Introduction An international six-centre prospective observational cohort study.

Objective. To assess the feasibility of radical surgical excisional treatment of spinal metastasis

Materials and methods. Patients with histologically confirmed spinal metastasis originating from epithelial primary site mostly treated with instrumented surgery were studied. Surgical strategies were either radical excisional (enbloc and debulking) or palliative decompressive surgery. Outcomes assessed were measures of quality of life including pain, mobility, sphincter and neurological functions.

Results. A total of 223 patients with a mean age of 61 years and equal number of males and females were studied. Breast, renal, lung and prostate accounted for three quarters of tumours and 60% had metastasis that extended beyond one vertebra. Most patients presented with pain (92%), paraparesis (24%) and abnormal urinary sphincter 22% (5% were incontinent). Seventy four percent of patients underwent radical surgery, 92% of all patients had instrumented fixation. 73% of the radical group had improved pain control (63% for palliative group), 72% regained ability to walk (45% for palliative group), 92% maintained a functional neurological function of Frankel E/D (64% for palliative) and 55% had improved sphincter control (21% for palliative group).

Overall of all petients who underwent surgery, 71% had improved pain control, 53% regained mobility, 64% improved by at least one Frankel grade or maintained normal neurology and 39% regained normal urinary sphincter function. While 18% were bed bound preoperatively, only 5% were still in bed postoperatively. Perioperative mortality rate was 5.8% and morbidity was 21%. The median survival for the cohort was 352 days (11.7 months). The radical surgery group had a median survival of 438 days and the palliative group 112 days (P = 0.003).

Conclusion. Surgical treatment of spinal metastatic tumour is feasible with low mortality, an acceptably low morbidity and affords patients better quality of remaining life. Radical surgical excision has better outcome than palliative surgery in pain control and in neurological function rescue including regaining mobility and improvement in sphincter control.

The analysis of failed spinal fusion usually always proves that either biomechanical or biological basic principles have not been observed. We find this in both fractures and tumors, but particularly also in degenerative changes within the region of the lumbar spine.

One must be aware of the fact that lumbar fusion which includes the lumbosacral hinge can have considerable impact on the entire sagittal profile of the spine. In particular in fusion over several in multisegmental fusion within the lumbar region this must be considered as in the case of an unfavorable position of the lumbosacral hinge and in fusion over several segments, no possibility remains for compensation of the malposition within the region of the lumbar spine.

It is obvious that an unfavorable sagittal profile with displacement of the gravity line anteriorly (lumbar kyphosis) results in an unfavorable distribution of the forces at the lumbosacral hinge so that a fusion is always jeopardized by the occurrence of higher bending moments and shearing forces.

Under this aspect, the restoration of an optimal sagittal profile with proper position of the sacrum above the hip joint should be given special attention. We know that the pseudarthrosis rate is significantly lower in correct position of the sagittal profile as in cases of potentially existing flattening of the lumbar spine in terms of a lumbar kyphosis.

There is a close link between the biomechanics and the biology of a fusion.

Particularly in older patients, these two parameters must be given considerable attention if fusion of the lumbar spine is intended, particularly if the lumbosacral hinge is included.