We retrospectively reviewed the data of 13 consecutive patients with neoplastic spinal compression who underwent palliative cervical surgery for spinal metastases and who also received immediate rehabilitation after surgery. Before the surgery, the impairment status was evaluated based on spine-specific and other factors, as previously reported [16]. We also examined neurological deficits, ambulation status, progression of pathological fracture, collapse, postoperative implant failure, and Barthel Index (BI) [18].
Patients
This retrospective study was conducted at Nara Medical University Hospital. The study protocol was approved by the hospital institutional review board. The study was conducted in accordance with the principles of the Declaration of Helsinki and the laws and regulations of Japan. A consecutive cohort of 13 patients with neoplastic spinal cord compression from 2010 to 2018 who met the surgical indications described below was enrolled. The treatment strategies for all patients were assessed by the multidisciplinary tumor board (MDTB) of our hospital. The inclusion criterion was palliative cervical surgery for cervical metastasis during the study period. The follow-up periods averaged 593 ± 643days (range, 60–1872 days).
Multidisciplinary tumor board for skeletal metastasis
An MDTB for the assessment of skeletal metastasis at Nara Medical University Hospital was established in 2010. Since then, the disability/impairment status of each patient has been evaluated. Moreover, treatment plans for approximately 100 patients are evaluated annually. The monthly board meetings are attended by physicians, medical oncologists, radiation oncologists, diagnostic radiologists, physiatrists, orthopedic oncologists, spine surgeons, advanced practitioners, oncological nurses, and clinical support staff. In addition to regular monthly board meetings, web discussions were held for emergency cases selected based on the electronic medical record system of the hospital. The cases eligible for presentation included new or existing outpatients or inpatients with skeletal metastasis. The multidisciplinary tumor board supported the coordination, communication, and decision-making among team members. Based on these board discussions, all patients immediately received intensive and regular adjuvant treatments, including radiation therapy, chemotherapy, palliative care, and rehabilitation.
Surgical indications for palliative cervical surgery
The surgical indications for palliative cervical surgery were comprehensively assessed by the MDTB for skeletal metastasis, based on the following clinical findings:
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Spinal instability.
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Radiological spinal compression.
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Prognosis.
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Feasibility of the stabilization surgery (presence of multiple spinal lesions).
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Presence of pain or neurological deficits.
We evaluated spinal instability using the spinal instability neoplastic scale (SINS) score [19]. The SINS is generated by tallying each score from the six individual components (location, pain, bone lesion quality, spinal alignment, vertebral body collapse, and posterolateral involvement of the spinal elements). It SINS showed excellent inter-and intra-observer reliabilities in determining three clinically relevant categories of stability [19]. A score ≥ 7 was classified as potentially unstable or unstable. A 6-point epidural spinal cord compression (ESCC) grading scale was also used [20]. This magnetic resonance (MR) imaging-based grading scale is based on the degree of impingement of the cerebrospinal fluid (CSF) space. The inter-and intra-observer reliabilities were reported to range from good to excellent [20]. After grading, the neurological findings were evaluated. Regarding prognosis, we referred to the Revised Tokuhashi [21] and new Katagiri [22] scores. Patients with an estimated life expectancy of ≥ 3 months were assessed for surgery. Palliative cervical surgery mainly involved posterior fixation. Patients with multiple spinal lesions expanding the vertebra of the planned fixation level were deemed unsuitable for surgery. In addition to fixation, posterior decompression was also performed in tumors occupying only the posterior epidural space and which were not considered hemorrhagic based on radiological and pathological findings.
Rehabilitation
Rehabilitation was started 1 day after the surgery and involved tasks such as sitting, standing, and walking, similar to rehabilitation programs performed after general (non-oncological) spine surgeries.
Outcome evaluations
All patients were hospitalized for surgery. Preoperative measurements were taken at admission, while postoperative measurements were performed at discharge by medical doctors in the Department of Rehabilitation Medicine. The primary outcome evaluations were the BI, neurological deficits using the Frankel Scale (A–E) [23], duration to start ambulation exercises, and overall survival.
The Frankel Scale
The Frankel Scale classifies the extent of the neurological/functional deficits into five grades. Frankel grade A patients show complete motor and sensory lesions, while Grade B patients had sensory-only function below the level of injury. Grade C patients showed some degree of motor and sensory function; however, they lacked retained/recovered motor function. Grade D patients had proper but abnormal motor function below the level of injury. Furthermore, grade E patients showed complete motor and sensory recovery [23].
Duration to the start of ambulation exercises
The duration (days) to the start of ambulation exercise after surgery was obtained from the medical records. We defined the level of mobility achieved during rehabilitation from levels 1 to 5, as described by Kim et al., with some modifications (Table 1) [24].
Table 1
Maximum levels of mobility during hospitalization
Level 1 | Therapeutic (in-bed) exercises | |
Level 2 | Bed mobility (supine-to-sit) | |
Level 3 | Transfer training (sit-to-stand/bed-to-chair) |
Level 4 | Gait training (walk with assistance) | |
Level 5 | Gait training (walk independently) | |
BI
The BI is one of the most widely used rating scales to measure activity limitations in patients with neuromuscular and musculoskeletal conditions [18]. The BI consists of 10 items that measure a person’s daily functioning, including feeding, bathing, grooming, dressing, toilet use, transfers, mobility, and stair use [18]. Previous studies reported high marks for reliability and validity ratings in various reports on the BI [25–27].
Statistical analysis
Statistical analysis was performed using JMP14.0 (SAS Institute, Cary, NC, USA) and G * Power software 3.1 (University of Dusseldorf). Statistical significance was set at p < 0.05. As the data using the Shapiro-Wilk test were nonparametric, Wilcoxon signed-rank tests were used to assess the differences in BI scores before and after the rehabilitation intervention.