Surgical Management of Spinal Metastases

Combined radiofrequency and kyphoplasty in painful osteolytic metastases to vertebral bodies

PURPOSE

The aim of this study was to assess retrospectively the safety and efficacy of combined radiofrequency (RF) and kyphoplasty (KP) in managing painful osteolytic metastases to vertebral bodies resistant to conservative treatments.

MATERIALS AND METHODS

Eleven patients (9 women and 2 men; mean age 68 years; age range 58-82) with painful osteolytic vertebral body metastases unresponsive to conservative treatments underwent RF combined with KP under general anaesthesia. Primary neoplasms were kidney carcinoma (n=1), breast carcinoma (n=1), thyroid carcinoma (n=2) and multiple myeloma (n=7). Lesion levels were cervical (n=1), thoracic (n=9) and lumbar (n=1). Combined RF and KP was well-tolerated by all patients. The procedures were performed using fluoroscopic guidance and intraoperative neurophysiology monitoring. Pain relief with the visual analogue scale (VAS) pain score and analgesic consumption were evaluated before and after treatment.

RESULTS

No complication occurred. In one case, we observed an asymptomatic cement leakage. Pain significantly decreased after treatment: the mean VAS pain score before treatment was 8 (range 7-10) vs. 1.8 (range 0-3) and 1.9 (range 1-3), respectively, 72 h and 6 weeks after the treatment. Analgesic reduction was achieved in all patients.

CONCLUSIONS

RF combined with KP represents a potential alternative method for palliation of painful spinal osteolytic metastases in selected patients. The procedures are safe and provide pain relief with bone augmentation and improvement in quality of life.

Future directions in percutaneous vertebroplasty

The first percutaneous vertebroplasty, used to treat a painful cervical haemangioma, was performed by a French team in 1984 and reported in the literature in 1987. This technique has rapidly become the standard of care for treatment of medically refractory painful vertebral compression fractures. Vertebral fractures usually become evident because of pain of varying intensity that reduces the patient's quality of life, producing functional limitations, depression, disability, height loss, spinal instability and kyphotic deformity associated with impaired lung capacity. Many diseases may underlie vertebral compression fractures, such as osteoporosis, trauma, neoplasms and haemangioma. Vertebroplasty, as derived from our experience and a review of the literature data, has more than 70%-90% effectiveness for short-term pain reduction and return to activity. The aim of this paper was to describe the state of the art of this spinal interventional radiology procedure and to examine the future directions of percutaneous vertebroplasty.

Esthesioneuroblastoma metastatic to the thoracic intradural and extradural space

BACKGROUND CONTEXT

Ethesioneuroblastoma (ENB) is a rare tumor of the olfactory epithelium that has been shown to metastasize mostly to the cervical lymphatics, with only infrequent spread to other locations. We report a rare case of ENB characterized by recurrence and distant metastasis to the T7-T8 intradural and extradural space.

PURPOSE

To report a rare case of recurrent ENB metastatic to the thoracic intradural and extradural space.

STUDY DESIGN/SETTING

Case report with a review of the literature.

METHODS

A 64-year-old man with recurrent ENB presented with chronic pain in the neck, shoulder, and back. His neurologic exam was normal. Computed tomography of the chest showed no pulmonary metastasis and a high-attenuation spinal canal mass at T8 was noted on magnetic resonance imaging. A laminectomy at T7-T8 was performed for resection of a large epidural mass. A tumor was seen penetrating through the dura, and a midline durotomy was performed for resection of a large intradural mass. Frozen section and permanent stains were consistent with metastatic ENB.

RESULTS

The postoperative period was uneventful, and included pain management and physical therapy, followed by chemotherapy and radiation. The patient remains free of spinal recurrence 2 years after surgery.

CONCLUSIONS

Metastasis of ENB to the spinal column is rare, and of those instances, 80% are localized to the cauda equina. Recurrent ENB metastatic to the thoracic intradural and extradural space is extremely rare, and was successfully treated with surgical resection.

The pharmacological management of skeletal-related events from metastatic tumors

Bone is one of the most common sites of metastatic disease from cancer, affecting around 400,000 patients each year. Skeletal-related events (SRE) include hypercalcemia, fractures, spinal cord compression or severe bone pain and may occur as a complication of metastasis. Bisphosphonate therapy is crucial in the prevention and treatment of SREs; zoledronic acid and pamidronate have both been shown to significantly reduce the development of SREs. Other agents such as corticosteroids and analgesics are also used in symptomatic management. The use of these agents in conjunction with radiation and surgery can help to improve patient outcomes.

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.

Intraosseous delivery of paclitaxel-loaded hydroxyapatitealginate composite beads delaying paralysis caused by metastatic spine cancer in rats

Object

Bone is frequently the first site and the only site of breast cancer at recurrence. Local control is important especially for metastatic spine cancer, because epidural spinal cord compression is significantly associated with the quality of life and survival of these patients. The authors have developed a local delivery system of paclitaxel in the form of hydroxyapatite-alginate composite beads. This study was conducted to clarify the therapeutic effect in a rat model of metastatic spine cancer.

Methods

Twenty-one rats with metastatic spine cancer were divided into 3 groups: a local treatment group (6 rats), a systemic treatment group (9 rats), and a control group (6 rats). The hind-limb motor function of the animals was monitored daily by using the Basso-Beattie-Bresnahan scale. The authors monitored the disease-free time and survival times. The log-rank test was used to define statistically significant differences between the 3 groups.

Results

The animals in the control group developed hind-limb paralysis at a mean of 10.8 days and died at a mean of 16.0 days. The animals treated with 2.4 wt% of paclitaxel-loaded hydroxyapatite-alginate composite beads (the local treatment group) showed a 140–150% increase in the disease-free time and survival time compared with that of the control group. Although an ~ 30-fold higher dosage of paclitaxel was administered, the therapeutic effect was not evident in the systemic treatment group.

Conclusions

Intraosseous delivery of paclitaxel-loaded hydroxyapatite-alginate composite beads delayed paralysis caused by metastatic spine cancer in rats. The results indicate that intraosseous chemotherapy may provide an effective local treatment of metastatic spine cancer.

Interventions for the treatment of metastatic extradural spinal cord compression in adults

BACKGROUND

Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery.

OBJECTIVES

To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity.

MAIN RESULTS

We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97).

AUTHORS' CONCLUSIONS

Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.

Minimally invasive thoracoscopic approach for anterior decompression and stabilization of metastatic spine disease

Object

The choices available in the management of metastatic spine disease are complex, and the role of surgical therapy is increasing. Recent studies have indicated that patients treated with direct surgical decompression and stabilization before radiation have better functional outcomes than those treated with radiation alone. The most common anterior surgical approach for direct spinal cord decompression and stabilization in the thoracic spine is open thoracotomy; however, thoracotomy for spinal access is associated with morbidity that can be avoided with minimally invasive techniques like thoracoscopy.

Methods

A minimally invasive thoracoscopic approach was used for the surgical treatment of thoracic and thoracolumbar metastatic spinal cord compression. This technique allows ventral decompression via corpectomy, inter-body reconstruction with expandable cages, and stabilization with an anterolateral plating system designed specifically for minimally invasive implantation. This technique was performed in 5 patients with metastatic disease of the thoracic spine, including the thoracolumbar junction.

Results

All patients had improvement in preoperative symptoms and neurological deficits. No complications occurred in this small series.

Conclusions

The minimally invasive thoracoscopic approach can be applied to the treatment of thoracic and thoracolumbar metastatic spine disease in an effort to reduce access morbidity. Preliminary results have indicated that adequate decompression, reconstruction, and stabilization can be achieved with this technique.

Metastatic spinal lesions: state-of-the-art treatment options and future trends

The purpose of this article is to review the current state of the art for treating symptomatic spinal fractures associated with malignant lesions and to present potential future trends in treatments for this patient population. Epidemiology, clinical presentation, and biomechanical ramifications of these lesions are summarized and treatment regimes, clinical outcomes, and complications and technical issues associated with treatments are presented. Potential future trends and new technologies for performing vertebral body augmentation in patients with metastatic spinal lesions are also discussed.

Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications.

METHODS

MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula.

RESULTS

Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients.

CONCLUSIONS

Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.

Metástases do segmento torácico e lombar da coluna vertebral: estudo prospectivo comparativo entre o tratamento cirúrgico e radioterápico com a imobilização externa e radioterapia

As metástases ósseas que acometem o segmento torácico e lombar da coluna vertrebal têm como principais complicações o fenômeno doloroso e a compressão medular ou radicular. O tratamento adotado dependerá das condições clínicas e neurológicas do paciente e do grau de invasão tumoral. Foram analisados, prospectivamente, 32 pacientes acometidos por metástases do segmento torácico e lombar da coluna vertebral, sendo tratados com cirurgia de descompressão e estabilização interna seguida por radioterapia ou irradiação com mobilização externa. A seleção dos grupos foi estabelecida de acordo com a sensibilidade do tumor a radioterapia, condições clínicas, grau de estabilidade da coluna, grau de compressão medular/radicular e opção do paciente. A escala de Frankel e o teste visual de dor foram aplicados no momento do diagnóstico e após 1 e 6 meses. O grupo cirúrgico apresentou melhores resultados, mantendo a deambulação por mais tempo, pois manteve a força muscular nos pacientes Frankel E, propiciou a reversão do déficit neurológico pré-operatório em 61,5% dos casos e propiciou melhora significativa da dor.

Phase I/II study of stereotactic body radiotherapy for spinal metastasis and its pattern of failure

OBJECT

The authors report data concerning the safety, effectiveness, and patterns of failure obtained in a Phase I/II study of stereotactic body radiotherapy (SBRT) for spinal metastatic tumors.

METHODS

Sixty-three cancer patients underwent near-simultaneous computed tomography-guided SBRT. Spinal magnetic resonance imaging was conducted at baseline and at each follow-up visit. The National Cancer Institute Common Toxicity Criteria 2.0 assessments were used to evaluate toxicity.

RESULTS

The median tumor volume of 74 spinal metastatic lesions was 37.4 cm3 (range 1.6-358 cm3). No neuropathy or myelopathy was observed during a median follow-up period of 21.3 months (range 0.9-49.6 months). The actuarial 1-year tumor progression-free incidence was 84% for all tumors. Pattern-of-failure analysis showed two primary mechanisms of failure: 1) recurrence in the bone adjacent to the site of previous treatment, and 2) recurrence in the epidural space adjacent to the spinal cord. Grade 3 or 4 toxicities were limited to acute Grade 3 nausea, vomiting, and diarrhea (one case); Grade 3 dysphagia and trismus (one case); and Grade 3 noncardiac chest pain (one case). There was no subacute or late Grade 3 or 4 toxicity.

CONCLUSIONS

Analysis of the data obtained in the present study supports the safety and effectiveness of SBRT in cases of spinal metastatic cancer. The authors consider it prudent to routinely treat the pedicles and posterior elements using a wide bone margin posterior to the diseased vertebrae because of the possible direct extension into these structures. For patients without a history of radiotherapy, more liberal spinal cord dose constraints than those used in this study could be applied to help reduce failures in the epidural space.

The role of minimally invasive techniques in the management of spine tumors: percutaneous bone cement augmentation, radiosurgery, and microendoscopic approaches

In a similar manner to which patients with degenerative spinal disorders have benefited from advances in minimally invasive spine surgery techniques, patients with spine tumors may benefit from the option of less invasive techniques for tumor ablation, resection, reconstruction, and stabilization. Percutaneous bone cement augmentation, radiosurgery, and microendoscopic approaches for the treatment of spine tumors have allowed for improved clinical outcomes while limiting procedure-related morbidity in this unique patient population.

Minimally invasive spine surgery: a historical perspective

Minimally invasive spine surgery has gained considerable momentum and increased acceptance among spine surgeons throughout the years. An understanding and awareness of the development of minimally invasive spine surgery and its role in the operative treatment of various spine conditions is imperative. This article provides a succinct historical perspective of the development of spine surgery from the more traditional, open procedures to the use of more "minimal access" or minimally invasive spine surgery procedures.

Feasibility of a percutaneous technique for repairing proximal femora with simulated metastatic lesions

Fracture of the proximal femur due to metastatic disease is a significant cause of morbidity and mortality among breast cancer patients. Prophylactic surgical fixation is advised for patients at risk of fracture and typically involves placement of an orthopaedic implant. We propose that some proximal femora with metastases can be repaired by removing the lesion and filling the resulting defect with bone cement (polymethylmethacrylate), a procedure that could be performed percutaneously without the use of hardware. We studied the strengths of 12 matched pairs of cadaveric proximal femora under single-limb stance loading. One femur from each pair remained intact, while a simulated metastatic lesion, measuring approximately 75% of the neck diameter, was burred into the neck of the contralateral femur. The defects were repaired using a procedure similar to the one proposed. Femoral strength was measured via mechanical testing to failure. The strengths of the repaired femora averaged 94.7% of the strength of their respective contralateral intact femur (standard deviation, 8.7%). These findings suggest that the proposed procedure may be useful for some patients with metastases in the femoral neck. If the proximal femur could be safely repaired using the proposed technique in place of conventional surgical fixation, the patient would benefit from a shorter and less invasive surgical procedure, less pain and discomfort, greatly reduced recovery time, and a shorter hospital stay-all at a much lower cost.

Traitement par kyphoplastie à foyer ouvert des métastases rachidiennes

INTRODUCTION

Metastatic spine fractures are very frequent, often occurring in patients with severe medical conditions. Open kyphoplasty and vertebroplasty are part of the classic management of this of fracture. In certain conditions such as spinal cord compression caused by epidural metastatic cancer or collapse of the vertebral body implying a local kyphosis, surgery should allow decompression of the spinal cord and stabilisation of the spine in a simple act. The purpose of this study is to assess a surgical technique combining surgical decompression by laminectomy frequently associated with posterior transpedicular instrumentation and at the same time, an open kyphoplasty to stabilize the anterior part of the spine.

MATERIAL AND METHODS

The same procedure was performed in 14 patients during an 18-month period. The average age of the patients was 54 years. All patients suffered severe pain before the surgical procedure (VSA mean: 7). Neurological deficiency was noted in 10 of the 14 patients with this spinal cord compression. Nineteen vertebrae were treated; a short posterior instrumentation was necessary in 11 patients. The average operative time was 90 minutes. Of the patients with neurological deficiency, the clinical status improved after surgery in all. The average VSA of this series 3 days after surgery was 2. The mean quantity of PMMA injected was 7 cc. Two PMMA leaks, one in the intervertebral disc and one forward, were identified on the postoperative CT scan. The average hospital stay was 7 days.

CONCLUSION

This procedure enables surgical decompression, vertebral body consolidation and consequently spinal stabilization of the spine. We did not have any complications related to this procedure which, particularly for the elderly population, is an attractive alternative to major surgery such as vertebrectomy.

Open kyphoplasty for management of metastatic and severe osteoporotic spinal fracture

Object

Elderly patients in poor general health frequently suffer vertebral body (VB) fractures due to osteoporosis or vertebral metastatic lesions. Kyphoplasty and vertebroplasty have become the standard treatment for these types of fractures. In certain conditions that cause local kyphosis, such as spinal cord compression due to a metastatic epidural tumor or the shortening of the spinal canal secondary to vertebral compression, the surgical treatment should provide decompression and stabilization during a short intervention. In this study the authors evaluated a surgical technique that frequently combines a same-session surgical decompression, such as a laminectomy, and posterior instrumentation-assisted stabilization during the same open intervention in which the VB is stabilized by kyphoplasty.

Methods

During an 18-month period, the authors treated 18 patients with VB fractures according to this protocol: 14 patients with vertebral metastatic lesions and four with osteoporosis. The patients' mean age was 60 years. All suffered severe pain preoperatively (mean visual analog scale [VAS] score of 7). Fourteen of the 18 patients suffered a neurological deficit. Twenty-three vertebral levels were treated; in 15 patients it was necessary to place posterior instrumentation. The mean duration of the intervention was 90 minutes.

Pain in all patients improved 3 days after the intervention, and the mean VAS score decreased to 2. Patients with a neurological dysfunction improved. The mean quantity of injected cement for the kyphoplasty procedure was 7 ml. The mean duration of hospitalization was 7 days. Neuroimaging revealed cement leaks in two cases: one into the disc interspace and one anteriorly into the fractured part of the vertebra. After the intervention, most patients with metastatic lesions underwent radiotherapy. No procedure-related complications occurred.

Conclusions

This procedure allows decompression of the spinal cord, consolidation of the VB and thus a stabilization of the vertebral column, and may provide an alternative treatment to invasive VB excision in patients in poor general health.

Circumferential stabilization with ghost screwing after posterior resection of spinal metastases via transpedicular route

Various surgical methods have been described for treating spinal metastases, namely, en bloc spondylectomy, minimally invasive techniques, and anterior and posterior approaches. The main goals in surgical intervention for these lesions are tumor removal and establishment of strong, durable stabilization. The least invasive method is always preferred. Posterior transpedicular spondylectomy meets all these needs, as this method achieves tumor excision and stabilization of the anterior and posterior spine through one posterior incision and in the same surgical session. The surgeon circumferentially excises a spinal metastasis and then achieves circumferential stabilization in the same session. Numerous circumferential stabilization methods have been used to date, including placement of free bone grafts or cages or acrylic grafts, or insertion of an acrylic graft supported by a Steinmann pin anteriorly and by posterior transpedicular fixators or a Luque rectangle posteriorly. This article describes seven cases of spinal metastasis in which an alternative circumferential stabilization technique known as "ghost screwing" was performed. The first step in this method is circumferential decompression, achieved with laminectomy followed by eggshell corpectomy via the transpedicular route. Then a short segmental transpedicular stabilization system is fixed to the vertebrae cranial and caudal to the laminectomy/corpectomy defect. Prior to fixing the rods in place, an additional screw is mounted on each rod such that the screw shaft protrudes into the defect space. Once the rods are fixed and the two extra screws are optimally positioned, acrylic bone cement is introduced into the defect site, encasing the ghost screws and forming an anterior graft upon hardening. The outcomes in our cases were excellent. All seven patients had uneventful postoperative periods and all experienced pain relief and were able to mobilize early. Direct connection of the anterior acrylic graft to the posterior fixation system via ghost screws makes this system strong and durable, and prevents subsidence or horizontal displacement of the graft. Such complications can be serious issues with other circumferential systems that use independent anterior and posterior fixators.

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.

Image-guided robotic radiosurgery for spinal metastases

BACKGROUND AND PURPOSE

To determine the effectiveness and safety of image-guided robotic radiosurgery for spinal metastases.

MATERIALS/METHODS

From 1996 to 2005, 74 patients with 102 spinal metastases were treated using the CyberKnife at Stanford University. Sixty-two (84%) patients were symptomatic. Seventy-four percent (50/68) of previously treated patients had prior radiation. Using the CyberKnife, 16-25 Gy in 1-5 fractions was delivered. Patients were followed clinically and radiographically for at least 3 months or until death.

RESULTS

With mean follow-up of 9 months (range 0-33 months), 36 patients were alive and 38 were dead at last follow-up. No death was treatment related. Eighty-four (84%) percent of symptomatic patients experienced improvement or resolution of symptoms after treatment. Three patients developed treatment-related spinal injury. Analysis of dose-volume parameters and clinical parameters failed to identify predictors of spinal cord injury.

CONCLUSIONS

Robotic radiosurgery is effective and generally safe for spinal metastases even in previously irradiated patients.

Malignant spinal cord compression in cancer patients may be mimicked by a primary spinal cord tumour

Although it is quite rare, second primary neoplasms in cancer patients may present with the signs and symptoms of malignant spinal cord compression. Primary spinal cord tumours in the cancer patients may be deceptive and considered as the recurrent first cancer. Therefore, it should be precisely differentiated and appropriately managed. We report such a case of intramedullary ependymoma of the cervical spinal cord mimicking metatstatic recurrent lymphoma and causing cord compression. A 50-year-old man developed intramedullary ependymoma of the cervical spinal cord 1.5 years following chemoradiation for Waldeyer's ring lymphoma. He presented with a 2-month history of neck pain, progressive upper- and lower-extremity numbness and weakness, and bowel and bladder dysfunction. Magnetic resonance imaging revealed an intramedullary expansive lesion extending from C4 to C6 levels of the cervical spinal cord. The clinical and radiological findings were suggestive of malignant process. A comprehensive investigation failed to detect another site of disease. He underwent operation, and the tumour was subtotally resected. The patient's neurological deficits improved subsequently. The development of the intramedullary ependymoma following treating lymphoma has not been reported. We describe the clinical, radiological and pathological findings of this case and review the literature.

Diagnosis and management of metastatic spine disease

Spinal metastases are a significant source of morbidity in patients with systemic cancer. Roughly 30% of patients with cancer develop symptomatic spinal metastases during the course of their illness, and up to 90% of cancer patients possess metastatic lesions within the spine at the time of death with advances in the treatment of systemic disease, survival in such patients has increased. This factor combined with improved imaging modalities will undoubtedly increase the incidence in which spinal metastases are encountered by physicians. In this review, the authors not only attempt to present the myriad ways in which patient with spinal metastases present, but also the means by which they are currently diagnosed and managed. In addition, we propose a simple algorithm to aid in deciding which patients are ideally treated medically and which patients may benefit from surgery.

Minimally Invasive Approaches to Vertebral Column and Spinal Cord Tumors

Minimally invasive approaches to spinal tumors have evolved rapidly over the past 15 to 20 years as clinicians seek to avoid the morbidity and long-term dysfunction associated with traditional open surgical procedures. We review the noninvasive, percutaneous, and minimally invasive surgical techniques currently available for the treatment of spinal column and intradural spinal tumors, including minimal access thoracic corpectomy and minimal access intradural tumor surgery. The various advantages and limitations of these approaches as well as their appropriate indications and uses are also presented here. A measured understanding of surgical objectives and iatrogenic effects on patients' quality of life allows the surgeon to implement such minimally invasive approaches in the design of individualized treatment plans that range from pure palliation to definitive cure.

Surgery insight: current management of epidural spinal cord compression from metastatic spine disease

Metastatic epidural spinal cord compression (MESCC) is becoming a more common clinically encountered entity as advancing systemic antineoplastic treatment modalities improve survival in cancer patients. Although treatment of MESCC remains a palliative endeavor, emerging surgical techniques, in combination with imaging modalities that detect spinal metastatic disease at an early stage, are resulting in improved outcomes. Here, we review the clinical presentation, diagnostic work-up and management options in the management of MESCC. A treatment paradigm is outlined with emphasis on early circumferential surgical decompression of the spinal cord with concomitant spinal stabilization. Radiation therapy has a clearly defined role in the treatment of patients with MESCC, particularly those with radiation-sensitive tumors in the setting of non-bony spinal cord compression and those with a limited life expectancy. Spinal stereotactic radiosurgery, vertebroplasty, and kyphoplasty, are emerging treatment options that are beginning to be used in selected patients with MESCC.

Oncologic emergencies: diagnosis and treatment

Patients with malignancies are subject to developing a unique set of complications that require emergent evaluation and treatment. With the increasing incidence of cancer in the general population and improved survival, these emergencies will be more frequently encountered. Physicians must be able to recognize these conditions and institute appropriate therapy after a focused initial evaluation. The approach to definitive therapy is commonly multidisciplinary, involving surgeons, radiation oncologists, medical oncologists, and other medical specialists. Prompt interventions can be lifesaving and may spare patients considerable morbidity and pain. In this review, we discuss the diagnosis of and initial therapy for common emergencies in hematology and oncology.

Interdisciplinary clinical evaluation of 58 patients with lumbar-vertebral metastases from cervico-uterine cancer

INTRODUCTION

Metastases in the vertebrae of patients with cervical cancer (CeCa) can be difficult to diagnose, and the treatment is palliative in many cases.

OBJECTIVES

The aim of this study was to assess the ti-me required for diagnosis, the lesion's locoregional extent and the therapeutic schemes applied, in a retrospective series of 58 patients with CeCa and with lumbar spinal metastases.

METHODS

The cases were studied using an updated interdisciplinary analysis to determine the clinical and radiological variables. This study evaluated the site and extent of bone lesions and correlated these variables with instability of the spine and cord compression.

RESULTS

The diagnosis of vertebrae metastases of Ce-Ca required more than 3 months in most cases. Lumbar vertebrae L4 and L5 and specifically the vertebral body were the most-frequently affected si-tes. Systemic and/or extra-compartmental-extended metastases (MosV4) were observed in 44/58 patients. Radiotherapy was the only option in this group and the palliative effect achieved was minimal, or null. In 14/58 patients there was intra compartmental-extended (MosV2) and extra-compartmental limited (MosV3) single vertebral metastases and the 3 different treatment schemes were administered. In the cases treated with marginal resection of metastases, vertebroplasty plus adjuvant radiotherapy achieved significant palliative effect.

CONCLUSIONS

In the present series of patients, the diagnosis of metastases of the lumbar vertebrae was late, and the disease was advanced. The results obtained with radiotherapy in advanced stage disease did not improve the quality of life of patients. Metastasectomy was the therapeutic scheme in cases with intermediate stage disease and was the basis of the integrated treatment We believe that it is necessary to shorten the diagnostic time and to apply a staging system for vertebral metastases so that appropriate individualised selection of interdisciplinary treatment would be facilitated.

Open Vertebral Cement Augmentation Combined With Lumbar Decompression for the Operative Management of Thoracolumbar Stenosis Secondary to Osteoporotic Burst Fractures

Osteoporotic burst fractures with neurologic symptoms are typically treated with neural decompression and multilevel instrumented fusion. These large surgical interventions are challenging because of patients' advanced ages, medical co-morbidities, and poor fixation secondary to osteoporosis. The purpose of this retrospective clinical study was to describe a novel technique for the treatment of osteoporotic burst fractures and symptomatic spinal stenosis via a limited thoracolumbar decompression with open cement augmentation [vertebroplasty (VP) or kyphoplasty (KP)]. Indications for decompression and cement augmentation were intractable pain at the level of a known osteoporotic burst fracture with symptoms of spinal stenosis. As such, 25 patients (mean age, 76.1 years) with low-energy, osteoporotic, thoracolumbar burst fractures (7 males, 18 females; 39 fractures) were included. In all cases, laminectomy of the stenotic level(s) was followed by vertebral cement augmentation (9 VP; 16 KP). When a spondylolisthesis at the decompressed level was present, instrumentation was applied across the listhetic level (n = 9). Clinical outcome (1 = poor to 4 = excellent) was assessed on last clinical follow-up (mean, 44.8 wks). In addition, a modified MacNab's grading criteria was used to objectively assess patient outcomes postoperatively. Radiographic analysis of sagittal contour was assessed preoperatively, immediately postoperatively, and at final follow-up. The average time from onset of symptoms to intervention was 19 weeks (range, 0.3-94 wks). A mean of 1.6 fractures/patient was augmented (range, 1-3 fractures) and 2.8 levels were decompressed (range, 1-6 levels). No statistical difference in anatomic distribution or number of fractures between the VP and KP groups or in the instrumented versus noninstrumented patients was noted (P > 0.05). An overall subjective outcome score of 3.4 was noted. Twenty of 25 patients were graded as excellent/good according to the modified MacNab's criteria. The choice of augmentation procedure or use of instrumentation did not predict outcome (P = 0.08). Overall, 1.7 degrees of sagittal correction was obtained at final follow-up. One patient was noted to have progressive kyphosis after KP. The use of a limited-posterior decompression and open cement augmentation via VP or KP is a safe treatment option for patients who have osteoporotic burst fractures and who are incapacitated from fracture pain and concomitant stenosis. After thoracolumbar decompression, open VP/KP provides direct visualization of the posterior vertebral body wall, allowing for safe cement augmentation of burst fractures, stabilizing the spine, and obviating the need for extensive spinal reconstruction. Although clinically successful, this technique warrants careful patient selection.

Kompressionssyndrome

Superior vena cava syndrome is a medical condition determined by the mechanisms of extrinsic compression, invasion or thrombosis of the superior vena cava. The most common underlying cause is a malignant process, especially lung cancer and lymphoma. Typical symptoms include progressive dyspnea, head and upper body edema and cyanosis. Most patients can be treated with appropriately directed chemotherapy or radiotherapy. Accurate diagnosis of the underlying etiology needs to be established before treatment. Only under extreme emergency conditions such as laryngeal or cerebral edema irradiation should be initiated without a histological diagnosis. With the refinement of endovascular stents, percutaneous stenting is being increasingly used as primary treatment modality. Metastatic spinal cord compression is one of the most dreadful complications of cancer. In most patients the initial symptom is progressive back pain with an axial or radicular distribution. MRI should be preferred in the diagnostic work-up, corticosteroids be administered promptly after biopsy. Radiation therapy or surgical treatment should be started as soon as possible.

A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease

Radiotherapy has been the primary therapy for managing metastatic spinal disease; however, surgery that decompresses the spinal cord circumferentially, followed by reconstruction and immediate stabilization, has also proven effective. We provide a quantitative comparison between the "new" surgery and radiotherapy, based on articles that report on ambulatory status before and after treatment, age, sex, primary neoplasm pathology, and spinal disease distribution. Ambulation was categorized as "success" or "rescue" (proportion of patients ambulatory after treatment and proportion regaining ambulatory function, respectively). Secondary outcomes were also analyzed. We calculated cumulative success and rescue rates for our ambulatory measurements and quantified heterogeneity using a mixed-effects model. We investigated the source of the heterogeneity in both a univariate and multivariate manner with a meta-regression model. Our analysis included data from 24 surgical articles (999 patients) and 4 radiation articles (543 patients), mostly uncontrolled cohort studies (Class III). Surgical patients were 1.3 times more likely to be ambulatory after treatment and twice as likely to regain ambulatory function. Overall ambulatory success rates for surgery and radiation were 85% and 64%, respectively. Primary pathology was the principal factor determining survival. We present the first known formal meta-analysis using data from nonrandomized clinical studies. Although we attempted to control for imbalances between the surgical and radiation groups, significant heterogeneity undoubtedly still exists. Nonetheless, we believe the differences in the outcomes indicate a true difference resulting from treatment. We conclude that surgery should usually be the primary treatment with radiation given as adjuvant therapy. Neurologic status, overall health, extent of disease (spinal and extraspinal), and primary pathology all impact proper treatment selection.

The lateral extracavitary approach to the thoracic and lumbar spine

The LECA is a technically challenging procedure with a steep learning curve. It is one of the most versatile approaches to the spine, however,with a logical sequence of maneuvers that can be combined to adapt the LECA for many different spinal procedures that need to be performed for decompression of the spinal cord and reconstruction of the spinal column in cancer patients.