Abstract
PurposePseudarthrosis within the spine tumor population is increased from perioperative radiation and complex stabilization for invasive and recurrent pathology. We report the radiographic and clinical rates of pseudarthrosis following multiple courses of instrumented fusion and perioperative stereotactic radiosurgery (SRS).MethodsWe performed a single institution review of 418 patients treated with non-isocentric SRS for spine between October 2002 and January 2013, identifying those with spinal instrumentation and greater than six months of follow-up. Surgical history, radiation planning, and radiographic outcomes were documented.ResultsEleven patients who met criteria for inclusion underwent 21 sessions of spinal SRS and 16 instrumented operations. Radiographic follow-up was 48.9 months; 3/11 (27%) were with radiographic hardware failure, and one (9%) separate case ultimately warranted externalization due to tumor recurrence. SRS was administered to treat progression of disease in 12/21 (57%) procedures, and residual lesions in 7/11 (64%) procedures. Following first and second SRS, 8/11 (73%) and 2/7 (29%) patients were with symptomatic improvement, respectively.ConclusionRisk of pseudarthrosis following SRS for patients with oncologic spinal lesions will become increasingly apparent with the optimized management of and survival from spinal pathologies. We highlight how the need for local control outpaces the risk of instrumentation failure.
Highlights
The management of spinal column metastasis has increasingly moved towards less invasive separation surgery followed by adjuvant stereotactic radiosurgery (SRS)
A complete survey of their clinical courses suggests that patients with spinal metastasis tolerate aggressive surgical management with perioperative SRS, and may present with progression and urgent decompression needs that outpace competing hardware risks
We suspect symptomatic pseudarthrosis rate is an overestimate of the problem given the number of patients lost to follow-up due to survival
Summary
The management of spinal column metastasis has increasingly moved towards less invasive separation surgery followed by adjuvant stereotactic radiosurgery (SRS). This decompressive approach reduces the post-operative recovery burden while preserving high levels of functional independence [1, 2]. Aggressive surgical stabilization and construct extension is still warranted among destabilizing and multiply-recurrent pathologies for preservation of function. Concerns for decreased periosteal osteoblastic proliferation, decreased vascularity, and increased bony pliancy subject patients to the risks of hardware failure, including implant migration, fusion failure, and biomechanical destabilizationassociated pain that can warrant surgical revision [8, 9]
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