It is disturbing to read the 2001 update of the clinical practice guideline on the management of chronic pain in patients with breast cancer as summarized in CMAJ by Chris Emery and colleagues.1 In the full text of these guidelines the authors state that bone pain from vertebral metastases is very common; however, there is absolutely no mention of surgical stabilization techniques despite the fact that they are an effective evidence-based option for treating mechanical axial skeletal pain due to bone metastases.
Among their descriptions of treatment options the authors are careful to include descriptions of complementary techniques with little or no evidence for their effectiveness, including neurosurgical ablative procedures such as rhizotomy and cordotomy, and psychotherapy. They fail to mention the excellent outcomes seen with surgical stabilization of pathological vertebral fractures and impending fractures. They even state that “except for spinal cord compression, neurosurgical interventions are rarely required in the management of cancer pain.” There is now a large body of literature that supports the surgical decompression and stabilization of spinal metastases as effective palliation of mechanical pain (not only for metastatic epidural spinal cord compression) with acceptable levels of morbidity.2,3,4,5 In fact, surgery followed by radiation appears to be more effective than radiation alone in improving local pain control and survival and reducing postoperative morbidity.2,3,4,5,6
No longer is it acceptable practice to deny surgical stabilization to appropriate patients with vertebral metastases. At the Combined Neurosurgical and Orthopaedic Spine Program at Vancouver General Hospital we have reported favourable outcomes in these surgically treated patients; we continue to follow their outcomes prospectively and are perfoming an economic evaluation of surgical treatment in these patients. It is a pity that the guidelines published by Emery and colleagues continue to perpetuate the lack of appropriate referral and access to effective spinal surgical care for this often inadequately palliated patient population.
Marcel Dvorak Charles G. Fisher Combined Neurosurgical and Orthopaedic Spine Program Vancouver General Hospital Vancouver, BC