The incidence of metastatic spine tumors has increased considerably as a result of the technological development of early diagnosis methods. The expected survival durations of patients with different cancer types also been prolonged in recent decades. Decompression and stabilization are indicated in patients with spinal metastases or nonpathological fractures who have high-grade epidural compression with or without neurological deficits and three-column instability. Since most bone metastasis-specific interventions are palliative in nature, health-related QoL (HRQoL) is arguably a more meaningful end point together with symptom control, when compared with traditional end points such as survival times and local control [15]. HRQoL focused on the patient’s feelings and experience after treatment. HRQoL issues are of critical importance for patients, when making decisions in the treatment of bone metastases. To date, there are few prospective studies on surgical outcomes and changes in QoL after surgery in patients with spinal metastases [5, 16, 17]. Therefore, we conducted this prospective study to investigate the change in HRQoL in a consecutive series of patients who underwent palliative surgery for vertebral metastases.
Compared with radiotherapy, external irradiation, or minimally invasive procedures such as vertebroplasty or kyphoplasty, surgery has the conceptual benefit of providing direct spinal cord decompression, reduction of local tumor burden, and the opportunity for mechanical stabilization of the diseased spine. In addition, surgical decompression provides cytoreduction and a margin around neural elements, that is, separation surgery, allowing subsequent adjuvant therapy, which is associated with improved local tumor control[18-21].
The various surgical approaches used to treat spinal metastasis include the following: anterior transcavitary and posterior, posterolateral (transpedicular, costotransversectomy, lateral extracavitary), and a combined approach. Because tumor location, the type of reconstruction needed, patient comorbidities, the extent of primary tumor, and the surgeon's preference have a great impact on the surgical approach, it is essential that the best surgical approach from the patient's perspective be carefully considered before surgery. In the past, many published retrospective studies have shown that 360 degree decompression with a single PTA provides circumferential decompression and stabilization simultaneously, which is associated with less morbidity in systemically compromised patients. The present study, based on 39 consecutive patients enrolled with spinal metastases, shows that 360 degree decompression with a single PTA results in significant improvements in pain, neurological function and HRQoL.
Patient-reported HRQoL outcome measures convey information that can be critical in clinical decision making. Among other HRQoL-measuring instruments, the EORTC QLQ-BM22 can effectively detect changes in QoL in diverse bone metastasis populations. This study shows that decompression with a single PTA improves pain, neurologic and functional status, and that EORTC QLQ-BM22 can measure health utilities and HRQoL for symptomatic patients. Compared with preoperative scores, postoperativeEORTC QLQ-BM22 scores for painful sites, pain characteristics, and functional interference scale were significantly lower at the 1-month and 3-, 6-, and 12-month follow-ups. As investigators mention in several other studies, spinal surgery for MESCC is associated with rapid, substantial, and sustained pain relief[5, 16]. Healthcare professionals will be able to reliably assess their patients’ QoL, help patients choose a treatment and assess the cost-effectiveness of the treatments. QoL outcomes in patients with bone matastasis will be compared across clinical trials through the utilization of a consistent and valid questionnaire.
In a previous study, researchers reported that the Eastern Cooperative Oncology Group (ECOG), the Short Form 36 Health Survey (SF-36), the VAS scale, and the assessment of ambulatory status and motor function effectively evaluated the factors that influence the health status of patients with spinal neoplastic disease. In a retrospective study, Chen et al. [22] reported that the EORTC QLQ-BM22 questionnaire showed improved QoL outcomes in patients with spinal metastasis afte microinvasive surgery combined with intraoperative radiotherapy. Our results support the fact that surgery improves function and QoL outcomes in patients with metastatic thoracic and lumbar tumors.
In this study, the psychosocial aspects in the EORTC QLQ-BM22 did not reach statistical significance after surgery; which is predominantly due to the small sample size. In addition, patients had different concerns. For example, some patients worried less about a potential loss of mobility, and more about economic factors. Some patients were more worried about becoming dependent on others. Moreover, patients with MESCC represent a frail population with few reserves to deal with additional physical or emotional stress. In future studies, more cases should be included so that each psychosocial items for each individual question can be analyzed to identify areas in which differences are particularly apparent.
This study had a several limitations. Although this is a prospective single center study, it is limited by its small sample size and lack of controls. Second, there was no stratification by pathological type due to the small sample of patients. Prospective clinical studies are necessary to further investigate the long-term treatment outcomes of surgery for spinal metastases.
Nonetheless, the present feasibility study found that the application of the posterolateral transpedicular approach for decompression and fusion in patients with spinal metastases can also benefit patients with MESCC in that it achieves prompt and sustained pain relief, reduceds neurolofic deficits and improves functional outcomes, health utilities and HRQoL. Given the overall low incidence, clinical heterogeneity, and rapid development of more efficient medical therapies for the treatment of MESCC, we support current efforts to collect prospective longitudinal data on spine oncology patients.