Treatment approaches for spinal metastases have evolved tremendously over the past 20–30 years. Once relegated to palliative radiation therapy as the only option, now pathological fractures and malignant epidural cord compression have multiple options for treatment including stereotactic body radiation therapy, percutaneous vertebroplasty, and surgery all of which have shown a defined effectiveness. In 2005, Patchell et al. [1] published a landmark study providing class 1 evidence that surgery followed by radiation therapy prolonged ambulatory status and even survival over radiation therapy alone for symptomatic spinal metastasis with malignant epidural compression at a single site. Further studies have corroborated these findings and as a result it is well accepted now that symptomatic spinal metastasis can and should be treated even if it involves invasive surgery [2-4].
The goals of surgery for spinal metastases mainly focuses on (1) stabilization of fractures that cause severe pain and deformity, and (2) decompression of neural structures to relieve pain and restore neurologic function. Achieving these goals allows for an improved quality of life despite a terminal diagnosis and allows patients to continue other systemic/adjuvant treatment options which ultimately have a greater impact on progression-free survival.
This paper compares patients with spinal metastases having surgery in an emergency setting versus planned setting and describes the cohorts characteristics and their outcomes [5]. Not surprisingly, having emergency surgery correlated with worse preoperative characteristics and worse postoperative outcomes compared to nonemergency surgery and that thoracic location of the metastasis was a risk factor for emergent surgery. Though obvious, these results should bring heightened attention for multidisciplinary spinal tumor boards to strive to avoid the conversion of a nonemergent situation to an emergent one and to be more cognizant of the “sneaky” nature of the thoracic location.
Ideally, patient with spinal metastases requiring surgery would be evaluated in a timely manner leading to a multidisciplinary discussion regarding treatment options and surgery scheduled in a controlled environment. Realistically, this is not always the case and spinal metastases find a way of presenting at the end of the day or week in need of urgent/emergent intervention. A regular and consistent approach to treating and monitoring patients with spinal metastases is encouraged in order to minimize the risk of a spinal metastases becoming and emergency surgery.
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