Evaluation and treatment of spinal metastatic disease

Vessel-Plasty Using Bone-Filling Mesh Container for Treatment of Malignant Severe Compression Fractures in Cervical Vertebrae

Objective

To evaluate the feasibility, safety, and efficacy of vessel-plasty using bone-filling mesh container (BFMC) for malignant severe compression fractures of cervical vertebra.

Methods

This study prospectively recruited fifteen consecutive patients (eight men, seven women; mean age, 57.4 years) with severe malignant compression fractures of cervical vertebrae for vessel-plasty. Procedure duration, incidence of cement leakage and other complications, pain relief and improvement of neck function were analyzed. Pain was assessed using a visual analog scale (VAS) and function by the neck disability index (NDI), with scores recorded before the procedure and at 3 days and 1, 3, 6 and 12 months after the procedure.

Results

A total of 16 vertebrae were treated. All vertebrae had destruction of bone in more than one place as well as broken bone walls. Mean procedure duration was 42.9±13.6 minutes. Bone cement leakage occurred in two vertebrae without any symptoms. No procedure-related complications occurred. Mean VAS and NDI declined from 7.1 ± 1.4 and 63.6 ± 16.3, respectively, before the procedure to 3.5 ± 1.1 and 37.4 ± 11.0, respectively, at three days after the procedure (P < 0.01). CT images at three months after the procedure confirmed that there were no cases of refractures at the treated or adjacent levels, recurrence of vertebral collapse and mobilization of bone cement block.

Conclusion

Vessel-plasty using BFMC appears to be effective and safe for malignant severe compression fractures in cervical vertebrae. It is effective in stabilizing vertebral body, relieving pain.

Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury

BACKGROUND

Preoperative embolization of spinal metastases may improve outcomes of resection by reducing surgical blood loss and operative time. Neurologic complications are rarely reported and the mechanisms leading to injury are poorly described.

METHODS

We present 2 illustrative cases of embolization-related neurologic injury from distinct mechanisms and the findings of a systemic literature review of similar complications according to the PRISMA guidelines.

RESULTS

A 77-year-old man with a history of renal cell carcinoma presented with gait dyscoordination and arm pain/weakness. Magnetic resonance imaging showed a C7/T1 mass causing severe compression of the C7/T1 roots and spinal cord. After embolization and tumor resection/fusion, lethargy prompted imaging showing multiple posterior circulation infarcts believed to be secondary to reflux of embolic particles. A 75-year-old man with renal cell carcinoma presented with L1 level metastasis causing conus compression and experienced paraplegia after superselective particle embolization presumed to be secondary to flow disruption of the artery of Adamkiewicz. Analysis of the literature yielded 6 articles reporting instances of cranial infarction/ischemia occurring in 10 patients, 12 articles reporting spinal cord ischemia/infarction occurring in 17 patients, and 5 articles reporting symptomatic postembolization tumoral swelling in 5 patients.

CONCLUSIONS

Neurologic injury is a risk of preoperative embolization of spinal metastasis from either compromise of spinal cord vascular supply or cranial stroke from reflux of embolic particles. Postprocedural tumor swelling rarely leads to clinical deficit. Awareness of these complications and the presumed mechanisms of injury may aid clinicians in implementing interventions and in counseling patients before treatment.

Efficacy and complications of 125I seeds combined with percutaneous vertebroplasty for metastatic spinal tumors: A literature review

To review the efficacy and complications of ¹²⁵I seeds combined with percutaneous vertebroplasty for the treatment of metastatic spinal tumors. We searched PubMed/MEDLINE from its inception to November 2018 for articles on metastatic spinal tumors treated with ¹²⁵I seeds combined with percutaneous vertebroplasty. A total of 273 articles were identified in PubMed/MEDLINE based on the search criteria. After deleting duplicate articles including two retrospective studies and three case control studies, five studies were included in this systematic review. In total, 161 patients aged from 49.2 to 62 years were included. The operative levels consisted of the thoracic vertebrae and lumbar vertebrae. Bone cement leakage occurred in 7 cases. None of the patients developed radiation myelopathy. Percutaneous vertebroplasty plus ¹²⁵I seeds implantation is an effective palliative treatment and can alleviate back pain and enhance vertebral body strength in patients with end-stage spinal metastatic tumors. In future research, the effective dosage of ¹²⁵I seeds implantation, the anchoring of seeds with safe distance, and the bone cement distribution in the vertebral body will be next research hotspot.

Anterolateral Cervical Kyphoplasty for Metastatic Cervical Spine Lesions

Study Design

Retrospective case series.

Purpose

To evaluate the clinical and radiological efficacy of anterolateral kyphoplasty for cervical spinal metastasis.

Overview of Literature

Although the spine is the third most common site of tumor metastasis, the cervical spine is the least commonly affected (incidence, 10%–15%). Surgical decompression is highly challenging because of the proximity of neural and vascular elements. Kyphoplasty for cervical spine metastasis has been described in small case reports with promising results.

Methods

Retrospective analysis of a prospective collected single-center spine metastasis database was done for cervical kyphoplasty cases. Data pertaining to age, sex, primary tumor diagnosis, modified Tokuhashi score, Spinal Instability Neoplastic Score (SINS), preoperative Visual Analog Scale (VAS) score, and analgesic medication were extracted. Postoperative data included VAS score at postoperative day 1, duration of hospitalization, self-reported functional outcome, and VAS score at the last follow-up.

Results

Eleven patients (mean age, 62.5 years) with cervical spine metastases were treated with 15-level kyphoplasty. Mean Tokuhashi score was 8.1, and mean SINS was 7.85. Mean preoperative pain score was 7.1, and 82% of patients used opioid analgesics. Mean total bleeding volume was 100 mL. Mean complication-free length of stay was 2.6 days with a decrease in postoperative pain (VAS score=2.8, p <0.05). There was a 56% decrease in opioid dosage and the number of consumed analgesics (1.09, p =0.004). Eighty-two percent of the patients reported excellent improvement at the last follow-up self-assessment.

Conclusions

To our knowledge, this case series represents the largest series of vertebral augmentation using balloon kyphoplasty for cervical spinal metastasis. This technique is associated with low postoperative complications as well as significant decrease in pain, use of opioids, and length of hospital stay. The main indications for vertebral kyphoplasty are lytic lesions of the cervical spine, painful lesions refractory to medical treatment, SINS score of 6–10, and absence of posterior wall defect.

Surgical site infection in spinal metastasis: incidence and risk factors

BACKGROUND

Surgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality.

OBJECTIVE

This study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors.

STUDY DESIGN

This is a retrospective analysis of a prospectively collected data.

METHODS

Preoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (<90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p<.05 as significance threshold.

RESULTS

A total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI.

CONCLUSION

This paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

Rapid bone repair in a patient with lung cancer metastases to the spine using a novel herbal medicine: A case report

The prognosis of lung carcinoma with metastasis to the bone, particularly to the spine, is poor. Chemotherapy and radiotherapy are established treatments for metastatic bone disease, but their effectiveness is unsatisfactory and bone repair following their use is slow and difficult. Medicine prepared from herbal extracts may be an alternative treatment option. The present study discusses the case of a 59-year-old patient diagnosed with squamous cell lung cancer (T2N3M1) in which first-line chemotherapy using docetaxel plus cisplatin failed. Heavy multiple bone metastases were detected in the T9 vertebra and sixth left rib, resulting in a high risk of pathological fracture. Eastern Cooperative Oncology Group (ECOG) and numerical rating scale (NRS) scores of pain were 2 and 4, respectively. A second-line treatment was chosen consisting of biological intracontrol treatment (BICT) plus bisphosphonates administered over 40 days. BICT is a therapy involving the use of herbal extracts (including ginseng, herba agrimoniae, hairyvein agrimonia herb, white flower patrinia herb and arginine) and palliative care. A partial positive response was reached following use of this regimen, particularly with regard to bone repair. A computed tomography scan revealed a 90% reduction in the broken area of the rib cage and T9 vertebra. The bone repair was rapid and almost complete. In addition, growth of the primary tumor in the right pulmonary hilar and metastasis in the mediastinal lymph nodes were stabilized following treatment. ECOG and NRS scores were decreased to 1 and 0, respectively, leading to an improved quality of life. Based on these results, the present study suggests that this herbal medicine-based regimen promotes bone repair and inhibits tumor growth, with low toxicity. However, the mechanism by which herbal medicine promotes rapid bone repair is unclear. Further studies are required to determine whether cells in the tumor microenvironment are stimulated to undergo re-differentiation by unidentified herbal substances.