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Although there is no class I evidence (double-blind randomized placebo-controlled trial) for any of the treatment modalities indicated in the treatment of spinal metastases,

Fig. 2 Long fixation in progressing deformity and instability a A 62-year-old woman with multiple-level involvement of the cervical, thoracic, and lumbar spine metastases of a breast cancer with neurological deficit and pain due to progressing deformity and instability. b Long fixation (sublaminar wiring-metal-cement compound) and partial correction from C1 to the lower thoracic spine in combination with irradiation was most efficient in reducing pain and neurological deficit for more than 3 years. c A 58-year-old man with a hypernephroid carcinoma and cervical involvement had previous anterior surgery and a cement block posteriorly (asterisk) with consecutive progression of the tumor, loosening of the fixation and a nonunion at the cement-bone interface (arrow). d Posterior removal of the cement block and stabilization were followed by e anterior revision and restabilization after a previous embolization of the tumor and occlusion of one of the vertebral arteries. The patient died 2 years after this surgery from metastatic complications other than the cervical spine there are several treatment options recommended. In the case of neurological deficit dexamethasone is the only treatment, which has proven evidence of therapeutic efficacy [29, 35, 40, 52]. The therapeutic decision in elderly frail patients is particularly difficult when they also have significant comorbity. Nevertheless there are today essentially four modalities of treatment available after the administration of steroid: (a) irradiation, (b) surgery, (c) bis-phosphonates, and (d) rarely chemotherapy and hormonal therapy as an adjuvant therapy in well defined tumor types [47]. A fifth possibility is a combination of all the above. The efficacy of these diverse treatment modalities and the survival rate of patients depend on the histological tumor type, tumor stage, therapeutic control of the primary tumor, and tumor spread. Overall survival in this patient category is around 12months [12, 15, 33, 48, 51, 54, 56].

The indications for treatment are given not merely by the neurocompression but also alsol by the major determinants of quality of life: (a) pain, be it radicular, medullar, or of dural origin caused by direct or chronic compression through instability and/or progressive deformity of the vertebral column, or be merely by intravertebral pressure elevation due to tumor invasion, (b) loss of mobility, and (c) nursing reasons. This decision-making process is diffi cult since a surgical option is often declined because of the possible comorbities, which, however, have never been evaluated in an appropriate controlled study.

Nevertheless it is clinical experience that patients who had surgery and were not delayed in the postsurgical recovery phase due to relevant medical problems and complications belong to the most grateful patients in spinal surgery although the surgery is purely palliative. This obviously raises the question of whether the surgery can be simplified and minimized in elderly patients to prevent as much as possible the adverse effects of surgery [37, 38]. Furthermore there is a still ongoing debate as to whether patients should be treated with radiation therapy alone or in combination with decompression, both modalities enhanced by the administration of high-dose steroids [14, 18, 58]. The general opinion has long been influenced -and still is - by a study in the 1980s which showed no significant difference between patients who had irradiation alone or decompression through laminectomy alone [58] with respect to pain relief, motor performance, and sphincter function. The combination of radiotherapy and laminec-tomy did not change the outcome significantly compared to radiation therapy alone. A major argument today, however, is that decompression alone in form of a laminec-tomy without a concomitant stabilization is in most cases insufficient to affect the pain relevantly; in fact decompression alone may even increase the instability and further contribute to pain syndrome and neurological deficit. Furthermore a laminectomy compared to a vertebrectomy or at least an anterior decompression cannot achieve the same degree of decompression since 80% of the tumor compressions arise anteriorly where it cannot be reached by laminectomy. The role of the decompression through laminectomy in spinal metastases has become increasingly debatable with the enhanced experimental biome-chanical knowledge as well as in vivo studies in monkeys, where the spinal cord hemodynamics could never be restored after laminectomy alone demonstrating the insufficient effect of a laminectomy alone [14]. The clinical ex-

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