Karnofsky and Tokuhashi scoring systems are currently used to determine the prognosis of the patients with metastatic spinal tumors before and after surgery [9, 10]. The prognosis of spinal tumors is related to many factors such as the general condition of the patient, their ability to carry on normal activity and care for them self, and the degree of their disability. Other important factors include the presence of extraspinal bone or other organ metastasis, the histological type of the primary tumor, the limited or diffuse nature of the primary tumor, and paralysis. These prognostic factors must be taken into account for objective determination of treatment modality. This is especially true in cases of radical surgery, where the operability of the patient should be thoroughly assessed using classification systems. Therefore, in cancer patients appropriate clinical and radiological scoring methods should be chosen with determination without any delay.
Here, anterolateral and combined approaches were performed in 33.3% of patients (19/57)with Karnofsky scores of 80–100 and in 26.3% of patients (15/57) with modified Tokuhashi scores of 0–1. Posterior approach was performed in 22.8% of patients (13/57) with Karnofsky scores 80–100 and in 17.5% of patients (10/57) with modified Tokuhashi scores of 0–1. In these patients, posterior spinal cord compressions were the main component of the tumor and spinal stabilization did not required. On the other hand, posterior approaches were performed in 33.3% of patients with a Karnofsky score of 50–70 and in 43.8% of patients with modified Tokuhashi score of 2–4. Sundaresan et al stated that effective surgical treatment of neoplastic compression requires anteroposterior resection in most patients with good score to achieve the goal of total tumor resection . Zarzycki D et al., also suggested that effective surgical treatment of neoplastic compression in most patients needs anteroposterior resection using instrumentation to achieve total tumor resection . Thus, combined and anterolateral approaches are applied to the patients with good scores. In patients with good scores and limited lesions, as in these cases, surgery can be performed. Nevertheless, surgical modalities even in patients without any neurological deficits are still controversial, and deciding on a treatment remains difficult. According to Taneichi et al., surgery should be performed if lesions affect 50–60% of the vertebral body, since these lesions increase the risk of vertebral body collapse . Additionally, lesions affecting the posterior cortex of the vertebra body and extending to the spinal cord without causing any neurological deficits carry potential risks for neurological deficits. Therefore, these lesions should be operated on even if the spinal column is stable.
For the patients without organ metastasis, the Karnofsky index may be more suitable than the Tokuhashi index for determination of treatment. However, the use of both scoring systems is most appropriate when determining treatment for spinal metastasis, especially when considering surgery. Both scoring systems separately have incapacity for determination of the clinical status of the patients. The Karnofsky scoring system is widely used for prognosis of central nervous system tumors. High Karnofsky scores are generally associated with long survival times. According to North et al., life expectancy and extended survival are highest for patients with limited pathology in one spinal segment and Karnofsky scores over 70% . In accord with this report, we found that patients with Karnofsky scores of 80–100 and modified Tokuhashi scores less than 2 had the highest survival times. When deciding upon surgery, the Karnofsky score should be taken into consideration if the modified Tokuhashi score is less than 2. If the general condition is not good (Karnofsky < 40%, modified Tokuhashi > 5), then palliative treatment modalities should be considered. Tokuhashi scoring systems was suggested in estimation of early death, which can be used to predict of life expectancy for selecting surgical procedure of spinal metastases after operation [2, 3, 15] Radiotherapy, alone, can be used to treat patients who are not in a good general condition, which can be used to avoid major operation and are suffering pain [16, 17]. Alternatively, it can be used in cases where surgery would not be effective for technical reasons . Radiotherapy has been shown to be effective after surgery and can reduce pain, even if the tumor has not been totally removed [16, 18].
Tumor recurrence after the surgery is one of the biggest problems associated with spinal metastasis. Nazarian et al. reported that, following surgery for spinal metastasis, recurrence was present at the same spinal level (local recurrence) in 11% of patients and at other spinal levels in 16.5% of patients . In another study, local recurrence was observed in 8.4% of patients . In our study, local recurrens rate was 10.5%. Palliative radiotherapy and supportive care should be considered for treatment of local recurrences without neurological deficits.