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Vengust / Rehabilitacija - letn. VII, supl. 3 (2008)
SURGERY OF EXTRADURAL 
METASTASES OF THE SPINE
R. Vengust R. Vengust
Dept. of Orthopaedic Surgery, UKC, Ljubljana, Slovenia Dept. of Orthopaedic Surgery, UKC, Ljubljana, Slovenia
in 17 cases. Other 11 patients were operated because of 
frank or incipient spinal instability. 
Segmental or partial segmental resection was performed 
in 19 cases and tumour debulking in 20 cases. Three 
weeks after surgery pain regressed on the bases of visual 
analogue scale from 7.5 (4-10), to 3.5 (1-7). Five out of 
eleven patients improved neurologically three weeks after 
surgery. In segmental resection patient pain dropped from 
7.2 (4-8) preoperatively to 1.9 (1-5) postoperatively. 15 
out of 19 patients with segmental resection were ambu-
latory three weeks after surgery. On the bases of our 
experience we conclude that segmental resection with 
stabilization should be performed in isolated breast or 
kidney metastases. In cases of lung metastases without 
neurological symptoms simple posterior decompression 
with stabilization provides acceptable morbidity with 
satisfactory result.
Abstract 
In last decade surgical treatment of spinal metastases 
improved significantly, mainly because of improvement 
in diagnostics and surgical technique. Concerning surgi-
cal technique anterior approach with corpectomy and 
stabilization is used whenever type, location and life 
expectancy do not dictate it as inappropriate. 
The aim of our study was to review our experience with 
segmental resection for spinal metastases. 
From February 2003 till February 2007 39 patients were 
operated for extradural spinal metastases. The primary 
tumour was located in breast in 16 cases and in lung in 
8 cases. There were 8 metastases from kidney and 5 from 
prostate. Once a disease originated from intestinal and 
laryngeal carcinoma. Surgery was indicated because of 
neurological symptoms in 11 cases and because of pain 
INTRODUCTION
Metastases are the most common form of skeletal tumours, 
met by orthopaedic surgeons. Spine is the most common 
place for bone metastases; therefore treatment of spine 
metastases represents an important part of all skeletal pathol-
ogy. In the last two decades there has been a significant 
change of attitude towards treatment of spinal metastases 
both around the world and in our country. There has been a 
large qualitative break through in the diagnostics and even 
more in surgical treatment of metastases. Anterior approach 
to all the regions of the spine, once practised only by a few 
orthopaedic surgeons in biggest spine centres, is becoming 
everyday practice of modern (contemporary) spinal surgeon. 
Through team approach, which combines spinal surgeon 
with oncologist, radiologist and neurologist, the quality of 
treatment has improved significantly for patients with spinal 
metastases.
METHODS AND SUBJECTS
In Dept. of Spinal Surgery, KC Ljubljana 39 patients with 
spinal metastases were operated between February 2003 
and February 2007. There were 22 females and 17 males. 
The primary tumour was located in breast in 16 cases and 
in lung in 8 cases. There were 8 metastases from kidney and 
5 from prostate. Once a disease originated from intestinal 
and laryngeal carcinoma. Average age of our patients was 
63 years (44 to 81). The most frequent area of the surgery 
was lumbar spine (18 times), followed by thoracic (14 times) 
and cervical spine (7 times). 
22 out of 39 patients either had chemo or radiotherapy 
prior to surgery. In 10 patients, in whom the location of the 
primary tumour was not known, we performed biopsy prior 
to surgery. Biopsy was always performed transpedicularly 
and was in all cases diagnostic. 
As a diagnostic procedure we always performed classical 
X- ray of affected region of the spine, scintigrafic scan using 
Technitium and MRI. Clinical examination was performed
prior to surgery and two to three weeks after the surgery. It
included neurological examination by neurologist or neuro-
physiologist. Pain was asserted according to visual analogue 
scale (VAS) (7).
Indications for surgery were acute neurologic deficit in 4 
cases, progression of neurologic deficit (symptoms) in 7 
cases, severe pain, non responsive to conservative treatment 
in 17 cases, other patients were operated because of frank 
or incipient spinal instability. In 8 cases only involvement 
of lower motorical neuron was noted, in 6 cases there was 
combined involvement of both lower and upper motorical 

186
neuron. All the patients but seven were able to walk by 
themselves or with assistance of physiotherapists prior 
to op. 
Right after the surgery and three weeks after the surgery clas-
sical X-ray of the operated region of the spine was taken.
RESULTS 
We managed to perform planned operation in 38 out of 39 
cases. The only case we weren’t able to finish the operation 
as planned was the case with kidney carcinoma metastases 
to fourth lumbar vertebra. We stopped the operation at the 
6000 ml loss of blood, whilst we were unable to control the 
bleeding. In other cases the loss of blood was always less 
then 2500 ml, except in the case of metastases of hyperne-
phroma when total blood loss was 11.000 ml of blood. 
Segmental resection was performed in 7 cases, all of them 
being metastases of breast carcinoma. Partial segmental 
resection was performed 5 times with metastases of kid-
ney 6 times breast carcinoma and once with metastases 
of laryngeal carcinoma. Other operations were palliative 
in nature with removal of tumour from nerve structures 
(debulking). 
Spine was stabilized in all cases except with partial seg-
mental resection of the kidney carcinoma metastasis to 
Th 10. That was one of 12 cases in which we performed 
only anterior approach. Combined anterior and posterior 
approach was performed 8 times, always during the same 
operation. In other cases we operated through posterior 
approach only. 
As obtained by VAS, the preoperative pain averaged 7.5 
(4-10) and three weeks after the surgery 3.5 (1-7). Neu-
rologic deficit was completely gone only in the case of 
metastasis to C4, where we preoperatively observed one 
sided deltoid muscle paralysis which lasted for two weeks. In 
other patients neurologic status partially improved or stayed 
the same as before surgery. Patient with hypernephroma 
metastasis to Th 12 developed cauda equina syndrome with 
retention of urine after the surgery, which still lasted three 
months postoperatively. 
Patients were mobilised as soon as possible. All but two of 
them were able to walk by themselves or with the help of 
physiatherapist from third postoperative day on. Patients 
that were not treated with radio or chemotherapy preopera-
tively were transferred to Oncological institute for adjuvant 
treatment. 
All patients were postoperatively given orthoses for addi-
tional immobilization of the operated segments of the spine, 
except those with segmental or partial segmental resection 
and stabilization.
DISCUSSION
Decision upon operative treatment of extradural spine 
metastases depends on many factors. The most important 
ones are location of the tumour, origin of primary carcinoma, 
radio- and chemosensitivity of the tumour, stability of the 
spine, pain, neurological deficit and general patient condi-
tion. Different kinds of specialists decide on those factors, 
therefore decision about treatments has to be made in a 
team. In the last two years we have established a nonformal 
team of oncologist, radiologist, neurologist and orthopaedic 
surgeon, which provides complex approach to treatment of 
spinal metastases. 
When we decided to operate, operative plan had to be made. 
There are numerous reports in the literature about advan-
tages of anterior approach decompression, mainly because it 
provides bigger improvement in the neurological status and 
stability of the spine. That is especially the case with thoracic 
spine where spinal canal is narrow and chances of additional 
neurological deficit whilst manipulating neurostructures 
bigger. It is not quite clear whether laminectomy combined 
with radiotherapy provides better results than radiotherapy 
alone (1, 3). 
Therefore we tended to operate our patients with anterior 
approach with thoracotomy, thoracolumbotomy or lum-
botomy, if bigger operation was appropriate according to 
life expectancy. In these cases we performed resection or 
segmental resection. We performed debulking (removal) of 
the tumour through posterior approach only when compres-
sion of neurological structures was only from the back. In 
our series it was only with metastases of prostate cancer to 
lumbar spine. Laminectomy with posterior decompression 
and stabilization was also performed when life expectancy 
was about six months. We decided not to operate if life 
expectancy was less then six weeks or if the patient with 
life expectancy of only several months was bedridden, with 
no hope of operative improvement (2). 
During the operation we always performed stabilization 
of the spine beside decompression, only in the case of the 
patient with limited involvement of Th 10, where tumour 
removal did not destabilize the spine. Proper stabilization 
provides chances of optimal postoperative mobilization, 
which in patients with spine metastases means significant 
improvement in the quality of remaining life. Anterior spinal 
column was supported in all cases of segmental resection, 
once with partial segmental resection and in all cases of 
operations on cervical spine. Spondylodesis was performed 
on patients with life expectancy more than one year, in other 
patients we performed only stabilization with osteosynthetic 
material with or without bone cement. 
Metastases of hypernephroma require specific treatment. 
Considering tumour is resistant to radio- and chemotherapy 
the only way to treat and significantly prolong life is through 
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187
surgery (9), especially when only one solitary metastasis 
is discovered. This kind of metastasis represents surgical 
challenge in its vascularity and consequential bleeding at 
removal. In the last three years we operated six cases of 
hypernephroma cancer. In the first case we were unable to 
extract the whole tumour at the level of L4 due to heavy 
bleeding, even though an embolization was performed a 
day prior to surgery. In the second case of hypernephroma 
metastases to Th 12 we planned posterior approach with 
reduction of tumour and stabilization, followed by anterior 
corpectomy and insertion of appropriate cage (10). Dur-
ing posterior operation blood loss amounted to 8000 ml, 
although we closed all proximal and distal epidural blood 
vessels prior to tumour removal. During anterior operation 
there was another 2000 ml of blood loss, although we closed 
all segmental blood vessels at three levels. In the third case 
of hypernephroma metastasis, it was confined to a part of 
Th 10 body and half of posterior elements. We decided on 
isolated anterior approach. We closed all segmental blood 
vessels at three levels and so managed to cut down blood loss 
to less than 1000 ml. Other three cases of hypernephroma 
metastases were anterior approach ligation of segmental ves-
sels and with blood loss of less than 2500 ml. On the basis 
of our limited experiences we conclude that, in operating 
metastases of hypernephroma it is best to first approach 
anteriorly, close all segmental blood vessels at several levels 
and then proceed with posterior operation if necessary. An 
embolization prior to surgery, though important, does not 
guarantee significant reduction of blood loss.
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