Accepted Manuscript The Surgical Management of Metastatic Spinal Tumours based on an Epidural Spinal Cord Compression (ESCC) Scale N.A. Quraishi, FRCS (T&O), LLM, Consultant spinal surgeon, G. Arealis, Clinical research Fellow, K.M.I. Salem, FRCS (T&O), DM, Senior spine surgery fellow, S. Purushothamdas, Clinical research fellow, Kimberly L. Edwards, BSc (Hons), MMedSci (distinction), PhD, Director of Sports & Exercise Medicine, B.M. Boszczyk, PD Dr.med., Consultant spinal surgeon PII:

S1529-9430(15)00327-7

DOI:

10.1016/j.spinee.2015.03.040

Reference:

SPINEE 56264

To appear in:

The Spine Journal

Received Date: 21 April 2014 Revised Date:

11 January 2015

Accepted Date: 20 March 2015

Please cite this article as: Quraishi NA, Arealis G, Salem KMI, Purushothamdas S, Edwards KL, Boszczyk BM, The Surgical Management of Metastatic Spinal Tumours based on an Epidural Spinal Cord Compression (ESCC) Scale, The Spine Journal (2015), doi: 10.1016/j.spinee.2015.03.040. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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The Surgical Management of Metastatic Spinal Tumours based on an Epidural Spinal Cord Compression (ESCC) Scale

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Authors: *N A Quraishi, FRCS (T&O), LLM Consultant spinal surgeon *G Arealis Clinical research Fellow

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*S Purushothamdas Clinical research fellow

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*K M I Salem, FRCS (T&O), DM Senior spine surgery fellow

^Kimberly L Edwards BSc (Hons), MMedSci (distinction), PhD Director of Sports & Exercise Medicine *B M Boszczyk PD Dr.med. Consultant spinal surgeon

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Affiliation:

*The Centre for Spinal Studies and Surgery (CSSS) Queens Medical Centre Campus of Nottingham University Hospitals NHS Trust

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Derby Road, Nottingham NG7 2UH

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United Kingdom

^Centre for Sports Medicine, University of Nottingham, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH

Corresponding Author N A Quraishi, FRCS (T&O), LLM

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Centre for Spinal Studies & Surgery, Centre for Spinal Studies and Surgery Queens Medical Centre Campus of Nottingham University Hospitals NHS Trust

Tel.: +44 115 9249924 / 65160 Fax: +44 115 9709991

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Email: [email protected]

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Nottingham, NG7 2UH

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Abstract:

2 BACKGROUND CONTEXT: There have been no previous studies looking at the outcome

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of surgical decompression (+/-stabilisation) for various grades of epidural spinal cord

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compression (ESCC) due to spinal metastases.

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PURPOSE: To determine the outcome of surgical treatment in patients with ESCC using the

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Bilsky 6-point scale.

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STUDY DESIGN/SETTING: Retrospective cohort review of prospectively collected data

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PATIENT SAMPLE: A consecutive series of 101 patients managed over the period of 3

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years for ESCC due to spinal metastases in a tertiary spine surgery referral unit were

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included.

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METHODS: Data on age, gender, revised Tokuhashi score, pre-operative Frankel grade,

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tumour histology, MRI scan based Bilsky cord compression grade, post-operative Frankel

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grade at last follow up, complications and survivorship data were collected.

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OUTCOME MEASURES: Frankel grading system for function was used to evaluate the

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patient’s pre- and post-operative neurological status. Patient survival and post-operative

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complications were also collected.

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RESULTS: Average patient age was 64.7 years (13-88); 62 male and 39 female. Mean

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follow-up: 7.3 months (3-23.3). Most primary tumours were prostate, breast, renal, lung and

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the blood dyscrasias. Within the lower grade of compression (Group 1) (Bilsky Gr 0,1a,

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1b,1c) (n= 40), 29 (72.5%) patients had no Frankel grade improvement, 7 (17.5%) improved

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while 4 (10%) deteriorated neurologically post-surgery. Within the higher compression grade

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(Group 2) (Bilsky Gr 2 and 3) (n = 61), 37 (60%) did not experience neurological change, 20

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(33%) improved while neurology worsened in 4 (7%). When compared to Group 2; Group 1

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patients had a better pre-operative Frankel scores and improved more significantly post-

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operatively. The mean revised Tokuhashi score for Group 1 and Group 2 was 10 and 9.1

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respectively (p=0.1). The complication rate for Group 1 and 2 was 25% and 42.6%

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respectively (p=0.052). Survival analysis showed no difference between groups (Group 1:

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median 376 days (12-1052); group 2: median 326 days (12-979), p=0.62)

3 CONCLUSION: Surgery can achieve improvements in neurology even in higher grades of

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cord compression. There is a trend towards more complications and worse survival with

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spinal surgery in patients with higher grades of compression.

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KEY WORDS: Epidural spinal cord compression grades

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Introduction

2 The treatment of spinal metastases is mostly palliative, with the goals of providing pain relief,

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maintenance or recovery of neurologic function, local durable tumour control, spinal stability,

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and improved quality of life [1]. Treatment decisions regarding metastatic spine disease are

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often dependent on a number of factors including clinical symptoms, the presence of

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myelopathy or functional radiculopathy, tumour histology and anticipated radio-sensitivity,

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spinal stability, medical comorbidities, and extent of disease [2].

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A significant anatomical factor is the degree of Metastatic Spinal Cord Compression (MSCC)

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[2]. This is defined radiographically as an epidural metastatic lesion causing true

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displacement of the spinal cord from its normal position in the spinal canal [3]. It is estimated

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that MSCC occurs in 5–10% of cancer patients (most commonly from breast, prostate and

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lung cancers), and in up to 40% of patients who have pre-existing non-spinal bone metastases

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[4,5]. Bilsky et al., have validated an Epidural Spinal Cord Compression (ESCC) grading

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system with the T2-weighted MRI images as being the most reliable for both inter- and intra-

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rater reliability [2]. This 6-point ESCC grading system has been shown by these authors to be

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an informative instrument that may guide treatment decisions [2]. In the absence of

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mechanical instability, Grades 0 (bone only disease), 1a (epidural impingement), and 1b

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(thecal sac deformation) may be considered for radiation as initial treatment. Grades 2 (cord

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compression with CSF visible) and 3 (cord compression with no CSF visible) describe high

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grade ESCC and, unless the tumour is highly radiosensitive, require surgical decompression

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prior to radiation therapy. The role of surgery and radiosurgery in patients with grade 1c

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(cord impingement) epidural tumours remains to be clearly defined, but the integration of

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high-dose hypo-fractionated radiation may allow administration of Stereotactic Radiosurgery

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(SRS) while avoiding spinal cord toxicity.

3 However, to our knowledge, there have been no previous studies looking at the outcome of

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surgical decompression (+/-stabilisation) for different grades of ESCC. Our aim was to

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determine the outcome of urgent surgical treatment in patients with ESCC using the Bilsky 6-

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point scale.

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8 Methods

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We performed a retrospective analysis of consecutive patients who underwent urgent spinal

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surgery (decompression +/- stabilisation) for MSCC from January 2009-November 2011 at a

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tertiary referral spinal unit. All patients who were surgically treated with a known or

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unknown primary were included in the study. Exclusion criteria included patients treated

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solely by radiotherapy, patients having a cement augmentation procedure without

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decompression and patients who had undergone previous surgery for spinal metastasis.

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Information was captured from medical notes and included age, gender, clinical presentation

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(type of primary tumour), revised Tokuhashi score [6]. The grade of spinal involvement as

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determined by pre-operative Magnetic Resonance Imaging (MRI) findings using the Bilsky et

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al grading scale [2] was also recorded. Patients were then divided into 2 groups – low grades

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of compression (Group 1: Bilsky Gr 0,1a, 1b and 1c) and high grades of compression (Group

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2: Bilsky Gr 2 and 3). All data was analysed by 3 independent spinal fellows. The surgical

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approach was dictated by the location of the epidural cord compression and surgical

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preference of the operating surgeon. Patients received adjuvant radiotherapy postoperatively

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as required.

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1 There were 3 outcome variables - the neurological outcome was assessed using the Frankel

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grade [7] in the immediate post-operative period, and at regular intervals until death; the

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presence or absence of any surgical or post-operative complications and the survival period.

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This study was deemed exempt from ethics approval as per institutional guidelines on service

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evaluation.

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7 Statistical analysis

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Statistical analysis was performed using SPSS 20.0 version software (Statistical Package for

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Social Sciences, IBM SPSS Inc.).

Since all parameters did not follow the normal

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distribution, non-parametric tests were used to analyse the statistical significance. The

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Wilcoxon–Mann–Whitney test was used to assess differences between continuous values and

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the Chi2 between nominal data.

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limit method and the survival plots were drawn for each group. Log rank (Mantel-Cox) and

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Breslow (Generalized Wilcoxon) tests were used to show difference in survival between

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groups. P values less than or equal to 0.05 were considered significant.

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Survival data were computed using Kaplan-Meier product

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Results

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Patient Characteristics, Tumour and Operative Data (Table 1)

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During the study period, there was a consecutive series of 101 patients in whom all

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information was recorded. All patients were divided into those with lower grade of

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compression (Group 1) (Bilsky Gr 0 (n=0), 1a (n=8), 1b (n=10), 1c (n=22); n= 40), and

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compared to those with higher grades of compression (Group 2) (Bilsky Gr 2 (n=41) and

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3(n=20); n = 61). There was no significant difference in the Mean Revised Tokuhashi score 5

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between groups (Table 1).

2 When looking at prior treatments, we found that in Group 1, 18 (45%) had no adjuvant

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treatment, 15 (38%) had chemotherapy, 5 (13%) radiotherapy and 2 (5%) both. In Group 2,

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34 (56%) had no adjuvant treatment, 8 (13%) had chemotherapy, 13 (21%) radiotherapy and

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6 (10%) both. The only statistically significant difference was in the administration of

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chemotherapy (p=0.004) with the patients in the low compression group more likely to have

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received chemotherapy pre-operatively (No prior treatment: p=0.289; Radiotherapy: p=0.258;

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Both p=0.378).

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10 11 Neurological Outcome

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The outcome variables are shown in Table 2. In Group 1, 29 patients did not have any

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change in Frankel grade, 7 showed improvement of at least one Frankel grade and 4 patients

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had neurological deterioration post spinal surgery. Of the patients with the higher grade of

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compression (Group 2; n = 61), 37 did not show any change in neurology, 20 patients

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improved one Frankel grade while neurology worsened in 4 patients (see Figures 1 & 2).

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When comparing grades of compression and pre-operative Frankel score, a significant

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difference was found (p=0.001) with a worse Frankel score in a higher degree of

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compression.

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Overall all, these changes in neurology post-operatively were not statistically significant

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(p=0.22). However, in Group 1, the median and mode preoperative and postoperative Frankel

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scores were E and in Group 2, they were D and this was statistically different (Pre-op

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p=0.001, post-op p=0.02). Even though most of the patients remained the same in both

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groups (Group 1=72.5%, Group 2 =60.7%, z-test p>0.05), in Group 2, there were more

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patients whose Frankel score improved (Group 1=17.5%, Group 2 =32.8%, z-test p