d32
  25. Kim DY, Lee SH, Chung SK, Lee HY : Comparison of multifidus muscle a trophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation. Spine (Phila Pa 1976) 30 : 123-129, 2005 https://doi.org/10.1097/01.brs.0000148999.21492.53
  26. Kim KT, Lee SH, Suk KS, Bae SC : The quantitative analysis of tissue injury markers after mini-open lumbar fusion. Spine (Phila Pa 1976) 31 : 712-716, 2006 https://doi.org/10.1097/01.brs.0000202533.05906.ea
  27. Klimo P Jr, Kestle JR, Schmidt MH : Treatment of metastatic spinal epidural disease: a review of the literature. Neurosurg Focus 15 : E1, 2003
  28. Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al. : The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist 18 : 744-751, 2013 https://doi.org/10.1634/theoncologist.2012-0293
  29. Park KW, Park JW, Choi JI, Kim TH, Kim SH, Park HS, et al. : Survival analysis of 904 patients with hepatocellular carcinoma in a hepatitis B virus-endemic area. J Gastroenterol Hepatol 23 : 467-473, 2008 https://doi.org/10.1111/j.1440-1746.2007.05112.x
  30. Pascal-Moussellard H, Broc G, Pointillart V, Simeon F, Vital JM, Senegas J : Complications of vertebral metastasis surgery. Eur Spine J 7 : 438-444, 1998 https://doi.org/10.1007/s005860050105
  31. 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 randomised trial. Lancet 366 : 643-648, 2005 https://doi.org/10.1016/S0140-6736(05)66954-1
  32. Pointillart V, Vital JM, Salmi R, Diallo A, Quan GM : Survival prognostic factors and clinical outcomes in patients with spinal metastases. J Cancer Res Clin Oncol 137 : 849-856, 2011 https://doi.org/10.1007/s00432-010-0946-0
  33. Pull ter Gunne AF, Skolasky RL, Ross H, van Laarhoven CJ, Cohen DB : Influence of perioperative resuscitation status on postoperative spine surgery complications. Spine J 10 : 129-135, 2010 https://doi.org/10.1016/j.spinee.2009.10.002
  34. Quan GM, Vital JM, Aurouer N, Obeid I, Palussiere J, Diallo A, et al. : Surgery improves pain, function and quality of life in patients with spinal metastases: a prospective study on 118 patients. Eur Spine J 20 : 1970-1978, 2011 https://doi.org/10.1007/s00586-011-1867-6
  35. Ragel BT, Kan P, Schmidt MH : Blood transfusions after thoracoscopic anterior thoracolumbar vertebrectomy. Acta Neurochir (Wien) 152 : 597-603, 2010 https://doi.org/10.1007/s00701-009-0549-1
  36. Schaefer C, Schroeder M, Fuhrhop I, Viezens L, Otten J, Fiedler W, et al. : Primary tumor dependent inhibition of tumor growth, angiogenesis, and perfusion of secondary breast cancer in bone. J Orthop Res 29 : 1251-1258, 2011 https://doi.org/10.1002/jor.21402
  37. Schneider F, Greineck F, Clausen S, Mai S, Obertacke U, Reis T, et al. : Development of a novel method for intraoperative radiotherapy during kyphoplasty for spinal metastases (Kypho-IORT). Int J Radiat Oncol Biol Phys 81 : 1114-1119, 2011 https://doi.org/10.1016/j.ijrobp.2010.07.1985
  38. Schroeder M, Viezens L, Wellbrock J, Fiedler W, Ruther W, Algenstaedt P, et al. : Sunitinib treatment reduces tumor growth and limits changes in microvascular properties after minor surgical intervention in an in vivo model of secondary breast cancer growth in bone. J Surg Oncol 113 : 515-521, 2016 https://doi.org/10.1002/jso.24185
  39. Schwab JH, Gasbarrini A, Cappuccio M, Boriani L, De Iure F, Colangeli S, et al. : Minimally invasive posterior stabilization improved ambulation and pain scores in patients with plasmacytomas and/or metastases of the spine. Int J Surg Oncol 2011 : 239230, 2011 https://doi.org/10.1155/2011/239230
  40. Sciubba DM, Gokaslan ZL : Diagnosis and management of metastatic spine disease. Surg Oncol 15 : 141-151, 2006 https://doi.org/10.1016/j.suronc.2006.11.002
  41. Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, et al. : Diagnosis and management of me tastatic spine disease. A review. J Neurosurg Spine 13 : 94-108, 2010 https://doi.org/10.3171/2010.3.SPINE09202
  42. Sohn S, Kim J, Chung CK, Lee NR, Park E, Chang UK, et al. : A nationwide epidemiological study of newly diagnosed spine metastasis in the adult Korean population. Spine J 16 : 937-945, 2016 https://doi.org/10.1016/j.spinee.2016.03.006
  43. Teasell R, Dittmer DK : Complications of immobilization and bed rest. Part 2: other complications. Can Fam Physician 39 : 1440-1442, 1445-1446, 1993
  44. Weigel B, Maghsudi M, Neumann C, Kretschmer R, Muller FJ, Nerlich M : Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine (Phila Pa 1976) 24 : 2240-2246, 1999 https://doi.org/10.1097/00007632-199911010-00012
  45. Wiesner L, Kothe R, Ruther W : Anatomic evaluation of two different techniques for the percutaneous insertion of pedicle screws in the lumbar spine. Spine (Phila Pa 1976) 24 : 1599-1603, 1999 https://doi.org/10.1097/00007632-199908010-00015
  46. Wise JJ, Fischgrund JS, Herkowitz HN, Montgomery D, Kurz LT : Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 24 : 1943-1951, 1999 https://doi.org/10.1097/00007632-199909150-00014
  47. Zairi F, Arikat A, Allaoui M, Marinho P, Assaker R : Minimally invasive decompression and stabilization for the management of thoracolumbar spine metastasis. J Neurosurg Spine 17 : 19-23, 2012 https://doi.org/10.3171/2012.4.SPINE111108

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