1. Metastatic Spinal Disease Jan 2011, West of Scotland Teaching.

2. Aims Diagnosis Patient Selection for Surgery Surgical Principles

3. Metastatic Spine Disease Spinal metastases are COMMON 40 -80% Nerve compression in 12% Spinal instability 10% Schaberg & Gainor 1985

4. Lumbosacral32% Thoracic 53% 53% Cervical 15% 15% Spinal Metastases Distribution Anterior75% Posterior15% Lateral10%

5. Biology Primary tumour type important Some respond to medical treatment Some are resistant Prognosis with lung disease dismal King et al 1991. Breast Prostate Lung Renal GI tract Thyroid

6. Evidence Surgery Beneficial Bailey & Badgley1960 Scoville et al1967 Gunn et al 1974 Jelsma & Kirsch1979 Harrington1981 Sundaresan et al1985 Siegal & Siegal1985 Turner et al1988 Kocialkowski & Webb1992 Siegal & Siegal 1980 O’Neil et al 1988 Manabe et al 1989 Olerud and Jonsson 1996 Bauer 1997

7. Evidence Surgery Beneficial Olerud1996 Rompe 1999 Weigel 1999 Giehl 1999 Wise 1999 Hatrick2000 Tomita2001

15. Breast Cancer Natural History 9000 women each year Breast cancer with bone metastases 1700 pathological spinal fractures 20% alive at 5 years

16. Natural History of Breast Cancer Factors associated with reduced survival

18. Treatment Planning Data Required Clinical problem Diagnosis Extent of local & general spread Life expectancy Fitness to withstand surgery Patient’s wishes

19. Imaging Radiographs Bone Scan CT scan MRI Redmond et al 1984, Boland et al 1982

20. Tokuhashi Score Spine 1990 General condition Number of extraspinal bony mets Number of vertebral mets Visceral mets Primary cancer Severity of cord injury

21. Tokuhashi Score 113 cases Nippon Sekei 1994 5 points and below 8 % survival 6/12 9 points and above 78 % alive at 1 yr

24. Patient Groups Primary known & fully investigated Unknown primary – BAD NEWS !!!

25. Known Primary 3 Groups 1.No symptoms 2.Pain 3.Neurological deficit

26. 3 Patient Groups Diagnosis Certain 1.No symptoms 2.Pain 3.Neurological deficit Minor involvement Major involvement & sensitive to DXT

27. 3 Patient Groups Diagnosis Certain 1.No symptoms 2.Pain 3.Neurological deficit Bony collapse on x-ray series Trial of support

28. Mechanical spinal pain Spinal instability Pathological # or impending #

29. Instability pain at L5 - No neurological deficit Flatley & Anderson 1984

30. 3 Patient Groups Diagnosis Certain 1.No symptoms 2.Pain 3.Neurological deficit

31. …Diagnosis Probably not surgically treatable

32. Neural compression by tumour

34. Treatment Indications for surgery Progressive neurological deficit Bony collapse with intractable pain Not radiosensitive Previous radiotherapy (maximum dose)

35. Surgical Goals Immediate stability Minimise complications Improve quality of life Adjunctive treatment usually required Surgery does NOT prolong life?

36. Neural compression by bone

38. Ligamentotaxis

42. Surgery Decompression & Stabilisation Stabilisation NOT Laminectomy

43. Medical Treatment Surgery not required Medical contra-indications Surgery is not possible Patient does not want surgery 75% Conservatively Managed

44. Vertebroplasty?

47. Vertebroplasty Cortet et al., Rev Rhum Engl Ed, 1997 Simple & effective Only in units with spinal surgery in case of complications

48. CS - Case Series, UPS - Uncontrolled Prospective Study Evidence Table

49. Evidence Base Vertebroplasty Numerous prospective studies report very significant improvement in mobility & function Deramond 1998, Cortet et al 1999, Lieberman et al 2001, Diamond et al 2003, Gangi et al 2003, Winking et al 2004. No prospective randomised controlled trials

50. SUMMARY Treatment of vertebral spinal tumours has evolved massively in the last 10 years -better primary Px -better assessment/ imaging - evidence surgery helps

51. SUMMARY Diagnosis is paramount -biology of primary -extent of bony spread -extent of extra-osseous involvement - is the tumour causing the problem

52. Primary Tumours Primary bone tumours are RARE 0.5% Primary spinal tumours are even RARER <0.05%

57. SUMMARY Surgery very effective in properly selected cases with specific aims -advances in technology -anaesthetic advances All these patients will succumb to their disease.