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Abstract
STUDY DESIGN The author describes a technique for complete vertebrectomy and anterior decompression followed by a formal anterior column reconstruction, using readily available endoscopic instruments. This procedure is indicated in patients with radioresistant metastasis of the thoracic spine, particularly those involving the upper thoracic segments where a thoracotomy is difficult and causes a high rate of morbidity. This is also a suitable technique for patients with pulmonary disease who cannot tolerate a standard thoracotomy. OBJECTIVES To demonstrate the feasibility and potential benefits of endoscopically controlled decompression through an extrapleural, posterolateral approach. SUMMARY OF BACKGROUND DATA Posterolateral decompression of the thoracic spine offers potential advantages in comparison with traditional anterior-posterior procedures combining thoracotomy and posterior instrumentation, including decreased operative time, decreased morbidity, and reduced hospital stay. Results of previous studies have not demonstrated the same benefit for posterolateral decompression as for anterior vertebrectomy and decompression. Drawbacks to the traditional posterolateral decompressions have included poor visualization of the spinal cord and anterior tumor, poor access to tumor on the side contralateral to the approach, and the need to manipulate the spinal cord to completely remove adjacent tumor and tumor adherent to the dura. METHODS Surgical indications, rationale, and technique are provided, and initial clinical results are described. RESULTS Transpedicular decompression using endoscopy is described in five patients. The mean operative time for the combined procedure was 7.25 hours, with a mean blood loss of 1800 mL. Neurologic recovery and maintenance were excellent. Inpatient days averaged 7.5, and intensive care days averaged 2. One patient died of disease 8 months after surgery, and four were living, with disease, 3-24 months after surgery. CONCLUSIONS Endoscopically assisted decompression can reduce morbidity, hospital stay, and treatment costs while matching the efficacy of traditional combined procedures. Endoscopy provides a readily available and easily applied tool that dramatically improves the surgeon's vision, providing light, magnification, and a direct view of remote structures.
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Affiliation(s)
- R F McLain
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Ohio, USA
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102
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Mathis JM, Petri M, Naff N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures. ARTHRITIS AND RHEUMATISM 1998; 41:171-5. [PMID: 9433883 DOI: 10.1002/1529-0131(199801)41:1<171::aid-art21>3.0.co;2-5] [Citation(s) in RCA: 150] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This report describes the case of a woman in whom multiple compression fractures of the lower thoracic and lumbar spine occurred in association with long-term corticosteroid therapy for systemic lupus erythematosus. Pain markedly limited the patient's mobility and daily activities, and conservative therapy with bracing and narcotic analgesics gave little improvement. Affected vertebrae were treated with polymethylmethacrylate, introduced percutaneously under fluoroscopic guidance. The resulting reinforcement of the fractured vertebral bodies eliminated the pain and the need for narcotic analgesics. The utilization of percutaneous verterbroplasty as a therapeutic alternative for the treatment of pain resulting from osteoporotic compression fractures is described.
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Affiliation(s)
- J M Mathis
- Johns Hopkins Hospital, Baltimore, Maryland, USA
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103
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Walsh GL, Gokaslan ZL, McCutcheon IE, Mineo MT, Yasko AW, Swisher SG, Schrump DS, Nesbitt JC, Putnam JB, Roth JA. Anterior approaches to the thoracic spine in patients with cancer: indications and results. Ann Thorac Surg 1997; 64:1611-8. [PMID: 9436544 DOI: 10.1016/s0003-4975(97)01034-5] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Multidisciplinary surgical teams enable an aggressive approach to tumors involving the thoracic spine. METHODS From February 1994 to July 1996, 61 patients underwent anterior resections of thoracic spine tumors. Their median age was 56 years. The indications for operation were curative in intent in 7 of 61 and palliative in 54 of 61 (to relieve intractable metastatic bone pain with neurologic compromise [n = 38] and pain alone [n = 16]). Sixteen patients came to our institution unable to ambulate with impending paraplegia. RESULTS Anterior approaches included combined left side of the neck and median sternotomy for lesions involving vertebrae T-1 through T-3 (n = 9), posterolateral thoracotomy for T-3 through T-10 (n = 39), and thoracoabdominal approach at T-11 and T-12 (n = 13). Median hospital stay was 9.0 days (range, 4 to 57 days). Complications occurred in 18 of 61 (29.5%). In 55 of 61 (90%), pain was significantly improved after the operation. Twelve of the 16 patients who initially presented in wheelchairs regained ambulatory function. There were five perioperative deaths (8.2%). The 1-year cumulative survival for the entire group was 60%. CONCLUSIONS An aggressive surgical approach in cancer patients with locally advanced or metastatic disease in the thoracic spine was associated with acceptable morbidity and mortality. There was significant improvement in their quality of life by control of intractable pain in 90% and recovery of ambulatory function in 75% of patients who presented with critical spinal cord compromise.
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Affiliation(s)
- G L Walsh
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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104
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Sundaresan N, Krol G, Steinberger AA, Moore F. Management of Tumors of the Thoracolumbar Spine. Neurosurg Clin N Am 1997. [DOI: 10.1016/s1042-3680(18)30299-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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105
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106
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Milross CG, Davies MA, Fisher R, Mameghan J, Mameghan H. The efficacy of treatment for malignant epidural spinal cord compression. AUSTRALASIAN RADIOLOGY 1997; 41:137-42. [PMID: 9153809 DOI: 10.1111/j.1440-1673.1997.tb00698.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The aims of this study were to document the efficacy of treatment and to identify factors that were predictive of the outcome in malignant epidural spinal; cord compression. The medical records of patients treated at the Prince Henry and Prince of Wales Hospitals in the period 1980-1989 with a diagnosis of malignant epidural spinal cord compression were reviewed. A total of 94 patients were eligible for the study and were treated by radiotherapy alone (37), surgery alone (19) and surgery followed by radiotherapy (38). Efficacy was determined by measuring complete resolution of symptoms and signs at 1 month after presentation, and also by using an overall functional improvement score (FIS). Complete resolution of individual pre-treatment symptoms that were measured 1 month after treatment occurred as follows: pain (30/88), sensory disturbance (12/61), weakness (8/17), bladder dysfunction (10/42), and bowel dysfunction (10/36). Complete resolution of motor deficit occurred in 7/82 and of sensory deficit in 9/73. The ability to walk was regained in 19/51 previously non-ambulatory patients, and bladder function improved sufficiently to remove an indwelling catheter in 9/32 previously catheterized patients. As judged by FIS, 67 patients improved, 15 patients remained stable and 12 patients deteriorated. Of the treatments given, a combination of surgery followed by radiotherapy was associated with the greatest functional improvement (P = 0.001). The coexistence of 'liver failure' was the only patient-related factor identified which was associated with outcome (P = 0.041). The treatment of malignant spinal cord compression appears to be worthwhile; however, the outcome of treatment is not easy to predict from pretreatment factors. A 'functional improvement score' may be useful in assessing treatment efficacy.
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Affiliation(s)
- C G Milross
- Department of Experimental Radiotherapy, University of Texas, MD Anderson Cancer Center, Houston, USA
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107
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Bauer HC. Posterior decompression and stabilization for spinal metastases. Analysis of sixty-seven consecutive patients. J Bone Joint Surg Am 1997; 79:514-22. [PMID: 9111395 DOI: 10.2106/00004623-199704000-00006] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The neurological function, survival, and rehabilitation of sixty-seven consecutive patients who had been managed operatively for spinal metastases with epidural compression were assessed. The epidural compression was in the thoracic spine in forty-one patients and in the lumbar spine in twenty-six. According to the system of Frankel et al. for the assessment of neurological function, twenty-six patients had a major neurological deficit (grade B or C), thirty-two had a minor deficit (grade D), and nine had no deficit (grade E). None of the patients had an operation to treat a pathological vertebral fracture without epidural compression. The operative treatment included wide decompression through a posterior approach followed by stabilization without bone-grafting. A Cotrel-Dubousset device was used in thirty-two patients; an Olerud posterior fixator, in sixteen; an Isola device, in twelve; and another device, in seven. The most common complication was wound infection (eleven patients). There were no perioperative or immediate postoperative deaths (within fourteen days). The rate of survival was 51 per cent (thirty-four of sixty-seven) at six months and 22 per cent (fifteen of sixty-seven) at twelve months. Over-all, forty-four of the fifty-eight patients who had had a neurological deficit preoperatively had complete or partial neurological recovery within the first two weeks postoperatively. The nine patients who had not had a neurological deficit preoperatively retained normal neurological function postoperatively. Thirty-eight of the forty-four patients who were alive at three months and twenty-nine of the thirty-four who were alive at six months were still able to walk. Thirty-nine of the forty-nine patients who survived more than two months were able to return home for a median of seven months. Fourteen patients had a reoperation on the spine. Six of these patients had recurrent epidural compression at another level of the spine, and five had recurrent compression at the previously treated level. Three patients had a reoperation because of loosening of the implant. The results of this study suggest that neurological function can be maintained or improved by decompression and stabilization through a posterior approach as treatment for spinal metastases.
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Affiliation(s)
- H C Bauer
- Oncology Service, Department of Orthopedics, Karolinska Hospital, Stockholm, Sweden.
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108
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Abstract
A 12-year-old Maltese terrier was evaluated for progressive tetraparesis and neck pain. On radiographs, there was a periosteal reaction involving the fourth cervical vertebra. Myelographically, there was extradural compression of the spinal cord associated with the lesion. The dog was euthanized and necropsied. Histopathologic diagnosis was parosteal osteosarcoma of the vertebra.
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Affiliation(s)
- W B Thomas
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville 37901-1071, USA
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109
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110
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Trindade AM, Antunes JL. Anterior approaches to non-traumatic lesions of the thoracic spine. Adv Tech Stand Neurosurg 1997; 23:205-48. [PMID: 9075474 DOI: 10.1007/978-3-7091-6549-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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111
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Sundaresan N, Steinberger AA, Moore F, Sachdev VP, Krol G, Hough L, Kelliher K. Indications and results of combined anterior-posterior approaches for spine tumor surgery. J Neurosurg 1996; 85:438-46. [PMID: 8751630 DOI: 10.3171/jns.1996.85.3.0438] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5-year period (1989-1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty-eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty-three patients (48%) underwent combined anterior-posterior resection and instrumentation. 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.
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Affiliation(s)
- N Sundaresan
- Department of Neurosurgery, Mount Sinai Hospital and Medical School, New York, New York, USA
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112
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Akeyson EW, McCutcheon IE. Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis. J Neurosurg 1996; 85:211-20. [PMID: 8755748 DOI: 10.3171/jns.1996.85.2.0211] [Citation(s) in RCA: 164] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple columns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resection of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid surgeons in selecting the optimum approach for individual patients.
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Affiliation(s)
- E W Akeyson
- Department of Neurosurgery, University of Texas M.D Anderson Cancer Center, Houston, USA
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113
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Sundaresan N, Steinberger AA, Moore F, Sachdev VP, Krol G, Hough L, Kelliher K. Indications and results of combined anterior-posterior approaches for spine tumor surgery. Neurosurg Focus 1996. [DOI: 10.3171/foc.1996.1.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5 year period (1989–1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty three patients (48%) underwent combined anterior-posterior resection and instrumentation, 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.
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114
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Rosenthal D, Marquardt G, Lorenz R, Nichtweiss M. Anterior decompression and stabilization using a microsurgical endoscopic technique for metastatic tumors of the thoracic spine. J Neurosurg 1996; 84:565-72. [PMID: 8613847 DOI: 10.3171/jns.1996.84.4.0565] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It is well accepted that the treatment of spinal tumors that threaten neurological integrity comprises resection, vertebral body reconstruction, and stabilization if the patient's condition is suitable. In spite of the excellent results reported using thoracotomy, the majority of investigators recommend posterolateral techniques because of lower morbidity, shorter hospitalization time, and the possibility of performing dorsal stabilization via the same incision. To overcome some of the disadvantages of thoracotomy, the authors developed an anterior procedure that permits vertebrectomy, reconstruction, and stabilization to be performed entirely by endoscopic technique. Microsurgical endoscopy and stabilization were performed in four patients with metastatic disease of the thoracic spine. All were ambulatory after surgery and at follow up; preoperative neurological and neurophysiological deficits improved as well. No complications occurred in this small series. Microsurgical endoscopy achieves a substantial reduction in trauma, use of analgesic medications, and hospitalization time. Early results seem to indicate that adequate decompression, stabilization and reduction of surgical morbidity can be achieved with this technique.
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Affiliation(s)
- D Rosenthal
- Department of Neurosurgery, Klinikum der Johann Wolfgang Goethe-Universitat, Frankfurt am Main, Germany
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115
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Kurosawa H, Kurumada H, Haga E, Sugita K, Eguchi M, Furukawa T, Kurosu Y, Fujiwara T, Hata J. Epidural metastasis in chemoresistant Wilms' tumor with perilobar nephroblastomatosis. Pediatr Surg Int 1996; 11:153-5. [PMID: 24057542 DOI: 10.1007/bf00183751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/1995] [Indexed: 10/26/2022]
Abstract
An 8-year-old boy with vertebral and epidural metastases was diagnosed with Wilms' tumor associated with perilobar nephroblastomatosis (NB) based on histologic examination. During combined chemotherapy with vincristine, actinomycin D, doxorubicin, and cyclophosphamide (NWTS-3 J protocol), a rapid increase in tumor size was observed. The treatment was replaced with etoposide and carboplatin (JET regimen). A transient response was sustained for 5 months during this chemotherapy. However, regrowth of the tumor was observed and the patient died 11 months after the initial chemotherapy.
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Affiliation(s)
- H Kurosawa
- The Second Department of Pediatrics, Dokkyo University School of Medicine, Tochigi, Japan
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116
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Abstract
This synthesis of the literature on radiotherapy for skeletal metastases is based on 171 scientific articles, including 13 randomized studies, 24 prospective studies, and 79 retrospective studies. These studies involve 13054 patients. Radiotherapy has been well documented as a method for alleviating pain, but the mechanisms underlying this effect are largely unknown. When used for pain palliation, radiotherapy achieves freedom from pain, or substantial alleviation of pain in nearly all cases, with few side effects. Half-body irradiation is effective in treating multiple metastatic sites and should be considered for use more frequently. However, this increases the requirements on equipment, dosimetry, and hospital beds. Systemic radiotherapy with radionuclides may be indicated for generalized skeletal pain. The role of radiotherapy in preventing or healing fractures is not fully evaluated. Optimum dose levels and fractionation schedules have not been established. Early radiotherapy for spinal cord compression may prevent symptoms from worsening, but the effects on existing paralysis are modest.
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117
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Clavel Escribano M, Clavel Laria P. Paraplejia secundaria a expansión vertebral metastásica. Caso clínico. Neurocirugia (Astur) 1996. [DOI: 10.1016/s1130-1473(96)70755-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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118
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Abstract
BACKGROUND Factors affecting survival were determined for 109 patients with thoracic spine metastases and cord compression. Lung, prostate, and breast were the most common primary sites (78%). All patients had surgical decompression of the spinal cord, and 99% received radiotherapy. METHODS Survival was determined based on anatomic site of primary carcinoma, preoperative neurologic deficit, extent of disease, number of vertebral bodies involved, tumor location (site of cord compression), and age. The respective compounding weight of the negative prognostic factors also was analyzed in terms of survival. RESULTS The overall median survival was 10 months. Patients preoperatively ambulatory survived statistically significantly longer than nonambulatory patients or those with sphincter incontinence (P = 3.469 x 10(-6)). Patients with renal cell carcinoma survived the longest, followed by those with breast, prostate, lung, and colon cancer. Patients with breast cancer survived statistically longer than those with lung cancer (P = 0.039). Patients with one vertebral body involved survived statistically significantly longer than patients with multiple vertebral level involvement (P = 0.027). Extent of disease, age, and tumor location did not significantly influence survival. In patients with vertebral column disease, the presence of two or more poor prognostic indicators (leg strength 0/5-3/5, lung or colon cancer, multiple vertebral body involvement), had a compounding adverse effect on survival. CONCLUSIONS For patients with spinal metastases and cord compression, the factors found to affect survival include preoperative neurological status, anatomic site of primary carcinoma, and number of vertebral bodies involved. Patients with vertebral column disease and two or more of the poor prognostic indicators have a short life expectancy, and, therefore, radical surgery is not recommended because the benefits may not be substantial.
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Affiliation(s)
- P J Sioutos
- Memorial Sloan-Kettering Cancer Center, Neurosurgery service, New York, New York, USA
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119
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Arbit E, Galicich JH. Vertebral body reconstruction with a modified Harrington rod distraction system for stabilization of the spine affected with metastatic disease. J Neurosurg 1995; 83:617-20. [PMID: 7674009 DOI: 10.3171/jns.1995.83.4.0617] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Anterior spinal decompression has become widely used for neoplasia arising from the vertebral bodies. Replacement for the resected vertebral body must achieve spinal stability, restitution of lost height, correction of kyphotic deformities, and allow for early ambulation. A spinal fixator based on the Harrington ratchet locking system was found to fulfill this requirement. The fixator, its technique of implementation, and surgical results in 10 patients are described.
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Affiliation(s)
- E Arbit
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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120
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Weller SJ, Rossitch E. Unilateral posterolateral decompression without stabilization for neurological palliation of symptomatic spinal metastasis in debilitated patients. J Neurosurg 1995; 82:739-44. [PMID: 7536235 DOI: 10.3171/jns.1995.82.5.0739] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with symptomatic spinal metastases and limited life expectancy are often too debilitated to withstand anterior or posterolateral spinal cord decompression and segmental stabilization. More limited surgery aiming solely at preservation or restoration of neurological function and relief from pain offers the potential for significant improvement in the quality of remaining life without incurring undue perioperative morbidity and mortality. Eight patients with spinal metastases and limited life expectancy underwent a unilateral transpedicular decompression procedure on their most symptomatic side and/or the side of maximum tumor involvement. All patients were neurologically improved within the 1st postoperative week; all were ambulatory and continent postoperatively. Postoperatively, all five patients with preoperative motor deficits demonstrated increased motor strength, and the three patients with predominant radicular pain reported marked improvement. There were no perioperative deaths and two transient perioperative complications. The average length of hospitalization was 6 days for patients without complications and 10 days for the entire group. Unilateral transpedicular decompression without stabilization is an effective and safe method for palliating symptomatic spinal metastases in debilitated patients with widespread malignancy and limited life expectancy. This therapeutic option should be considered in select cases as an alternative to either nonoperative management or anterior or posterolateral decompression and segmental stabilization.
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Affiliation(s)
- S J Weller
- Department of Neurosurgery, Brigham and Women's Hospital/Children's Hospital, Boston, Massachusetts, USA
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121
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Estabilización mediante pilar intervertebral metálico tras espondilectomía anterior en metástasis del raquis dorsolumbar. Neurocirugia (Astur) 1995. [DOI: 10.1016/s1130-1473(95)70764-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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122
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Abstract
Approximately 200,000 men will be diagnosed with prostate cancer in 1994. While localized disease is potentially curable with surgery or radiation therapy, metastatic disease is incurable. The most frequent site of metastasis is bone. Spinal cord compression occurs in approximately 7% of men with prostate cancer. Back pain often heralds the diagnosis of spinal cord compression. In prostate cancer patients with back pain or signs of myelopathy or radiculopathy, plain radiographs of the spine and magnetic resonance imaging should be performed. Early diagnosis is of utmost importance. The neurologic status prior to treatment is the major determinant influencing outcome. Following diagnosis, corticosteroid therapy should begin immediately. Hormonal therapy should be instituted in those patients who have not previously undergone hormonal manipulation. The standard approach to definitive therapy is radiation. Surgical decompression plays a role in patients with severe myelopathy, spinal instability, and in those patients whose neurologic status deteriorates during or after radiation therapy.
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Affiliation(s)
- J L Osborn
- Department of Medicine, University of Pittsburgh School of Medicine, PA 15213, USA
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123
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Management of the Vertebral Artery in Excision of Extradural Tumors of the Cervical Spine. Neurosurgery 1995. [DOI: 10.1097/00006123-199501000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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124
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Sen C, Eisenberg M, Casden AM, Sundaresan N, Catalano PJ. Management of the vertebral artery in excision of extradural tumors of the cervical spine. Neurosurgery 1995; 36:106-15; discussion 115-6. [PMID: 7708146 DOI: 10.1227/00006123-199501000-00014] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Extradural tumors of the cervical spine may involve the vertebral artery on one or both sides, posing one of the limiting factors toward the radical resection of such neoplasms. A standard anterior approach may be inadequate for the management of such tumors. An anterolateral approach allows the dissection and mobilization of the vessel, which can then be preserved, resected, or reconstructed with a vein graft. An anterior approach can be supplemented with this for tumor resection and stabilization. This management strategy is described in 10 patients with a variety of tumors.
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Affiliation(s)
- C Sen
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
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125
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Krikler SJ, Marks DS, Thompson AG, Merriam WF, Spooner D. Surgical management of vertebral neoplasia: who, when, how and why? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 1994; 3:342-6. [PMID: 7532537 DOI: 10.1007/bf02200148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To determine the role of surgery in vertebral neoplasia, we conducted a retrospective review of patients undergoing surgery for vertebral neoplasia in the Royal Orthopaedic Hospital, Birmingham, and Coventry and Warwickshire Hospital, Coventry. Surgery included decompression, stabilisation or both. The neurological status was assessed by Frankel grading before and after surgery. Of 70 patients undergoing surgery, 14 were neurologically intact preoperatively, and a further 25 were weak but ambulatory. Following surgery, 35 were intact, and a further 22 were ambulatory. Sixty-six patients (94%) obtained good pain relief. Survival correlated with histology and younger age at presentation, but not with level, neurology at presentation or type of surgery. We conclude that neurological status, pain relief and mechanical stability are better after appropriate surgery than after radiotherapy or inappropriate surgery. Failure to consider the surgical option may deny the chance of significant neurological recovery.
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126
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127
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Abstract
Myelopathy, the rapid or insidious onset of motor and sensory abnormalities referable to the spinal cord, occurs as a result of a variety of causes that may be classified on the basis of their location of origin (intramedullary, intradural-extramedullary, and extradural). The first goal of imaging is to appropriately assign the observed abnormality to its location of origin and, therefore, into the correct diagnostic list. This article focuses on the plain film, computed tomography, and magnetic resonance demonstration of extradural causes of myelopathy.
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Affiliation(s)
- M I Rothman
- Anna Gudelsky Magnetic Resonance Imaging Center, University of Maryland Medical Systems, Baltimore 21201
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128
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Grant R, Papadopoulos SM, Sandler HM, Greenberg HS. Metastatic epidural spinal cord compression: current concepts and treatment. J Neurooncol 1994; 19:79-92. [PMID: 7815108 DOI: 10.1007/bf01051052] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Metastatic epidural spinal cord compression (MESCC) is a medical emergency complicating the course of 5-10% of patients with cancer [1]. When diagnosis and treatment is early with the patient ambulatory prognosis for continued ambulation is good [2]. If the patient is nonambulatory or paraplegic, prognosis for meaningful recovery of motor and bladder function is markedly decreased. In the last decade, significant advances in the understanding, management and treatment of metastatic epidural spinal cord compression have occurred. Recent pathophysiological and pharmacological animals studies have afforded insights into disease mechanisms [3-9]. The audit of standard methods of investigation and magnetic resonance imaging have resulted in revision of guidelines for patient evaluation [10-17]. Finally, new surgical philosophies and technical advances have generated interest and controversy [18-25]. With improved clinical awareness, new imaging modalities will help us diagnose epidural spinal cord compression earlier and institute appropriate treatment.
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Affiliation(s)
- R Grant
- Department of Clinical Neurosciences-Neurology Unit, Western General Hospital, Edinburgh, Scotland, UK
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129
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Leviov M, Dale J, Stein M, Ben-Shahar M, Ben-Arush M, Milstein D, Goldsher D, Kuten A. The management of metastatic spinal cord compression: a radiotherapeutic success ceiling. Int J Radiat Oncol Biol Phys 1993; 27:231-4. [PMID: 8407396 DOI: 10.1016/0360-3016(93)90232-k] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE In assessing the effectiveness of the management of metastatic spinal cord or cauda equina compression, we performed a retrospective analysis of 70 patients with this complication whom we treated from 1985 to 1989. METHODS AND MATERIALS The most frequent primary diagnoses in our series were carcinomas of unknown origin and of the breast, lymphoproliferative disease, lung cancer, and prostatic carcinoma. We used the Findlay classification to group all patients according to their pre-therapeutic functional motor status as Grade I (24 patients or 34%), Grade II (27, or 39%) or Grade III (19 or 27%). Treatment consisted of 30-45 Gy of irradiation (using two different schedules) together with high-dose dexamethasone; in only five cases was there surgical intervention. RESULTS We found that a powerful predictor of response to radiotherapy was the patient's neurologic status (Findlay grade) at the time of diagnosis: 66% of previously ambulatory patients remained so, whereas 30% of non-ambulatory patients and only 16% of paraplegic patients regained the ability to walk. Another important predictor of response was primary tumor histology, with the most favorable responses to radiation therapy having been observed in lymphoproliferative diseases and in breast cancer, but with some response in other radiosensitive malignancies as well. CONCLUSION The similarity of our results to those of other centers leads us to conclude that a radiotherapeutic success ceiling of 80% may have been reached for Findlay Grade I patients with metastatic spinal cord compression. In view of this, we suggest that future therapeutic endeavour would be best directed toward early diagnosis of the condition.
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Affiliation(s)
- M Leviov
- Department of Oncology, Rambam Medical Center, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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130
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Hacking HG, Van As HH, Lankhorst GJ. Factors related to the outcome of inpatient rehabilitation in patients with neoplastic epidural spinal cord compression. PARAPLEGIA 1993; 31:367-74. [PMID: 8336999 DOI: 10.1038/sc.1993.61] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In this study we have tried to develop a method to predict the survival and the functional outcome following neoplastic spinal cord injury (SCI), which can be helpful when selecting patients for an intensive inpatient rehabilitation programme. We reviewed the clinical records of all patients with neoplastic epidural spinal cord compression, admitted to any Dutch spinal cord unit (SCU) between 1-1-1985 and 1-1-1990 (n = 74). According to the outcome on 1-1-1991 the average stay at the SCU was 111 days, whereas the average survival after discharge was 423 days. Seven patients died during their stay. Of all of the factors analysed, six showed a positive relationship with prolonged survival (> one year after discharge) and improved functional level: tumour biology (lymphoma, myeloma, breast and kidney tumours); SCI as the presenting symptom of the malignancy; slow (> 1 week) progression rate of neurological symptoms; tumours treated with a combination of surgery and radiotherapy; (partial) bowel control at admission; and (partial) independence regarding transfer activities at admission. A sum score (range 0-6) of these indicators is introduced. A patient with a sum score of 0-1 has zero probability of living longer than one year after discharge and 0.19 of functional improvement during stay at the SCU. A score of 5-6 yields probabilities of 0.77 and 0.92 respectively. We conclude that the sum score can be helpful when selecting patients for an intensive inpatient rehabilitation programme or modifying such a programme. Validation for application in a general hospital is needed.
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Affiliation(s)
- H G Hacking
- Rehabilitation Centre, Amsterdam, The Netherlands
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131
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Boogerd W, van der Sande JJ. Diagnosis and treatment of spinal cord compression in malignant disease. Cancer Treat Rev 1993; 19:129-50. [PMID: 8481926 DOI: 10.1016/0305-7372(93)90031-l] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- W Boogerd
- Department of Neurology, The Netherlands Cancer Institute (Antoni van Leeuwenhoekziekenhuis), Amsterdam
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132
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133
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Cooper PR, Errico TJ, Martin R, Crawford B, DiBartolo T. A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine. Neurosurgery 1993; 32:1-8. [PMID: 8421537 DOI: 10.1227/00006123-199301000-00001] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The anterior approach to the thoracic and lumbar spine for neoplastic disease is now a well-accepted procedure, with results, for the most part, superior to those achieved with laminectomy. However, the specific indications for anterior decompression and the selection of reconstruction techniques based on the location and extent of bony destruction have received surprisingly little attention. The authors report their experience with the operative management of 33 patients with benign and malignant tumors of the thoracic and lumbar spine, using the anterior transthoracic or retroperitoneal approach. The role of stabilization and the relative indications for anterior or posterior instrumentation are emphasized. The mean age of patients was 58 years. Twenty-three patients were male. Five patients had benign tumors, and the remainder had a variety of metastatic lesions. Twenty-nine patients had lower extremity motor deficits, although 25 were ambulatory preoperatively. Thirty-seven noncontiguous resections were performed in 33 patients. In 13 patients, the resected vertebral body was replaced with acrylic or bone without instrumentation; in 18, the acrylic was supplemented with anterior instrumentation; and in 6, both anterior and posterior instrumentation were used. Above T11, vertebral reconstruction techniques were used to restore stability after decompression. Between T11 and L4, anterior instrumentation was used to supplement vertebral reconstruction in all patients. Supplemental posterior instrumentation was used for three-column involvement. Motor function was stabilized or improved in 94% of patients, and 88% of patients were ambulatory postoperatively. Of 28 patients with malignant disease, 23 died after a mean survival of 10.2 months (range, 2-51 mo) and 5 are alive a mean of 34.4 months since their operation.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P R Cooper
- Department of Neurosurgery, New York University Medical Center, New York
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134
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A Systematic Approach to Spinal Reconstruction after Anterior Decompression for Neoplastic Disease of the Thoracic and Lumbar Spine. Neurosurgery 1993. [DOI: 10.1097/00006123-199301000-00001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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135
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Podd TJ, Carpenter DS, Baughan CA, Percival D, Dyson P. Spinal cord compression: prognosis and implications for treatment fractionation. Clin Oncol (R Coll Radiol) 1992; 4:341-4. [PMID: 1463687 DOI: 10.1016/s0936-6555(05)81121-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A review of 158 cases of metastatic extradural spinal cord compression referred to three radiotherapy departments shows that the median survival time is less than 3 months, that recovery of motor and sphincter function is uncommon, and that low fraction (2-5) regimens have a similar clinical outcome to more protracted regimens.
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Affiliation(s)
- T J Podd
- Radiotherapy Department, Newcastle General Hospital, Newcastle upon Tyne, UK
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136
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137
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138
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Sharafuddin MJA, Haddad FS, Hitchon PW, Haddad SF, El-Khoury GY. Treatment Options in Primary Ewingʼs Sarcoma of the Spine. Neurosurgery 1992. [DOI: 10.1227/00006123-199204000-00025] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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139
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Abstract
Metastatic disease from osteosarcoma most commonly occurs in the lung and bony sites. Both primary spinal osteosarcomas and spinal metastatic lesions are rare. A case is reported of a nonosseous epidural metastatic lesion from osteosarcoma. It was visualized best by metrizamide-enhanced computed tomographic scanning. The patient symptomatically improved with excision of the lesion although there was massive recurrence despite combined therapy.
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Affiliation(s)
- J H Schimandle
- Division of Orthopaedic Surgery, University of Maryland Hospital, Baltimore
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140
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Barberá J. Cirugía de los tumores malignos del raquis dorsolumbar. Neurocirugia (Astur) 1992. [DOI: 10.1016/s1130-1473(92)70878-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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141
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142
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Cybulski GR, Stone JL, Opesanmi O. Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine. SURGICAL NEUROLOGY 1991; 35:280-5. [PMID: 2008643 DOI: 10.1016/0090-3019(91)90005-t] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Fifteen patients with thoracic spinal cord compression from metastatic neoplastic processes were managed by spinal canal decompression via a modified costotransversectomy approach. Ten of the patients also underwent sequential posterior stabilization with Luque or Harrington instrumentation based upon proximity of the lesion to the thoracolumbar junction, prognosis for regaining or maintaining ambulatory ability, and additional spinal stability considerations. A modified lateral decubitus position with the scapula falling away from the side of exposure was used for T1-5 segment lesions, and a prone position was used for the (T-6)-(T-12) segment. Adequate decompression of the spinal canal was achieved in all cases. All patients who were ambulating preoperatively maintained ambulatory ability, and pain and/or further neurological improvement as well occurred in 75%.
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Affiliation(s)
- G R Cybulski
- Division of Neurosurgery, Cook County Hospital, Chicago, Illinois
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143
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Ratanatharathorn V, Powers WE. Epidural spinal cord compression from metastatic tumor: diagnosis and guidelines for management. Cancer Treat Rev 1991; 18:55-71. [PMID: 1933911 DOI: 10.1016/0305-7372(91)90004-j] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- V Ratanatharathorn
- Radiation Oncology Department, Wayne State University School of Medicine, Detroit, Michigan 48201
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144
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Coraddu M, Nurchi GC, Floris F, Meleddu V. Surgical treatment of extradural spinal cord compression due to metastatic tumours. Acta Neurochir (Wien) 1991; 111:18-21. [PMID: 1927619 DOI: 10.1007/bf01402508] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The authors present a group of 23 patients with extradural spinal metastases who had undergone surgical treatment with different approaches, with reference to the anatomical site of the tumours. They report the results and discuss the criteria of the different surgical technical choices.
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Affiliation(s)
- M Coraddu
- Division of Neurosurgery, G. Brotzu Hospital, Cagliari, Italy
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145
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146
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Johnston R. Spinal surgery. J Neurol Neurosurg Psychiatry 1990; 53:1021-3. [PMID: 2292690 PMCID: PMC488306 DOI: 10.1136/jnnp.53.12.1021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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147
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Sundaresan N, Choi IS, Hughes JE, Sachdev VP, Berenstein A. Treatment of spinal metastases from kidney cancer by presurgical embolization and resection. J Neurosurg 1990; 73:548-54. [PMID: 2398386 DOI: 10.3171/jns.1990.73.4.0548] [Citation(s) in RCA: 92] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Surgical treatment of bone metastases from kidney cancer is often complicated by profuse blood loss. The authors report the results of a retrospective review of 30 consecutive patients who underwent surgery for spinal metastases from kidney cancer. Seventeen patients (57%) were operated on after failing radiation therapy. Prior to operation, selective spinal angiography and embolization were performed in 17 patients with no permanent neurological deficits resulting. Gross total resection of the tumor and stabilization of the spine were then accomplished with acceptable blood loss. Twenty-seven (90%) of the 30 patients improved neurologically following surgery. There was a median survival time of 16 months, a 2-year survival rate of 33%, and a 5-year survival rate of 15%. Major surgical complications in this series were related to excessive blood loss in patients without embolization. These data suggest that patients with spinal metastases from kidney cancer should undergo spinal angiography and embolization prior to resection of the tumor. To improve upon current results, such treatment should be carried out prior to external radiation therapy.
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Affiliation(s)
- N Sundaresan
- Department of Neurosurgery, Mount Sinai Hospital and Medical School, New York, New York
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148
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Abstract
Wilms' tumor metastasis to the spinal cord is very rare at any age. We recently encountered a case of a 4-year-old girl, who had a solitary lumbar spinal cord metastasis about 1 year following the initial nephrectomy and an incomplete course of chemotherapy for a stage I Wilms' tumor. The patient recovered uneventfully after decompressive laminectomy, removal of the extradural spinal cord tumor, adjuvant chemotherapy, and radiotherapy according to the National Wilms' Tumor Study (NWTS)-IV protocol.
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Affiliation(s)
- W T Chang
- Department of Surgery, Veterans General Hospital, Taichung, Taiwan, Republic of China
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149
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150
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Acikgoz B, Akkurt C, Erbengi A, Bertan V, Ozgen T, Ozcan O. Metastatic spinal cord tumours. PARAPLEGIA 1989; 27:359-63. [PMID: 2601985 DOI: 10.1038/sc.1989.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In this report 84 patients who had surgical intervention for metastatic spinal cord tumours are presented. The primary tumours were mainly from lungs, breast or of haematological origin, and were commonest in the thoracic region. In all but 2 patients laminectomy was performed. Surgical decompression permitted diagnosis, and there was neurological improvement in nearly half of the patients.
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Affiliation(s)
- B Acikgoz
- Kahramanmaras State Hospital, Ankara, Turkey
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