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Scheurer F, Kaiser D, Kobe A, Smolle M, Suter D, Spirig JM, Müller D. The effect of preoperative embolization on giant cell tumors of the bone localized in the iliosacral region of the pelvis. Surg Oncol 2024; 55:102101. [PMID: 39018867 DOI: 10.1016/j.suronc.2024.102101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/05/2024] [Accepted: 05/27/2024] [Indexed: 07/19/2024]
Abstract
INTRODUCTION Giant cell tumors of the bone (GCTB) are aggressive neoplasms, with rare occurrences in the posterior pelvis and sacral area. Surgical challenges in this region include the inability to apply a tourniquet and limited cementation post-curettage due to proximity to neurovascular structures, leading to potential complications. This case-control study explores the impact of preoperative embolization on GCTB located in the iliosacral region. METHODS Five surgeries (January-December 2021) for pelvic GCTB (3 sacrum, 2 posterior ilium) were performed on four patients. Diagnosis was confirmed through preoperative CT-guided biopsies. One surgery involved curettage with PMMA cement filling, while four surgeries had curettage without cavity filling. Preoperative embolization of the tumor feeding vessel occurred approximately 16 h before surgery in two cases. Denosumab treatment was not administered. RESULTS Tumor volume, assessed by preoperative MRI, was comparable between patients with and without preoperative embolization (p = .14). Surgeries without embolization had a mean intraoperative blood loss of 3250 ml, erythrocyte transfusion volume of 1125 ml, and a mean surgical time of 114.5 min for two surgeries. Surgeries with preoperative embolization showed a mean intraoperative blood loss of 1850 ml, no erythrocyte transfusion requirement, and a mean surgical time of 68 min. CONCLUSION Curettage of GCTB in the posterior pelvis and sacrum presents challenges, with significant intraoperative blood loss impacting surgical time and transfusion needs. Preoperative embolization may be beneficial in reducing blood loss during surgery in these cases.
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Affiliation(s)
- Fabrice Scheurer
- University Sarcoma Center Zürich (CCCZ), Balgrist University Hospital, University of Zurich, Switzerland.
| | - Dominik Kaiser
- University Sarcoma Center Zürich (CCCZ), Balgrist University Hospital, University of Zurich, Switzerland
| | - Adrian Kobe
- Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Switzerland
| | - Maria Smolle
- University Sarcoma Center Zürich (CCCZ), Balgrist University Hospital, University of Zurich, Switzerland
| | - Daniel Suter
- University Sarcoma Center Zürich (CCCZ), Balgrist University Hospital, University of Zurich, Switzerland
| | - José Miguel Spirig
- University Spine Center Zürich, Balgrist University Hospital, University of Zurich, Switzerland
| | - Daniel Müller
- University Sarcoma Center Zürich (CCCZ), Balgrist University Hospital, University of Zurich, Switzerland
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Makishima J, Yamamoto S, Yata S, Takasugi S, Kamata Y, Tanishima S, Fujii S. Efficacy of Subtraction Computed Tomography Arteriography During Preoperative Embolization in Spinal Tumors. Yonago Acta Med 2024; 67:61-67. [PMID: 38371281 PMCID: PMC10867234 DOI: 10.33160/yam.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/25/2023] [Indexed: 02/20/2024]
Abstract
Background This study aimed to evaluate the efficacy of subtraction computed tomography arteriography (s-CTA) during preoperative embolization in spinal tumors. Methods The study analyzed 17 vertebrae in 13 patients who underwent preoperative embolization before spinal fixation surgery for malignant spinal tumors to decrease blood loss at our hospital from 2019 to 2021. Their ages ranged from 56 to 88 years (average, 73.5 years). Metastatic bone tumors were most common, including five cases originating as lung carcinomas and three as renal cancers. After digital subtraction angiography of selected tumor-feeding arteries and non-subtraction CTA (ns-CTA) were performed, s-CTA was conducted using data obtained from both procedures. A clarity score of the boundary between the normal bone and tumor was derived for each patient, which was then classified into four grades (good, 3 points; fair, 2 points; faint, 1 point; poor, 0 points) by two experienced radiologists, followed by a comparison between the s-CTA and ns-CTA groups using the Wilcoxon signed-rank test. Results Clarity scores were significantly higher in the s-CTA group than in the ns-CTA group (P < 0.001). The agreement of Cohen's coefficients between the two radiologists was κ = 0.724 in s-CTA scoring and κ = 0.622 in ns-CTA scoring, which were moderately matched. Seven arteries were not embolized due to insufficient tumor contrast enhancement and their poor relation to the surgical invasion zone. No complications were observed during or after embolization. Conclusion S-CTA successfully distinguished between tumor and normal bone and may help avoid unnecessary embolization.
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Affiliation(s)
- Jun Makishima
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shuichi Yamamoto
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinsaku Yata
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shohei Takasugi
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yuji Kamata
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinji Tanishima
- Division of Orthopedic Surgery, Department of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Shinya Fujii
- Division of Radiology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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Qiao R, Ma R, Zhang X, Lun D, Li R, Hu Y. Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:4272-4296. [PMID: 37661228 DOI: 10.1007/s00586-023-07898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. METHODS A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. RESULTS The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3 mL in the NE group and 1716.4 mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15 mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). CONCLUSIONS PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.
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Affiliation(s)
- Ruiqi Qiao
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China
| | - Rongxing Ma
- Graduate School, Tianjin Medical University, Tianjin, China
| | | | - Dengxing Lun
- Department of Bone Oncology, Weifang People's Hospital, Weifang, China
| | - Ruifeng Li
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yongcheng Hu
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China.
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Faiella E, Santucci D, Vertulli D, Russo F, Vadalà G, Papalia R, Beomonte Zobel B, Denaro V, Grasso RF. Preoperative Embolization of Vertebral Metastasis: Comprehensive Review of the Literature. Diseases 2023; 11:109. [PMID: 37754305 PMCID: PMC10528004 DOI: 10.3390/diseases11030109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/17/2023] [Indexed: 09/28/2023] Open
Abstract
The aim of this review is to determine the safety and efficacy of pre-operative spinal metastases embolization procedures. Two reviewers independently conducted the literature search (on MEDLINE databases), including in the review of all the studies that used pre-operative TAE to treat spinal metastases. Twelve articles on pre-operative spinal metastases embolization were selected. Most of the studies demonstrated the low complication rate of pre-operative embolization. The most important study strength is that there are very few reviews in the literature with the setting on pre-operative vertebral metastases embolization. A limitation of the review is that the studies included were predominately retrospective case-control studies, increasing the risk of bias in the primary data. Plus, divergent surgical and embolization procedures were performed in the studies, causing a potential risk of bias in the pooled results. We can conclude that preoperative arterial embolization of vertebral metastases is a safe, well-tolerated technique that reduces surgical blood loss and facilitates surgical tumor resection.
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Affiliation(s)
- Eliodoro Faiella
- Department of Radiology, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (E.F.); (D.V.); (B.B.Z.); (R.F.G.)
| | - Domiziana Santucci
- Department of Radiology, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (E.F.); (D.V.); (B.B.Z.); (R.F.G.)
| | - Daniele Vertulli
- Department of Radiology, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (E.F.); (D.V.); (B.B.Z.); (R.F.G.)
| | - Fabrizio Russo
- Department of Orthopaedics, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (F.R.); (G.V.); (R.P.); (V.D.)
| | - Gianluca Vadalà
- Department of Orthopaedics, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (F.R.); (G.V.); (R.P.); (V.D.)
| | - Rocco Papalia
- Department of Orthopaedics, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (F.R.); (G.V.); (R.P.); (V.D.)
| | - Bruno Beomonte Zobel
- Department of Radiology, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (E.F.); (D.V.); (B.B.Z.); (R.F.G.)
| | - Vincenzo Denaro
- Department of Orthopaedics, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (F.R.); (G.V.); (R.P.); (V.D.)
| | - Rosario Francesco Grasso
- Department of Radiology, University of Rome “Campus Bio-Medico”, Via Alvaro del Portillo, 21, 00128 Rome, Italy; (E.F.); (D.V.); (B.B.Z.); (R.F.G.)
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Huang YC, Tsuang FY, Lee CW, Lin YH. Efficacy of preoperative embolization for metastatic spinal tumor surgery using angiographic vascularity assessment. Eur Radiol 2023; 33:2638-2646. [PMID: 36449062 DOI: 10.1007/s00330-022-09276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/22/2022] [Accepted: 10/27/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVES Preoperative embolization (PE) for metastatic spinal tumors is a method of minimizing intraoperative blood loss during aggressive surgery. This study specified angiographic standards and investigated the influence of these and other factors on blood loss in patients with spinal metastases and various pathologies. METHODS The cohort comprised 126 consecutive patients receiving PE from 2015 to 2021. Their clinical, surgical, and angiographic characteristics were reviewed. Standard angiographic grading was used for vascularity assessment. Degree of embolization was divided into complete (≥ 90%), near complete (67 to < 90%), and partial (< 67%). Logistic regression analysis was used to investigate factors predictive of massive blood loss (> 2500 mL). A proportional odds model was used to assess factors predictive of the degree of embolization. RESULTS Mean intraoperative blood loss was 1676 mL. Among the patients, 62 had hypervascular tumors and 64 had nonhypervascular tumors, according to the angiographic classification. Intraoperative blood loss differed significantly with embolization degree, both overall (p < 0.001) and in the hypervascular and nonhypervascular groups (p = 0.01 and 0.03). Angiographic hypervascularity, spinal metastasis invasiveness index, and embolization degree were significant predictors of massive blood loss in univariate analysis, but only embolization degree was significant in multivariate analysis. Only the presence of the radiculomedullary artery at the target level was significant in both the univariate and multivariate analyses for embolization degree. CONCLUSIONS In addition to pathological classification, angiographic vascularity assessment is valuable. Although complete embolization is a reasonable goal, it is challenging to achieve in cases of visible radiculomedullary artery. KEY POINTS • Angiography has a supplementary role in vascularity assessment for spinal metastatic surgery. • Better embolization degree is associated with less intraoperative blood loss in both angiographic hypervascular and nonhypervascular groups. • Presence of radiculomedullary artery in the target level causes worse embolization outcome.
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Affiliation(s)
- Yu-Cheng Huang
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Fon-Yih Tsuang
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan
| | - Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan.
- Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan.
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Zhai S, Hu P, Liu X, Li Z, Wang B, Zhou H, Liu Z, Liu X, Li Y, Wei F. Prognostic Analysis of Spinal Metastasis Secondary to Lung Cancer after Surgeries: A Unicentric, Large-Cohort, Retrospective Study. Orthop Surg 2022; 15:70-78. [PMID: 36331128 PMCID: PMC9837295 DOI: 10.1111/os.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Spinal metastases of lung cancer (SMLC) usually have high degree of malignancy and require surgical treatment. However, there are several controversies about the efficacy of surgery. This study aimed to investigate factors predicting prognosis of SMLC after surgery-based comprehensive treatment. METHODS A cohort of 112 cases of SMLC who underwent surgical treatment between 2009 and 2020 were retrospectively reviewed and analyzed. The surgical strategies included total en-bloc spondylectomy, debulking surgery, palliative decompression, and vertebral augmentation procedures. The patients were regularly followed-up. Survival analysis was performed, as well as analysis of the patients' neurological recovery, pain relief, and improvement of Karnosky performance score (KPS). Cox regression was used to analyze influencing factors of survival time, and Kaplan-Meier method was performed in survival analysis. RESULTS The cohort included 63 males and 49 females, with an average age of 60.6 ± 10.6 years. Median survival time was 16 months. A total of 86.7% of paralysis patients' neurological function recovered and 83.9% of patients with low KPS score (10-40) improved. Surgical method was significantly correlated with improvement of neurological function (p < 0.001) and KPS (p < 0.001). The mean bleeding volume was 502 ml and operative time was 170 min. The survival rates at 3, 6, 12, 24, and 36 months were 92.0%, 80.4%, 63.4%, 63.4%, and 22.6%, respectively. Postoperative Frankel grade (p < 0.001), postoperative KPS score (p = 0.001), and application of molecular targeted drugs (p < 0.001) were significantly correlated with survival time in univariate analysis, while application of molecular targeted drugs was an independent predictor for a longer survival by a multivariate analysis. CONCLUSION Surgery-based comprehensive treatment brought a fair outcome, with elongated survival time. Surgery can significantly improve patients' neurological function and physical performance status. Adjuvant targeted therapy is an independent positive factor for patients' survival.
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Affiliation(s)
- Shuheng Zhai
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Panpan Hu
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Xiao Liu
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Zihe Li
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Ben Wang
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Hua Zhou
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Zhongjun Liu
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Xiaoguang Liu
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Yan Li
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
| | - Feng Wei
- Department of OrthopaedicsPeking University Third HospitalBeijingChina,Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationBeijingChina,Beijing Key Laboratory of Spinal Disease ResearchBeijingChina
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Cui Y, Shi X, Mi C, Wang B, Li H, Pan Y, Lin Y. Risk factors of total blood loss in the posterior surgery for patients with thoracolumbar metastasis. BMC Musculoskelet Disord 2021; 22:898. [PMID: 34686157 PMCID: PMC8540176 DOI: 10.1186/s12891-021-04789-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/13/2021] [Indexed: 01/15/2023] Open
Abstract
Background Blood loss in posterior surgery patients with thoracolumbar metastasis posed a significant challenge to surgeons. This study aimed to explore the risk factors of blood loss in posterior surgery for patients with thoracolumbar metastasis. Methods One hundred forty-two patients were retrospectively reviewed. Their baseline characteristics were recorded. The Gross equation was used to calculate blood loss on a surgical day. Multivariate linear regression was used to analyze the risk factors. Results Mean blood loss of 142 patients were 2055 ± 94 ml. Hypervascular primary tumor (kidney, thyroid and liver) (P = 0.017), wide or marginal excision (en-bloc: P = 0.001), metastasis at the lumbar spine (P = 0.033), and the presence of extraosseous tumor mass (P = 0.012) were independent risk factors of blood loss in the posterior surgery. Sub-analysis showed that wide or marginal excision (en-bloc: P < 0.001) and metastasis at lumbar spine (P = 0.007) were associated with blood loss for patients with non-hyper vascular primary tumors. Wide or marginal excision (piece-meal: P = 0.014) and the presence of an extraosseous tumor mass (P = 0.034) were associated with blood loss for patients with hypervascular primary tumors. Conclusion Hypervascular primary tumor (kidney, thyroid, and liver) was an independent risk factor of blood loss in the posterior surgery. The presence of extraosseous tumor mass and wide or marginal excision (piece-meal) were independent risk factors for patients with hypervascular primary tumors. Metastasis at the lumbar spine and wide or marginal excision (en-bloc) were independent risk factors for patients with non-hyper vascular primary tumors.
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Affiliation(s)
- Yunpeng Cui
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China
| | - Xuedong Shi
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China.
| | - Chuan Mi
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China
| | - Bing Wang
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China
| | - Huaijin Li
- Department of Anesthesia, Peking University First Hospital, Beijing, China
| | - Yuanxing Pan
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China
| | - Yunfei Lin
- Department of Orthopaedics, Peking University First Hospital, No.7 Xishiku Street, Xicheng District, Beijing, 100032, China
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Facchini G, Parmeggiani A, Peta G, Martella C, Gasbarrini A, Evangelisti G, Miceli M, Rossi G. The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2839-2851. [PMID: 34415449 DOI: 10.1007/s00586-021-06963-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Claudia Martella
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Rossi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
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Gao ZY, Zhang T, Zhang H, Pang CG, Xia Q. Effectiveness of Preoperative Embolization in Patients with Spinal Metastases: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e745-e757. [PMID: 34153484 DOI: 10.1016/j.wneu.2021.06.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/12/2021] [Accepted: 06/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Debate on the effectiveness of preoperative embolization for spinal metastatic lesions, especially for nonhypervascular tumors, has persisted. The present study aimed to identify the effectiveness of preoperative embolization in patients who had undergone surgery for spinal metastasis. METHODS Two of us (Z.T. and Z.H.) independently searched the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases to identify eligible clinical studies that had compared the outcomes of patients treated surgically for spinal metastatic disease with or without preoperative embolization. The primary outcomes included intraoperative blood loss, perioperative blood loss, and transfusion requirements. The secondary outcomes include the operative time, overall survival, and complication rates. Meta-analyses were performed for subgroups of hypervascular, nonhypervascular, and mixed tumors. A fixed effects model was applied when I2 was <50%, and a random effects model was applied when I2 was >50%. RESULTS A total of 12 studies (1 randomized controlled trial and 11 retrospective case-control studies), with 744 patients, were included. Significantly less intraoperative blood loss (mean difference [MD], -1171.49 mL; 95% confidence interval [CI], -2283.10 to -59.88; P = 0.039), fewer blood transfusions (MD, -3.13 U; 95% CI, -4.86 to -1.39; P < 0.001), and shorter operative times (MD, -33.91 minutes; 95% CI, -59.65 to -8.17; P = 0.010) were identified for the embolization group in the hypervascular subgroup. In the nonhypervascular and mixed tumor subgroups, no differences in effectiveness were identified in blood loss, transfusion requirement, or operative time when stratified by the use of embolization. The overall survival and complication rates were similar between the embolization and nonembolization groups in each subgroup. CONCLUSIONS The current data support the use of preoperative embolization for hypervascular metastatic tumors to the spine. However, little evidence is available to support the use of preoperative embolization for nonhypervascular metastatic tumors to the spine.
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Affiliation(s)
- Zhong-Yu Gao
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Tao Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Hui Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | | | - Qun Xia
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China.
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10
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Zhao YJ, Du XC, Deng XQ, Zhang H, Zhang HR, Qiao RQ, Zhang JY, Hu YC. Resuscitative Endovascular Balloon Occlusion of the Aorta for Blood Control in Lumbar Spine Tumor Resection Surgery: A Technical Note. Orthop Surg 2021; 13:1540-1545. [PMID: 34086401 PMCID: PMC8313148 DOI: 10.1111/os.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 12/01/2022] Open
Abstract
Objectives To describe the technique of the aorta balloon occlusion, and evaluate the blood loss in lumbar spine tumor surgery assisted by aortic balloon occlusion, and to observe the balloon‐related complications. Methods Six patients with lumbar spine tumor underwent resuscitative endovascular balloon occlusion of the aorta prior to tumor resections in our institution between May 2018 to January 2021. Medical records including demographic, diagnosis, tumor location, surgical approach, intraoperative blood loss, surgical duration, and perioperative balloon‐related complication were evaluated retrospectively. Results This series included four males and two females, with a median age of 50 years (range 22 to 69). Of these, three primary tumors were plasmacytoma, giant cell tumor of bone, and osteosarcoma, while recurrence of undifferentiated pleomorphic sarcoma (UPS), recurrence of giant cell tumor of bone (GCT), and metastatic thyroid cancer were diagnosed in cases 1, 6, and 2, respectively. L2 was involved in cases 1 and 5. L3 was involved in case 6. L4 was involved in case 2, 3, and 6. L5 was involved in case 4. One‐stage total en bloc resection surgery (TES) was accomplished in all patients; of this series, signal anterior approach was conducted in case 1, signal posterior approach was utilized in cases 2, 3, and 6, while combined anterior and posterior approach was performed in cases 4 and 5. The median intraoperative blood loss was 1683 mL and ranged from 400 to 3200 mL with a median surgical duration of 442 min and a range from 210 to 810 min. During the perioperative period, no serious balloon‐related complications occurred. Conclusions Endovascular balloon occlusion of the aorta successfully controls intraoperative exsanguination, contributing to a more radical tumor resection and a low rate of tumor cell contamination in lumbar tumor surgery.
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Affiliation(s)
- Yong-Jie Zhao
- Tianjin Medical University, Tianjin Medical University, Tianjin, China.,Binzhou Medical University Hospital, Binzhou Medical University Hospital, Binzhou, China
| | - Xin-Chong Du
- Tianjin Medical University, Tianjin Medical University, Tianjin, China
| | - Xiao-Qiang Deng
- Tianjin Medical University, Tianjin Medical University, Tianjin, China
| | - Hao Zhang
- Tianjin Medical University, Tianjin Medical University, Tianjin, China
| | - Hao-Ran Zhang
- Tianjin Medical University, Tianjin Medical University, Tianjin, China
| | - Rui-Qi Qiao
- Tianjin Medical University, Tianjin Medical University, Tianjin, China
| | - Jing-Yu Zhang
- Tianjin Hospital, Department of Bone Tumor and Soft Tissue Oncology, Tianjin Hospital, Tianjin, China
| | - Yong-Cheng Hu
- Tianjin Hospital, Department of Bone Tumor and Soft Tissue Oncology, Tianjin Hospital, Tianjin, China
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11
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A clinical calculator for predicting intraoperative blood loss and transfusion risk in spine tumor patients. Spine J 2021; 21:302-311. [PMID: 33007469 DOI: 10.1016/j.spinee.2020.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death. PURPOSE To develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors. STUDY DESIGN/SETTING Retrospective, single-center study. PATIENT SAMPLE Consecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer center OUTCOME MEASURES: IOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused. METHODS We identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression. RESULTS Mean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=-244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/). CONCLUSIONS Here we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion.
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12
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Gong Y, Wang C, Liu H, Liu X, Jiang L. Only Tumors Angiographically Identified as Hypervascular Exhibit Lower Intraoperative Blood Loss Upon Selective Preoperative Embolization of Spinal Metastases: Systematic Review and Meta-Analysis. Front Oncol 2021; 10:597476. [PMID: 33585214 PMCID: PMC7874195 DOI: 10.3389/fonc.2020.597476] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/02/2020] [Indexed: 01/25/2023] Open
Abstract
Background The role of preoperative embolization (PE) in reducing intraoperative blood loss (IBL) during surgical treatment of spinal metastases remains controversial. Methods A systematic search was conducted for retrospective studies and randomized controlled trials (RCTs) comparing the IBL between an embolization group (EG) and non-embolization group (NEG) for spinal metastases. IBL data of both groups were synthesized and analyzed for all tumor types, hypervascular tumor types, and non-hypervascular tumor types. Results In total, 839 patients in 11 studies (one RCT and 10 retrospective studies) were included in the analysis. For all tumor types, the average IBL did not differ significantly between the EG and NEG in the RCT (P = 0.270), and there was no significant difference between the two groups in the retrospective studies (P = 0.05, standardized mean difference [SMD] = −0.51, 95% confidence interval [CI]: −1.03 to 0.00). For hypervascular tumors determined as such by consensus (n = 542), there was no significant difference between the two groups (P = 0.52, SMD = −0.25, 95% CI: −1.01 to 0.52). For those determined as such using angiographic evidence, the IBL was significantly lower in the EG than in the NEG group, in the RCT (P = 0.041) and in the retrospective studies (P = 0.004, SMD = −0.93, 95% CI: −1.55 to −.30). For IBL of non-hypervascular tumor types, both the retrospective study (P = 0.215) and RCT (P = 0.947) demonstrated no statistically significant differences in IBL between the groups. Conclusions Only tumors angiographically identified as hypervascular exhibited lower IBL upon PE in this study. Further exploration of non-invasive methods to identify the vascularity of tumors is warranted.
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Affiliation(s)
- Yining Gong
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Health Science Center, Peking University, Beijing, China
| | - Changming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hua Liu
- Health Science Center, Peking University, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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13
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Westbroek EM, Pennington Z, Ahmed AK, Xia Y, Boone C, Gailloud P, Sciubba DM. Comparison of complete and near-complete endovascular embolization of hypervascular spine tumors with partial embolization. J Neurosurg Spine 2020; 33:245-251. [PMID: 32244203 DOI: 10.3171/2020.1.spine191337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative endovascular embolization of hypervascular spine tumors can reduce intraoperative blood loss. The extent to which subtotal embolization reduces blood loss has not been clearly established. This study aimed to elucidate a relationship between the extent of preoperative embolization and intraoperative blood loss. METHODS Sixty-six patients undergoing preoperative endovascular embolization and subsequent resection of hypervascular spine tumors were retrospectively reviewed. Patients were divided into 3 groups: complete embolization (n = 22), near-complete embolization (≥ 90% but < 100%; n = 22), and partial embolization (< 90%; n = 22). Intraoperative blood loss was compared between groups using one-way ANOVA with post hoc comparisons between groups. RESULTS The average blood loss in the complete embolization group was 1625 mL. The near-complete embolization group had an average blood loss of 2021 mL in surgery. Partial embolization was associated with a mean blood loss of 4009 mL. On one-way ANOVA, significant differences were seen across groups (F-ratio = 6.81, p = 0.002). Significant differences in intraoperative blood loss were also seen between patients undergoing complete and partial embolization (p = 0.001) and those undergoing near-complete and partial embolization (p = 0.006). Pairwise testing showed no significant difference between complete and near-complete embolization (p = 0.57). Analysis of a combined group of complete and near-complete embolization also showed a significantly decreased blood loss compared with partial embolization (p < 0.001). Patient age, tumor size, preoperative coagulation parameters, and preoperative platelet count were not significantly associated with blood loss. CONCLUSIONS Preoperative endovascular embolization is associated with decreased intraoperative blood loss. In this series, blood loss was significantly less in surgeries for tumors in which preoperative complete or near-complete embolization was achieved than in tumors in which preoperative embolization resulted in less than 90% reduction of tumor vascular blush. These findings suggest that there may be a critical threshold of efficacy that should be the goal of preoperative embolization.
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Affiliation(s)
| | | | | | | | - Christine Boone
- 2Department of Interventional Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Philippe Gailloud
- 3Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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14
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Evaluation of spinal instrumentation following organ transplantation: A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.730276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Igoumenou VG, Mavrogenis AF, Angelini A, Baracco R, Benzakour A, Benzakour T, Bork M, Vazifehdan F, Nena U, Ruggieri P. Complications of spine surgery for metastasis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:37-56. [DOI: 10.1007/s00590-019-02541-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/28/2019] [Indexed: 02/07/2023]
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16
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Omid-Fard N, Fisher CG, Heran MKS. The evolution of pre-operative spine tumour embolization. Br J Radiol 2019; 92:20180899. [PMID: 30817177 PMCID: PMC6724624 DOI: 10.1259/bjr.20180899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/22/2019] [Accepted: 02/27/2019] [Indexed: 11/05/2022] Open
Abstract
Pre-operative spine tumour embolization is a useful adjunct to minimize operative complications and blood loss during complex resections. While the efficacy of this procedure has been well studied, relatively little is documented regarding how to optimize technical parameters for tumour characteristics. This pictorial case series seeks to review our centre's experience over the last decade in using a range of embolization techniques. As experience with this procedure has matured, we propose an approach based on the patient's vascular anatomy and tumour angioarchitecture. This includes the use of coils as protective barriers rather than primary embolics; particle embolization to permeate fine capillary networks; consideration for liquid embolic agents in the presence of large caliber tumour vessels with associated arteriovenous shunting; and percutaneous intralesional embolization when endovascular access is insufficient to achieve the desired outcome. In many cases, a combination of these methods is needed, and close communication with the surgeon ensures the best outcome. Despite these advances, continued work is needed to determine how to optimize complete devascularization, and thus surgical benefit, while safely sparing critical neuroanatomical structures.
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Affiliation(s)
- Nima Omid-Fard
- University of British Columbia Medical School, Vancouver, Canada
| | - Charles G Fisher
- Division of Spine Surgery, Vancouver General Hospital, University of British Columbia. Past President, Canadian Spine Society, Vancouver Spine Surgery Institute, Vancouver, Canada
| | - Manraj KS Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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17
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Galgano M, Fridley J, Oyelese A, Telfian A, Kosztowski T, Choi D, Gokaslan ZL. Surgical management of spinal metastases. Expert Rev Anticancer Ther 2018; 18:463-472. [PMID: 29560739 DOI: 10.1080/14737140.2018.1453359] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Metastatic spinal disease is a source of significant morbidity in patients with cancer. Recent advancements in adjuvant oncologic therapy has led to increased survival for many patients who harbor neoplastic disease. As a result of this, the chance of developing metastatic spinal disease over the course of a cancer patient's lifespan has increased. Symptomatic metastatic spinal disease can cause significant morbidity including severe pain, neurologic deficit, and loss of ambulation. Current treatment of these patients typically involves the use of multiple modalities, including surgery, radiation, and chemotherapy. Areas covered: An extensive literature review was performed to support the author's opinion on the matter of surgical management of spinal metastatic disease. Pubmed was utilized as a primary search engine. Expert commentary: Despite advances in chemotherapy and radiation therapy, surgery remains a mainstay in many of these patients, particularly with those with either significant metastatic spinal epidural compression or spinal instability. This review discusses the surgical management of metastatic spinal disease including a framework for decision making and technical considerations when deciding to operate on these patients.
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Affiliation(s)
- Michael Galgano
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - Jared Fridley
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - Adetokunbo Oyelese
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - Albert Telfian
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - Thomas Kosztowski
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - David Choi
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
| | - Ziya L Gokaslan
- a Department of Neurosurgery , Warren Alpert Medical School of Brown University , Providence , USA
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