Local control and sequelae in localised Ewing tumours of the spine: a French retrospective study

OBJECTIVES

To evaluate both local outcome and sequelae of non-metastatic spinal Ewing tumours (EWT).

PATIENTS AND METHODS

A French cohort of patients ≤ 50years with localised spinal EWT treated between 1988 and 2009, was analysed in regard to tumour characteristics (e.g. volume, vertebral compartment, spinal cord compression, paraspinal soft tissue invasion), local treatment modalities (surgery (S) and margin quality, radiotherapy (RT) dose), response to treatment (e.g. histological response to neoadjuvant chemotherapy (CT)), tumour local control (LC) and sequelae.

RESULTS

Seventy-five patients treated in successive trials were evaluated for LC: SFOP-EW88 (n=14), SFOP-EW93 (n=17) and EuroEwing99 (n=44). Fifty-seven patients (79%) presented initial neurological compression and 69% had inaugural decompressive S. Local treatment modality was S+RT (n=50), RT alone (n=19) and S alone (n=6). Surgery was mainly intralesional (66%). Local recurrences had occurred in 19 patients (14 local, 5 loco-regional) with a median interval of 25 months (1-50). After a 7 year median follow-up (1-22 years), the 5-year LC, relapse-free survival (RFS) and overall survival (OS) reached 78.0% (95%CI: 62.6-84.6), 57.0% (95%CI: 45.2-68.9) and 70.0% (95%CI: 59.1-81.0), respectively. Vertebral compartment involved was the only prognostic factor (5-year LC rate 100% versus 71% for favourable and unfavourable compartment, p<0.03). Among 41 five-year survivors, we observed spinal curvature deformation (35%), growth retardation (28%), spinal reduction mobility (40%), spinal pain (25%) and neurological sequelae (32%) without any significant association with a particular local procedure.

CONCLUSION

RT is the backbone of a successful local treatment of spinal EWT. The place of S remains a pending question. Its actual benefit will likely evolve with new available RT techniques.

[Spinal claudication]

Spinal claudication refers to symptoms caused by nerve compression in the spinal canal brought on during strain. The symptoms are felt as lower limb pain, numbness or fatigue, but back pain that becomes worse under stress is also common. The symptoms are usually associated with the erect position and relieved when sitting or laying down. The underlying condition is most commonly narrowing of the spinal canal. While the diagnosis is often clear, MRI imaging is worth conducting if the symptoms are atypical or cause a clear-cut disability or functional limitation. Most patients are treated conservatively.

[Spinal cord compression: a multidisciplinary approach to a real neuro-oncological emergency]

Spinal cord compression must be considered a top-priority neuro-oncological emergency. Hence, a multi-disciplinary approach and swiftness in establishing appropriate therapeutic measures are crucial to optimise the functional (and perhaps vital) prognosis of these patients. The nihilistic attitudes that have prevailed up until now in some professional sectors, possibly stemming from the perception of a poor short-term prognosis, must be completely eradicated. The overall improvement in survival rates among cancer patients in general, the availability of new neurosurgical techniques in the vast majority of our hospitals and the obvious improvements in radiotherapy equipment and techniques all this pathology to be addressed with greater chances of success. This greater likelihood of accomplishing a better outcome refers not only to the control of the development of the tumour itself, but also to pain control, maintenance of the functioning of the spinal cord and the overall survival of the patient. In this context, we consider it essential for all hospitals to have specific protocols on how to proceed in cases of acute spinal cord compression. The fact that this kind of protocol has been introduced in the Centro Medico de Asturias has prompted us to conduct a review of the current state-of-the-art in this field, with special emphasis on the evidence available for each of the modes of therapy that are discussed.

A multinational, multidisciplinary consensus for the diagnosis and management of spinal cord compression among patients with mucopolysaccharidosis VI

Cervical cord compression is a sequela of mucopolysaccharidosis VI, a rare lysosomal storage disorder, and has devastating consequences. An international panel of orthopedic surgeons, neurosurgeons, anesthesiologists, neuroradiologists, metabolic pediatricians, and geneticists pooled their clinical expertise to codify recommendations for diagnosing, monitoring, and managing cervical cord compression; for surgical intervention criteria; and for best airway management practices during imaging or anesthesia. The recommendations offer ideal best practices but also attempt to recognize the worldwide spectrum of resource availability. Functional assessments and clinical neurological examinations remain the cornerstone for identification of early signs of myelopathy, but magnetic resonance imaging is the gold standard for identification of cervical cord compression. Difficult airways of MPS VI patients complicate the anesthetic and, thus, the surgical management of cervical cord compression. All patients with MPS VI require expert airway management during any surgical procedure. Neurophysiological monitoring of the MPS VI patient during complex spine or head and neck surgery is considered standard practice but should also be considered for other procedures performed with the patient under general anesthesia, depending on the length and type of the procedure. Surgical interventions may include cervical decompression, stabilization, or both. Specific techniques vary widely among surgeons. The onset, presentation, and rate of progression of cervical cord compression vary among patients with MPS VI. The availability of medical resources, the expertise and experience of members of the treatment team, and the standard treatment practices vary among centers of expertise. Referral to specialized, experienced MPS treatment centers should be considered for high-risk patients and those requiring complex procedures. Therefore, the key to optimal patient care is to implement best practices through meaningful communication among treatment team members at each center and among MPS VI specialists worldwide.

The combined use of surgery and radiotherapy to treat patients with epidural cord compression due to metastatic disease: a cost-utility analysis

Neoplastic metastatic epidural spinal cord compression is a common complication of cancer that causes pain and progressive neurologic impairment. The previous standard treatment for this condition involved corticosteroids and radiotherapy (RT). Direct decompressive surgery with postoperative radiotherapy (S + RT) is now increasingly being chosen by clinicians to significantly improve patients' ability to walk and reduce their need for opioid analgesics and corticosteroids. A cost-utility analysis was conducted to compare S + RT with RT alone based on the landmark randomized clinical trial by Patchell et al. (2005). It was performed from the perspective of the Ontario Ministry of Health and Long-Term Care. Ontario-based costs were adjusted to 2010 US dollars. S + RT is more costly but also more effective than corticosteroids and RT alone, with an incremental cost-effectiveness ratio of US$250 307 per quality-adjusted life year (QALY) gained. First order probabilistic sensitivity analysis revealed that the probability of S + RT being cost-effective is 18.11%. The cost-effectiveness acceptability curve showed that there is a 91.11% probability of S + RT being cost-effective over RT alone at a willingness-to-pay of US$1 683 000 per QALY. In practice, the results of our study indicate that, by adopting the S + RT strategy, there would still be a chance of 18.11% of not paying extra at a willingness-to-pay of US$50 000 per QALY. Those results are sensitive to the costs of hospice palliative care. Our results suggest that adopting a standard S + RT approach for patients with MSCC is likely to increase health care costs but would result in improved outcomes.

A 2011 updated systematic review and clinical practice guideline for the management of malignant extradural spinal cord compression

PURPOSE

To update the 2005 Cancer Care Ontario practice guidelines for the diagnosis and treatment of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MESCC).

METHODS

A review and analysis of data published from January 2004 to May 2011. The systematic literature review included published randomized control trials (RCTs), systematic reviews, meta-analyses, and prospective/retrospective studies.

RESULTS

An RCT of radiation therapy (RT) with or without decompressive surgery showed improvements in pain, ambulatory ability, urinary continence, duration of continence, functional status, and overall survival. Two RCTs of RT (30 Gy in eight fractions vs. 16 Gy in two fractions; 16 Gy in two fractions vs. 8 Gy in one fraction) in patients with a poor prognosis showed no difference in ambulation, duration of ambulation, bladder function, pain response, in-field failure, and overall survival. Retrospective multicenter studies reported that protracted RT schedules in nonsurgical patients with a good prognosis improved local control but had no effect on functional or survival outcomes.

CONCLUSIONS

If not medically contraindicated, steroids are recommended for any patient with neurologic deficits suspected or confirmed to have MESCC. Surgery should be considered for patients with a good prognosis who are medically and surgically operable. RT should be given to nonsurgical patients. For those with a poor prognosis, a single fraction of 8 Gy should be given; for those with a good prognosis, 30 Gy in 10 fractions could be considered. Patients should be followed up clinically and/or radiographically to determine whether a local relapse develops. Salvage therapies should be introduced before significant neurologic deficits occur.

A review of intrathecal morphine therapy related granulomas

The development of catheter associated granulomatous masses in intrathecal morphine therapy is an uncommon, but potentially serious problem. While these systems have historically been used in patients with short life expectancies, more recently patients with pain from a benign source have benefited from this therapy, and new complications are being encountered secondary to the patients' longer life spans. Morphine is the most commonly used intrathecal opioid and evidence exists that the formation of granulomatous masses are related to the use of higher doses. When the patients' requirement of morphine increases significantly, the physician should be alert for signs of spinal cord compression, such as new neurological deficits, myelopathy, or radiculopathy. Patients that require these higher doses should be properly informed of the association with granulomas and their associated risks. Indolent infection may also be the etiology of granulomatous masses, and the presence of organisms, both aerobic and anaerobic, should be routinely investigated. Patients with catheter-associated granulomas appear to share several features. They exhibit the onset of symptoms several months following the initiation of intraspinal opioids and commonly present with an increase in pain that precedes signs and symptoms of neurological deterioration. While MRI might be the preferred method of detection of intrathecal granulomas, its cost and availability are prohibitive for routine screening. CT myelogram via pump side port injection of contrast can also be performed to detect catheter tip related granulomas/obstructions. Serial neurological examinations for new deficits may be performed and recorded during pump refill visits to recognize a granulomatous mass in its early stages. If an abnormality is identified, imaging studies are appropriate. Awareness of the condition and vigilance are the keys to successful management of this complication.

Cervical spondylotic myelopathy: conservative versus surgical treatment after 10 years

It is not known whether the results of decompressive surgery to treat the mild and moderate forms of spondylotic cervical myelopathy (CSM) are any better than those of a conservative approach. A 10-year prospective randomised study was performed. The objective of the study was to compare conservative and operative treatments of mild and moderate, non-progressive, or slowly progressive, forms of CSM. Sixty-four patients were randomised into two groups of 32. Group A was treated conservatively while group B was treated surgically. The clinical outcome was evaluated by modified JOA score, timed 10-m walk, score of daily activities recorded by video and evaluated by two observers blinded to the type of therapy, and by subjective assessment by the patients themselves. Seventeen patents died of natural, unrelated causes, during the follow-up. A total of 25 patients in the conservatively and 22 in the surgically treated group were used for the final evaluation. There was no statistically significant difference between both groups in mJOA score, in subjective evaluation by the patients themselves and in evaluation of video-recordings of daily living activities by two observers blinded to treatment mode. There was neither any difference found in the percentage of patients losing the ability to walk nor in the time taken to cover the 10-m track from a standing start. Comparison of conservative and surgical treatment in mild and moderate forms of CSM in a 10-year follow-up has not shown, on average, a significant difference in results. In both groups, patients get better and worse. According to the power analysis it is necessary admit that these results possess the low ability to answer definitely the question which treatment is better for the patients with a mild and moderate non-progressive CSM because of the low number of patients for the final evaluation and for clinically negligible differences between two compared arms. These findings can serve as a worthy odds-on hypothesis which needs the confirmation.

Method of the nerve root selection in diagnostic and therapeutic process in patients with multilevel nerves entrapment in lumbar spine due to the degenerative process

This paper presents a method for determining the proper diagnostic techniques and the respective therapy in patients affected with nerve root compression in the lumbar region of the spine based on developing an algorithm that attempts to assess the level of compression and determine the afflicted nerve root. The clinical picture of degenerative disease of the lumbar spine is characterized by symptoms related to the affected nerve root. The diagnosis and respective therapy benefits from the use of minimally invasive techniques, such as selective root blocks or use of the radiofrequency. For instance, with changes on many levels it is necessary to comply with the rules for the selection of the correct nerve roots so there can be referral for proper treatment. The method of selection is dependent on the correlation of the results of the clinical examination, as well as secondary diagnostic studies, of which the gold standard is the MRI. In clinical practice we rely on the results of magnetic resonance imaging to determine the nerve root level in the lumbar spine. This allows the classification of the roots in relation to the frequency of compression occurrence along its course. The morphologic changes resulting in a similar clinical picture may indirectly suggest a degree of exacerbated risk. In addition, we suggest a system of describing the MRI scans, which allows us to retrospectively obtain information on the locations of potential compression of nerve roots.

May 2001: 32 year old female with dural mass encircling cervical spinal cord

The May COM. A 32-year-old woman with a history of previous mastoid surgery presented with bilateral extremity weakness and ambulatory instability. MRI revealed a dural-based mass completely encircling the upper cervical spinal cord. Workup was significant for an abnormally elevated c-ANCA, positive at a dilution of 1:128. A portion of the lesion was removed by a posterior surgical approach to decompress the cervical cord. Histologic examination of the dura showed a dense granulomatous infiltrate with vasculitis and giant cells; coupled with the positive c-ANCA, the process was felt to be most consistent with Wegener's granulomatosis. Wegener's granulomatosis infrequently involves the dura or meninges and has not previously been reported to affect dura of the cervical cord. Symptomatic improvement followed surgical decompression and high-dose corticosteroid therapy, with resultant resolution of an elevated c-ANCA titer.

An audit of current practice and management of metastatic spinal cord compression at a regional cancer centre

Metastatic spinal cord compression (MSCC) is an oncological emergency requiring prompt recognition and management to preserve neurological function and mobility. We performed an audit to assess current practice of MSCC against current best practice as outlined by NICE. Our retrospective audit identified 10 patients from January to December 2009 with confirmed MSCC. The most common primary tumours were prostate 3 (30%), breast 3 (30%) and lung 2 (20%). Pain was the main presenting symptom 9 (90%), followed by weakness 7 (70%) and sensory changes 1 (10%). 5 (50%) had MRI within 24 hours and only 6 (60%) underwent full MRI scan. 8 (80%) had corticosteroids before MRI scan. 6 (60%) received radiotherapy within 24 hours. Only 4 (40%) were referred to orthopaedics and none of these patients had been recommended surgery. Up 14 days following radiological confirmation of MSCC, the number of patients who were unable to walk increased by 20%. Only 5 (50%) were discharged during this period of study. Our audit reported a number of variances in management compared to NICE guideline. These can be improved by following a'fast track' referral pathway and regular education for junior doctors and primary care doctors.

Case reports: Painful limbs/moving extremities: report of two cases

BACKGROUND

Painful limbs/moving extremities is a relatively rare condition characterized by aching pain in one limb and involuntary movement in the affected fingers or toes. Its pathomechanism is unknown. We report two patients with painful limbs/moving extremities. In one patient with a painful arm and moving fingers, the symptoms were resolved after surgery.

CASE DESCRIPTIONS

Patient 1 was a 36-year-old man with a painful arm and moving fingers. Treatment with administration of analgesics was not effective. Postmyelographic CT showed stenosis of the right C5/C6 foramen attributable to cervical spondylosis and a defect of the contrast material at the foramen. He was treated with cervical foraminotomy. Patient 2 was a 26-year-old woman with a painful leg and moving toes. The pain and involuntary movement appeared 2 weeks after discectomy at L5/S1. Lumbar MRI and myelography showed no indications of nerve root compression. She was treated with a lumbar nerve root block. The pain and involuntary movement completely disappeared in both patients after treatment.

LITERATURE REVIEW

Numerous studies report treatments for painful limbs/moving extremities, but few report successful treatment. Recently, botulinum toxin A injection and epidural spinal cord stimulation have been used and are thought to benefit this condition. Successful surgical treatment previously was reported for only one patient.

PURPOSES AND CLINICAL RELEVANCE

If imaging indicates compression of nerve tissue, we believe surgical decompression should be considered for patients with painful limbs/moving extremities who do not respond to nonoperative treatment.

Payer costs for inpatient treatment of pathologic fracture, surgery to bone, and spinal cord compression among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer

BACKGROUND

Patients with bone metastasis secondary to prostate or breast cancer or multiple myeloma are predisposed to skeletal-related events (SREs), such as surgery or radiation to the bone, pathologic fracture, and spinal cord compression. Inpatient costs of these and other SREs represent an estimated 49%-59% of total costs related to SREs. However, information on payer costs for hospitalizations associated with SREs is limited, especially for costs associated with specific SREs by tumor type.

OBJECTIVE

To examine costs from a payer perspective for SRE-associated hospitalizations among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer.

METHODS

Patients with SRE hospitalizations were selected from the MarketScan commercial and Medicare databases (January 1, 2003, through June 30, 2009). Sampled patients had at least 2 medical claims with primary or secondary ICD-9-CM diagnosis codes for prostate cancer, breast cancer, or multiple myeloma and at least 1 subsequent hospitalization with principal diagnosis or procedure codes indicating bone surgery, pathologic fracture, or spinal cord compression. For patients with prostate cancer or breast cancer, a diagnosis code for bone metastasis was also required. If secondary diagnoses or procedure codes for SREs were present in the claim, they were used to more precisely identify the type of SRE for which the patient was treated, resulting in 3 mutually exclusive categories: spinal cord compression with or without pathologic fracture and/or surgery to the bone; pathologic fracture with or without surgery to the bone; and only surgery to the bone. Related readmissions within 30 days of a previous SRE-associated hospitalization date of discharge were excluded to minimize the risk of underestimating costs. Mean health plan payments per hospitalization, measured as net reimbursed amounts paid by the health plan to a hospital after subtracting patient copayments and deductibles, were analyzed by cancer type and type of SRE.

RESULTS

A total of 555 patients contributed 572 hospitalizations that met the study criteria for prostate cancer, 1,413 patients contributed 1,542 hospitalizations for breast cancer, and 1,361 patients contributed 1,495 hospitalizations for multiple myeloma. The mean age range was 61 to 72 years, and the mean length of stay per admission was 5.9 to 11.6 days across the 3 tumor types. The ranges of mean health plan payment per hospital admission across tumor types were $43,691-$59,854 for spinal cord compression, with or without pathologic fracture and/or surgery to the bone; $22,390-$26,936 for pathologic fracture without spinal cord compression, with or without surgery to the bone; and $31,016-$42,094 for surgery to the bone without pathologic fracture or spinal cord compression.

CONCLUSIONS

The inpatient costs associated with treating SREs are significant from a payer perspective. Our study used a systematic process for patient selection and mutually exclusive categorization by SRE type and provides a per episode estimate of the inpatient financial impact of cancer related SREs assessed in this study from a third-party payer perspective.

Pneumorachis: a possible source of traumatic cord compression

The presence of air within the spinal canal secondary to trauma is a rare condition. These rare cases are generally asymptomatic. We report our first case of closed thoracic trauma with pneumorachis associated with neurological disorders. According to a review of the literature and after personal record analysis, neurologic symptoms can be correlated to the occurrence of intraspinal air. Therefore pneumorachis appears as a possible cause of traumatic spinal cord compression. In this particular case, pneumorachis spontaneously resolved and early outcome was favourable.

[Neurological disturbance of the lower extremities by an extramedullary hematopoietic mass complicated with primary myelofibrosis]

A 59-year-old man with primary myelofibrosis developed motor and sensory neurological disturbance of the legs. Magnetic resonance imaging (MRI) demonstrated a mass lesion of the thoracic vertebra at Th4-6, and in the thoracic vertebral canal at Th4-9, which compressed the spinal cord. Needle biopsy of the mass lesion demonstrated extramedullary hematopoiesis. Initial treatment with bolus methylprednisolone was ineffective and, after subsequent radiation therapy, the mass lesion disappeared and the neurological symptoms ameliorated; however, regrowth of the extramedullary lesion was observed one month later. Surgical resection of the extramedullary lesion, laminectomy, and subsequent radiation were performed. The clinical course after the final treatment was good with no neurological symptoms, although the follow-up period is still short.

[Updates on ossification of posterior longitudinal ligament. Ossification front of posterior longitudinal ligament and cellular biological assessment of chronic mechanical compressed spinal cord]

Mechanisms of ossification processes, pathological changes, and treatment/assessment of myelopathy symptoms because of ossification of the posterior longitudinal ligament (OPLL) remain obscure. Enchondral ossification process of OPLL was closely associated with degenerative changes of elastic fibers and cartilage formation, together with the appearance of metaplastic hypertrophic cartilage cells and neovascularization. There are differences in expression degrees of cytokines and transcription factors between mixed and localized OPLL. While the chronic compressed spinal cord may have plasticity ; the use of stem cell implants, supplementation of neurotrophic factors, in addition to surgical treatment, may bring a better clinical outcome,encouraging the development of these basic research studies. Assessment using new imaging techniques needs to determine the affected level and judge the severity of symptoms.

Extensive vertebral haemangioma with cord compression in two patients: review of the literature

Two cases of extensive vertebral haemangioma with progressive neurological deficits are described. Successful treatment was accomplished with palliative surgical decompression after preoperative embolization in one case and with postoperative radiotherapy in the other. Preoperative embolization, palliative surgical decompression and postoperative radiotherapy appear to provide satisfactory outcome in patients with extensive haemangiomas.

Guiding principles in choosing a therapeutic table for DCI hyperbaric therapy

Hyperbaric therapy is the basis of treatment for pervasive development disorders. For this reason, the choice of the right therapeutic table for each case is critical. Above all, the delay in recompression time with respect to the first symptoms and to the severity of the case must be considered. In our experience, the use of low-pressure oxygen tables resolves almost all cases if recompression takes place within a short time. When recompression is possible almost immediately, the mechanical effect of reduction on bubble volume due to pressure is of remarkable importance. In these cases, high-pressure tables can be considered. These tables can also be used in severe spinal-cord decompression sickness. The preferred breathing mixture is still disputed. Heliox seems to be favored because it causes fewer problems during the recompression of divers, and above all, because nitrox can cause narcosis and contributes nitrogen. Saturation treatment should be avoided or at least used only in special cases. In cases of arterial gas embolism cerebral injury, it is recommended to start with an initial 6 ATA recompression only if the time between symptom onset and the beginning of recompression is less than a few hours.