The PVCR (posterior vertebral column resection) as a safe procedure for the treatment of unstable metastases with extensive epidural tumor growth

Background: Spinal metastases can result in spinal cord compression through epidural tumor growth (ETG) and bony destruction. In these cases, the superiority of surgical therapy over radiation alone has been shown in the past. A gold standard regarding the choice of surgical procedure does not yet exist. Due to the increasing life expectancy -even in the case of metastatic disease- bony fusion is also gaining in importance. In our clinic we have been performing pVCR for decompression and stabilization for many years in patients with ETG-related spinal cord compression and concomitant instability of the ventral column. The aim of this study was to examine the clinical and radiological outcome of the patients treated in this way. Method: All patients from 2013-2021 who were treated with pVCR for a tumor disease were included in a prospective database. Age, primary tumor, NRS, Frankel score, SINS, Karnofsky status (KPS) and radiological parameters were recorded from the HIS-system.

Results: 79 patients were included. The mean follow-up was 524±762 days. At the time of the operation, the age was 64.9±10.5 years. The most common underlying diseases were multiple myelomas (n = 22), breast cancer (n = 16), and lung cancer (n = 11). The SINS was 11.6±2.4. The Epidural Spinal Cord Compression Score (ESCC) was 2.7±0.5. The NRS (pre- 6.1±1.7 vs. postop 3.3±1.6) and segmental kyphosis (pre- 13.8 °±8.4 ° vs. postop 3.8 °±5.5 °) decreased significantly (p <0.001). The Frankel score worsened postoperatively in two (3%) patients, while an improvement was documented in 14 (18%) patients. The KPS remained constant during the observation period (preoperatively 73.0±18.4% vs. follow-up 78.4±18.2%). Bony fusion was observed in 32 of 37 (86.5%) patients who received CT imaging more than 100 days after index surgery.

Conclusion: This study shows, that pVCR is a reliable surgical technique in patients with epidural tumor compression and concomitant instability. It could be shown that the NRS was reduced in the short- and mid-term outcome, the KPS could be kept stable despite the seriously ill patients. The improvement in the Frankel score shows that the surgical objective can be reliably achieved. Despite the postoperative radiation, fusion rates of 86% could be observed. We conclude that pVCR is a safe, fast and efficient strategy to achieve stability and pain relief in the long term in patients with epidural tumor compression.