Evaluation and treatment of spinal metastases: an overview

Treatment of cervical vertebral (C1) metastasis of lung cancer with radiotherapy: A case report

The present study discusses a patient with C1 vertebral metastasis from adenocarcinoma of the left lung. The patient was a 31-year-old female suffering from neck pain who was referred by her physician. Magnetic resonance imaging revealed osteolytic destruction of the C1 vertebra. Chest and computed tomographic scans revealed lung carcinoma changes involving the left lung. A biopsy confirmed adenocarcinoma of the left lung. Abnormal activity was present in the cervical spine (C1) region in a radionuclide bone scan. The patient was then referred to an oncologist. The spine was stabilized with a rigid collar and a course of radiation therapy and pain medication was initiated immediately. At the 9-month follow-up examination, there was no evidence of progression on the MRI scans and the main neck symptoms had disappeared. At present, the overall survival (OS) time is 11 months. Patients complaining of new onset back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory and imaging examinations.

Estudo epidemiológico de 55 pacientes portadores de doença vertebral metastática sintomática em Santo André - SP, Brasil

OBJETIVO: Apresentar o perfil epidemiológico dos pacientes portadores de doença vertebral metastática sintomática de serviço público de atenção terciária na região do ABC. MÉTODO: Avaliamos de Janeiro de 2008 a Janeiro de 2011, 55 pacientes com diagnóstico de metástase vertebral e coletamos dados de idade no diagnóstico de lesão metastática, sexo, tipo de tumor, topografia vertebral e sintomatologia. A evolução da doença foi observado nas datas: biópsia da neoplasia primária; início de sintomas vertebrais; diagnóstico de doença vertebral metastática (imagem) e data da cirurgia. RESULTADOS: A idade dos pacientes variou de 28 a 85 anos; 40% homens e 60% mulheres. Os principais tumores foram carcinoma de mama (32,7%), mieloma múltiplo (25,4%) e carcinoma de próstata (14,5%). Observamos 25 pacientes (45,4%) com lesões na coluna torácica; 13 pacientes (23,6%) lombares ou sacrais; 11 pacientes (20%) difusas e 6 pacientes (10,9%) cervicais. 34 pacientes (61,8%) apresentavam somente dor, os demais (38,2%) apresentavam também alteração neurológica. O intervalo entre a lesão primária e a manifestação clínica de lesão vertebral apresentou mediana de 190 dias; entre a sintomatologia na coluna e o diagnóstico por imagem teve mediana de 70 dias; aos submetidos a cirurgia, entre o diagnóstico e o procedimento foi de 288 dias. CONCLUSÃO: Observamos os dados epidemiológicas, compatíveis a literatura: predomínio do sexo feminino (60%), com idade média de 55 anos; metástases predominantemente toracolombares (69%) por neoplasia de mama, mieloma múltiplo e próstata (72%). Observamos ampla variação no intervalo de tempo na descrição cronológica dos eventos clínico-diagnósticos e cirúrgicos.

Rehabilitation and treatment of spinal cord tumors

CONTEXT

Due to advances in acute oncological treatment, patients with spinal cord tumors exhibit improved survival. However, these patients have not received the full benefits of rehabilitation services to address their neurological deficits and rehabilitation goals.

OBJECTIVE

To evaluate the epidemiology and pathophysiology of spinal cord tumors, address methods of acute oncological management, review treatment for neurological sequelae, and understand the implications as they relate to rehabilitation.

METHODS

An extensive literature review was performed regarding the epidemiology, pathophysiology, acute oncological management, neurological sequelae, and rehabilitation for patients with spinal cord tumors. Databases used included pubmed.gov and OVID, as well as individual journal and textbook articles.

RESULTS

Access to treatment should be increased given improved survival and functional deficits for patients with spinal cord tumors. Individuals can benefit from inpatient rehabilitation programs, in spite of increased medical co-morbidity and neurological deficits. Specific areas of improvement include functionality, mood, quality of life, and survival. Adjustments to treatment plans must incorporate medical complications from cancer and its treatment, perceived quality of life, and prognosis.

CONCLUSIONS

Patients with spinal cord tumors who participate in rehabilitation programs show general improvement in function, mood, quality of life, and survival. Adaptations to care plans should be made to accommodate medical co-morbidities from cancer and its treatment, patient perceptions, and prognosis.

Minimally invasive solid long segmental fixation combined with direct decompression in patients with spinal metastatic disease

This study seeks to discuss the efficiency of minimally invasive surgery of posterior long segmental fixation plus direct decompression in patients with spinal metastatic tumors. Twenty-five patients received minimally invasive surgery of long segmental fixation combined with direct decompression from posterior approach. Pain and neurologic improvement in these patients pre- and post operation were evaluated by Denis' Pain Scale and Frankel Score, respectively. Seventeen patients (68.0%) showed significant decreases in Denis' Pain score after surgery (p < 0.0001). Paralysis symptoms were improved in nineteen patients (76.0%). The Frankel Score exhibited significant difference between pre-operation and post-operation (p < 0.0001). Operation time and blood loss in this cohort were 324 ± 90 min and 1047 ± 730 ml, respectively. No fatal complications were observed as a result of surgery. In conclusion, minimally invasive surgery of posterior long segmental fixation combined with direct decompression is a safe and efficient strategy to release pain and improve neurological function in patients with spinal metastatic tumors.

MRI and neurological findings in patients with spinal metastases

BACKGROUND

Magnetic resonance imaging (MRI) is the recommended primary investigation method for metastatic spinal cord compression (MSCC). Initiating treatment before the development of motor deficits is essential to preserve neurological function. However, the relationship between MRI-assessed grades of spinal metastatic disease and neurological status has not been widely investigated.

PURPOSE

To analyze the association between neurological function and MRI-based assessment of the extent of spinal metastases using two different grading systems.

MATERIAL AND METHODS

A total of 284 patients admitted to our institution for initial radiotherapy or surgery for symptomatic spinal metastases were included in the study. Motor and sensory deficits were categorized according to the Frankel classification system. Pre-treatment MRI evaluations of the entire spine were scored for the extent of spinal metastases, presence and severity of spinal cord compression, and nerve root compression. Two MRI-based scales were used to evaluate the degree of cord compression and spinal canal narrowing and relate these findings to neurological function.

RESULTS

Of the patients included in the study, 28 were non-ambulatory, 49 were ambulatory with minor motor deficits, and 207 had normal motor function. Spinal cord compression was present in all patients with Frankel scores of B or C, 23 of 35 patients with a Frankel score of D (66%), and 48 of 152 patients with a Frankel score of E (32%). The percentage of patients with severe spinal canal narrowing increased with increasing Frankel grades. The grading according to the scales showed a significant association with the symptoms according to the Frankel scale (P < 0.001).

CONCLUSION

In patients with neurological dysfunction, the presence and severity of impairment was associated with the epidural tumor burden. A significant number of patients had radiological spinal cord compression and normal motor function (occult MSCC).

Intradural extramedullary metastasis of small cell lung cancer: a case report

A 60-year-old man presented with para-anesthesia and a tingling sensation in the saddle area. Intradural extramedullary (IDEM) tumors in conus medullaris were observed by radiologic studies. The patient underwent laminoplastic laminotomy at the T12-L2 level and subtotal removal of the tumor because of the ill-defined margin. Postoperatively, hypesthesia was improved up to 50%. The IDEM tumor revealed a metastatic cancer originated from small cell lung cancer (SCLC) by histologic examination, and additional studies showed multiple metastases including adrenal gland, brain, and bone. Clinicians need to consider IDEM metastasis when SCLC patients were complained of neurologic symptoms mimic paraneoplastic syndrome. The pathophysioloigy of IDEM metastasis may be not only tertiary drop metastasis, but also faster mechanisms such as direct invasion.

The Efficacy of Percutaneous Vertebroplasty in Pain Relief in Patients with Pathological Vertebral Fractures due to Metastatic Spinal Tumors

BACKGROUND

Metastatic spinal tumors are common and major causes of pathological spinal fractures that result in severe pain, weakness, and progressive neurological deficits. This study aims to evaluate the efficacy of percutaneous vertebroplasty (PVP) in pain-relief in patients with spinal fractures due to metastatic spinal tumors.

METHODS

We evaluated 25 documented cases of metastatic spinal tumors with pathologic vertebral fractures who were suffering from severe pain and underwent vertebroplasty. Degree of pain was measured by visual analog scale (VAS). The symptoms were evaluated 24 hours and 2 months after vertebroplasty regarding the degree of pain relief.Complications such as leakage, embolism and infection were assessed.

RESULTS

MeanVAS score was 8.23 before therapy in the patients that was reduced to 2.12 and 1 in the patients 24 hours and 2 months after vertebroplasty, respectively. The most common complication was cement leakage (44%) and there was no embolism or infection. Data was analyzed by SPSS version 18 software through ANOVA test with Greenhouse-Geisser correction and P-value of 0.00 was obtained in the patients 24 hours and 1 month after surgery.

CONCLUSION

Considering significant decrease in the mean pain severity degree after the treatment, veretebroplasty seems to be significantly effective in pain relief in metastatic spinal tumors.

Complications in the management of metastatic spinal disease

Metastatic spine disease accounts for 10% to 30% of new cancer diagnoses annually. The most frequent presentation is axial spinal pain. No treatment has been proven to increase the life expectancy of patients with spinal metastasis. The goals of therapy are pain control and functional preservation. The most important prognostic indicator for spinal metastases is the initial functional score. Treatment is multidisciplinary, and virtually all treatment is palliative. Management is guided by three key issues; neurologic compromise, spinal instability, and individual patient factors. Site-directed radiation, with or without chemotherapy is the most commonly used treatment modality for those patients presenting with spinal pain, causative by tumours which are not impinging on neural elements. Operative intervention has, until recently been advocated for establishing a tissue diagnosis, mechanical stabilization and for reduction of tumor burden but not for a curative approach. It is treatment of choice patients with diseaseadvancement despite radiotherapy and in those with known radiotherapy-resistant tumors. Vertebral resection and anterior stabilization with methacrylate or hardware (e.g., cages) has been advocated.Surgical decompression and stabilization, however, along with radiotherapy, may provide the most promising treatment. It stabilizes the metastatic deposited areaand allows ambulation with pain relief. In general, patients who are nonambulatory at diagnosis do poorly, as do patients in whom more than one vertebra is involved. Surgical intervention is indicated in patients with radiation-resistant tumors, spinal instability, spinal compression with bone or disk fragments, progressive neurologic deterioration, previous radiation exposure, and uncertain diagnosis that requires tissue diagnosis. The main goal in the management of spinal metastatic deposits is always palliative rather than curative, with the primary aim being pain relief and improved mobility. This however, does not come without complications, regardless of the surgical intervention technique used. These complication range from the general surgical complications of bleeding, infection, damage to surrounding structures and post operative DT/PE to spinal specific complications of persistent neurologic deficit and paralysis.

Neurological and survival outcomes after surgical management of subaxial cervical spine metastases

STUDY DESIGN

A clinical retrospective study.

OBJECTIVE

To investigate the clinical outcomes of surgery for cervical spine metastasis and identify factors affecting survival and neurological result.

SUMMARY OF BACKGROUND DATA

Metastatic disease in the cervical spine is known to be a poorer prognosis than in thoracic and lumbar regions. Few reports focused on cervical spine metastasis are available.

METHODS

A retrospective analysis of medical records and radiological data was performed on 46 patients who underwent surgical treatment due to cervical spine metastasis from 2000 to 2010. The incidence of cervical metastasis, overall survival, progression-free survival, and neurological and pain outcomes were analyzed. In addition, factors affecting survival, local recurrence, and neurological and pain outcomes among the 46 study subjects were analyzed. These factors included; age, sex, primary tumor growth rate, preoperative disease-progression status (expressed with Tomita score), irradiation, timing of irradiation, postoperative adjuvant therapy, time of diagnosis of spinal metastasis, cord compression or foraminal invasion on magnetic resonance image, preoperative neurological status, and preoperative pain level.

RESULTS

The incidence of cervical metastasis was 17.3%. Mean postoperative overall survival was 16.89 months, the recurrence rate was 39.1%, and mean progression free survival was 11.82 months. Factors related to prolonged survival were slow primary tumor growth, low Tomita score, irradiation of the lesion, and postoperative adjuvant therapy. Postoperative adjuvant therapy was also found to be effective for preventing recurrence. Patients with high preoperative Japanese Orthopaedic Association Score achieved better neurological outcomes. Foraminal invasion was found to be negatively correlated with postoperative pain outcome.

CONCLUSION

Surgical management for subaxial cervical spinal metastasis was found to be effective in terms of neurological recovery and pain control. Furthermore, surgical treatment plus adjuvant therapy was found to achieve sufficient local control during postoperative follow-up.

Intradural extramedullary metastasis from papillary carcinoma of thyroid

Although spinal metastasis is a common finding in malignancies, however intradural extramedullary metastasis is very rare. This paper presents a 71-year-old woman, known case of papillary carcinoma of thyroid with intradural extramedullary metastasis in thoracic spine.

Minimally invasive decompression and stabilization for the management of thoracolumbar spine metastasis

OBJECT

Spinal metastasis with spinal cord involvement is a frequent complication in cancer patients. As the spinal compression frequently occurs ventrally, performing a simple posterior laminectomy alone is generally ineffective and dangerous. Many aggressive surgical strategies have been developed to improve outcomes for patients with metastatic spine disease. These strategies are associated with high morbidity and complication rates, especially in patients with numerous neoplasm-associated comorbidities, which can limit their indication in patients with a limited life expectancy. The authors performed a prospective evaluation of minimally invasive decompression and stabilization for the palliative management of symptomatic thoracolumbar spine metastasis.

METHODS

Ten patients with metastasis to the thoracolumbar spine and neurological compromise underwent minimally invasive transpedicular vertebrectomy and spinal cord decompression through a tubular expandable retractor. Percutaneous stabilization was also systematically performed to ensure spinal stability.

RESULTS

No complications during the procedure were reported. The mean operative duration was 170 minutes and the mean estimated blood loss was 400 ml. The postoperative course of all patients was uneventful, with the exception of 1 benign urinary tract infection. Eight patients (80%) improved at least 1 Frankel grade.

CONCLUSIONS

Minimally invasive treatment of thoracolumbar spine metastasis is a safe and effective palliative option in patients with limited life expectancy, to limit morbidity and preserve quality of life.

A case report of "spinal cord apoplexy" elicited by metastatic intramedullary thyroid carcinoma

A 31-year-old man presented with acute onset of paraplegia. The patient's history was significant for thyroid carcinoma that had been treated 2 years earlier by thyroidectomy. A magnetic resonance imaging scan showed an enhancing intramedullary lesion at T7-8. Patient underwent surgical treatment and a tumor with hematoma was resected via posterior midline myelotomy. Postoperatively, the patient's motor weakness was improved to grade 3. The lesion showed typical histologic features consistent with papillary thyroid carcinoma. Early diagnosis and microsurgical resection can result in improvement in neurological deficits and quality of life of patients with an ISCM.

Predictive value of Tokuhashi scoring systems in spinal metastases, focusing on various primary tumor groups: evaluation of 448 patients in the Aarhus spinal metastases database

STUDY DESIGN

We conducted a prospective cohort study of 448 patients with spinal metastases from a variety of cancer groups.

OBJECTIVE

To determine the specific predictive value of the Tokuhashi scoring system (T12) and its revised version (T15) in spinal metastases of various primary tumors.

SUMMARY OF BACKGROUND DATA

The life expectancy of patients with spinal metastases is one of the most important factors in selecting the treatment modality. Tokuhashi et al formulated a prognostic scoring system with a total sum of 12 points for preoperative prediction of life expectancy in 1990 and revised it in 2005 to a total sum of 15 points. There is a lack of knowledge about the specific predictive value of those scoring systems in patients with spinal metastases from a variety of cancer groups.

METHODS

We included 448 patients with vertebral metastases who underwent surgical treatment during November 1992 to November 2009 in Aarhus University Hospital NBG. Data were retrieved from Aarhus Metastases Database. Scores based on T12 and T15 were calculated prospectively for each patient. We divided all the patients into different groups dictated by the site of their primary tumor. Predictive value and accuracy rate of the 2 scoring systems were compared in each cancer group.

RESULTS

Both the T12 and T15 scoring systems showed statistically significant predictive value when the 448 patients were analyzed in total (T12, P < 0.0001; T15, P < 0.0001). The accuracy rate was significantly higher in T15 (P < 0.0001) than in T12. The further analyses by primary cancer groups showed that the predictive value of T12 and T15 was primarily determined by the prostate (P = 0.0003) and breast group (P = 0.0385). Only T12 displayed predictive value in the colon group (P = 0.0011). Neither of the scoring systems showed significant predictive value in the lung (P > 0.05), renal (P > 0.05), or miscellaneous primary tumor groups (P > 0.05). The accuracy rate of prognosis in T15 was significantly improved in the prostate (P = 0.0032) and breast group (P < 0.0001).

CONCLUSION

Both T12 and T15 showed significant predictive value in patients with spinal metastases. T15 has a statistically higher accuracy rate than T12. Among the various cancer groups, the 2 scoring systems are especially reliable in prostate and breast metastases groups. T15 is recommended as superior to T12 because of its higher accuracy rate.

Delayed onset of paralysis and slowed tumor growth following in situ placement of recombinant human bone morphogenetic protein 2 within spine tumors in a rat model of metastatic breast cancer

Object

Recombinant human bone morphogenetic proteins (rhBMPs) are FDA-approved for specific spinal fusion procedures, but their use is contraindicated in spine tumor resection beds because of an unclear interaction between tumor tissue and such growth factors. Interestingly, a number of studies have suggested that BMPs may slow the growth of adenocarcinomas in vitro, and these lesions represent the majority of bony spine tumors. In this study, the authors hypothesized that rhBMP-2 placed in an intraosseous spine tumor in the rat could suppress tumor and delay the onset of paresis in such animals.

Methods

Twenty-six female nude athymic rats were randomized into an experimental group (Group 1) or a positive control group (Group 2). Group 1 (tumor + 15 μg rhBMP-2 sponge,13 rats) underwent transperitoneal exposure and implantation of breast adenocarcinoma (CRL-1666) into the L-6 spine segment, followed by the implantation of a bovine collagen sponge impregnated with 15 μg of rhBMP-2. Group 2 (tumor + 0.9% NaCl sponge, 13 rats) underwent transperitoneal exposure and tumor implantation in the lumbar spine but no local treatment with rhBMP-2. An additional 8 animals were randomized into 2 negative control groups (Groups 3 and 4). Group 3 (15 μg rhBMP-2 sponge, 4 rats) and Group 4 (0.9% NaCl sponge, 4 rats) underwent transperitoneal exposure of the lumbar spine along with the implantation of rhBMP-2– and saline-impregnated bovine collagen sponges, respectively. Neither of the negative control groups was implanted with tumor. The Basso-Beattie-Bresnahan (BBB) scale was used to monitor daily motor function regression and the time to paresis (BBB score ≤ 7).

Results

In comparison with the positive control animals (Group 2), the experimental animals (Group 1) had statistically significant longer mean (25.8 ± 12.2 vs 13 ± 1.4 days, p ≤ 0.001) and median (20 vs 13 days) times to paresis. In addition, the median survival time was significantly longer in the experimental animals (20 vs 13.5 days, p ≤ 0.0001). Histopathological analysis demonstrated bone growth and tumor inhibition in the experimental animals, whereas bone destruction and cord compression were observed in the positive control animals. Neither of the negative control groups (Groups 3 and 4) demonstrated any evidence of neurological deterioration, morbidity, or cord compromise on either gross or histological analysis.

Conclusions

This study shows that the local administration of rhBMP-2 (15 μg, 10 μl of 1.5-mg/ml solution) in a rat spine tumor model of breast cancer not only fails to stimulate local tumor growth, but also decreases local tumor growth and delays the onset of paresis in rats. This preclinical experiment is the first to show that the local placement of rhBMP-2 in a spine tumor bed may slow tumor progression and delay associated neurological decline.

Vertebral compression fracture risk after stereotactic body radiotherapy for spinal metastases

Object

The aim of this study was to identify potential risk factors for and determine the rate of vertebral compression fracture (VCF) after intensity-modulated, near-simultaneous, CT image–guided stereotactic body radiotherapy (SBRT) for spinal metastases.

Methods

The study group consisted of 123 vertebral bodies (VBs) in 93 patients enrolled in prospective protocols for metastatic disease. Data from these patients were retrospectively analyzed. Stereotactic body radiotherapy consisted of 1, 3, or 5 fractions for overall median doses of 18, 27, and 30 Gy, respectively. Magnetic resonance imaging studies, obtained at baseline and at each follow-up, were evaluated for VCFs, tumor involvement, and radiographic progression. Self-reported average pain levels were scored based on the 11-point (0–10) Brief Pain Inventory both at baseline and at follow-up. Obesity was defined as a body mass index ≥ 30.

Results

The median imaging follow-up was 14.9 months (range 1–71 months). Twenty-five new or progressing fractures (20%) were identified, and the median time to progression was 3 months after SBRT. The most common histologies included renal cancer (36 VBs, 10 fractures, 10 tumor progressions), breast cancer (20 VBs, 0 fractures, 5 tumor progressions), thyroid cancer (14 VBs, 1 fracture, 2 tumor progressions), non–small cell lung cancer (13 VBs, 3 fractures, 3 tumor progressions), and sarcoma (9 VBs, 2 fractures, 2 tumor progressions). Fifteen VBs were treated with kyphoplasty or vertebroplasty after SBRT, with 5 procedures done for preexisting VCFs. Tumor progression was noted in 32 locations (26%) with 5 months' median time to progression. At the time of noted fracture progression there was a trend toward higher average pain scores but no significant change in the median value. Univariate logistic regression showed that an age > 55 years (HR 6.05, 95% CI 2.1–17.47), a preexisting fracture (HR 5.05, 95% CI 1.94–13.16), baseline pain and narcotic use before SBRT (pain: HR 1.31, 95% CI 1.06–1.62; narcotic: HR 2.98, 95% CI 1.17–7.56) and after SBRT (pain: HR 1.34, 95% CI 1.06–1.70; narcotic: HR 3.63, 95% CI 1.41–9.29) were statistically significant predictors of fracture progression. On multivariate analysis an age > 55 years (HR 10.66, 95% CI 2.81–40.36), a preexisting fracture (HR 9.17, 95% CI 2.31–36.43), and baseline pain (HR 1.41, 95% CI 1.05–1.9) were found to be significant risks, whereas obesity (HR 0.02, 95% CI 0–0.2) was protective.

Conclusions

Stereotactic body radiotherapy is associated with a significant risk (20%) of VCF. Risk factors for VCF include an age > 55 years, a preexisting fracture, and baseline pain. These risk factors may aid in the selection of which spinal SBRT patients should be considered for prophylactic vertebral stabilization or augmentation procedures. Clinical trial registration no.: NCT00508443.

Initial experience with the use of an expandable titanium cage as a vertebral body replacement in patients with tumors of the spinal column: a report of 95 patients

OBJECTIVE

Vertebral body resection to treat spine tumors necessitates reconstruction to maintain spinal stability. The durability of reconstruction may be a challenge in cancer patients as treatment with chemotherapy and/or radiation coupled with poor nutritional status may compromise bone quality. We present a series of patients who underwent implantation of an expandable titanium cage (ETC) for reconstruction after vertebral body resection for primary or metastatic spine tumors. We report the functional outcome, assess the durability of reconstruction, and describe complications associated with this procedure.

METHODS

A retrospective review of patients undergoing placement of ETC after vertebrectomy for spinal tumor at our institution was performed.

RESULTS

From September 2001 to August 2006, 95 patients underwent implantation of an ETC for reconstruction of the anterior spinal column following vertebrectomy for tumor (75 one-level, 19 two-level, 1 three-level). All patients underwent spinal stabilization as well. The median survival after surgery was 13.7 months; 23 patients had primary spinal tumors and 72 had metastatic tumors. Numerical pain scores were significantly improved postoperatively indicating a palliative benefit. No new neurological deficits were noted postoperatively, except when intentional neurological sacrifice was performed for oncologic reasons. Median height correction of 14% (range 0-118%) and median improvement in sagittal alignment of 6° (range 0-28°) were demonstrated on immediate postoperative imaging. Three patients experienced hardware related complications, one of which had posterior migration of the ETC. On postoperative imaging, 12 patients demonstrated subsidence of greater than 1 mm, but none required operative revision.

CONCLUSION

Use of an ETC for spinal reconstruction in patients with spinal tumors is safe, decreases pain associated with pathologic fracture, protects neurologic function, and is durable. We found a very low incidence of cage-related construct failures and no significant problems with subsidence.

A systematic review of the current role of minimally invasive spine surgery in the management of metastatic spine disease

Although increasingly aggressive decompression and resection methods have resulted in improved outcomes for patients with metastatic spine disease, these aggressive surgeries are not feasible for patients with numerous comorbid conditions. Such patients stand to benefit from management via minimally invasive spine surgery (MIS), given its association with decreased perioperative morbidity. We performed a systematic review of literature with the goal of evaluating the clinical efficacy and safety of MIS in the setting of metastatic spine disease. Results suggest that MIS is an efficacious means of achieving neurological improvement and alleviating pain. In addition, data suggests that MIS offers decreased blood loss, operative time, and complication rates in comparison to standard open spine surgery. However, due to the paucity of studies and low class of available evidence, the ability to draw comprehensive conclusions is limited. Future investigations should be conducted comparing standard surgery versus MIS in a prospective fashion.

Qualidade de vida de pacientes submetidos à descompressão por lesão vertebral metastática

OBJETIVO: Avaliar a qualidade de vida de pacientes com lesão metastática em coluna vertebral operados por abordagem posterior. MÉTODO: Foram avaliados 32 pacientes (17 do gênero feminino e 15 do masculino), idade média de 56,46 anos, com diagnóstico de metástase em coluna vertebral. Os critérios para indicação cirúrgica foram a presença de alteração neurológica progressiva (6 pacientes - 18,75%); dor incapacitante (23 pacientes - 71,87%) ou ainda pacientes que sofriam destas condições combinadas (3 pacientes - 9,37%). Foi aplicado o questionário SF36 para avaliação da qualidade de vida no período pré operatório e 1 e 6 meses após a cirurgia. RESULTADO: Foi observada uma variação estatística significante nos domínios de capacidade funcional, dor, saúde mental e aspectos sociais do questionário do SF36. CONCLUSÃO: Os pacientes operados por abordagem posterior para descompressão nas lesões metastáticas da coluna vertebral apresentaram uma melhora da qualidade de vida. Nível de Evidência: Nível II, estudo prospectivo longitudinal.

Metastatic disease in the thoracic and lumbar spine: evaluation and management

Spinal metastases are found in most patients who die of cancer. The number of patients with symptomatic spinal metastases likely will increase as therapy for the primary disease improves and as cardiovascular mortality decreases. Understanding the epidemiology of metastatic spine disease and its presentation is essential to developing a diagnostic strategy. Treatment may involve chemotherapy, corticosteroids, radiotherapy, surgery, and/or percutaneous procedures (eg, vertebroplasty, kyphoplasty). A rational treatment plan can help improve quality of life, preserve neurologic function, and prolong survival.

Micro-computed tomography-based highly automated 3D segmentation of the rat spine for quantitative analysis of metastatic disease

Noninvasive evaluation of metastatic disease in the spine has generally been limited to 2D qualitative or semiquantitative analysis techniques. This study aims to develop and evaluate a highly automated micro-CT-based quantitative analysis tool that can measure the architectural impact of metastatic involvement in whole vertebrae. Micro-CT analysis of rat whole vertebrae was conducted using a combination of demons deformable registration, level set curvature evolution, and intensity based thresholding techniques along with upsampling and edge enhancement techniques. The algorithm was applied to 6 lumbar vertebrae (L1-3) from 6 rnu/rnu rats (3 healthy rats and 3 with metastatic involvement). Osteolytic metastatic involvement was modeled via MT1 human breast cancer cells. Excellent volumetric concurrency was achieved in comparing the automated micro-CT-based segmentations of the whole vertebrae, trabecular centrums, and individual trabecular networks to manual segmentations (98.9%, 96.1%, and 98.3%, respectively; 6 specimens), and the automated segmentations were achieved in a fraction of the time. The algorithm successfully accounted for discontinuities in the cortical shell caused by vasculature and osteolytic destruction. As such, this work demonstrates the potential of this highly automated segmentation tool to permit rapid precise quantitative structural analysis of the spine with minimum user interaction in the analysis of both healthy and pathological (metastatically involved) vertebrae. Future optimization and the incorporation of lower-resolution imaging parameters may allow automated analysis of clinical CT-based measures in addition to preclinical micro-CT-based analyses of the structural impact and progression of pathological processes in the spine.

Spine metastases: current treatments and future directions

Spinal metastases are the most frequently encountered spinal tumour and can affect up to 50% of cancer patients. Both the incidence and prevalence of metastases are thought to be rising due to better detection and treatment options of the systemic malignancy resulting in increased patient survival. Further, the development and access to newer imaging modalities have resulted in easier screening and diagnosis of spine metastases. Current evidence suggests that pain, neurological symptoms and quality of life are all improved if patients with spine metastases are treated early and aggressively. However, selection of the appropriate therapy depends on several factors including primary histology, extent of the systemic disease, existing co-morbidities, prior treatment modalities, patient age and performance status, predicted life expectancy and available resources. This article reviews the currently available therapeutic options for spinal metastases including conventional external beam radiation therapy, open surgical decompression and stabilisation, vertebral augmentation and other minimally invasive surgery (MIS) options, stereotactic spine radiosurgery, bisphosphonates, systemic radioisotopes and chemotherapy. An algorithm for the management of spine metastases is also proposed. It outlines a multidisciplinary and integrated approach to these patients and it is hoped that this along with future advances and research will result in improved patient care and outcomes.

Large cell neuroendocrine carcinoma of the lung metastatic to the cauda equina

BACKGROUND CONTEXT

Large cell neuroendocrine carcinoma of the lung is an aggressive tumor with unique histopathological features. It is not known to metastasize to the spine.

PURPOSE

To report a metastatic case of this rare tumor to the cauda equina.

STUDY DESIGN

Case report.

METHODS

Retrospective case review and review of the literature.

RESULTS

The authors report a rare case of a large cell neuroendocrine lung metastasis to the lumbar spine, causing right foot drop. Magnetic resonance imaging revealed a heterogeneously enhancing intradural extramedullary mass at L2/L3 level compressing the surrounding nerve roots. During surgery, the identified nerve roots were encased by the tumor, and the dissection was tedious. Postoperatively, the patient reported significantly improved back pain and he had severe foot weakness. The functional outcome was poor because the patient lost entirely his foot function; however, his back pain improved significantly after surgery.

CONCLUSIONS

This is the first published study in which the authors described a metastasis of a rather uncommon lung cancer to the cauda equina. When a lesion of the cauda equina presents with a rapid progressive neurological deficit, leptomeningeal metastasis should be in the differential diagnosis.

Clinical results of cyberknife(r) radiosurgery for spinal metastases

OBJECTIVE

Primary treatment of spinal metastasis has been external beam radiotherapy. Recent advance of technology enables radiosurgery to be extended to extracranial lesions. The purpose of this study was to determine the clinical effectiveness and safety of stereotactic radiosurgery using Cyberknife in spinal metastasis.

METHODS

From June, 2002 to December, 2007, 129 patients with 167 spinal metastases were treated with Cyberknife. Most of the patients (94%) presented with pain and nine patients suffered from motor deficits. Twelve patients were asymptomatic. Fifty-three patients (32%) had previous radiation therapy. Using Cyberknife, 16-39 Gy in 1-5 fractions were delivered to spinal metastatic lesions. Radiation dose was not different regarding the tumor pathology or tumor volume.

RESULTS

After six months follow-up, patient evaluation was possible in 108 lesions. Among them, significant pain relief was seen in 98 lesions (91%). Radiological data were obtained in 83 lesions. The mass size was decreased or stable in 75 lesions and increased in eight lesions. Radiological control failure cases were hepatocellular carcinoma (5 cases), lung cancer (1 case), breast cancer (1 case) and renal cell carcinoma (1 case). Treatment-related radiation injury was not detected.

CONCLUSION

Cyberknife radiosurgery is clinically effective and safe for spinal metastases. It is true even in previously irradiated patients. Compared to conventional radiation therapy, Cyberknife shows higher pain control rate and its treatment process is more convenient for patients. Thus, it can be regarded as a primary treatment modality for spinal metastases.

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global Spine Tumour Study Group

Choosing the right operation for metastatic spinal tumours is often difficult, and depends on many factors, including life expectancy and the balance of the risk of surgery against the likelihood of improving quality of life. Several prognostic scores have been devised to help the clinician decide the most appropriate course of action, but there still remains controversy over how to choose the best option; more often the decision is influenced by habit, belief and subjective experience. The purpose of this article is to review the present systems available for classifying spinal metastases, how these classifications can be used to help surgical planning, discuss surgical outcomes, and make suggestions for future research. It is important for spinal surgeons to reach a consensus regarding the classification of spinal metastases and surgical strategies. The authors of this article constitute the Global Spine Tumour Study Group: an international group of spinal surgeons who are dedicated to studying the techniques and outcomes of surgery for spinal tumours, to build on the existing evidence base for the surgical treatment of spinal tumours.

Metastatic renal cell carcinoma initially presented with an intramedullary spinal cord lesion: a case report

Introduction

One of the rare manifestations of systemic neoplasia is intramedullary spinal cord metastasis that causes serious diagnostic and therapeutic dilemma. It has been very rarely reported as the initial manifestation of carcinoma. This is report of a metastatic renal cell carcinoma initially presented with intramedullary spinal cord lesion, to our knowledge there are few similar reports in literature.

Case presentation

We report a 51-year-old Iranian woman who presented with back pain and paraparesis. MR imaging study of her spine showed an enhancing cystic lesion at the level of conus medullaris. Despite detailed investigation, no specific aetiology was found till a bone scan obtained to evaluate an agonizing pain on the dorsum of the left hand revealed photon deficient area within the left kidney in addition to oseoblastic bony lesions. After thorough imaging investigation she underwent radical nephrectomy which confirmed renal cell carcinoma.

Conclusion

Considering the prevalence of cancer, it is imperative that clinicians be mindful of occult carcinoma as the cause of suspicious intramedullary spinal cord lesion.

The efficacy of percutaneous vertebroplasty for vertebral metastases associated with solid malignancies

BACKGROUND

Percutaneous vertebroplasty appears beneficial for patients with acute compression fractures of multiple aetiologies including myeloma, osteoporosis and trauma. There are few reports on its use in the setting of metastatic solid malignancy.

METHODS

We identified all individuals who had undergone percutaneous vertebroplasty at our institution since 2004 and focused on those with metastatic solid malignancies. Their clinical characteristics and outcomes were investigated.

RESULTS

From 136 cases that underwent percutaneous vertebroplasties, 19 were performed mainly in breast, prostate, lung and renal cancers. Of these 19 cases, 10 patients (53%) were treated for solitary lesions, 3 (16%) were injected at two levels and the remaining 6 cases (31%) underwent cement injection at three levels. The majority of individuals (84%) reported short- and long-term symptomatic improvements. At a median follow-up of one year, six patients have died.

CONCLUSIONS

Percutaneous vertebroplasty appears as an effective palliative procedure in patients with compression fractures secondary to metastatic solid malignancy. Its use can be successfully combined with other treatment modalities (radiotherapy and chemotherapy).

Solitary vertebral metastasis

As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

A Case of Vertebral Metastasis With Pathologic C2 Fracture

OBJECTIVE

This report discusses a patient with a pathologic fracture of the C2 vertebra secondary to osteolytic metastasis from squamous cell carcinoma of the lung.

CLINICAL FEATURES

The patient was a 68-year-old man with a chief complaint of neck pain who was referred by his physician to a chiropractic office. The initial onset of neck pain began after a forceful sneeze that resulted in a sensation of "a twig snapping" in the neck. Radiographs revealed osteolytic destruction and pathologic fracture of the C2 spinous process.

INTERVENTION AND OUTCOME

The patient was referred back to his primary care physician, who then referred him to an oncologist, who immediately initiated a course of radiation therapy and pain medication. Palliative care by the chiropractor consisted of soft tissue massage of the cervical spine musculature to treat associated muscle spasms and pain. The patient responded well to gentle myofascial therapy. However, the osteolytic destruction of the C2 posterior elements progressed, resulting in an unstable subluxation of C2 and associated cord compression. The spine was stabilized with a rigid collar, but the metastatic destruction progressed, eventually resulting in quadriplegia and subsequent death from respiratory distress.

CONCLUSION

Patients with a history of cancer complaining of new onset of back or neck pain should be assumed to have vertebral metastasis until proven otherwise. Trivial trauma should be taken seriously in these cases and investigated with appropriate clinical, laboratory, and imaging examinations. Vertebral malignancies may be a contraindication to spinal manipulation; however, the chiropractic physician plays a significant role in early detection and diagnosis.

Treatment of Vertebral Tumor with Posterior Wall Defect Using Image-guided Radiofrequency Ablation Combined with Vertebroplasty: Preliminary Results in 12 Patients

PURPOSE

To evaluate the safety and clinical benefit of vertebral tumor treatment by combined radiofrequency ablation (RFA) and vertebroplasty, for pain reduction in patients who are unable to benefit from noninvasive treatment methods.

MATERIALS AND METHODS

Twelve patients with painful vertebral tumors with posterior wall defect, in whom medical treatment together with radiation therapy and/or chemotherapy had failed, were treated with RFA combined with vertebroplasty. Procedures were performed using multislice CT-fluoroscopy and lateral C-arm fluoroscopic guidance. All patients had posterior wall defects of the vertebra being treated. Ten had lytic posterior wall destruction and two had posterior wall fracture. The visual analog scale (VAS) pain score was measured before, one week after, and three months after treatment. VAS patient satisfaction score was measured before and one week after treatment. The VAS score range was 0-20. The analgesic use was evaluated before and four weeks after treatment and complications were monitored.

RESULTS

Combined RFA and vertebroplasty treatment was technically successful in all patients. Pain significantly decreased after treatment: the mean VAS pain score before treatment was 17.33 +/- 2.46 (range, 13-20) versus 9.25 +/- 4.81 (range, 2-18) one week after treatment (P < .001) and was 7.00 +/- 5.26 (range, 1-14) three months after treatment (P = .020). The mean VAS satisfaction score of all patients was 15.83 +/- 4.26 (range, 4-20). Analgesic use decreased after treatment. No serious treatment related complications occurred.

CONCLUSION

RFA in combination with vertebroplasty for treating vertebral tumors with posterior wall defect appeared safe, and reduced pain substantially in patients who did not benefit from other noninvasive treatment methods.

Chirurgisches Management von Wirbelsäulenmetastasen

The spine is the most frequent site of skeletal metastases. Among all spinal malignancies metastatic disease is most frequent and indicative of disseminating tumor disease. Depending on primary tumor entity, estimated survival time, general health status of the patient, presence of spinal instability and neurological deficits an oncological useful and patient-specific therapeutic intervention should be performed. New anterior approaches, resections and reconstruction techniques are making surgery a preferred method over radiation therapy. For differential indication of the multiple surgical treatment modalities prognostic scores are available to assist individual decision making. Indications for surgery include survival prognosis of minimum 3 months, intractable pain, progress of myelon compression and/or neurological deficits under radiochemotherapy, spinal instability and necessity for histological diagnosis. Resulting quality of life depends on efficient decompression of the spinal cord and restoration of spinal stability. To achieve these ultimate goals there are different anterior and posterior approaches, instrumentations and vertebral body replacement implants available. Preoperative embolization should be performed in hypervascular tumors, e.g., renal cell cancer. Vertebro-/Kyphoplasty as a percutaneous intervention should be considered for painful multisegmental disease and symptomatic osteolysis without epidural tumor compression to reach analgesia and stability. A multidisciplinary approach in patient selection, decision making and management is an essential precondition for complication avoidance and acceptable quality of life.

Percutaneous vertebroplasty in tumoral osteolysis

Percutaneous vertebroplasty is a minimally invasive, radiologically guided procedure in which bone cement is injected into structurally weakened or destructed vertebrae in order to achieve additional biomechanical stability. In addition to treating osteoporotic vertebral fractures, this technique gains popularity to relieve pain by stabilizing vertebrae compromised by, for example, metastases, aggressive hemangiomas or multiple myeloma that are at risk of pathologic fracture. Since conservative treatment with narcotic analgesics, bed rest, biphosphonates and back bracing for several weeks is often ineffective and the analgesic effect of radiation therapy is delayed, percutaneous vertebroplasty may play a beneficial role in the management of metastases to the spine.

Development of a model with which to predict the life expectancy of patients with spinal epidural metastasis

BACKGROUND

The surgical treatment of spinal epidural metastasis is evolving. To be a surgical candidate, a patient should have a life expectancy of at least 3 months. Estimation of survival by experienced specialists has proven to be unreliable.

METHODS

The Cox proportional hazards model was used to make a prediction model. To validate the model, Efron optimism correction by bootstrapping was performed. Retrospective data of patients treated for a spinal metastasis were used. Possible predictive factors were defined based on clinical experience and the literature. Statistical methods and clinical knowledge were also used to reveal an optimal set of predictors of survival. Data from patients treated at the Department of Radiation Oncology for spinal metastasis between 1998 and 2005 were evaluated.

RESULTS

The case notes of 219 patients form the base of this study. In the final model, only 5 variables were required to predict the survival of a patient with spinal metastasis: sex, location of the primary lesion, intentional curative treatment of the primary tumor, cervical location of the spinal metastasis, and Karnofsky performance score. Examples with different predictors are given. The R(2) (N) index of Nagelkerke was 0.36 (95% confidence interval [95% CI], 0.28-0.48) and the c-index 0.72 (95% CI, 0.68-0.77).

CONCLUSIONS

A reliable and simple model with which to predict the survival of a patient with spinal epidural metastasis is presented. Without the need for extensive investigations, survival can be predicted and only 5 easily obtainable parameters are required.

National inpatient complications and outcomes after surgery for spinal metastasis from 1993–2002

BACKGROUND

Information regarding patient outcomes, complications, and mortality after surgery for spinal metastasis has previously been derived from single-institution series. The aim of this study was to report inpatient mortality, complications, and outcomes on a national level.

METHODS

The National Inpatient Sample (NIS) was utilized to identify 26,233 admissions of surgically managed spinal metastasis in the U.S. from 1993 through 2002. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on outcomes such as mortality, complications, discharge disposition, and length of stay.

RESULTS

The in-hospital mortality rate was 5.6% and the complication rate was 21.9%. Pulmonary (6.7%) and postoperative hemorrhages or hematomas (5.9%) were the most common complications reported. A single postoperative complication increased the mean length of stay (LOS) by 7 days and the mortality rate by 11%. Multivariate analysis showed that complications were more likely in older patients and in patients with 2 or more comorbidities. With patients having no comorbidities as the reference group, 1 comorbidity increased the risk of in-hospital death by almost 4-fold. Mortality was significantly higher in men, in patients who had postoperative complications, and in patients who were operated in the earlier (1993-1997) year group.

CONCLUSIONS

A national perspective is provided on inpatient complications and outcomes after surgery for spinal metastasis in the U.S. The significant negative effect of postoperative complications on mortality and resource utilization is demonstrated. Furthermore, preoperative comorbidity is identified as an important risk factor and its impact is defined on patient outcomes.

Diagnosis and treatment of vertebral column metastases

The vertebral column is recognized as the most common site for bony metastases in patients with systemic malignancy. Patients with metastatic spinal tumors may present with pain, neurologic deficit, or both. Some tumors are asymptomatic and are detected during screening examinations. Treatment options include medical therapy, surgery, and radiation. However, diversity of patient condition, tumor pathology, and anatomical extent of disease complicate broad generalizations for treatment. Historically, surgery was considered the most appropriate initial therapy in patients with spinal metastasis with the goal of eradication of gross disease. However, such an aggressive approach has not been practical for many patients. Now, operative intervention is often palliative, with pain control and maintenance of function and stability the major goals. Surgery is reserved for neurologic compromise, radiation failure, spinal instability, or uncertain diagnosis. Recent literature has revealed that surgical outcomes have improved with advances in surgical technique, including refinement of anterior, lateral, posterolateral, and various approaches to the anterior spine, where most metastatic disease is located. We review these surgical approaches for which a team of surgeons often is needed, including neurosurgeons and orthopedic, general, vascular, and thoracic surgeons. Overall, a multimodality approach is useful in caring for these patients. It is important that clinicians are aware of the various therapeutic options and their indications. The optimal treatment of individual patients with spinal metastases should include consideration of their neurologic status, anatomical extent of disease, general health, age, and qualilty of life.

Metastatic spinal cord syndromes: imaging appearances and treatment planning

Metastatic spinal cord syndromes usually result from neural compression by adjacent vertebral disease but are occasionally caused by intradural or intramedullary disease. MRI is the most accurate method for evaluation of such syndromes. Knowledge of the relevant imaging appearances and therapeutic options enables the radiologist to make an accurate assessment of the extent of disease and contribute information relevant to treatment planning.