Elsevier

The Spine Journal

Volume 11, Issue 11, November 2011, Pages 1015-1023
The Spine Journal

Clinical Study
Resumption of ambulatory status after surgery for nonambulatory patients with epidural spinal metastasis

https://doi.org/10.1016/j.spinee.2011.09.007Get rights and content

Abstract

Background context

Improving the surgical outcome of nonambulatory patients with metastatic epidural spinal compression has been of great interest lately. Although there have been many reports regarding the surgical outcome of spinal metastasis, the surgical outcome in terms of the probability of operative success for nonambulatory patients has not been thoroughly described. If the probability of ambulatory recovery is known, the optimal surgical indications can be determined and implemented.

Purpose

To predict the surgical outcome and probability of ambulatory resumption for nonambulatory patients with spinal metastasis.

Study design

Retrospective analysis.

Patient sample

The surgical outcomes of patients who could not ambulate independently because of spinal metastasis from 1987 to 2010 were analyzed.

Outcome measures

The primary end point was postoperative ambulatory status. The secondary end point was survival time.

Methods

Fifty-seven patients who could not ambulate independently at the time of surgery were included in the study. We defined “independent ambulation” as a better functional status than Nurick Grade 3, which is defined as “difficulty in walking which was not so severe as to require someone's help to walk.” Preoperatively, functional status was Nurick Grade 4 in 21 patients and Grade 5 in 36 patients. Weakness developed 10.5±11.9 days (median, 7.0; range, 1–80) before the operation and steadily worsened. Patients were unable to walk starting from 3.6±4.9 days (median, 1.8; range, 0.5–23) before the operation. The spinal metastases were circumferentially decompressed.

Results

Postoperatively, 39 patients (68%) could walk. Complications occurred in 26% (15/57) of the patients, and the major complication rate was 12% (7/57). The mortality rate was 5% (3/57). The patient survival time was 287±51 days (median, 128) after the operation. Postoperative ambulatory status (yes vs. no, p<.01) and occurrence of major complication (yes vs. no, p<.01) affected survival time. Overall, patients could walk for 193±41 days (median, 114) postoperatively. Motor grade (grade≥4/5 vs. <4/5, p<.01) and the occurrence of a major complication (yes vs. no, p<.01) were significant factors for resumption of ambulation. The rate of ambulation resumption was 95% (20/21) in patients with a motor grade of 4 of 5, whereas it was 53% (19/36) in patients with a motor grade less than 4 of 5 (p<.01).

Conclusions

The survival time of nonambulatory patients was dependent on ambulation recovery. About 95% of the nonambulatory patients could walk after surgery, when the operation was done in a timely manner with good remaining motor function. However, given the short life expectancy and the considerable surgical complication rate, surgery should only be prudently recommended to patients with optimal indications.

Introduction

Evidence & Methods

Patients with spinal metastases resulting in an inability to walk present challenges, both surgically and in the surgical decision-making process.

In this retrospective review of 57 patients undergoing surgery, 68% could walk after surgery. Those with less motor weakness, who were operated on within 3 days and were fortunate to avoid complications, did best.

These patients had a median survival time of 128 days following surgery. Whether aggressive operation is warranted given such survival in light of the high surgical complication and mortality rates is an open question. Certainly in the “best-case” or “worst-case” scenarios (patients with 4/5 strength, slow-growing tumors, presenting early or those with 0/5, aggressive and multiple tumors, presenting 6 weeks into paralysis), the recommendations can be clearer. Unfortunately, most patients present in a grey zone, and information, such as that presented in this article and elsewhere, is valuable for truly informed consent and case-by-case care.

—The Editors

About 10% of patients with cancer suffer from spinal metastasis [1], [2], [3]. With the development of various therapeutic modalities for various cancers, there is a greater interest in achieving longer survival times and a better quality of life. Survival time is correlated to ambulation period, and the maintenance or resumption of ambulatory ability is the most important surgical goal [1], [3], [4], [5], [6], [7]. Until now, radiotherapy has been the cornerstone in metastatic cancer treatment [8]. However, if spinal metastasis causes neurologic deterioration by epidural spinal cord compression, surgical decompression may be a better option considering the delayed response of solid tumors to radiotherapy [6], [9]. Although there have been many reports regarding the surgical outcome for spinal metastasis, the surgical outcome in terms of the probability of operative success for nonambulatory patients has not been thoroughly described [3], [9]. If we know the probability of ambulatory resumption, their prognosis could be predicted and the optimal surgical indications could be determined and implemented. The aim of this study was to present the surgical outcomes of metastatic spinal tumors for nonambulatory patients and the probability of ambulatory resumption according to preoperative variables.

Section snippets

Patients

From January 1987 to August 2010, 367 metastatic spinal tumor patients were operated on. Among them, patients who could not ambulate by themselves at the time of surgery because of epidural spinal cord compression were selected. The patients' medical records and radiologic studies were reviewed retrospectively. Fifty-seven patients were enrolled in this cohort (Men:Women=38:19; mean age, 53.4±13.9 years; range, 19–77). Spinal metastasis was present at the cervical level (n=1), thoracic level

Overall outcome

Postoperative neurologic status was assessed at the time of discharge (within 1 month after the operation) using the Nurick grade [10]. The neurologic status improved in 39 patients, was stable in 10 patients, and was aggravated in 8 patients, including death in 5 patients. Postoperatively, 39 patients could walk independently (68%), whereas the other 18 patients could not. Postoperatively, the Nurick grade was 1 in 14, 2 in 6, 3 in 19, and 5 in 18 patients.

In the preoperative magnetic

Discussion

The primary goal for patients with spinal cord compression with metastatic cancer is “walking and living their life” [12]. Ambulatory ability is considered an important factor for a better quality of life and longer survival time [1], [3], [5], [6], [7], [9], [13], [14], [15]. As revealed in the present study, postoperative ambulatory resumption was associated with a longer survival time. Patients who regained their ambulatory ability survived 1.97 times longer than patients who did not. It has

Conclusion

The survival time of nonambulatory patients with epidural spinal cord compression depends on ambulatory recovery. Considering the short survival time in patients with spinal metastasis, it is important to choose subgroups of patients who are more likely to ambulate and survive postoperatively. About 95% of the nonambulatory patients could walk after the surgery when the operation was done in a timely manner with good remaining motor function. However, given the short life expectancy and the

Acknowledgment

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea Government (MEST)(2011-0018259). This study was orally presented at the 2011 North American Spine Society meeting.

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    Author disclosures: CHK: Nothing to disclose. CKC: Nothing to disclose. TAJ: Nothing to disclose. HJK: Nothing to disclose.

    This study was approved by the institutional review board of Clinical Research Institute in Seoul National University Hospital (H-0910-014-296).

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