Preoperative catheter spinal angiography and embolization of cervical spinal tumors: Outcomes from a single center

Spinal tumor embolization: benefit for surgical resection

The embolization of hypervascular spinal tumors preoperatively has shown to be a worthwhile adjunctive procedure to minimize the elevated risks associated with surgical resection, such as intraoperative blood loss and its associated complications. Resection of these hypervascular tumors is necessary for local tumor control, reduction in patient-reported pain, improved neurological functioning, and spinal stability. This adjunctive procedure has been associated with improved surgical outcomes and easier facilitation of surgical resection. As such, we provide a review of the current literature examining the employment of this technique. Specifically, this article (a) reviews the techniques of embolization, with anatomical considerations of the arterial framework of the spinal network; (b) relativizes and outlines the post-embolization management of spinal tumor resection; (c) provides a critical outlook on the reported benefit of preoperative embolization before surgical resection with support from clinical studies in the literature; and (d) discusses the efficacy and reliability of provocative testing and post-procedural management and follow-up. Ultimately, a thorough and updated review of preoperative spinal tumor embolization and its clinical benefits will summarize the current fund of knowledge and encourage future research toward continued improvements in patient outcomes for those needing to undergo surgical resection of spinal lesions.

Review of Cervical Schwannomas: Presentation, Pathogenesis, Management, Complications and Future Directions

Cervical schwannomas are benign peripheral nerve sheath tumors, relatively uncommon pathologies. The purpose of this review is to summarize and expand on the existing literature on cervical schwannomas, focusing on clinical presentation, pathogenesis, surgical and radiologic management and innovative therapies including ultrasound-guided techniques. Pubmed and SCOPUS databases were searched using combinations of terms including "cervical schwannoma", "surgery", "fusion", "complications", "radiosurgery", and others. The findings regarding these unique clinical entities are presented below.

Reconstruction after resection of C2 vertebral tumors: A comparative study of 3D-printed vertebral body versus titanium mesh

Background

Surgical resection of C2 vertebral tumors is challenging owing to the complex anatomy of C2 vertebrae and the challenges to surgical exposure. Various surgical approaches are available, but some are associated with excessively high risks of complications. An additional challenge is reconstruction of the upper cervical spine following surgery. In the last decade, additive-manufacturing personalized artificial vertebral bodies (AVBs) have been introduced for the repair of large, irregular bony defects; however, their use and efficacy in upper cervical surgery have not been well addressed. Therefore, in this study, we compared instrumented fixation status between patients who underwent conventional titanium mesh reconstruction and those who underwent the same resection but with personalized AVBs.

Methods

We performed a retrospective comparative study and recruited a single-institution cohort of patients with C2 vertebral tumors. Clinical data and imaging findings were reviewed. Through data processing and comparative analysis, we described and discussed the feasibility and safety of surgical resection and the outcomes of hardware implants. The primary outcome of this study was instrumented fixation status.

Results

The 31 recruited patients were divided into two groups. There were 13 patients in group A who underwent conventional titanium mesh reconstruction and 18 group B patients who underwent personalized AVBs. All patients underwent staged posterior and anterior surgical procedures. In the cohort, 9.7% achieved total en bloc resection of the tumor, while gross total resection was achieved in the remaining 90.3%. The perioperative complication and mortality rates were 45.2% and 6.5%, respectively. The occurrence of perioperative complications was related to the choice of anterior approach (p < 0.05). Group A had a higher complication rate than group B (p < 0.05). Four patients (4/13, 30.8%) developed hardware problems during the follow-up period; however, this rate was marginally higher than that of group B (1/18, 5.6%).

Conclusions

Total resection of C2 vertebral tumors was associated with a high risk of perioperative complications. The staged posterior and retropharyngeal approaches are better surgical strategies for C2 tumors. Personalized AVBs can provide a reliable reconstruction outcome, yet minor pitfalls remain that call for further modification.

Does the anatomical region predict blood loss or neurological deficits in embolized renal cancer spine metastases? A single-center experience with 31 patients

Background

No comparison of a single hypervascular tumor entity in terms of major complications in different spinal regions has been performed. We aimed to evaluate post-embolic and post-operative outcomes in anatomic regions with renal cell carcinoma (RCC) metastases to the spine.

Methods

We retrospectively evaluated data from patients with confirmed, embolized, and surgically treated RCC spine metastases at a single-spine center between 2010 and 2020. Patients were divided into thoracic (TSM) and lumbar (LSM) spine metastasis groups.

Results

Seventeen patients had TSM and 14 had LSM. In all cases, embolization was performed preoperatively. The ΔHb value did not differ between the two groups pre- and postoperatively (p=0.3934). There was no significant difference in intraoperative blood loss between both groups either within 1 day or 2 days after embolization. Neurological deficits occurred in eight patients after embolization or surgery, with no significant difference between TSM (n=5) and LSM (n=3).

Conclusions

Embolization is the standard procedure for the preoperative treatment of hypervascular spinal metastases, possible up to 48 h before surgery, without the risk of higher intraoperative blood loss. Regardless of intraoperative complications, major complications can occur up to several hours after embolization. We recommend surgery the day after embolization to reliably detect neurologic complications from this procedure.

Presentation, management and outcome of primary leiomyosarcoma of the spine: A systematic review

OBJECTIVE

Primary spinal leiomyosarcoma (PSL) is extremely rare. A case is presented, followed by a systematic review establishing the consensus on presentation, diagnosis, management and outcomes. Comparison being made with metastatic spinal leiomyosarcoma (MSL).

METHODS

A systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligibility criteria was decided upon before the literature search was conducted. Data were extracted and analysed.

RESULTS

397 articles were identified, 25 articles conformed to the eligibility criteria. 34 cases were included in the analysis. PSL had a female preponderance (69.2%) with back pain being the most common presenting symptom (60.9%). Neurological signs were present in the majority (69.6%) with tumours typically being in the thoracic spine (46.9%). Diagnosis was primarily made using MRI (64.7%) and CT (55.9%), with a histological sample being obtained in all cases. Most patients underwent operative management (91.2%) with variable use of neoadjuvant and adjuvant therapies. Operative approach differed greatly and outcome following surgical management was stated in 48.4% of cases, all noting an improvement from presentation. Patient follow up was limited (median 7 months), with the majority of patients being free of disease (43.8%).

CONCLUSIONS

PSL diagnosis is challenging with PET-CT and histopathological sampling playing an important role. There is a limited evidence base for the treatment strategies employed but surgical management is key with generally good outcomes. Prognosis for PSL would appear to be better than MSL. There is scope for more dedicated research in PSL and MSL.

Rate and Characteristics of Vertebral Artery Injury Following C1-C2 Posterior Cervical Fusion: A Systematic Review and Meta-Analysis

BACKGROUND

Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion.

METHODS

An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature.

RESULTS

Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6-78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%-4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%-2%) among 2238 screws placed.

CONCLUSIONS

The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.

Imaging features of Vertebral Aneurysmal Bone Cyst and the clinical value of interventional embolization

The current study aimed to investigate the imaging manifestations of vertebral aneurysmal bone cyst (ABC), and examine the clinical value of interventional embolization. Imaging examinations of 5 patients with pathologically confirmed spinal ABC were analysed and arterial angiography and embolization were performed prior to surgery. The cases in this cohort exhibited different degrees of intrusion into the vertebral arch and spinous and transverse processes. Lesions that protruded into the spinal canal resulted in compression of the thecal sac and spinal cord. Enlargement of arteries was detected by digital subtraction angiography and decreased significantly following embolization. Blood loss during surgery was also significantly reduced. Preoperative embolization of ABC reduces bleeding and allows for easy access to tissue, which is of great clinical value.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Embolization of an Exophytic Posterior Neck Mass Secondary to a Cutaneous Renal Cell Carcinoma Metastasis

Renal cell carcinoma (RCC) commonly metastasizes to the lung, liver, bones, and brain; however, cutaneous metastases remain rare with few reported cases. Since RCCs have the propensity to metastasize to highly vascular areas, the scalp and skin of the head and neck region are likely locations for cutaneous metastases. We report a rare case of a large, exophytic, cauliflower-like, hemorrhagic, metastatic mass of the posterior neck. This is the first reported case of a head and neck cutaneous RCC metastasis treated with endovascular embolization prior to surgical resection. Due to the increased vascularity of RCCs and risk of excessive hemorrhage during resection, adjunctive embolization of cutaneous head and neck metastasis may have a role. Essential characteristics to our treatment strategy are discussed with a review of pertinent literature.

Embolization of Basilar Tip Aneurysm via Ascending Cervical Artery

BACKGROUND

Unusual vascular anatomy can present treatment challenges as traditional approaches may be unfeasible.

CASE DESCRIPTION

In this case we describe a patient who presented with subarachnoid hemorrhage due to a ruptured basilar apex aneurysm, with an occluded left vertebral artery and severely stenotic right vertebral artery. Coil embolization was performed via catheterization of an ascending cervical artery, with a successful clinical and radiographic outcome.

CONCLUSIONS

This demonstrates novel use of an endovascular technique in the setting of multiple vascular pathologies.

Update on Preoperative Embolization of Bone Metastases

Management of patients with bone metastasis is complex and should include different specialties. Goals of therapy should be identified for each individual patient prior to the start of treatment. Preoperative embolization has generally been considered a safe and effective means of reducing intraoperative blood loss with recent studies and advances in technique reported. Update on indications, contraindications, technique, and efficacy, as well as prognostic factors and complications of preoperative embolization of bone metastases will be reviewed. New trends such as transradial arterial access and usage of liquid embolic agents will be discussed. Large tumor size, increased preprocedural tumor vascularity, longer embolization-to-surgery interval, and radical surgical procedures are associated with greater intraoperative blood loss and prolonged operative time. An accurate, noninvasive method to evaluate tumor vascularity prior to angiography is needed to identify patients who are most likely to benefit from preoperative embolization. Particular attention will be paid to skeletal metastases and spinal metastases as each has its own set of complexity.

Superselective angiography of the wrist in patients with Kienböck's disease

BACKGROUND

Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels.

METHODS

Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test.

RESULTS

We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position.

CONCLUSION

The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

A rare case of Paget's disease affecting the cervical spine

We present the case of a 75-year-old man with a rapidly progressive cervical myelopathy on a background of a 3-year history of neck pain and a severely degenerative cervical spine. The patient developed progressive myelopathy over a six-month period and suffered from worsening kyphosis. Suspicion of an underlying oncological process prompted transfer to our tertiary referral unit. Biopsy was consistent for Paget's disease, an extremely rare diagnosis of the cervical spine. Magnetic resonance imaging revealed cord compression between C4 and C6 with associated cord signal change indicative of myelopathy. A three-level corpectomy and posterior instrumented fusion was performed. There was significant blood loss (3.5l) intraoperatively, consistent with a diagnosis of Paget's disease of the bone. Cell salvage was used, as was neuromonitoring for both the anterior and posterior part of the procedure. Postoperatively, neurological function improved slightly and the patient required community neurorehabilitation to allow independent living.