Neurological Results in Spinal Cord Metastases M. Baldini1, G. P. Tonnarelli2, L. Princi', C. Vivenza3, V. Nizzoli2 1 The State University Clinic of Neurosurgery, School oí Medicine, Pavia (Italy) 2 Department of Neurosurgery, City Hospital of Legnano, Legnano (Italy) 3 Department of Neurosurgery, City Hospital »Borgo Trento« of Verona, Verona (Italy)

Summary

Zusammenfassung

Between 1971 and 1978 140 cases of spinal metastasis treated by decompression or possible removal of secondary neoplasm, were studied. Patients were divided according to their preoperative neurological conditions and then evaluated on the ground of regression of spinal cord and root symptom. The possibility of treating this type of compressive spinal pathology surgically is discussed.

Neurologische Befunde bei spinalen Metastasen

Key-Words: Spinal cord metastases treatment - Dural decompression removal

Surgical Tumour

Alan hat 140 Fälle von Wirbelmetastasen studiert, die einer chirurgischen Behandlung von osteo-duraler Dekompression und/oder von Abnahme der sekundären Geschwulst zwischen 1971-1978 unterzogen wurden. Die Patienten, die nach den neurologischen preoperativen Lagen unterschieden wurden, sind nachher aufgrund der eventuellen Regression der Mark- und Wurzelsymptomatologie beurteilt. Die Möglichkeiten der chirurgischen Behandlung in diesem Typ von kompressiver Rückenmarkspathologie werden diskutiert.

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Neurochirurgia 22 (1979) 159-165 © Georg Thieme Verlag Stuttgart

M. Baldini, G. P. Tonnarelli, L. Princi, C. Vivenza, V. Nizzoli

Introduction

Tab. 1

Two problems are usually involved in spinal compression from metastases of known or unknown origin: - the necessity of an urgent spinal cord decompression in rapidly progressive compression of unknown cause; - the opportunity of surgical treatment in metastases of known origin. (8, 11, 15, 16). Half of the observed cases were so called "revealing" metastases, in which the diagnosis of a primary tumour state was only made when a spinal metastasis was recognised surgically (12). In this study 140 consecutive cases of spinal metastasis undergoing operation were evaluated.

Primary Carcinomas

N°

Breast Lung Prostate Kidney Stomach Thyroid Intestine Uterus Larynx Unknown

24 20 16 9 7 5 4 4 3 33

Total

125

Percentage % 19-2 16 12-8 7-2 5-6 5 3-2 3.2 2-4 26-4 100

Tab. 2 Clinical Evolution of 80 % of Spinal Metastases spinal and root pain 1-3 months paraparesis 1 month paraplegia

Methods Between 1971 and 1978 140 patients were operated on: 84 males (average age 59-5 years) and 46 females (57-7 years). There were 15 cases of sarcoma (10-78 %) and 125 cases of carcinoma (10-33 % ) , the site of origin and incidence of which are reported in table 1. The occurrence of metastases was generally accompanied by a localized spinal pain, often associated with root irritation. The latter could also appear alone. After 1-3 months, these first symptoms progressed, to a paraparesis that inevitably turned into paraplegia within less than 30 days (Table 2). Such an evolution of the illness was ob-

served in 80 % of the cases. In the other 20 %, paraplegia appeared suddenly not accompanied by other symptoms even in less than 24 hours, or was preceded briefly by pain without the intermediate occurence of paraparesis. From a clinical point of view (8), the percentage of severe neurological deficit (paraparesis with motor paralysis) or complete neurological lesion (motor and

Tab. 3 Signs and Symptoms

Carcinomas

Sarcomas

Total

%

Back pain Root signs Slight medullary deficit Severe medullary deficit Complete medullary deficit No medullary signs Sphincter involvement

71 63 25 33 43 24 84

9 7 8 6

80 70 33 39 43 25 93

57 50 24 28 31 18 66

1 9

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\ go

Neurological results in Spinal Cord Metastases Tab. 6

Tab. 4 Sarcoma

Carcinoma

Cervical

8

(6-4%)

2

(13-3 %)

Cervico-thoracic

3

(2-4%)

1

(6-6%)

Thoracic upper third Thoracic middle third Thoracic lower third

19

2

28

> (56-8%) 3

24

1

3

(2-4%) 3

Thoraco-lumbar Lumbar

29 '

(20-0%)

2 ^

11 .

Carcinoma

Sarcoma

Osteolytic Lesions - Vertebral body - Arch and pedicles - Pathological fracture Osteosclerotic Lesions

76 51 55 16 13

15 6 10 3

-

> (40-0 %)

> (32-0%) Sacral

Radiological Reports

(20-0%) J

sensory paraplegia) was very high, in all 59 % of the cases. On the contrary 24 % of the cases presented a slight neurological deficit (paraparesis with ability to walk) while only 18 % did not show - at the time of operation - any sign of a cord lesion but only root pains or other root symptoms. The signs and clinical symptoms in the observed cases of spinal metastases are summarized in table 3. A correct evaluation of the severity of the sensory lesion was difficult to make, as it often depended on the examiner's personal judgement; nevertheless it occurred in a large number of paraparetics and was always present in paraplegic patients. Concerning localization (Table 4), metastases involved mostly the thoracic spine and secondly the lumbar and sacral areas with extension over 3-4 segments and with an almost constant extradural position. Subdural lesions were very unusual and intramedullary ones quite exceptional (Table 5).

A radiographically identifiable lesion, frequently of osteolytic kind, localized in vertebral body, either pedicle or arch, was observed in 75 % of the cases (Table 6). This result also emerged from tomographic investigations, while the standard radiographic studies were positive only in a small number. Isotopic study of the spine with a B9m technetium-methylene disphonate was useful for bonelesion identification (Fig. 1). Myelography or radiculography, in lumbo-sacral locations, showed a complete block or, less frequently, an incomplete one in 97 % of the cases. This block was also identified by myeloscintigraphy that was sometimes used (Fig. 2). Only recently, we have used the CT Total Body Scan (Fig. 3) and Amipaque myelography (10).

Tab. 5 Spinal Localization

Carcinoma

Sarcoma

Epidural Epidural and vertebra Intradural Intramedullary

56 63 4 2

6 5 4

11 Neurochirurgia 22,5

-

Fig. 1: Concentration of " ra Tc-M.D.P. at the level of a lumbar spinal body.

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Level

161

162

M. Baldini, G. P. Tonnarelli, L. Princi, C. Vivenza, V. Nizzoli cacious only when spinal cord compression was slight, while in severe preoperative compressions, a high percentage of non-improvement or of aggravation was observed. Even when the operation was performed a few hours after the appearance of paraplegia, neurological recovery was never possible (Table 7).

Motor Deficits

Improved n. %

Unchanged n. %

Worse n. %

Slight Severe Complete

28 (63-6) 14 (274) 0 -

12 (27-2) 14 (27-4) 45 (100-0)

4 (9-1) 23 (45-2) 0 -

Pain: this symptom, on the contrary, was alleviated in about 70 of the cases. Decompression of the spinal cord and roots with associated rhizotomy, contributed to the high percentage of success (Table 8). Tab. 8 Fig. 2: Myeloscintigraphy by ""Tc-H.S.A.: spinal block at the second and sixth hour.

Surgical treatment consisted always in decompressive laminectomy of the durai sac with removal, as far as possible, of neoplastic material; decompression was extended also to the involved roots which were sometimes sectioned in order to obtain the best analgesic effect. In only one case of cervical cord compression the involved body was excised and an interbody fusion with acrylic material was performed (Fig. 4).

Results Evaluation of the surgical results in patients divided according to the severity of their medullary deficit, was made on the basis of changes in the two basic clinical functions. Motor deficit: surgical treatment was effi-

Pain

N° of cases

%

Disappeared Regressed

90

69-2

Unchanged

42

31-8

The mortality occurred in IS % of the cases in the postoperative phase.

Discussion From the reported results some conclusions can be drawn regarding the surgical treatment of spinal metastases. 1. Patients affected with metastases of unknown origin, together with severe or complete spinal cord deficit and a myélographie block, did not show any neurological improvement after decompressive laminectomy (1, 3, 5, 9, 17).

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Tab. 7

163

Fig. 3: Lumbar spinal metastasis: associated invasion of the body, the left lamina, the left articular process and, only partially, of the spinal canal. However surgical treatment was necessary to provide a histological diagnosis and to preserve the spinal cord compressed by a tumour whose malignancy had not yet been demonstrated. No radiotherapy was recommended for totally paraplegic patients on account of their neurological condition. On the other hand, in patients who, improved after operation and were in good general condition, radiotherapy was combined with surgery. 2. Patients already suffering from carcinoma and exposed to metastatic spinal compression were the most difficult. After the general condition of the patients and the possibility of sutgical intervention had been investigated, the evaluation of three factors led us to this kind of treatment: a) absence of radiosensitivity in the primary tumour il*

b) mode of onset of medullary compression c) intensity of pain In cases of acute paraplegia without pain the final result was usually so unfavourable, in addition to the frequent appearance of a medullary ischaemic lesion, that it was felt justifiable to abandon any surgical intervention. However spinal pain, which was always alleviated by operation, justified by itself an immediate intervention. In intermediate cases, those in which painful symptoms were associated with a progressive motor deficit, surgical treatment was justified only when the cord lesion had not yet reached the paraplegic state. Our studies confirmed the necessity of making a careful distinction among patients with epidural spinal metastases (2, 7). Having regard to the extremely poor results (4, 9, 13) obtained in paraplegic and

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Neurological results in Spinal Cord Metastases

M. Baldini, G. P. Tonnarelli, L. Princi, C. Vivenza, V. Nizzoli paraparetic patients, intervention should be performed at an early stage, when only those premonitory symptoms of motor deficit are present, that is to say only in patients with satisfactory spinal function (2). Cases of lymphoma are excluded from the above consideration on account of their particular radiosensitivity (14). On the other hand, cases of spinal metastasis and breast carcinoma are reported, although Cobb et al., in a recent comparative study between two groups of patients affected with this type of secondary tumour, observed that regression of medullary lesions due to radiotherapy alone gave better results than when associated with surgical treatment. According to these authors, only pain is relieved by surgical treatment (6). We have the feeling, when examining our cases, that many patients who were already under chemotherapy and often in poor general conditions, are slowly affected by a spinal cord compression without being submitted to the necessary investigations that would enable a spinal decompression to be performed before the neurological lesion became irreversible. Acknowledgements

Fig. 4. Excision of C 6 body and its replacement by Methyl-Methacrylate: stabilisation of the spinal column by metallic prosthesis.

We are grateful to Dr. Bonino of the Maggioni Farmaceutici Milano for his kind technical cooperation.

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Dr. Mario Baldini, Clínica Neurochirurgie

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