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The Evolution of Surgical Management for Vertebral Column Tumors

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The Evolution of Surgical Management for Vertebral Column Tumors LITERATURE REVIEW J Neurosurg Spine 30:417–423, 2019 The evolution of surgical management for vertebral column tumors JNSPG 75th Anniversary Invited Review Article Jared Fridley, MD, and Ziya L. Gokaslan, MD Department of Neurosurgery, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island Surgery for the resection of vertebral column tumors has undergone a remarkable evolution over the past several de- cades. Multiple advancements in surgical techniques, spinal instrumentation, technology, radiation therapy, and medical therapy have led to improved patient survival, function, and decreased morbidity. In this review, the authors discuss ma- jor changes in each of these areas in further detail. https://thejns.org/doi/abs/10.3171/2018.12.SPINE18708 KEYWORDS spine tumor; primary tumor; secondary tumor; spinal radiosurgery; separation surgery; oncology HE treatment of vertebral column tumors has under- advances. In this review, we discuss the ongoing evolution gone significant transformation over the past several of spine tumor treatment, particularly with regard to man- decades. Advances in surgical techniques, chemo- agement of metastatic and primary spine tumors. Ttherapy, radiation therapy, and the incorporation of tech- nological innovations into the operating room have led to Advances in Surgical Strategies an overall shift in the management of patients with spine tumors, all with the goal of minimizing treatment-related The treatment of primary spine tumors remains pri- morbidity. Perhaps the most significant changes have been marily surgical. This simple fact belies the relatively re- the recent advances in spinal radiosurgery and cancer im- cent change in how we resect these tumors. Principles for munotherapy and the incorporation of patient and tumor- the treatment of long bone primary tumors developed and specific genomic and molecular information to personal- published by Enneking et al.19 in the 1980s were adapted ize cancer therapy, particularly for metastatic disease. for the spine by Weinstein and colleagues7 in the 1990s. While the goal of surgery for metastatic spine disease The Weinstein-Boriani-Biagini system became an es- remains palliative, the typical poor prognosis given to sential tool in presurgical planning for these tumors as it these patients is trending toward a more optimistic out- standardized the staging of primary spine tumors (Fig. 1). look. With each advance, traditional prognostic scoring Specification of the exact tumor location in relation to the methods for metastatic spinal disease are becoming less bony elements of the vertebra allows the surgeon to tai- accurate. Unlike metastases, most primary spine tumors lor the surgical approach, based on histology and location, continue to be treated primarily with surgery, but ad- which is particularly useful for tumors in which an en bloc vances in surgical techniques that have incorporated prin- resection is desired. While en bloc resection of primary ciples from the treatment of long bone tumors have led spine tumors carries significant approach-related morbid- to decreased tumor recurrence rates and, in some cases, a ity, the local recurrence rate and tumor-associated mortal- potential for cure. Research into adjuvant therapy for pri- ity can be significantly reduced.2,6 The Weinstein-Boriani- mary tumors is progressing, with many recent promising Biagini classification also standardized the terminology ABBREVIATIONS EBRT = external-beam radiation therapy; NOMS = neurological, oncological, mechanical, and systemic; SINS = spinal instability neoplasia score; SRS = stereotactic radiosurgery. SUBMITTED December 1, 2018. ACCEPTED December 14, 2018. INCLUDE WHEN CITING DOI: 10.3171/2018.12.SPINE18708. ©AANS 2019, except where prohibited by US copyright law J Neurosurg Spine Volume 30 • April 2019 417 Unauthenticated | Downloaded 10/05/21 11:04 AM UTC Fridley and Gokaslan FIG. 1. Weinstein-Boriani-Biagini classification for spinal tumors. Reproduced with permission from Boriani S, Weinstein JN, Biagini R: Primary bone tumors of the spine. Terminology and surgical staging. Spine (Phila Pa 1976) 22(9):1036–1044, 1997. https://journals.lww.com/spinejournal/pages/default.aspx. used when describing extent of resection, which allowed Concurrent to the Patchell trial, work was also being accurate comparison of treatment strategies between insti- done to study the utility of a new spinal radiation modal- tutions and in the published literature. ity: spinal stereotactic radiosurgery (SRS), which built off Surgery for spinal metastases has perhaps undergone the success of radiosurgery for brain metastases. In 2007, the most significant transformation in terms of surgi- Gerszten et al.24 published the results of a series of 500 cal technique. Prior to the 1990s many surgeons were metastases to the spine in 393 patients who underwent spi- performing either simple posterior bony decompression nal radiosurgery; they excluded patients with neurological or primary external-beam radiation therapy (EBRT) for deficits or spinal instability. The results were particularly patients with metastatic epidural spine disease, causing encouraging, with high rates of long-term pain control cord compression. Young et al.61 demonstrated that these 2 (86%) and long-term tumor control (90%). Radiosurgery treatments had similar efficacy in terms of pain relief, am- will be discussed in more detail below, but suffice it to say bulation, and sphincter function, leading many to question that these results led again to a change in treatment para- the utility of a simple decompression. In addition, it was digm for patients with metastatic spine disease. noted that many patients who underwent a laminectomy The success of SRS led to many metastatic spine tumor would develop kyphotic deformity over time, leading to patients being treated with primary radiation therapy rath- significant patient morbidity. The landmark trial of Patch- er than surgical intervention. Currently, the 2 main indica- ell et al.,47 published in 2005, which excluded radiosensi- tions for primary surgical intervention are decompression tive tumors, demonstrated that a direct circumferential de- of the spinal cord and stabilization of the spine if there compression of the spinal cord with postoperative EBRT is evidence of instability. While the former had demon- had significant benefit in terms of the ability to regain or strated utility thanks in large part to the study of Patch- preserve ambulatory function and reduced the need for ell et al.,47 spinal instability had not been well defined for corticosteroids and opioid analgesics. Subsequently, there the metastatic spine disease population. There had been was an increased focus on the benefit of surgical inter- significant heterogeneity in the literature regarding who vention with surgeons performing circumferential decom- might benefit from stabilization surgery, and there were no pression supplemented with vertebral column reconstruc- consensus guidelines available. In 2010, the Spine Oncol- tion and posterior segmental instrumentation in increasing ogy Study Group published the spinal instability neoplasia numbers. score (SINS),20 a scoring system to determine who may 418 J Neurosurg Spine Volume 30 • April 2019 Unauthenticated | Downloaded 10/05/21 11:04 AM UTC Fridley and Gokaslan TABLE 1. The SINS for scoring spinal instability in patients with patients who should be considered for surgery are those spine tumors who have high-grade spinal cord compression and/or spi- Element of SINS Score nal instability (Fig. 2). The high rate of local tumor con- trol with SRS led to the concept of “separation surgery” in Location patients with high-grade metastatic epidural spinal cord Junctional (occiput–C2, C7–T2, T11–L1, L5–S1) 3 compression.46 The goal of separation surgery is to limit Mobile spine (C3–C6, L2–L4) 2 the amount of tumor resection needed by creating a tumor- Semi-rigid (T3–T10) 1 free margin around the thecal sac and using postopera- Rigid (S2–S5) 0 tive SRS for the remaining spinal tumor. By minimizing tumor resection, the hope is that surgical morbidity can be Pain relief with recumbency and/or pain with movement/ reduced, although this needs further study. Recently, Tat- loading of the spine sui et al.53,55 published their experience using spinal laser Yes 3 interstitial thermotherapy (sLITT) for separation surgery, No (occasional pain but not mechanical) 1 combined with percutaneous instrumentation. This tech- Pain-free lesion 0 nique minimizes surgical morbidity by treating epidural Bone lesion tumor with LITT rather than resection. This may be par- Lytic 2 ticularly useful in patients who either are poor surgical Mixed (lytic/blastic) 1 candidates or need to be given systemic treatment for their metastatic disease with minimal delay to treatment after Blastic 0 surgery. Radiographic spinal alignment Subluxation/translation present 4 Advances in Surgical Instrumentation and De novo deformity (kyphosis/scoliosis) 2 Technology Normal alignment 0 Technological innovation in industry and academia Vertebral body collapse has led to the incorporation of many different surgical ad- >50% collapse 3 juncts to decrease patient morbidity and improve surgical <50% collapse 2 efficacy. Some of these innovations have become widely No collapse with >50% body involved 1 adopted, including screw-rod constructs, expandable tita- None of the above 0 nium cages, kyphoplasty/vertebroplasty, computer-assist- Posterolateral involvement of the
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