Noncontiguous spinal metastases and plasmocytomas should be operated on through a single posterior midline approach, and circumferential decompression should be performed with individualized reconstruction.

BACKGROUND

In noncontiguous spinal metastatic disease, anterior or combined anterior-posterior surgery is an effective treatment. The objective of this study is to investigate whether circumferential decompression through a single-stage posterior midline approach with individualized spinal reconstruction can still achieve comparable results for functional improvement and for maintenance of spinal alignment in the absence of the risks associated with the more invasive transcavitary or combined approaches.

METHOD

Seventeen patients with noncontiguous spinal metastases and plasmocytomas at one or two adjacent levels were included in this series. Circumferential decompression was obtained with anterior reconstruction and posterior fixation in ten patients, and with posterior instrumentation alone in seven patients. Postoperatively the patients were prospectively followed, and their functional status and spinal alignment were periodically evaluated.

FINDINGS

Fourteen patients died from progression of their underlying cancer. Their mean survival time was 8 months (range: 1 to 21 months). Three survivors were evaluated at 10, 4 and 3 months respectively. At one month after surgery, 14 patients (82%) showed neurological improvement. Of 10 preoperative nonambulators, seven regained walking capacity. Five patients who were ambulatory with assistance improved to full functional independence. Local tumour recurrence was recorded in one patient after subtotal vertebrectomy for a plasmocytoma at L5. No other tumour recurrences were noted. In one patient a partial loss of correction occurred at T6 - without functional deterioration, however. Spinal alignment was maintained in all other patients who became or remained ambulatory. No major intra-operative complications or peri-operative deaths occurred. CSF leakage was recorded as the most common complication in four patients.

INTERPRETATION

Circumferential decompression and spinal reconstruction through a single-stage posterior midline approach is feasible and effective. The extent of surgery can be individualized by means of this technique to the patient's specific problem. In patients with limited life expectancy from metastatic neoplastic disease, the results compare favourably with the more invasive anterior or combined antero-posterior procedures.