Computed tomography (CT) of the chest, abdomen, and pelvis failed to reveal visceral metastasis. Bone scan and MRI of the spinal axis revealed the lesions at T3 and T4 to be isolated. Karnofsky performance status was 80 prior to his recent neurologic decline.

The patient acutely underwent surgical intervention. The goals of surgery were to prevent neurologic decline, alleviate pain, stabilize the affected motion segments, and possibly restore lost neurologic function. Also, surgical intervention was a good option given that the vertebral and epidural metastases were from radioresistant NSCLC. The patient underwent single-stage transpedicular vertebrectomies at T3 and T4 with circumferential decompression and fixation. Anterior vertebral body reconstruction was completed with polymethylmethacrylate (PMMA). Posterior segmental instrumented fusion was completed via pedicle screws and rods from T1–T6 (Fig. 95.2). Local radiotherapy and systemic chemotherapy were initiated after the wound healed. The patient was ambulatory after treatment with significant pain relief. His survival was 6 months.

• T2-weighted sagittal images (Fig. 95.1A) demonstrate hypointense lesions at T3 and T4 level involving the vertebral bodies, pedicles, and posterior elements. There is evidence of signal changes within the spinal cord.
  
• There is circumferential epidural involvement with spinal cord compression.
  
• The osseous and epidural infiltration are further demonstrated on axial T2-weighted images (Fig. 95.1B).

• Corticosteroids are indicated for the prevention of neurologic deterioration and analgesia.¹
  
• Additionally, there may be an oncolytic effect for certain histology types (such as breast cancer and lymphoma).²
  
• The patient should be admitted to the hospital and placed on high-dose intravenous steroids such as dexamethasone (50 mg once followed by 10 mg every 6 hours) with gastrointestinal prophylaxis.
  
• Additionally, a Foley catheter may be placed given the elevated postvoid residuals.
  
• A CT scan of the chest, abdomen, and pelvis and a radiograph of the chest should be performed to restage the cancer.
  
• A total body bone scan, using technetium-99m (Tc-99m) labeled phosphate compounds, can be used to determine whether a lesion is solitary or multifocal. Uptake depends on local blood flow and osteoblastic activity; therefore, malignancies such as multiple myeloma are not usually detected via this method.

• More than 90% of spinal tumors are metastatic.
  
• Breast, lung, and prostate cancer make up 60–70% of neoplasms that metastasize to the spinal column and cause symptomatic spinal cord compression.^3,4
  
• Less frequently, lymphoma, renal cell carcinoma, colon carcinoma, melanoma, and sarcomas metastasize to the spinal column.^2,5

• The prognosis and survival rates are poor in lung cancer patients with metastasis to the spine.^3,4,6
  
• Conservative nonoperative treatment consists of radiation and/or chemotherapy.
  
• However, others believe advanced NSCLC in patients with symptomatic spinal cord compression is worth treating aggressively, especially young patients.⁷
  
• Surgical treatment can be justified on the basis of palliation, preservation or improvement of neurological function, and/or spinal stabilization to improve mobility.⁸
  
• Surgical therapy can be followed by radiation therapy, chemotherapeutic drugs, and targeted therapeutic agents.

• For a circumferential metastatic lesion in the thoracic spine, there are a few surgical options.
  
• Surgical approaches include an anterior transthoracic vertebrectomy or a posterior transpedicular vertebrectomy with instrumented stabilization.⁸
  
• Chen et al.⁷ reviewed surgical results of metastatic spinal cord compression secondary to NSCLC.
  
  
  
  • Patients underwent palliative surgery using a posterolateral transpedicular approach or combined anterior and posterior procedures.
    
  • 68% regained the ability to walk; overall 74% of patients were able to walk after surgery.
    
  • Median survival was 8.8 months.
  
  
• Dagnew et al.⁹ achieved a high success rate with respect to functional outcome and pain relief in individuals with spinal metastasis who underwent a single-stage transpedicular vertebrectomy with circumferential decompression and fixation.

• Radiosensitive tumors include breast, prostate, small cell lung cancer, lymphoma, and multiple myeloma.
  
• Renal cell carcinoma, melanoma, and NSCLC are relatively radioresistant.¹
  
• Typically, total radiation dose ranges from 2500–3600 cGy. It is usually given in 10–15 fractions to avoid significant side effects.¹⁰

• Kovner et al.¹¹ demonstrated that motor strength before radiation therapy was predictive of ambulatory function.
  
• 90% of patients who were ambulatory before treatment remained so; 33% of the nonambulatory patients regained their ability to walk.
  
• Among the nonambulatory patients, 50% of those who were paretic became ambulatory, whereas only 14% of those who were plegic became ambulatory.

• A randomized trial¹² assigned 101 patients with cord compressions to either radiotherapy alone (n = 51) or decompression surgery followed by radiotherapy (n = 50).
  
• Results demonstrated that surgery plus radiotherapy is superior to radiotherapy alone in the treatment of spinal cord compression caused by metastasis.
  
• Patients who underwent surgery were able to walk more than 3.5 times longer than those who received radiotherapy alone: a median of 126 days versus 35 days, respectively (p = 0.006).
  
• Of the 16 patients in each group who entered the trial unable to walk, 56% of those in the surgery arm regained mobility, compared with 19% of patients who received radiation alone (p = 0.03).
  
• Overall survival was not affected.¹⁰

• Percutaneous vertebroplasty and kyphoplasty represent a successful option for the palliative treatment of intractable spinal pain associated with malignant spinal tumors and metastases.¹³

• In general, vertebral column metastatic disease survival rates are highest in patients with radiosensitive tumors, single spinal metastasis, and individuals with preserved ambulation.¹
  
• The presence of two or more poor prognostic indicators (leg strength 0/5–3/5, lung or colon cancer, multiple vertebral body involvement) usually predicts shorter survival rates.^1,3
  
• Currently, there are two major grading systems that can be used to guide surgical decision making for spinal metastasis: these were derived by Tokuhashi et al. in 1990 and Tomita et al. in 2001.^14,15
  
• Tomita et al.¹⁵ designed a scoring system based on three prognostic factors: grade of malignancy (rate of growth), visceral metastasis (treatable versus untreatable), and bone metastasis (solitary or multiple).
  
• The lower scores suggested a wide or marginal excision for long-term local control. The highest scores indicated nonoperative supportive care. Intermediate scores justified intralesional excision or palliative surgery.
  
• Survival and extent of local control correlated well with the treatment strategy.
  
• Of note, a recent large series of spinal metastasis from breast cancer did not show prognostic value for the presence of visceral metastasis or multiplicity of spinal lesions.¹⁶

• Ogihara et al.⁶ conducted a retrospective study of 114 patients to identify prognostic factors of patients with spinal metastases from lung cancer.
  
• Multivariate analysis showed that the significant prognostic factors for survival after spinal metastases from NSCLC were performance status, calcium levels, and albumin.
  
• Among SCLC patients, calcium levels, albumin, and a history of chemotherapy were significant (p = 0.05) in univariate analysis.⁶

• PMMA bone cement is a load-sharing entity, which is resistant to compressive forces and offers an immediate stabilizing construct when used in the anterior spine.
  
• In patients with a short life span undergoing palliative surgery or postoperative radiation, PMMA is recommended.¹⁰
  
• On the other hand, in patients with a prolonged life expectancy, allograft or autograft bone is preferred and is used when possible.^10,17

• Spinal radiation before surgical decompression for metastatic spinal cord compression is associated with a significantly higher wound complication rate.18
  
• Risk of wound infection may be up to 3-fold higher than in those individuals undergoing surgery de novo.¹⁰