Spinal metastasis in the elderly

  • Max Aebi


Bony metastases are a frequent problem in elderly patients affected by cancer, and those with bony metastases involve the spine in approx. 50%. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer. The chance that an elderly patient (60–79 years old) is affected by bony metastases is four times higher in men and three times higher in women than a middle- aged patient (40–59 years old). Since the medical treatment with all the adjuvant treatment options prolong the survival of this particular patient group, the spinal metastases may become a mechanical issue, thus requesting surgical treatment. Different classification systems have been proposed to rationalize surgical indications, some concentrating solely on the local spinal tumor involvement and some including the overall clinical situation. Since most of the surgical options are of palliative character, it is more important to base the decision on an overall clinical classification including the different treatment modalities — irradiation, chemotherapy, steroids, bisphosphonates, and surgery — to make a shared decision. In case surgery is indicated — neural compression, pathological fracture, instability, and progressive deformity, nursing reasons — the most straightforward procedures should be chosen, which may not need an intensive care unit stay. In the thoracolumbar spine a posterior decompression and posterolateral vertebral body resection through a posterior approach only, with a concomitant reconstruction and stabilization, has shown to work sufficiently well. In the middle and lower cervical spine the anterior approach with anterior decompression and anterior column reconstruction is most effective and has a low morbidity, whereas the occipitocervical junction can generally be treated by posterior resection and stabilization. The outcome should be determined by the survival time in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. Surgical management shows the greatest improvement in pain reduction, but also in other domains of quality of life. Since prospective randomized studies comparing different treatment modalities for spinal metastases including surgery are not available and are ethically difficult to achieve, each case remains an interdisciplinary, shared decision making process for what is considered best for a patient or elderly patient. However, whenever surgery is an option, it should be planned before irradiation since surgery after irradiation has a significant higher complication rate.


Spinal metastases Vertebral metastases Elderly Spinal tumor Vertebral tumor 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Abdu WA, Provencher M (1998) Primary and metastatic tumors of the cervical spine. Spine 23:2767–2776CrossRefPubMedGoogle Scholar
  2. 2.
    Bartanusz V, Porchet F (2003) Current strategies in the management of spinal metastatic disease. Swiss Surg 9:55–62PubMedGoogle Scholar
  3. 3.
    Batson OV (1940) The function of the vertebral veins and their role in the spread of metastases. Am Surg 112:138–145Google Scholar
  4. 4.
    Berenson JR, Hillner BE, Kyle RA, Anderson K, Lipton A, Yee GC, Biermann JS, American Society of Clinical Oncology Bisphosphonates Expert Panel (2002) American Society of Clinical Oncology practice guidelines: the role of bisphosphonates in multiple myeloma. J Clin Oncol 20:19–36CrossRefGoogle Scholar
  5. 5.
    Bilsky MH, Boland P, Lis E, Raizer JJ, Healey JH (2000) Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases. Spine 25:2240–2250CrossRefPubMedGoogle Scholar
  6. 6.
    Bilsky MH, Shannon FJ, Sheppard S, Prabhu V, Boland PJ (2002) Diagnosis and management of a metastatic tumor in the atlantoaxial spine. Spine 27:1062–1069CrossRefPubMedGoogle Scholar
  7. 7.
    Boriani S, Chevalley F, Weinstein JN, Biagini R, Campanacci L, De Iure F, Piccill P (1996) Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases. Spine 21:1569–1577CrossRefPubMedGoogle Scholar
  8. 8.
    Boriani S, Biagini R, De Iure F, Bertoni F, Malaguti MC, Di Fiore M, Zanoni A (1996) En bloc resections of bone tumors of the thoracolumbar spine. A preliminary report on 29 patients. Spine 21:1927–1931CrossRefPubMedGoogle Scholar
  9. 9.
    Boriani S, Weinstein JN, Biagini R (1997) Primary bone tumors of the spine Terminology and surgical staging. Spine 22:1036–1044CrossRefPubMedGoogle Scholar
  10. 10.
    Bridwell KH, Jenny AB, Saul T, Rich KM, Grubb RL (1988) Posterior segmental spinal instrumentation (PSSI) with posterolateral decompression and debulking for metastatic thoracic and lumbar spine disease. Limitations of the technique. Spine 13:1383–1394PubMedGoogle Scholar
  11. 11.
    Coman DR, DeLong RP (1951) The role of the vertebral venous system in the metastasis of cancer into the spinal cord: experiments with tumor cell suspensions in rats and rabbits. Cancer 4:610–618PubMedGoogle Scholar
  12. 12.
    DeLaney TF, Suit HD (2000) Treatment of spine tumors: radiation therapy. Curr Opin Orthop 11:502–507CrossRefGoogle Scholar
  13. 13.
    DeWald RL, Bridwell KH, Prodromas C, Rodts MF (1985) Reconstructive spinal surgery as palliation for metastatic malignancies of the spine. Spine 10:21–26PubMedGoogle Scholar
  14. 14.
    Doppman JL, Girton RT (1976) Angiographic study of the effect of laminectomy in the presence of acute anterior epidural masses. J Neurosurg 45:195–202PubMedGoogle Scholar
  15. 15.
    Dürr HR, Wegener B, Krödel A, Müller PE, Jansson V, Refior HJ (2002) Multiple myeloma: surgery of the spine. Spine 27:320–326CrossRefPubMedGoogle Scholar
  16. 16.
    Enkaoua EA, Doursounian L, Chatellier G, Mabesoone F, Aimard T, Saillant G (1997) Vertebral metastases. A critical appreciation of the preoperative prognostic Tokuhashi Score in a series of 71 cases. Spine 22:2293–2298CrossRefPubMedGoogle Scholar
  17. 17.
    Enneking WF, Spanier SS, Goodman MA (1980) A system for surgical staging of musculoskeletal sarcoma. Clin Orthop 153:106–120PubMedGoogle Scholar
  18. 18.
    Findlay GFG (1984) Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 47:761–768PubMedGoogle Scholar
  19. 19.
    Fleisch H (2000) Bisphosphonates in bone disease. From the laboratory to the patient. Academic, San DiegoGoogle Scholar
  20. 20.
    Gerszten CP, Welch W (2000) Current surgical management of metastatic spinal disease. Oncology 14:1013–1024PubMedGoogle Scholar
  21. 21.
    Ghogawala Z, Mansfield FL, Borges LF (2001) Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine 26:818–824CrossRefPubMedGoogle Scholar
  22. 22.
    Green JR, Müller K, Jaeggi KA (1994) Preclinical pharmacology of CGP 42’446, a new, potent, heterocyclic bisphosphonate compound. J Bone Miner Res 9:745–751PubMedGoogle Scholar
  23. 23.
    Greenlee RT, Murray T, Bolden S, Wingo PA (2000) Cancer statistics, 2000. CA Cancer J Clin 50:7–33PubMedGoogle Scholar
  24. 24.
    Groot MT et al (2003) Costs of prostate cancer metastasis to the bone in The Netherlands. Eur Urol 43:226–232CrossRefPubMedGoogle Scholar
  25. 25.
    Grosman R. Rouchal M, Chalupka R (2000) The long-term results of surgical management of spine metastatic tumours from breast cancer. Scripta Med (Brno) 73:169–172Google Scholar
  26. 26.
    Grossman RI, Yousem DM (1994) Neuroradiology. The requisites. Mosby Year Book, St. Louis, pp 491–495Google Scholar
  27. 27.
    Gunterberg B (1997) Point of view: a system for surgical staging and management of spine tumors. A clinical outcome study of giant cell tumors of the spine. Spine 22:1783CrossRefGoogle Scholar
  28. 28.
    Hart RA, Boriani S, Biagini R, Currier B, Weinstein JN (1997) A system for surgical staging and management of spine tumors. A clinical outcome study of giant cell tumors of the spine. Spine 22:1773–1782CrossRefPubMedGoogle Scholar
  29. 29.
    Heiss JD, Papavassiliou E, Merrill M et al (1996) Mechanism of dexamethasone suppression of brain tumor-associated vascular permeability in rats. J Clin Invest 98:1400–1408PubMedGoogle Scholar
  30. 30.
    Hortobagyi GN, Theriault RL, Lipton A et al (1998) Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate. J Clin Oncol 16:2038–2044PubMedGoogle Scholar
  31. 31.
    Jenis LG, Dunn EJ, An HS (1999) Metastatic disease of the cervical spine. Clin Orthop 359:89–103CrossRefPubMedGoogle Scholar
  32. 32.
    Kanayama M, Cunningham BW, Abumi K, Kaneda K, McAfee PC (1999) Biomechanical analysis of anterior versus circumferential spinal reconstruction for various anatomic stages of tumor lesions. Spine 24:445–450CrossRefPubMedGoogle Scholar
  33. 33.
    Katagiri H, Takahashi M, Inagaki J, Kobayashi H, Sugiura H, Yamamura S, Iwata H (1998) Clinical results of nonsurgical treatment for spinal metastases. Int J Radiat Oncol Biol Phys 42:1127–1132CrossRefPubMedGoogle Scholar
  34. 34.
    Khan DC, Malhotra S, Stevens RE, Steinfeld AD (1999) Radiotherapy for the treatment of giant cell tumor of the spine: a report of six cases and review of the literature. Cancer Invest 17:110–113PubMedGoogle Scholar
  35. 35.
    Koehler PJ (1995) Use of corticosteroids in neuro-oncology. Anticancer Drugs 6:19–33Google Scholar
  36. 36.
    Landis SH et al (1999) Global cancer statistics. CA Cancer J Clin 49:33–64PubMedGoogle Scholar
  37. 37.
    Lemke DM, Hacein-Bey L (2003) Metastatic compression fractures — vertebroplasty for pain control. J Neurosci Nurs 35:50–55PubMedGoogle Scholar
  38. 38.
    Lieberman IH, Dudeney S, Reinhardt MK et al (2001) The initial outcome and efficacy of ‘kyphoplasty’ in the treatment of painful osteoporotic vertebral compression fractures. Spine 26:1631–1636PubMedGoogle Scholar
  39. 39.
    Lipton A, Theriault RL, Hortobagyi GN et al (2000) Pamidronate prevents skeletal complications and is an effective palliative treatment in women with breast carcinoma and osteolytic bone metastases. Long-term follow-up of two randomized, placebo-controlled trials. Cancer 88:1082–1090CrossRefPubMedGoogle Scholar
  40. 40.
    Loblaw DA, Laperriere NJ (1998) Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline. J Clin Oncol 16:1613–1624PubMedGoogle Scholar
  41. 41.
    Marchesi D, Arlet V, Aebi M (2003) Treatment of spinal metastases by posterolateral decompression and pedicle screw fixation. Spine (in press)Google Scholar
  42. 42.
    Mazel C, Grunenwald D, Laudrin P, Marmorat JL (2003) Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases. Spine 28:782–792CrossRefPubMedGoogle Scholar
  43. 43.
    Mundy GR (1999) Bisphosphonates as cancer drugs. Hosp Pract (Off Ed) 34:81–94Google Scholar
  44. 44.
    Rosen LS, Harland SJ, Oosterlinck W (2002) Broad clinical activity of zoledronic acid in osteolytic to osteoblastic bone lesions in patients with a broad range of solid tumors. Am J Clin Oncol 25:19–24CrossRefGoogle Scholar
  45. 45.
    Schick U, Marquardt G, Lorenz R (2001) Intradural and extradural spinal metastases. Neurosurg Rev 24:1–5PubMedGoogle Scholar
  46. 46.
    Siegal T, Siegal T (1989) Current considerations in the management of neoplastic spinal cord compression. Spine 14:223–228PubMedGoogle Scholar
  47. 47.
    Smith MR et al (2003) Zometa increases bone mineral density in men receiving androgen deprivation therapy for nonmetastatic prostate cancer. J Urol 169:2008–2012CrossRefPubMedGoogle Scholar
  48. 48.
    Sundaresan N, Galicich JH, Lane JM, Bains MS, McCormack P (1985) Treatment of neoplastic epidural cord compression by vertebral body resection and stabilization. J Neurosurg 63:676–684PubMedGoogle Scholar
  49. 49.
    Sundaresan N, Rothmann A, Manhart K, Kelliher K (2002) Surgery for solitary metastases of the spine. Rationale and results of treatment. Spine 27:1802–1806CrossRefPubMedGoogle Scholar
  50. 50.
    Tokuhashi Y, Matsuzaki H, Toriyama S. Kawano H, Ohsaka S (1990) Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine 15:1110–1113PubMedGoogle Scholar
  51. 51.
    Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T (2001) Surgical strategy for spinal metastases. Spine 26:298–306CrossRefPubMedGoogle Scholar
  52. 52.
    Vecht CJ, Haaxma-Reiche H, van Putten WLJ, de Visser M, Vries EP, Twijnstra A (1989) Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 39:1255–1257PubMedGoogle Scholar
  53. 53.
    Vinholes J et al (1996) Effects of bone metastases on bone metabolism: implications for diagnosis, imaging and assessment of response to cancer treatment. Cancer Treat Rev 22:289–331CrossRefPubMedGoogle Scholar
  54. 54.
    Wai EK, Finkelstein JA, Tangente RP, Holden L, Chow E, Ford M, Yee A (2003) Quality of life in surgical treatment of metastatic spine disease. Spine 28:508–512CrossRefPubMedGoogle Scholar
  55. 55.
    Weigel B, Maghsudi M, Neumann C, Kretschmer R, Müller FJ, Nerlich M (1999) Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine 24:2240–2246CrossRefPubMedGoogle Scholar
  56. 56.
    Wise JJ, Fischgrund JSA, Herkowitz HN, Mongomery D, Kurz LT (1999) Complications, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine 24:1943–1951CrossRefPubMedGoogle Scholar
  57. 57.
    York JE, Berk RH, Fuller GN, Rao JS, Abi-Said D, Wildrick DM, Gokaslan ZL (1999) Chondrosarcoma of the spine: 1954 to 1997. J Neurosurg 90[Suppl 1]:73–78PubMedGoogle Scholar
  58. 58.
    Young RF, Post EM, King GA (1980) Treatment of spinal epidural metastases: randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 53:741–748PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2005

Authors and Affiliations

  • Max Aebi
    • 1
  1. 1.Institute for Evaluative Research in Orthopedic SurgeryUniversity of BerneBerneSwitzerland

Personalised recommendations