Quraishi, Nasir A.
(2020)
Outcome and health-related quality of life in patients undergoing surgery for spinal metastases and metastatic spinal cord compression.
PhD thesis, University of Nottingham.
Abstract
Background
Surgical treatment for spinal metastases has been shown to improve pain and neurological outcome. However, there remains limited literature on timing of surgery, effects of embolisation, prognostic scoring as well as patient-reported and health-related quality of life (HRQOL) outcome scores in this patient cohort. Furthermore, as most spinal metastases are detected at later stages, the impact of treatment on HRQOL is an important consideration in the choice of treatment.
Purpose
The aims of this study were to explore the importance of timing of surgery and embolisation in the neurological outcome and survival in patients undergoing urgent surgery for metastatic spinal cord compression (MSCC) [Chapters 2 and 3]; to assess the accuracy of scoring systems in predicting survival and neurological outcome in patients undergoing surgery for MSCC [Chapters 4 and 5]; to investigate the HRQOL and functional outcome following surgery for MSCC and spinal metastases [Chapter 6]; finally, to report on complications from surgical interventions in these patients as well as re-operative rates [Chapter 7].
Methods
Analysis was undertaken on data, which were ambispectively-collected during the study period (retrospective 2005-2011; prospective 2011-2013). Pre-operative, intra-operative and post- operative outcome data of the functional and neurological status of all surgically treated patients for spinal metastases and MSCC including HRQOL scores, complications and survival were analysed.
Results
This thesis found earlier decompression surgery (within 24 hours of acute presentation) in patients with MSCC (n=121; mean age 61 years (17-86); 75M: 46F), resulted in a better neurological improvement compared to surgery after 24 hours (p = 0.01). However, the post- operative length of hospital stay, complications or patient survival were not influenced by earlier surgical intervention [Chapter 2]. With regard to embolisation and surgery for vascular renal cell metastases to the spine (n = 25), it was shown that blood loss (just over a mean of 1.5l) and complications (in 1/3 of patients) remained concerning; the timing and grade of embolisation did not significantly affect intra-operative blood loss [Chapter 3]. Linear regression modelling showed that more extensive cord compression by metastases, as given by the Epidural Spinal Cord Compression Scale (ESCC) scale, led to significantly greater blood loss, and that it was still important to perform spinal surgery even in higher grades of cord compression to improve neurological outcome [Chapter 4].
Focus then turned to the popular prognostic scoring system for survival - the revised Tokuhashi score. In a large study of over 200 patients, there appeared to be only a modest agreement of 66% between the predicted (from the revised Tokuhashi score) and the actual survival [Chapter 5]. A detailed prospective analysis of patient-reported outcome and quality of life scores in 199 patients undergoing surgery for spinal metastases showed that surgical treatment did significantly improve pain and HRQOL [Chapter 6]; the overall complication rate was 27%. In the penultimate chapter [Chapter 7], a modest re-operation rate (10%) is reported in patients treated surgically for spinal metastases, and most of these re-operations were for surgical site infection and were performed during the same admission as the primary surgery. The survival times did not differ significantly in those patients who received single surgery against those patients who underwent revision surgery (single surgery n = 258, median survival 250 days (5-2597) vs. revision n = 31, median survival 215 days (9-1352); p = 0.722).
Conclusions
In conclusion, this thesis has found that earlier surgery for MSCC is associated with improved neurological outcome. Timing or the grade of pre-operative embolisation did not significantly affect intra-operative blood loss in surgery for vascular renal cell spinal metastases, suggesting that other factors could play a role. Indeed, a linear regression model did reveal significantly greater blood loss to be associated with a higher degree of MSCC (as given by the ESCC scale), and that decompression surgery was still beneficial even with the more severe grades of cord compression.
The revised Tokuhashi scoring system showed only modest agreement for survival suggesting that some of the parameters within this scoring system remained important and need further investigation. Very convincing evidence was provided from patient-reported outcomes and quality of life scores that surgical treatment did significantly improve pain and health-related quality of life in these patients. Finally, one in four patients sustained a complication and there was a 10% re-operation rate in a large cohort of surgically treated patients for spinal metastases, where most of these re-operations were for surgical site infection performed during the same admission as the primary surgery. It was beneficial for these patients to undergo revision surgery to achieve comparable survival (to those not having revision surgery).
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