Abstract
Background
Spinal cord compression and fracture are potential complications of spine metastasis (SM). Rapid management by an expert team can reduce these adverse developments. Delays in seeking therapeutic advices, which lead to the need for sub-optimal emergency procedures, were already demonstrated nearly 20 years ago. We aimed to analyze the current weak points of referrals for vertebral metastasis so as to improve the care pathways.
Methods
We retrospectively reviewed the data of all patients admitted on an emergency or elective basis who underwent palliative surgery for the treatment of neoplastic spine lesions in our institution (tertiary referral neurosurgical unit) between January 2009 and December 2016.
Results
This retrospective study included 201 patients, 121 men and 80 women (mean age 65.1 years ± 10.9). Cancer was known for 59.7% of cases. Patients were neurologically asymptomatic in 52.7% of cases (Frankel E), and 123 (60.7%) were hospitalized for emergency reasons, including 51 (41.5% of emergencies) on a Friday (p < 0.0001). A significant increase in emergencies occurred over the studied period (p = 0.0027). The “emergency” group had significantly unfavorable results in terms of neurological status (p < 0.001), the occurrence of complications (p = 0.04), the duration of hospitalization (p = 0.02), and the clinical evolution (p = 0.04). Among 123 patients hospitalized for emergency reasons, 65 (52.8%) had known cancers, of which 33 had an identified SM, including 22 with neurological deficits (Frankel A–D), without prior surgical assessment (17.8% of emergencies).
Conclusion
Too many patients with previously identified metastases are referred for emergency reasons, including with a neurological deficit. Optimizing upstream pathways and referrals is imperative for improving the management of these patients. Involving a spine surgeon at the slightest symptom or an abnormal image is critical for defining the best treatment upstream. The use of telemedicine and the development of dedicated tumor boards are ways of improving this involvement.
Similar content being viewed by others
Abbreviations
- EBM:
-
Evidence-based medicine
- KPS:
-
Karnofsky performance status
- LOS:
-
Length of stay
- MRI:
-
Magnetic resonance imaging
- SM:
-
Spinal metastasis
References
Arana E, Kovacs FM, Royuela A, Asenjo B, Pérez-Ramírez Ú, Zamora J, Spanish Back Pain Research Network Task Force for the Improvement of Inter-Disciplinary Management of Spinal Metastasis (2016) Agreement in metastatic spinal cord compression. J Natl Compr Cancer Netw 14(1):70–76
Bakar D, Tanenbaum JE, Phan K, Alentado VJ, Steinmetz MP, Benzel EC, Mroz TE (2016) Decompression surgery for spinal metastases: a systematic review. Neurosurg Focus 41(2):E2
Choi D, Bilsky M, Fehlings M, Fisher C, Gokaslan Z (2017) Spine oncology-metastatic spine tumors. Neurosurgery 80(3S):S131–S137
Christian E, Adamietz IA, Willich N, Schäfer U, Micke O, German Working Group Palliative Radiotherapy, German Society for Radiation Oncology (DEGRO) (2008) Radiotherapy in oncological emergencies—final results of a patterns of care study in Germany, Austria and Switzerland. Acta Oncol Stockh Swed 47(1):81–89
Dea N, Versteeg A, Fisher C, Kelly A, Hartig D, Boyd M, Paquette S, Kwon BK, Dvorak M, Street J (2014) Adverse events in emergency oncological spine surgery: a prospective analysis. J Neurosurg Spine 21(5):698–703
Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD, Walsh JJ (1969) The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I Paraplegia 7(3):179–192
Galasko CS, Norris HE, Crank S (2000) Spinal instability secondary to metastatic cancer. J Bone Joint Surg Am 82(4):570–594
Groenen KHJ, van der Linden YM, Brouwer T et al (2018) The Dutch national guideline on metastases and hematological malignancies localized within the spine; a multidisciplinary collaboration towards timely and proactive management. Cancer Treat Rev 69:29–38
Guzik G (2018) Analysis of factors delaying the surgical treatment of patients with neurological deficits in the course of spinal metastatic disease. BMC Palliat Care 17(1):44
Harris JK, Sutcliffe JC, Robinson NE (1996) The role of emergency surgery in malignant spinal extradural compression: assessment of functional outcome. Br J Neurosurg 10(1):27–33
Jalil R, Ahmed M, Green JSA, Sevdalis N (2013) Factors that can make an impact on decision-making and decision implementation in cancer multidisciplinary teams: an interview study of the provider perspective. Int J Surg Lond Engl 11(5):389–394
Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN, McNeil BJ (2013) Tumor boards and the quality of cancer care. J Natl Cancer Inst 105(2):113–121
Kim JM, Losina E, Bono CM, Schoenfeld AJ, Collins JE, Katz JN, Harris MB (2012) Clinical outcome of metastatic spinal cord compression treated with surgical excision ± radiation versus radiation therapy alone: a systematic review of literature. Spine 37(1):78–84
Koiter E, Poortmans P, Cloin B (2013) Always on a Friday: referral pattern for metastatic spinal cord compression. Radiother Oncol J Eur Soc Ther Radiol Oncol 107(2):259–260
Lee C-H, Chung CK, Jahng T-A et al (2015) Which one is a valuable surrogate for predicting survival between Tomita and Tokuhashi scores in patients with spinal metastases? A meta-analysis for diagnostic test accuracy and individual participant data analysis. J Neuro-Oncol 123(2):267–275
Levack P, Graham J, Collie D et al (2002) Don’t wait for a sensory level—listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clin Oncol R Coll Radiol G B 14(6):472–480
Marshall CL, Petersen NJ, Naik AD, Vander Velde N, Artinyan A, Albo D, Berger DH, Anaya DA (2014) Implementation of a regional virtual tumor board: a prospective study evaluating feasibility and provider acceptance. Telemed J E-Health 20(8):705–711
Maurice-Williams RS, Richardson PL (1988) Spinal cord compression: delay in the diagnosis and referral of a common neurosurgical emergency. Br J Neurosurg 2(1):55–60
Nemelc RM, Stadhouder A, van RBJ, Jiya TU (2014) The outcome and survival of palliative surgery in thoraco-lumbar spinal metastases: contemporary retrospective cohort study. Eur Spine J 23(11):2272–2278
Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366(9486):643–648
Poortmans P, Vulto A, Raaijmakers E (2001) Always on a Friday? Time pattern of referral for spinal cord compression. Acta Oncol Stockh Swed 40(1):88–91
Quraishi NA, Ramoutar D, Sureshkumar D, Manoharan SR, Spencer A, Arealis G, Edwards KL, Boszczyk BM (2014) Metastatic spinal cord compression as a result of the unknown primary tumour. Eur Spine J 23(7):1502–1507
Redd V, Levin S, Toerper M, Creel A, Peterson S (2015) Effects of fully accessible magnetic resonance imaging in the emergency department. Acad Emerg Med Off J Soc Acad Emerg Med 22(6):741–749
Ropper AE, Ropper AH (2017) Acute spinal cord compression. N Engl J Med 376(14):1358–1369
Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, Rhines LD, Gokaslan ZL (2010) Diagnosis and management of metastatic spine disease. A review. J Neurosurg Spine 13(1):94–108
Shea CM, Teal R, Haynes-Maslow L, McIntyre M, Weiner BJ, Wheeler SB, Jacobs SR, Mayer DK, Young M, Shea TC (2014) Assessing the feasibility of a virtual tumor board program: a case study. J Healthc Manag Am Coll Healthc Exec 59(3):177–193
Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J (2005) A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine 30(19):2186–2191
Zairi F, Fahed Z, Vieillard M-H et al (2015) Management of neoplastic spinal tumors in a spine surgery care unit. Clin Neurol Neurosurg 128:35–40
Zairi F, Vieillard M-H, Assaker R (2015) Spine metastases: are minimally invasive surgical techniques living up to the hype? CNS Oncol 4(4):257–264
www.scansante.fr/applications/casemix_ghm_cmd?secteur=MCO. Activité établissement - Casemix MCO | Stats ATIH. Accessed 26 Feb 2019
Acknowledgements
The authors thank Drs. Jean-Paul Lescure and Philippe Bousquet for their neurosurgical support.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent
For this type of study formal consent is not required.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Spine - Other
Rights and permissions
About this article
Cite this article
Debono, B., Braticevic, C., Sabatier, P. et al. The “Friday peak” in surgical referrals for spinal metastases: lessons not learned. A retrospective analysis of 201 consecutive cases at a tertiary center. Acta Neurochir 161, 1069–1076 (2019). https://doi.org/10.1007/s00701-019-03919-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00701-019-03919-z