Spinal metastasis in the elderly

Abstract

Bony metastases are a frequent problem in elderly patients affected by cancer, and those with bony metastases involve the spine in approx. 50%. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer. The chance that an elderly patient (60-79 years old) is affected by bony metastases is four times higher in men and three times higher in women than a middle-aged patient (40-59 years old). Since the medical treatment with all the adjuvant treatment options prolong the survival of this particular patient group, the spinal metastases may become a mechanical issue, thus requesting surgical treatment. Different classification systems have been proposed to rationalize surgical indications, some concentrating solely on the local spinal tumor involvement and some including the overall clinical situation. Since most of the surgical options are of palliative character, it is more important to base the decision on an overall clinical classification including the different treatment modalities-irradiation, chemotherapy, steroids, bisphosphonates, and surgery-to make a shared decision. In case surgery is indicated-neural compression, pathological fracture, instability, and progressive deformity, nursing reasons-the most straightforward procedures should be chosen, which may not need an intensive care unit stay. In the thoracolumbar spine a posterior decompression and posterolateral vertebral body resection through a posterior approach only, with a concomitant reconstruction and stabilization, has shown to work sufficiently well. In the middle and lower cervical spine the anterior approach with anterior decompression and anterior column reconstruction is most effective and has a low morbidity, whereas the occipitocervical junction can generally be treated by posterior resection and stabilization. The outcome should be determined by the survival time in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. Surgical management shows the greatest improvement in pain reduction, but also in other domains of quality of life. Since prospective randomized studies comparing different treatment modalities for spinal metastases including surgery are not available and are ethically difficult to achieve, each case remains an interdisciplinary, shared decision making process for what is considered best for a patient or elderly patient. However, whenever surgery is an option, it should be planned before irradiation since surgery after irradiation has a significant higher complication rate.

Fig. 1.

Tokuhashi et al. [50] scoring system to establish preoperative prognosis of metastatic spine tumor

Fig. 2.

Long fixation in progressing deformity and instability a A 62-year-old woman with multiple-level involvement of the cervical, thoracic, and lumbar spine metastases of a breast cancer with neurological deficit and pain due to progressing deformity and instability. b Long fixation (sublaminar wiring-metal-cement compound) and partial correction from C1 to the lower thoracic spine in combination with irradiation was most efficient in reducing pain and neurological deficit for more than 3 years. c A 58-year-old man with a hypernephroid carcinoma and cervical involvement had previous anterior surgery and a cement block posteriorly (asterisk) with consecutive progression of the tumor, loosening of the fixation and a nonunion at the cement-bone interface (arrow). d Posterior removal of the cement block and stabilization were followed by e anterior revision and restabilization after a previous embolization of the tumor and occlusion of one of the vertebral arteries. The patient died 2 years after this surgery from metastatic complications other than the cervical spine

Fig. 3.

Surgery ideally should be carried out before irradiation [1]. Irradiation which preceding surgery [2] has a significantly higher complication rate [21]

Fig. 4.

Anterior surgery for metastatic spine disease. a Woman with a kidney cancer, metastasing in the middle-thoracic spine. b Anterior resection and stabilization by a metal-cement compound and subsequent irradiation. c A 62-year-old woman with a breast cancer metastases into the C7 vertebra. d Resection, reconstruction with a tricalcium bone substitute block, and plating with consecutive irradiation

Fig. 5.

Posterior surgery for metastatic spine disease. a A 73-year-old man with a metastases in L2 from a stomach cancer. b, c Through a single median posterior incision laminectomy, posterolateral resection of the vertebral body through both pedicles, and posterior reconstruction and stabilization with a short pedicular, angle stable system combined with an anterior column reconstruction with metal-cement compound through the posterior approach. d, e Partial resection and posterior stabilization of the upper cervical spine involved by lung metastases followed by irradiation in a 73-year-old man. Note the combination of a metal-cement compound posteriorly instead of bony fusion

Fig. 6.

Decision algorithm of the treatment tailored to the individual patient's need and therapeutic option