Minimally invasive management of spinal metastases

Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm

STUDY DESIGN

Narrative Review. The spine remains the most common site for bony metastasis. It is estimated that up to 70% of cancer patients harbor secondary spinal disease. And up to 10% will develop a clinically significant lesion. The last two decades have seen a substantial leap forward in the advancements of the management of spinal metastases. What once was a death sentence is now a manageable, even potentially treatable condition. With marked advancements in the surgical treatment and post-operative radiotherapy, a standardized approach to stratify and manage these patients is both prudent and now feasible.

OBJECTIVES

This article looks to examine the best available evidence in the stratification and surgical management of patients with spinal metastases. So the aim of this review is to offer a standardized approach for surgical management and surgical planning of patients with spinal metastases.

Minimally Invasive Posterolateral Approach for Surgical Resection of Dumbbell Tumors of the Lumbar Spine

Minimally invasive spine surgery (MISS) has many advantages over traditional open surgical procedures that can be conducted for the therapy of different diseases of the spine. MISS provide many prospective advantages such as, for example, small incisions, less damage to soft tissues, early activation of patients, and a shorter postoperative hospital stay. The aim of the study was to evaluate institutional experience with Dumbbell tumors and metastatic lesions of the lumbar spine and compare it with traditional open surgical resection of this type of tumors. Fourteen patients underwent the surgery with minimally invasive posterolateral approach in experimental group, and 10 patients of the control group were operated using the traditional open surgery procedure at the Department of spinal neurosurgery and pathology of peripheral nervous system of JSC “National Center for Neurosurgery.” The intraoperative neuro monitoring system (ISIS IOM System Compact, Inomed, Germany) was used in both groups. Sensory and motor evoked potentials were intraoperatively recorded. The present study was approved by the local Ethics Committee of the National Center for Neurosurgery. Patients signed informed consent before the surgical procedure. The experimental group included 14 patients, that underwent the surgery during the period from January 2020 till March 2021. And the control group included 10 patients that was operated from January 2018 to December 2019. The results of the treatment in both groups were assessed according to the generally accepted visual analog scale (VAS) and the Oswestry scales before, on the third day, and 3 months after the surgery. In experimental group, average reduction of the pain syndrome of 3.36 points (from 3 to 0 points) was observed in patients postoperatively according to the VAS 3 days, and of 4.0 points (from 2 to 0 points) 3 months after surgical procedures. Improvement by 23.86% (36–16%) was also observed using the Oswestry Disease Index (ODI) 3 days after the surgery, and then reduced to 21.00% (16–34%) in average in 3 months. All patients were revived 3 h after transfer to the specialist department. The average stay in the hospital was 6.5 (9–4) days in both groups. In control group, average reduction of the pain syndrome of 2.60 points (from 4 to 1 points) was observed postoperatively according to the VAS 3 days after the operation, and of 3.9 points (from 2 to 0 points) 3 months after the surgery. The ODI of patients was also improved by an average of 35.40% (50–20%) 3 days after the surgical procedure, and reduced to 24.20% (16–32%) in average 3 months after the surgery.

Central Nervous System Metastases

The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.

Ablation Techniques in Cancer Pain

Painful bone metastases are a frequently encountered problem in oncology practice. The skeletal system is the third most common site of metastatic disease and up to 85% of patients with breast, prostate, and lung cancer may develop bone metastases during the course of their disease.

Localized Chronic Form of Langerhans Cell Histiocytosis in the Femur of a 16-Year-Old Male Successfully Treated with Radiofrequency Ablation

Only three cases of patients suffering from a localized chronic form of Langerhans cell histiocytosis (LCH) successfully treated with radiofrequency ablation (RFA) have been published so far. This is the first case report of a patient with a localized chronic form of LCH of the femur, which was successfully treated with percutaneous image-guided RFA, and who was evaluated pre-RFA and followed up post-RFA for a period of 48 months, in order to validate the safety and efficacy of this method and to obtain imaging studies depicting the actual in situ changes taking place post-RFA. RFA was proved to be a safe and efficient method when treating patients with a localized chronic form of LCH.

Successful treatment of metastatic adrenocortical carcinoma in the spine: A case report and literature review

RATIONALE

Adrenocortical carcinoma is a rare aggressive type of cancer whose prognosis is poor, particularly for metastatic entities. Metastatic adrenocortical carcinoma in the spine is a rare disease with no standard curative managements yet. The objective of this study is to report a very rare case of spinal metastases of adrenocortical carcinoma successfully managed by combination of cement augmentation, radiotherapy together with adjuvant programmed cell death 1 (PD-1) therapy. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 42-year-old woman presented with a 3-month history of continuous and progressive back pain. The patient, who had been diagnosed of right pheochromocytoma, received surgical treatment of right adrenalectomy 14 months ago in another hospital, followed by no further treatment.

DIAGNOSIS

Magnetic resonance imaging of spine showed vertebral pathological fracture of L1, spinal cord compression secondary to the epidural component of the L1 mass, with increased metastatic marrow infiltration of the right L1 vertebral body, which presented as a solid tumor. Postoperative pathology confirmed the diagnosis of spinal metastases of adrenocortical carcinoma.

INTERVENTIONS

The patient underwent cement augmentation via a posterior approach, radiotherapy, radiofrequency ablation of psoas major muscle occupying lesions, right chest wall, liver and kidney recess together with adjuvant PD-1 therapy.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 6-month and 1-year follow-up visit. There were no complications associated with the operation during the follow-up period.

LESSONS

Combined efforts of specialists from orthopedics, urology, interventional radiology, radiotherapy, pathology, endocrinology, and medical oncology led to the successful diagnosis and management of this patient. Metastatic adrenocortical carcinoma of the spine, although rare, should be part of the differential diagnosis when the patient has a history of adrenal carcinoma and presents with back pain, myelopathy, or radiculopathy. We recommend the posterior approach for total excision of the spinal metastatic adrenocortical carcinoma when the tumor has caused neurological deficits. Osteoplasty by cement augmentation, radiotherapy, and targeted PD-1 therapy may also be good choices for treatment.

[Usefulness of minimally invasive spine surgery for the management of thoracolumbar spinal metastases]

Objetivo:

Describir los resultados quirúrgicos y evolución de pacientes con metástasis espinales toraco-lumbares operadas con técnica mínimamente invasiva (MISS) utilizando para la decisión terapéutica la evaluación: Neurológica, Oncológica, Mecánica y Sistémica (NOMS).

Material y Métodos:

Se incluyeron en forma prospectiva pacientes con metástasis espinales toraco-lumbares operados con técnica MISS por el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires entre Junio de 2014 y Junio de 2017. Se utilizó en todos los casos el algoritmo de evaluación NOMS para la decisión terapéutica. Se analizaron los resultados quirúrgicos postoperatorios como el Karnofsky performance status, dolor (VAS – visual analog scale), Frankel, pérdida sanguínea, necesidad de transfusiones, complicaciones, uso de opioides y días de internación. Se consideró como estadísticamente significativo una P < 0.05.

Resultados:

Durante el período de estudio 26 pacientes cumplieron los criterios de inclusión, de los cuales 13 fueron mujeres. La edad promedio fue 57 (27-83) años. El origen más frecuente de las lesiones fue cáncer de mama (27%). El síntoma más constante fue el dolor (96%), aunque 12 pacientes manifestaron inicialmente mielopatía (46%). Se observaron grados avanzados de invasión del canal con requerimiento de descompresión en el 65% de los casos. Acorde al Spinal Instability Neoplastic Score, 23 pacientes (89%) presentaron lesiones potencialmente inestables o inestables, requiriendo estabilización. Se evidenció una mejoría estadísticamente significativa del VAS en el 77% y del Frankel en el 67% de los casos tras la cirugía. No hubo necesidad de transfusiones. Se registró sólo una complicación quirúrgica leve (4%). La media de internación fue de 5.5 días.

Conclusión:

En nuestra serie y utilizando como algoritmo terapéutico el NOMS, la cirugía MISS resultó efectiva tanto para la descompresión como para la estabilización espinal, con baja tasa de complicaciones y rápida recuperación postoperatoria.

Which Combination Treatment Is Better for Spinal Metastasis: Percutaneous Vertebroplasty With Radiofrequency Ablation, 125I Seed, Zoledronic Acid, or Radiotherapy?

BACKGROUND

Percutaneous vertebroplasty (PVP) can not only alleviate pain but also restore mechanical stability with injection of bone cement, whereas it exhibits a poor effect on antitumor activity. But through combinations with other therapies, it may be possible to achieve the maximum effect in clinical treatment. Thus, this study is designed to assess the clinical efficacy of PVP separately combined with 4 ways for spinal metastasis (SM) treatment.

STUDY QUESTION

Which combination treatment is better for spinal metastasis, percutaneous vertebroplasty with radiofrequency ablation, I seed, zoledronic acid or radiotherapy?

STUDY DESIGN

A total of 169 patients with SM were retrospectively recruited and randomly assigned to 4 groups to receive 4 different ways separately: 49 patients (group A) received PVP plus I seed, 51 (group B) received PVP plus radiofrequency ablation (RFA), 38 (group C) underwent PVP plus zoledronic acid (ZA), and 31 (group D) underwent PVP plus radiotherapy (RT).

MEASURES AND OUTCOMES

All of them underwent routine examinations before operation. Visual analog scale (VAS), World Health Organization (WHO) Pain Relief, and ODI were applied to evaluate pain relief and motor function.

RESULTS

PVP plus RT achieved the best efficacy in relieving pains, with the highest WHO Pain Relief (P < 0.05). The PVP plus RFA exhibited lowest ODI, suggesting the best outcome after treatment (P < 0.05). The PVP plus I showed the lowest VAS score, but it was the worst to improve the routine exercise ability and relieve pains from patients. The PVP plus ZA presented higher VAS and ODI (P < 0.05).

CONCLUSIONS

PVP combined with I seed exhibited the best clinical efficacy in terms of VAS, PVP combined with RT was the best choice in terms of WHO Pain Relief, and PVP combined with RFA showed the best effect in terms of ODI for the treatment of SM.

A review and update of vertebral fractures due to metastatic tumors of various sites to the spine: Percutaneous vertebroplasty

Background

Vertebral fractures (VFs) are the most usual convolution of metastatic tumors and the vertebral column is the third most ordinary site for painful bone metastases and remains a chief factor of morbidity in cancer patients.

Methods

In this paper, we investigated the previous literature on the status of clinical and prospects for the use of percutaneous vertebroplasty (PVP) with polymethylmethacrylate as a remedial alternative for the therapy of refractory pain resulting from malignant vertebral compression and pathologic fractures associated with metastatic tumors of various sites in numerous studies. The scientific document for this remedy, containing safety, immediate and long-term efficacy, and outcome measures, and also the risks of complications, was analyzed in detail.

Results

PVP is a safe, feasible, reliable, effective, and useful procedure, a minimally invasive treatment, and a significant tool for reduction of pain and the relief of pain symptoms.

Conclusions

This method can be employed as a further or narcotic remedy in elected patients. The techniques of PVP present a novel alternative therapy for diverse metastases with potentially large application.

Intraoperative Radiotherapy during Kyphoplasty for Vertebral Metastases (Kypho-IORT): First Clinical Results

Aims and background

Kyphoplasty is an effective procedure providing structural stability and pain alleviation in vertebral metastases. To prevent early regrowth, patients typically receive postoperative fractionated radiotherapy, which is associated with long treatment duration. Therefore, we established a new approach to deliver intraoperative radiotherapy during kyphoplasty to shorten the treatment time and reach structural stability and sterilization of the metastases (Kypho-IORT).

Methods and study design

For Kypho-IORT, a 50 kV X-ray source with a specially designed applicator was used. A radiation dose of 8 Gy in 5 mm distance was delivered. After radiation the device was removed and the kyphoplasty was completed according to the standard procedure. Since August 2009, 18 patients with instable or painful spinal metastases received Kypho-IORT. The median age was 63 years (range, 43–73).

Results

Kypho-IORT was successfully performed in 18 of 21 vertebral lesions (86%). No severe complications occurred during or early after IORT. The median pain score using a visual analogue scale decreased from 5/10 before the procedure to 2.5/10 at day 1 (P <0.001) and to 0/10 six weeks after the procedure (P = 0.001). Imaging studies were available for 15 of 18 patients. Stable disease within the irradiated vertebral body was seen in 14 patients (93%) and local progressive disease in one patient (7%). No re-irradiation due to local progressive disease or pain recurrence was necessary within the median follow-up of 4.5 months.

Conclusions

Kypho-IORT is well tolerated without severe side effects and provides fast improvement of pain. Although stable disease was seen in 93% of the patients, a longer follow-up is necessary to assess the effectiveness. A dose escalation study to establish the maximally tolerated dose has been initiated.

Metastatic Spine Tumor Surgery: A Comparative Study of Minimally Invasive Approach Using Percutaneous Pedicle Screws Fixation Versus Open Approach

STUDY DESIGN

Prospective cohort study.

SUMMARY OF BACKGROUND DATA

Minimally invasive spinal surgery (MISS) has been gaining recognition in patients with metastatic spine disease (MSD). The advantages are reduction in blood loss, hospital stay, and postoperative morbidity. Most of the studies were case series with very few comparing the outcomes of MISS to open approaches.

OBJECTIVE

To evaluate and compare the clinical and perioperative outcomes of MISS versus open approach in patients with symptomatic MSD, who underwent posterior spinal stabilization and/or decompression.

PATIENTS AND METHODS

Our study included 45 MSD patients; 27 managed by MISS and 18 by open approach. All patients had MSD presenting with symptoms of neurological deficit, spinal instability, or both. Preoperative, intraoperative, and postoperative data were collected for comparison of the 2 approaches. All patients were followed up until the end of study period (maximum up to 4 years from time of surgery) or till their demise. The clinical outcome measures were pain control, neurological and functional status, whereas perioperative outcomes were blood loss, operative time, length of hospital stay, and time taken to initiate radiotherapy/chemotherapy after index surgery.

RESULTS

Majority of patients in both groups showed improvement in pain, neurological status, independent ambulation, and ECOG score in the postoperative period with no significant differences between the 2 groups. There was a significant reduction in intraoperative blood loss (621 mL less, P<0.001) in the MISS group. The average time to initiate radiotherapy after surgery was 13 days (range, 12-16 d) in MISS and 24 days (range, 16-40 d) in the open group. This difference was statistically significant (P<0.001). Operative time and duration of hospital stay were also favorable in the MISS group, although the differences were not significant.

CONCLUSIONS

MISS is comparable with open approach demonstrating similar improvements in clinical outcomes, that is pain control, neurological and functional status. MISS approaches have also shown promising results due to lesser intraoperative blood loss and allowing earlier radiotherapy/chemotherapy.

A Novel Groove-Entry Technique for Inserting Thoracic Percutaneous Pedicle Screws

STUDY DESIGN

Surgical technique.

OBJECTIVE

To evaluate the efficacy of a novel groove-entry technique for thoracic percutaneous pedicle screw (PPS) insertion.

SUMMARY OF BACKGROUND DATA

Minimally invasive spine stabilization (MISt) using posterior thoracolumbar instrumentation has many advantages over open procedures. Because of the variability among PPS entry points, the sloped cortex of the transverse process, and the narrow thoracic pedicle, thoracic PPS placement is technically challenging.

MATERIALS AND METHODS

A retrospective review of 24 patients who underwent minimally invasive spine stabilization procedures involving 165 thoracic PPS placements using the novel technique was performed. The thoracic PPS entry is a groove formed by 3 bony elements: the cranial portion of the base of the transverse process, the rib neck, and the posterolateral wall of the pedicle. This groove can be easily identified under fluoroscopy with a Jamshidi needle allowing thoracic PPS insertion in the craniocaudal direction.

RESULTS

Of the 165 thoracic PPSs placed, "Good" or "Acceptable" PPS placement accuracy was achieved in 152 (92.1%) and 164 (99.4%) placements, respectively. No complications such as organ injury, and screw loosening or breakage were observed with thoracic PPS insertion.

CONCLUSIONS

This novel technique is both safe and reliable, with low misplacement and complication rates. In hospitals in which computer image guidance or navigation is unavailable, this groove-entry technique may become the standard for thoracic PPS insertion.

Percutaneous vertebroplasty and interventional tumor removal for malignant vertebral compression fractures and/or spinal metastatic tumor with epidural involvement: a prospective pilot study

OBJECTIVE

The aim of this study was to compare the efficacy of percutaneous vertebroplasty (PVP) and interventional tumor removal (ITR), with PVP alone for malignant vertebral compression fractures and/or spinal metastatic tumor with epidural involvement.

PATIENTS AND METHODS

A total of 124 patients were selected for PVP and ITR (n = 71, group A) and PVP alone (n = 53, group B). A 14 G needle and guide wire were inserted into the vertebral body, followed by sequential dilatation of the tract until the last cannula reached the anterior portion of the pedicle. Tumors were then ablated with a radiofrequency probe. ITR was performed with marrow nucleus rongeurs, and then cement was injected into the extirpated vertebra. Outcomes were collected preoperatively and at 1, 3 and 6 months and every subsequent 6 months.

RESULTS

The rates of pain relief and increased mobility at the last follow-up were higher in group A than those in group B (P < 0.05). There were significant differences in visual analog scale (VAS) score and Oswestry disability index (ODI) score at 1, 3 and 6 months, 1 year and >1 year in group A than in group B (P < 0.05). The rates of paraplegia recovery and vertebral stability in group A were higher than those in group B (P < 0.05).

CONCLUSION

PVP and ITR proved to be an effective approach for patients with malignant vertebral compression fractures and/or spinal metastatic tumor and provided distinct advantages in pain relief, function recovery and vertebral stability that are comparable to that obtained with PVP alone.

Comparison of percutaneous vertebroplasty with and without interventional tumor removal for spinal metastatic tumor without epidural involvement

AIM

To evaluate the efficacy of percutaneous vertebroplasty (PVP) combined with interventional tumor removal (ITR) in providing pain relief, reducing disability, and improving functional performance in patients with malignant vertebral compression fractures without epidural involvement.

METHODS

Patients with malignant vertebral compression fractures (n=58) were treated with either PVP+ITR (n=31, group A) or PVP alone (n=27, group B). A 14 G needle was inserted into the vertebral body, and the tract was sequentially dilated with working cannulae. When the last working cannula had reached the distal pedicle of vertebral arch, ITR was performed with a marrow nucleus rongeurs inserted through the working cannula. Finally, cement was injected into the excavated vertebral body. Patients were followed up at 1, 3, and 6 months after the procedure, and every 6 months thereafter.

RESULTS

The overall excellent and good pain relief rate during follow-ups was significantly better in group A than in group B (94% vs.56%; p=0.002). The average VAS, ODI, and KPS scores at 3 months, 6 months, 1-year, and >1 year were all significantly lower in group A than in group B (p<0.05). The mean cement filling volume and the stability of the treated vertebrae were significantly higher in group A than in group B (p<0.05).

CONCLUSIONS

The combination of PVP+ITR is a safe and effective procedure, capable of providing significantly greater pain relief and vertebral stability than PVP alone in patients with malignant vertebral compression fractures.

Video-Assisted Thoracoscopic Surgery and Minimal Access Spinal Surgery Compared in Anterior Thoracic or Thoracolumbar Junctional Spinal Reconstruction: A Case-Control Study and Review of the Literature

There are no published reports that compare the outcomes of video-assisted thoracoscopic surgery (VATS) and minimal access spinal surgery (MASS) in anterior spinal reconstruction. We conducted a retrospective case-control study in a single center and systematically reviewed the literature to compare the efficacy and safety of VATS and MASS in anterior thoracic (T) and thoracolumbar junctional (TLJ) spinal reconstruction. From 1995 to 2012, there were 111 VATS patients and 76 MASS patients treated at our hospital. VATS patients had significantly (p < 0.001) longer operating times and significantly (p < 0.022) higher thoracotomy conversion rates. We reviewed 6 VATS articles and 10 MASS articles, in which there were 625 VATS patients and 399 MASS patients. We recorded clinical complications and a thoracotomy conversion rate from our cases and the selected articles. The incidence of approach-related complications was significantly (p = 0.021) higher in VATS patients. The conversion rate was 2% in VATS patients and 0% in MASS patients (p = 0.001). In conclusion, MASS is associated with reduction in operating time, approach-related complications, and the thoracotomy conversion rate.

Tageted bipolar radiofrequency decompression with vertebroplasty for intractable radicular pain due to spinal metastasis: a case report

Metastatic spinal tumors are usually quite difficult to treat. In patients with metastatic spinal tumors, conventional radiotherapy fails to relieve pain in 20–30% of cases and open surgery often causes considerable trauma and complications, which delays treatment of the primary disease. Percutaneous vertebroplasty (PVP) is considered to be useful in achieving rapid pain control and preventing further vertebral collapse due to spinal metastasis. However, symptoms of intraspinal neural compression can be contraindications to PVP. To overcome this problem, we performed PVP following targeted bipolar radiofrequency decompression, and examined the effect of the combined treatment in relieving severe radicular pain related to spinal cord compression caused by malignant metastatic tumors.

Metastatic adrenal cortical carcinoma to T12 vertebrae

We report spinal metastasis of adrenal cortical carcinoma (ACC) to the T12 vertebrae with epidural extension. ACC is a rare malignancy with poor prognosis and high rates of metastasis. However, spinal lesions of ACC are rare, and few have been reported in the literature. We discuss our management of this lesion and review the current understanding and treatment of ACC and spinal metastasis.

Comparison of minimally invasive surgery with standard open surgery for vertebral thoracic metastases causing acute myelopathy in patients with short- or mid-term life expectancy: surgical technique and early clinical results

OBJECT Spinal metastasis is common in patients with cancer. About 70% of symptomatic lesions are found in the thoracic region of the spine, and cord compression presents as the initial symptom in 5%-10% of patients. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, with the aim of decreasing the morbidity associated with more traditional open spine surgery; furthermore, the recovery time is reduced after MISS, such that postoperative chemotherapy and radiotherapy can begin sooner. METHODS Two series of oncological patients, who presented with acute myelopathy due to vertebral thoracic metastases, were compared in this study. Patients with complete paraplegia for more than 24 hours and with a modified Bauer score greater than 2 were excluded from the study. The first group (n = 23) comprised patients who were prospectively enrolled from May 2010 to September 2013, and who were treated with minimally invasive laminotomy/laminectomy and percutaneous stabilization. The second group (n = 19) comprised patients from whom data were retrospectively collected before May 2010, and who had been treated with laminectomy and stabilization with traditional open surgery. Patient groups were similar regarding general characteristics and neurological impairment. Results were analyzed in terms of neurological recovery (American Spinal Injury Association grade), complications, pain relief (visual analog scale), and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] QLQ-C30 and EORTC QLQ-BM22 scales) at the 30-day follow-up. Operation time, postoperative duration of bed rest, duration of hospitalization, intraoperative blood loss, and the need and length of postoperative opioid administration were also evaluated. RESULTS There were no significant differences between the 2 groups in terms of neurological recovery and complications. Nevertheless, the MISS group showed a clear and significant improvement in terms of blood loss, operation time, and bed rest length, which is associated with a more rapid functional recovery and discharge from the hospital. Postoperative pain and the need for opioid administration were also significantly less pronounced in the MISS group. Results from the EORTC QLQ-C30 and QLQ-BM22 scales showed a more pronounced improvement in quality of life at follow-up in the MISS group. CONCLUSIONS In the authors' opinion, MISS techniques should be considered the first choice for the treatment for patients with spinal metastasis and myelopathy. MISS is as safe and effective for spinal cord decompression and spine fixation as traditional surgery, and it also reduces the impact of surgery in critical patients. However, further studies are needed to confirm these findings.

Interventional tumor removal: a new technique for malignant spinal tumor and malignant vertebral compression fractures without epidural involvement

BACKGROUND

Percutaneous vertebroplasty (PVP) is associated with incomplete pain relief and vertebral instability due to cement leakages.

PURPOSE

To evaluate the feasibility of a new method of PVP, radiofrequency ablation (RFA) and interventional tumor removal (ITR) for malignant spinal tumor and malignant vertebral compression fractures without epidural involvement.

MATERIAL AND METHODS

Twelve patients were treated with PVP, RFA, and ITR. A 14 G needle and a guidewire were inserted into the vertebral body, followed by sequential dilatation of the tract with the working cannula until the last working cannula reached the anterior portions of the pedicle. Thereafter, tumors were ablated with a radiofrequency probe, and ITR was performed with a marrow nucleus rongeurs. Then, cement was injected into the extirpated vertebral body. The data were collected and follow-up was performed after 1, 3, and 6 months, and thereafter every 6 months postoperatively.

RESULTS

PVP, RFA, and ITR were technically successful in all patients. The average preoperative pain visual analog scale (VAS) score was 7.0 ± 1.0, which decreased to 2.1 ± 1.2 at 1 month, to 1.6 ± 1.4 at 6 months, to 1.8 ± 1.7 at 1 year, and was maintained at 1.3 ± 1.1 at >1-year follow-up. A total of 92% patients (11/12) obtained excellent and good pain relief with improvement of quality of life. Seven patients continued with follow-up healthcare, and five patients died of the underlying disease.

CONCLUSION

PVP, RFA, and ITR may be a feasible approach for malignant spinal tumor and malignant vertebral compression fractures without epidural involvement.

Two-year cost comparison of vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: are initial surgical costs misleading?

The costs for treating kypho- and vertebroplasty patients were evaluated at up to 2 years postsurgery. There were no significant differences in adjusted costs in the first 9 months postsurgery, but kyphoplasty patients were associated with significantly lower adjusted treatment costs by 6.8-7.9% in the remaining periods through 2 years postsurgery.

INTRODUCTION

Vertebral augmentation has been shown to be safe and effective for treating vertebral compression fractures. Comparative cost studies of initial treatment costs for kypho- and vertebroplasty have been mixed. The purpose of our study was to compare the costs for treating kypho- and vertebroplasty patients at up to 2 years postsurgery.

METHODS

Vertebroplasty and kyphoplasty patients diagnosed with pathologic or closed lumbar/thoracic vertebral fractures were identified from the 5% sample of the Medicare dataset (2006-2009). The final study cohort with at least 2 years follow-up comprised of 1,609 vertebroplasty and 2,878 kyphoplasty patients. The cumulative treatment costs (adjusted to June 2011 US$) were determined from the payer perspective. Differences in costs and length of stay were assessed by generalized linear mixed model regression, adjusting for covariates.

RESULTS

The average adjusted costs for vertebroplasty patients within the first quarter and the first 2 years postsurgery were $14,585 [95% confidence interval (CI), $14,109-15,078] and $44,496 (95% CI, $42,763-46,299), respectively. The corresponding average adjusted costs for kyphoplasty patients were $15,117 (95% CI, $14,752-15,491) and $41,339 (95% CI, $40,154-42,560). There were no significant differences in adjusted costs in the first 9 months postsurgery, but kyphoplasty patients were associated with significantly lower adjusted treatment costs by 6.8-7.9% in the remaining periods through 2 years postsurgery.

CONCLUSION

Our present study addresses some of the limitations in previous comparative cost studies of vertebroplasty and kyphoplasty. The higher adjusted costs for vertebroplasty patients than kyphoplasty patients by 1 year following the surgery reflect greater utilization of medical resources.

Spinal cord compression

OPINION STATEMENT

Malignant epidural spinal cord compression (MESCC) remains a common neuro-oncologic emergency with high associated morbidity. Despite widespread availability of MRI, the diagnosis frequently goes unmade until myelopathy supervenes, which is unfortunate because the strongest predictor of neurologic outcome with treatment is the neurologic status when treatment is initiated. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should be started on high-dose corticosteroids (eg, dexamethasone, 10-100 mg intravenously, followed by 16 to 100 mg/d in divided doses). Definitive therapy of MESCC almost always includes radiation therapy and in some cases surgical intervention; factors considered include the patient's performance status and extent of visceral and skeletal disease, spinal stability, the tumor's underlying radiosensitivity, and the degree of spinal cord compression. Patients with spinal instability or radioresistant tumors are likely to have a much better neurologic outcome with tumor resection and spinal stabilization prior to radiation; the same may also pertain to patients with moderately radiosensitive tumors who have good life expectancy in terms of their systemic tumor. Conventional radiation has historically been beneficial after surgery and in patients who are not surgical candidates. Recent studies suggest a role for stereotactic body radiation therapy in patients with spinal metastasis from radioresistant tumors and in patients who have received prior standard radiotherapy, so long as the spinal cord has been decompressed.

Kyphoplasty for lytic tumour lesions of the spine: prospective follow-up of 11 cases from procedure to death

BACKGROUND

The life span of cancer patients has improved due to advancements in cancer management. With long survival periods, more patients show metastatic disease. Osteolytic tumours of spine are generated by metastatic deposits or primary tumours of the spine. A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of the thoracic and lumbar spine.

MATERIALS AND METHODS

Eleven patients (age range 52-77/average 65 years; 7 female, 4 male) with osteolytic tumours of the spine were treated with kyphoplasty. The main Tokuhashi score was registered preoperatively. Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time.

RESULTS

Preoperative VAS (average 7.5; range 2.6-10) dropped to 3.0, 5 days postoperatively and remained below 5 for follow-up. Main Tokuhashi score was 6.3, ranging from 3 to 9. Survival time ranged from 2 to 293 (average 74.4) weeks. Average walking distance, standing and sitting time and ECOG performance score showed improvement. All patients returned home and no patient required re-operation or readmission due to local disease progression or recurrence.

CONCLUSION

Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine even with low Tokuhashi scores allowing rapid pain relief and mobilisation to increase the quality of life.

Metastatic spine disease in the elderly: diagnostic and management considerations

Metastatic spine disease is becoming a more frequent problem in cancer patients as advancements in treatment for primary tumors prolong patient survival. Elderly patients over 60 years of age make up the majority of these cases, with the incidence of metastatic disease several folds higher in the elderly than in any other age group. These patients are also the most challenging group to treat, given higher rates of comorbidities and decreased tolerance to medical, surgical and radiation therapies. Advancements in therapeutic strategies, including minimally invasive surgeries and stereotactic radiosurgery, have provided increasingly attractive treatment options for elderly patients owing to their decreased procedure-associated morbidity. This article will discuss efficacy and limitations of conventional, as well as more recent, treatment modalities with an emphasis on their role in the management of elderly patients.

Mortality risk for operated and nonoperated vertebral fracture patients in the medicare population

Vertebral compression fractures (VCFs) are associated with increased mortality risk, but the association between surgical treatment and survivorship is unclear. We evaluated the mortality risk for VCF patients undergoing conservative treatment (nonoperated), kyphoplasty, and vertebroplasty. Survival of VCF patients in the 100% U.S. Medicare data set (2005-2008) was estimated by the Kaplan-Meier method, and the differences in mortality rates at up to 4 years were assessed by Cox regression (adjusted for comorbidities) between operated and nonoperated patients and between kyphoplasty and vertebroplasty patients. An instrumental variables analysis was used to evaluate mortality-rate difference between kyphoplasty and vertebroplasty patients. A total of 858,978 VCF patients were identified, including 119,253 kyphoplasty patients and 63,693 vertebroplasty patients. At up to 4 years of follow-up, patients in the operated cohort had a higher adjusted survival rate of 60.8% compared with 50.0% for patients in the nonoperated cohort (p < .001) and were 37% less likely to die [adjusted hazard ratio (HR) = 0.63, p < .001]. The adjusted survival rates for VCF patients following vertebroplasty or kyphoplasty were 57.3% and 62.8%, respectively (p < .001). The relative risk of mortality for kyphoplasty patients was 23% lower than that for vertebroplasty patients (adjusted HR = 0.77, p < .001). Using physician preference as an instrument, the absolute difference in the adjusted survival rate at 3 years was 7.29% higher in patients receiving kyphoplasty than vertebroplasty (p < .001), compared with a crude absolute rate difference of 5.09%. This study established the mortality risk associated with VCFs diagnosed between 2005 and 2008 with respect to different treatment modalities for elderly patients in the entire Medicare population.

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

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

Percutaneous vertebroplasty or kyphoplasty

Percutaneous vertebral augmentation techniques performed with vertebroplasty or kyphoplasty are safe and effective for the treatment of osteoporotic vertebral compression fractures, primary or secondary spine tumors, and selected traumatic fractures. This article compares the procedures and outlines their advantages and disadvantages. It concludes that vertebroplasty should be performed in most cases, but kyphoplasty is preferable in selected cases.

Spine metastases: current treatments and future directions

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

Kypho-IORT--a novel approach of intraoperative radiotherapy during kyphoplasty for vertebral metastases

BACKGROUND

Instable and painful vertebral metastases in patients with progressive visceral metastases present a common therapeutic dilemma. We developed a novel approach to deliver intraoperative radiotherapy (IORT) during kyphoplasty and report the first treated case.

METHODS/RESULTS

60 year old patient with metastasizing breast cancer under chemotherapy presented with a newly diagnosed painful metastasis in the 12th thoracic vertebra. Under general anaesthesia, a bipedicular approach into the vertebra was chosen with insertion of specially designed metallic sleeves to guide the electron drift tube of the miniature X-ray generator (INTRABEAM, Carl Zeiss Surgical, Oberkochen, Germany). This was inserted with a novel sheet designed for this approach protecting the drift tube. A radiation dose of 8 Gy in 5 mm distance (50 kV X-rays) was delivered. The kyphoplasty balloons (KyphX, Kyphon Inc, Sunnyvale) were inflated after IORT and polymethylmethacrylate cement was injected. The whole procedure lasted less than 90 minutes.

CONCLUSION

In conclusion, this novel, minimally invasive procedure can be performed in standard operating rooms and may become a valuable option for patients with vertebral metastases providing immediate stability and local control. A phase I/II study is under way to establish the optimal dose prescription.

Thoracoscopy for minimally invasive thoracic spine surgery

Thoracoscopy has been used worldwide for many years by thoracic surgeons. Despite a long learning curve and technical demands of the procedure, thoracoscopy has several advantages, including better cosmesis, adequate exposure to all levels of the thoracic spine from T2 to L 1, better illumination and magnification at the site of surgery, less damage to the tissue adjacent to the surgical field, less morbidity when compared with standard thoracotomy in terms of respiratory problems, pain, blood loss, muscle and chest wall damages, consequent shorter recovery time, less postoperative pulmonary function impairment, and shorter hospitalization. Good results at short- and medium-term follow-up need to be confirmed at long-term follow-up.