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Zhou J, Zhou Y, Qian S, Li X, Lin H, Dong J, Zhou X. Computed Tomography Perfusion Combined With Preoperative Embolization for Reducing Intraoperative Blood Loss in Separation Surgery for Thoracolumbar Metastases. Spine (Phila Pa 1976) 2024; 49:E183-E190. [PMID: 37477335 DOI: 10.1097/brs.0000000000004780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/02/2023] [Indexed: 07/22/2023]
Abstract
STUDY DESIGN A prospective consecutive case study. OBJECTIVE This study aimed to assess the accuracy of computed tomography perfusion (CTP) in evaluating the vascularity of thoracolumbar metastases and to determine the impact of combining CTP with preoperative embolization on reducing intraoperative blood loss during separation surgery. SUMMARY OF BACKGROUND DATA Surgery for thoracolumbar metastases is a complex procedure with the potential for substantial blood loss. Therefore, assessing tumor vascularity before surgery and taking measures to minimize intraoperative blood loss is essential. METHODS A total of 62 patients with thoracolumbar metastases were prospectively enrolled. All patients underwent separation surgery using the posterior approach. Before surgery, the vascularity of the metastases was evaluated using CTP. On the basis of the CTP results, patients were categorized into hypervascular and hypovascular groups. Preoperative angiography and embolization were performed for the hypervascular group. Clinical data were abstracted, including intraoperative blood loss, perioperative complications, visual analog scale score, neurological status, and the accuracy of vascularity evaluation by CTP confirmed by angiography. χ 2 testing was used to compare categorical variables, whereas independent sample t tests were used to compare continuous variables, with paired t tests used to assess differences from preoperative to postoperative time points. RESULTS The mean intraoperative blood loss was 485±167 and 455±127.6 mL in the two groups, respectively. The accuracy of vascularity evaluation by CTP was 100%. In the hypervascular group, 80.6% of the patients experienced at least one level of improvement in neurological status, while the hypovascular group had 81.5% of patients with similar improvement. None of the patients experienced neurological deterioration. There was a significant reduction in visual analog scale scores in both groups after the operation. CONCLUSIONS The vascularity of thoracolumbar metastases could be accurately evaluated using noninvasive CTP. When combined with preoperative embolization, this approach effectively and safely reduced intraoperative blood loss in the setting of separation surgery.
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Affiliation(s)
- Jian Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Zhou
- Department of Diagnostic Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Sheng Qian
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xilei Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Lin
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaogang Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Omid-Fard N, Salameh JP, McInnes MD, Fisher CG, Heran MK. Pre-operative spine tumour embolization: Clinical outcomes and effect of embolization completeness. J Med Imaging Radiat Oncol 2024; 68:440-446. [PMID: 38563287 DOI: 10.1111/1754-9485.13650] [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: 08/28/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION To assess the association between the impact of the completeness of pre-operative spine tumour embolisation and clinical outcomes, including estimated blood loss (EBL), neurological status and complications. METHODS Retrospective chart review of all preoperative spine tumour embolisation procedures performed over 11 years by a single operator (2007-2018) at Vancouver General Hospital on 44 consecutive patients (mean age 57; 77% males) with 46 embolisation procedures, of which surgery was done en bloc in 26 cases and intralesional in the remaining 20. A multivariable negative binomial regression model was fit to examine the association between EBL and surgery type, tumour characteristics, embolisation completeness and operative duration. RESULTS Among intralesional surgeries, complete versus incomplete embolisation was associated with reduced blood loss (772 vs 1428 mL, P < 0.01). There was no statistically significant difference in neurological outcomes or complications between groups. Highly vascular tumours correlated with greater blood loss than their less vascular counterparts, but tumour location did not have a statistically significant effect. CONCLUSION This study provides evidence in support of our hypothesis that complete as opposed to incomplete tumour embolisation correlates with reduced blood loss in intralesional surgeries. Randomised control trials with larger samples are necessary to confirm this benefit and to ascertain other potential clinical benefits.
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Affiliation(s)
- Nima Omid-Fard
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean-Paul Salameh
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Matthew Df McInnes
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Charles G Fisher
- Department of Neurological Surgery, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Manraj Ks Heran
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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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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Maddy K, Trenchfield D, Destine H, Waiters V, Nwatu D, Lucke-Wold B. Spinal tumor embolization: benefit for surgical resection. BOHR INTERNATIONAL JOURNAL OF NEUROLOGY AND NEUROSCIENCE 2023; 1:71-80. [PMID: 37576947 PMCID: PMC10421648 DOI: 10.54646/bijnn.2023.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
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.
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Affiliation(s)
- Krisna Maddy
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Henson Destine
- University of Miami Miller School of Medicine, Miami, FL, United States
| | | | - Daniel Nwatu
- University of Miami Miller School of Medicine, Miami, FL, United States
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
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Maciejczak A, Gasik R, Kotrych D, Rutkowski P, Antoniak K, Derenda M, Dobiecki K, Górski R, Grzelak L, Guzik G, Harat M, Janusz W, Jarmużek P, Łątka D, Maciejczyk A, Mandat T, Potaczek T, Rocławski M, Trembecki Ł, Załuski R. Spinal tumours: recommendations of the Polish Society of Spine Surgery, the Polish Society of Oncology, the Polish Society of Neurosurgeons, the Polish Society of Oncologic Surgery, the Polish Society of Oncologic Radiotherapy, and the Polish Society of Orthopaedics and Traumatology. 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; 32:1300-1325. [PMID: 36854861 DOI: 10.1007/s00586-023-07546-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/31/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The purpose of these recommendations is to spread the available evidence for evaluating and managing spinal tumours among clinicians who encounter such entities. METHODS The recommendations were developed by members of the Development Recommendations Group representing seven stakeholder scientific societies and organizations of specialists involved in various forms of care for patients with spinal tumours in Poland. The recommendations are based on data yielded from systematic reviews of the literature identified through electronic database searches. The strength of the recommendations was graded according to the North American Spine Society's grades of recommendation for summaries or reviews of studies. RESULTS The recommendation group developed 89 level A-C recommendations and a supplementary list of institutions able to manage primary malignant spinal tumours, namely, spinal sarcomas, at the expert level. This list, further called an appendix, helps clinicians who encounter spinal tumours refer patients with suspected spinal sarcoma or chordoma for pathological diagnosis, surgery and radiosurgery. The list constitutes a basis of the network of expertise for the management of primary malignant spinal tumours and should be understood as a communication network of specialists involved in the care of primary spinal malignancies. CONCLUSION The developed recommendations together with the national network of expertise should optimize the management of patients with spinal tumours, especially rare malignancies, and optimize their referral and allocation within the Polish national health service system.
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Affiliation(s)
- A Maciejczak
- Department of Neurosurgery, Szpital Wojewódzki Tarnów, University of Rzeszów, Rzeszów, Poland.
| | - R Gasik
- Department of Neuroorthopedics and Neurology, National Geriatrics, Rheumatology and Rehabilitation Institute, Warsaw, Poland
| | - D Kotrych
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - P Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - K Antoniak
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - M Derenda
- Department of Neurosurgery, University of Warmia and Mazury, Olsztyn, Poland
| | - K Dobiecki
- Department of Orthopedics, Traumatology and Musculoskeletal Oncology, Pomeranian Medical University, Szczecin, Poland
| | - R Górski
- Department of Neurosurgery and Spine Surgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - L Grzelak
- Department of Neurosurgery, City Hospital, Toruń, Poland
| | - G Guzik
- Department of Oncologic Orthopedics, Sub-Carpathian Oncology Center, Brzozów, Poland
| | - M Harat
- Department of Oncology and Brachytherapy, Oncology Center Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - W Janusz
- Department of Orthopedics and Traumatology, Medical University of Lublin, Lublin, Poland
| | - P Jarmużek
- Department of Neurosurgery, University of Zielona Góra, Zielona Góra, Poland
| | - D Łątka
- Department of Neurosurgery, University of Opole, Opole, Poland
| | - A Maciejczyk
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - T Mandat
- Department of Nervous System Neoplasms, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - T Potaczek
- Department of Orthopedics and Rehabilitation, University Hospital Zakopane, Jagiellonian University, Kraków, Poland
| | - M Rocławski
- Department of Orthopaedics, Medical University of Gdansk, Gdańsk, Poland
| | - Ł Trembecki
- Department of Oncology, Wroclaw Medical University, Wroclaw, Poland
| | - R Załuski
- Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland
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Koob S, Schulze-Steinen H, Plöger MM, Randau TM, Strauß AC, Placzek R, Strauß AC. Preoperative embolization of renal cell carcinoma metastases to the bone prior to stabilization procedures does not result in reduction in intraoperative blood loss. Clin Exp Metastasis 2023; 40:117-122. [PMID: 36435893 PMCID: PMC9898427 DOI: 10.1007/s10585-022-10195-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The effect of preoperative embolization of bone metastases prior to stabilization procedures in reducing intraoperative blood loss remains controversial. This study aimed to analyze the effect of preoperative embolization on orthopedic stabilization procedures of the extremities and spine in cases with bone metastases from renal cell carcinomas. In particular, do these patients suffer less blood loss during the operation and do they need lesser fluid replacements or packed red cell bags intra- and perioperatively? Does preoperative embolization reduce the duration of surgery? METHODS We retrospectively reviewed stabilization procedures of the spine and extremities at our institution between 2011 and 2021 for group differences (embolization vs. no embolization) in terms of blood loss, fluid substitution, need for packed red cell transfusions, tumor size, and duration of surgery. RESULTS We reviewed 79 stabilization procedures of the spine (n = 36) and extremities (n = 43), of which 30 included preoperative embolization procedures. Surprisingly, the embolization group showed a statistically significant increase in blood loss, the need for fluid substitution, and red cell transfusions. Subgroup analysis revealed a significant negative effect of preoperative embolization on stabilization procedures of the extremities. CONCLUSION Based on our data, preoperative embolization of renal cell carcinoma metastases of the extremities had a negative effect on intraoperative blood loss and the need for fluid substitution and should therefore be avoided. Our data did not show an effect on stabilization procedures of the spine.
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Affiliation(s)
- Sebastian Koob
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Henrike Schulze-Steinen
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Milena M Plöger
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas M Randau
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Anna C Strauß
- Department of Diagnostic and Interventional Radiology, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Richard Placzek
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Andreas C Strauß
- Department of Orthopaedics and Trauma Surgery, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Zhang B, Yu H, Zhao X, Cao X, Cao Y, Shi X, Wang Z, Liu Y. Preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression: A retrospective analysis. Front Oncol 2022; 12:1098182. [PMID: 36591512 PMCID: PMC9798328 DOI: 10.3389/fonc.2022.1098182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/29/2022] [Indexed: 12/16/2022] Open
Abstract
Purpose The purpose of the study was to assess the effectiveness and safety of preoperative embolization in the treatment of patients with metastatic epidural spinal cord compression (MESCC). Methods A retrospective analysis of 138 MESCC patients who underwent decompressive surgery and spine stabilization was performed in a large teaching hospital. Among all enrolled patients, 46 patients were treated with preoperative embolization (the embolization group), whereas 92 patients did not (the control group). Patient's baseline clinical characteristics, surgery-related characteristics, and postoperative neurological status, complications, and survival prognoses were collected and analyzed. Subgroup analysis was performed according to the degree of tumor vascularity between patients with and without preoperative embolization. Results Patients with severe hypervascularity experienced more mean blood loss in the control group than in the embolization group, and this difference was statistically significant (P=0.02). The number of transfused packed red cells (PRC) showed a similar trend (P=0.01). However, for patients with mild and moderate hypervascularity, both blood loss and the number of PRC transfusion were comparable across the two groups. Regarding decompressive techniques, the embolization group (64.29%, 9/14) had a higher proportion of circumferential decompression in comparison to the control group (30.00%, 9/30) among patients with severe hypervascularity (P=0.03), whereas the rates were similar among patients with mild (P=0.45) and moderate (P=0.54) hypervascularity. In addition, no subgroup analysis revealed any statistically significant differences in operation time, postoperative functional recovery, postoperative complications, or survival outcome. Multivariate analysis showed that higher tumor vascularity (OR[odds ratio]=3.69, 95% CI [confident interval]: 1.30-10.43, P=0.01) and smaller extent of embolization (OR=4.16, 95% CI: 1.10-15.74, P=0.04) were significantly associated with more blood loss. Conclusions Preoperative embolization is an effective and safe method in treating MESCC patients with severe hypervascular tumors in terms of intra-operative blood loss and surgical removal of metastatic tumors. Preoperative tumor vascularity and extent of embolization are independent risk factors for blood loss during surgery. This study implies that MESCC patients with severe hypervascular tumors should be advised to undergo preoperative embolization.
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Affiliation(s)
- Bin Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China
| | - Haikuan Yu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Chinese PLA Medical School, Beijing, China
| | - Xiongwei Zhao
- Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xuyong Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Yuncen Cao
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Clinical Medical College of Anhui Medical University, Beijing, China
| | - Xiaolin Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Zheng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
| | - Yaosheng Liu
- Senior Department of Orthopedics, The Fourth Medical Center of PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Chinese PLA General Hospital, Beijing, China,Department of Orthopedic Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China,*Correspondence: Yaosheng Liu, ; ; Zheng Wang, ; Xiaolin Shi,
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Binh NT, Hoa TQ, Linh LT, My TTT, Anh PQ, Duc NM. Preoperative embolization of hypervascular spinal tumors: Two case reports. J Clin Imaging Sci 2022; 12:21. [PMID: 35673594 PMCID: PMC9168289 DOI: 10.25259/jcis_20_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/11/2022] [Indexed: 11/09/2022] Open
Abstract
The performance of preoperative embolization on a spinal tumor can be a useful adjunctive procedure that minimizes blood loss and complications, particularly for both metastatic and non-metastatic hypervascular tumors. We discuss two cases of hypervascular spinal tumors that were successfully treated with preoperative embolization and surgery. The first patient was an 18-year-old man who presented with cervical and shoulder pain for two months without paralysis or weakness. Magnetic resonance imaging revealed a tumor located in the D2 posterior vertebral arch that extended into the spinal canal and compressed the spinal cord. The second patient was a 68-year-old man with back pain that radiated to the legs for ten days. Magnetic resonance imaging revealed a mass in the L4 vertebral body. Both patients received tumor embolization and surgery. After surgery, neither patient experienced any major complications. Histological examination revealed osteoblastoma in the first patient and plasmacytoma in the second patient.
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Affiliation(s)
- Nguyen Thai Binh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Quoc Hoa
- Department of Human Anatomy, Hanoi Medical University, Hanoi, Vietnam
| | - Le Tuan Linh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Thieu-Thi Tra My
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Pham Quynh Anh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam,
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11
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Maethungkul R, Atthakomol P, Phinyo P, Phanphaisarn A, Murakami H, Sangsin A. Adjunctive Topical Tranexamic Acid for Blood Salvage Does Not Reduce Postoperative Blood Loss Compared with Placebo in Patients Who Undergo Palliative Decompressive Spinal Metastasis Surgery: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2022; 47:187-194. [PMID: 34802026 DOI: 10.1097/brs.0000000000004280] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Randomized controlled trial. OBJECTIVE To evaluate the efficacy of adjunctive topical tranexamic acid (tTXA) in reducing postoperative blood loss and packed red cell (PRC) transfusion in patients who underwent palliative decompressive spinal metastasis surgery for malignant epidural spinal cord compression. SUMMARY OF BACKGROUND DATA Palliative decompressive spinal metastasis surgery is associated with massive postoperative blood loss and increased transfusion rate. tTXA reduces blood loss in traumatic or degenerative spinal surgery; however, the role of topical TXA in decompressive spinal metastasis surgery remains controversial. METHOD A total of 65 patients who underwent palliative decompressive thoracolumbar spinal metastasis surgery were included in this study. In 33 patients, 1 g of tTXA (20 mL) was soaked in an absorbable gelatin sponge and placed lateral to the decompressive site. The remaining 32 patients in the control group received the same procedures with normal saline at the same volume, instead of TXA. All of the patients received standard 1 g intravenous TXA, just before initiating the operation. The primary outcome was postoperative blood loss, and the secondary outcomes were postoperative PRC transfusion and complications. RESULTS No differences were found in postoperative blood loss between tTXA and placebo group (P50 778 mL [IQR 347, 1,122 mL] versus P50 490 mL [IQR 295, 920 mL]; P = 0.238). The number of patients requiring postoperative PRC transfusion were quite similar in tTXA and placebo groups (PRC transfusion in 15 patients [45.45%] versus 16 patients [50%]; P = 0.585). No complications related to TXA and absorbable gelatin sponge were observed. CONCLUSION We do not recommend tTXA as an adjunctive treatment for patients undergoing decompressive spinal metastasis surgery since it does not provide additional benefit to prophylactic intravenous TXA in postoperative blood loss and transfusion rate.Level of Evidence: 2.
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Affiliation(s)
- Ronnakrit Maethungkul
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine and Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Areerak Phanphaisarn
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
| | - Hideki Murakami
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Apiruk Sangsin
- Department of Orthopaedics Surgery, Faculty of Medicine Chiang Mai University, Maharaj Nakorn Chiangmai Hospital, Chiangmai, Thailand
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Cui Y, Pan Y, Lin Y, Mi C, Wang B, Shi X. Risk factors for predicting cement leakage in percutaneous vertebroplasty for spinal metastases. J Orthop Sci 2022; 27:79-83. [PMID: 33158733 DOI: 10.1016/j.jos.2020.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/20/2020] [Accepted: 10/07/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The study aimed to identify the risk factors of cement leakage following percutaneous vertebroplasty for spinal metastases. METHODS 230 consecutive patients with 530 vertebrae were retrospectively reviewed. Characteristics including age, primary cancer, location, pathological fracture, the integrity of the posterior wall, and the volume of bone cement were considered as potential risk factors. Cement leakage was evaluated by postoperative imaging examination and classified into three subtypes with different potential sequelae: spinal canal leakage, intravascular leakage around vertebrae, intradiscal and paravertebral leakage. Univariate and multivariate analyses were used to assess the risk factors. RESULTS Leakage was detected in 185 vertebrae (34.9%), 18.3% for intradiscal and paravertebral, 13.2% for intravascular around vertebrae, and 7.0% for spinal canal. Multivariate analysis showed that incomplete posterior wall (P = 0.001) and breast cancer (P = 0.015) were strong predictive factors for spinal canal leakage, incomplete posterior wall (P = 0.024) was for intravascular leakage around vertebrae, thoracic (P = 0.010) and pathological fracture (P = 0.000) were for intradiscal and paravertebral leakage. CONCLUSIONS Our findings suggest that cement leakage is common following percutaneous vertebroplasty for spinal metastases. The incomplete posterior wall is an unfavourable factor for intravascular leakage around vertebrae. Vertebrae with incomplete posterior wall and breast cancer metastases are more likely to develop spinal canal leakage.
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Affiliation(s)
- Yunpeng Cui
- Department of Orthopaedics, Peking University First Hospital, Beijing, China
| | - Yuanxing Pan
- Department of Orthopaedics, Peking University First Hospital, Beijing, China
| | - Yunfei Lin
- Department of Orthopaedics, Peking University First Hospital, Beijing, China
| | - Chuan Mi
- Department of Orthopaedics, Peking University First Hospital, Beijing, China
| | - Bing Wang
- Department of Orthopaedics, Peking University First Hospital, Beijing, China
| | - Xuedong Shi
- Department of Orthopaedics, Peking University First Hospital, Beijing, China.
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13
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Madhu S, Thomas AC, Tang SS, Shen L, Ramakrishnan SA, Kumar N. Analysis of Short-Term versus Long-Term Readmission-Free Survival After Metastatic Spine Tumor Surgery. World Neurosurg 2021; 158:e946-e955. [PMID: 34863936 DOI: 10.1016/j.wneu.2021.11.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Readmission-free survival (ReAFS) is a novel clinical and quality metric after metastatic spine tumor surgery (MSTS). We believe that factors influencing ReAFS after index MSTS vary based on time. We considered 2 time frames and defined short-term ReAFS as survival without an unplanned hospital readmission up to 90 days and long-term ReAFS as survival without unplanned hospital readmission up to 1 year after MSTS. METHODS We retrospectively analyzed 266 patients who underwent MSTS between 2005 and 2016. All relevant oncologic, surgical and follow-up data were collected. Multivariate logistic regression analysis was used to analyze prognostic factors associated with higher probability of short-term ReAFS and long-term ReAFS. RESULTS Multivariate analysis showed that Eastern Cooperative Oncology Group score ≤2 (P = 0.011), preoperative hemoglobin (Hb) level >12 g/dL (P = 0.008), ≤3 comorbidities (P = 0.052), shorter index length of stay ≤10 days (P = 0.007), and absence of neurologic/hematologic complications during index stay (P = 0.015) significantly increased the probability of short-term ReAFS, whereas preoperative Hb level >12 g/dL (P = 0.003) or tumor primaries with advanced treatment modalities such as breast (P = 0.012), hematologic (P = 0.006), prostate (P = 0.004), and renal/thyroid (P = 0.038) as opposed to aggressive lung tumor primaries were associated with significantly higher probability of long-term ReAFS. CONCLUSIONS Patient and treatment factors predominantly influence ReAFS up to 90 days, whereas primary tumor-related factors alongside general health influence ReAFS beyond 90 days after index MSTS. Awareness of these factors may help oncologists and surgeons optimize treatment planning. The clinical significance of this study will continue to evolve, because we have been witnessing over the past decade that patients are becoming more involved in both their general health and understanding the natural history of the diseases that affect them.
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Affiliation(s)
- Sirisha Madhu
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | | | - Sarah Shuyun Tang
- Department of Orthopaedic Surgery, National University Health System, Singapore
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, Singapore
| | | | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Health System, Singapore.
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Cui Y, Shi X, Mi C, Wang B, Pan Y, Lin Y. Comparison of Minimally Invasive Tubular Surgery with Conventional Surgery in the Treatment of Thoracolumbar Metastasis. Cancer Manag Res 2021; 13:8399-8409. [PMID: 34795525 PMCID: PMC8593345 DOI: 10.2147/cmar.s332985] [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] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/03/2021] [Indexed: 12/01/2022] Open
Abstract
Background This study aimed to evaluate the perioperative safety and efficacy of minimally invasive tubular surgery for patients with spinal metastasis. Methods A total of 161 consecutive patients with spinal metastasis between June 2017 and June 2020 were retrospectively reviewed. A total of 36 patients were included in this study, 14 patients underwent minimally invasive tubular surgery (M), and 22 patients underwent conventional surgery (C). T-test and chi-square tests were used to evaluate demographic and perioperative data differences between the two groups. Results Baseline characteristics did not differ significantly between M and C groups except for the SINS (p=0.002) and preoperative Alb (p=0.026). There was no significant difference in operative time and complications between M and C groups (p<0.05). The M group had less mean blood loss than the C group (1275 vs 718mL, p=0.045). Blood transfusion was comparable between the two groups (p<0.05). The mean amount and drainage time were lower than the C group (141 vs 873mL, p<0.001; 3.1 vs 7.0 days, P<0.001). The mean postoperative hospitalization of the M group was 8.8 days, which was lower than the C group (11.3 days, p=0.045). Sub-analysis showed that for patients with hyper-vascular tumor, the M group had less mean amount and time of drainage compared with the C group (p<0.05); for patients with hypo-vascular tumor, the mean blood loss and amount of blood transfusion were also reduced in M group (p<0.05). The mean blood loss and drainage time of patients with hypo-vascular tumors were less than patients with hyper-vascular tumors in the M group (p<0.05). Conclusion In selected cases, minimally invasive tubular surgery is safe and effective for patients with spinal metastasis. Patients with hypo-vascular tumors were more suitable for this technique with less blood loss, fewer blood transfusions, minor drainage, and shorter postoperative hospitalization.
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Affiliation(s)
- Yunpeng Cui
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Xuedong Shi
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Chuan Mi
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Bing Wang
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Yuanxing Pan
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
| | - Yunfei Lin
- Department of Orthopaedics, Peking University First Hospital, Beijing, People's Republic of China
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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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Chatani S, Haimoto S, Sato Y, Hasegawa T, Murata S, Yamaura H, Inaba Y. Preoperative Embolization of Spinal Metastatic Tumor: The Use of Selective Computed Tomography Angiography for the Detection of Radiculomedullary Arteries. Spine Surg Relat Res 2021; 5:284-291. [PMID: 34435153 PMCID: PMC8356237 DOI: 10.22603/ssrr.2020-0202] [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] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/14/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Preoperative embolization for metastatic spinal cord compression (MSCC) has a risk of spinal ischemia. This study aimed to assess the efficacy and safety of preoperative embolization in patients with MSCC and evaluate the use of computed tomography (CT) angiography for the detection of the radiculomedullary arteries (RMA). Methods This retrospective study included 20 patients (12 men and 8 women; median age, 66 years), who underwent preoperative embolization before a decompression surgery, which corresponded to 22 embolization procedures. The detection ability of RMA was evaluated using angiography and selective CT angiography. Surgical data including intraoperative blood loss and transfusion were also evaluated. Results Six RMAs were identified at the levels of affected vertebrae and one level above and below in the diagnostic spinal angiography. In addition to spinal angiography, adjunctive selective CT angiography allowed visualization of another five RMAs. Overall, 11 RMAs were identified in 9 patients. Preoperative embolization was successfully achieved in all patients. As regards complications related to embolization procedure, palsy exacerbated in one patient (4.5%), which improved postoperatively. During the surgical procedure, the mean intraoperative blood loss was 353.4±254.2 mL without intraoperative transfusion in all patients. Conclusions The present study showed small amounts of intraoperative blood loss without any severe complications related to preoperative embolization. Selective CT angiography was a useful technique to detect RMAs and contributed to the safety of preoperative embolization.
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Affiliation(s)
- Shohei Chatani
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shoichi Haimoto
- Department of Neurosurgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yozo Sato
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takaaki Hasegawa
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinichi Murata
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hidekazu Yamaura
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitaka Inaba
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan
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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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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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Mohme M, Mende KC, Pantel T, Viezens L, Westphal M, Eicker SO, Dreimann M, Krätzig T, Stangenberg M. Intraoperative blood loss in oncological spine surgery. Neurosurg Focus 2021; 50:E14. [PMID: 34003622 DOI: 10.3171/2021.2.focus201117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraoperative blood loss in patients undergoing oncological spine surgery poses a major challenge for vulnerable patients. The goal of this study was to assess how the surgical procedure, tumor type, and tumor anatomy, as well as anesthesiological parameters, affect intraoperative blood loss in oncological spine surgery and to use this information to generate a short preoperative checklist for spine surgeons and anesthesiologists to identify patients at risk for increased intraoperative blood loss. METHODS The authors performed a retrospective analysis of 430 oncological patients who underwent spine surgery between 2013 and 2018 at the university medical spine center. Enrolled patients had metastatic tumor of the spine requiring surgical decompression of neural structures and/or stabilization including tumor biopsy using an open, percutaneous, and/or combined dorsoventral approach. Patients requiring vertebro- and kyphoplasty or biopsy only were excluded. Statistical analyses performed included a multiple linear regression analysis. RESULTS The mean intraoperative blood loss in the study patient cohort was 1176 ± 1209 ml. In total, 33.8% of patients received intraoperative red blood cell transfusions. The statistical analyses showed that tumor histology indicating myeloma, operative procedure length, epidural spinal cord compression (ESCC) score, tumor localization, BMI, and surgical strategy were significantly associated with increased intraoperative blood loss or risk of needing allogeneic blood transfusions. Anesthesiological parameters such as the American Society of Anesthesiologists (ASA) Physical Status classification score were not associated with blood loss. Multiple linear regression analysis demonstrated good predictive value (r = 0.437) for a five-item preoperative checklist to identify patients at risk for high intraoperative blood loss. CONCLUSIONS The analyses performed in this study demonstrated key factors affecting intraoperative blood loss and showed that a simple preoperative checklist including these factors can be used to identify patients undergoing surgery for metastatic spine tumors who are at risk for increased intraoperative blood loss. ABBREVIATIONS ABT = allogeneic blood transfusion; ASA = American Society of Anesthesiologists; ESCC = epidural spinal cord compression; KW = Kruskal-Wallis; MET = metabolic equivalent of task; RBC = red blood cell.
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Affiliation(s)
| | | | | | - Lennart Viezens
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Marc Dreimann
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Martin Stangenberg
- 2Division of Spine Surgery, Department of Trauma and Orthopedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Echt M, Stock A, De la Garza Ramos R, Der E, Hamad M, Holland R, Cezayirli P, Nasser R, Yanamadala V, Yassari R. Separation surgery for metastatic epidural spinal cord compression: comparison of a minimally invasive versus open approach. Neurosurg Focus 2021; 50:E10. [PMID: 33932918 DOI: 10.3171/2021.2.focus201124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to compare outcomes of separation surgery for metastatic epidural spinal cord compression (MESCC) in patients undergoing minimally invasive surgery (MIS) versus open surgery. METHODS A retrospective study of patients undergoing MIS or standard open separation surgery for MESCC between 2009 and 2019 was performed. Both groups received circumferential decompression via laminectomy and a transpedicular approach for partial corpectomy to debulk ventral epidural disease, as well as instrumented stabilization. Outcomes were compared between the two groups. RESULTS There were 17 patients in the MIS group and 24 in the open surgery group. The average age of the MIS group was significantly older than the open surgery group (65.5 vs 56.6 years, p < 0.05). The preoperative Karnofsky Performance Scale score of the open group was significantly lower than that of the MIS group, with averages of 63.0% versus 75.9%, respectively (p = 0.02). This was also evidenced by the higher proportion of emergency procedures performed in the open group (9 of 24 patients vs 0 of 17 patients, p = 0.004). The average Spine Instability Neoplastic Score, number of levels fused, and operative parameters, including length of stay, were similar. The average estimated blood loss difference for the open surgery versus the MIS group (783 mL vs 430 mL, p < 0.05) was significant, although the average amount of packed red blood cells transfused was not significantly different (325 mL vs 216 mL, p = 0.39). Time until start of radiation therapy was slightly less in the MIS than the open surgery group (32.8 ± 15.6 days vs 43.1 ± 20.3 days, p = 0.069). Among patients who underwent open surgery with long-term follow-up, 20% were found to have local recurrence compared with 12.5% of patients treated with the MIS technique. No patients in either group developed hardware failure requiring revision surgery. CONCLUSIONS MIS for MESCC is a safe and effective approach for decompression and stabilization compared with standard open separation surgery, and it significantly reduced blood loss during surgery. Although there was a trend toward a faster time to starting radiation treatment in the MIS group, both groups received similar postoperative radiotherapy doses, with similar rates of local recurrence and hardware failure. An increased ability to perform MIS in emergency settings as well as larger, prospective studies are needed to determine the potential benefits of MIS over standard open separation surgery.
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Affiliation(s)
- Murray Echt
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Ariel Stock
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rafael De la Garza Ramos
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Mousa Hamad
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Ryan Holland
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Phillip Cezayirli
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Rani Nasser
- 3Department of Neurological Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Vijay Yanamadala
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
| | - Reza Yassari
- 1Spine Research Group and.,2Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; and
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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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Timonin SY, Konovalov NA. Surgical Treatment of Intramedullary Hemangioblastomas: Current State of Problem (Review). Sovrem Tekhnologii Med 2021; 13:83-94. [PMID: 35265353 PMCID: PMC8858416 DOI: 10.17691/stm2021.13.5.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Indexed: 12/25/2022] Open
Abstract
Intramedullary hemangioblastomas (HAB) refer to very rare highly vascularized vascular spinal cord tumors associated with various neurological disorders. Effective HAB therapy to a greater extent depends on diagnostic accuracy and the absence of intra- and postoperative complications. The present study is a review of publications concerned with modern diagnostic and therapeutic techniques to control spinal HAB. The authors showed that perfusion computed tomography, computed tomographic angiography, and magnetic resonance angiography can be reasonably used for diagnosis and differentiation in a number of HAB due to their high vascularization. Preoperative embolization significantly reducing intraoperative bleeding risks is highly efficient. Some authors recommend this procedure in case of large lesions and high risks of intraoperative bleeding. The review also considered intraoperative imaging of a tumor and its feeding vessels using indocyanine green providing inspectability over the total tumor resection and clear imaging of tumor vascular architecture. The advantages and restrictions of the mentioned procedures were described.
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Affiliation(s)
- S Yu Timonin
- PhD Student N.N. Burdenko National Medical Research Center for Neurosurgery, Ministry of Health of the Russian Federation, 16, 4 Tverskaya-Yamskaya St., Moscow, 125047, Russia
| | - N A Konovalov
- Professor, Corresponding Member of the Russian Academy of Sciences, Head of 10 Neurosurgery Department; Deputy Director for Science N.N. Burdenko National Medical Research Center for Neurosurgery, Ministry of Health of the Russian Federation, 16, 4 Tverskaya-Yamskaya St., Moscow, 125047, Russia
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Loblaw A, George K, Misra V. Surgical and Radiotherapeutic Management of Malignant Extradural Spinal Cord Compression. Clin Oncol (R Coll Radiol) 2020; 32:745-752. [DOI: 10.1016/j.clon.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
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Abstract
STUDY DESIGN Case series. OBJECTIVE For each of the most frequent clinical scenarios, the authors reached a consensus on how should be timing and indications be optimized to reduce risk while maintaining the expected outcomes under the Covid-19 pandemics. SUMMARY OF BACKGROUND DATA The organization of health care has been changed by the Covid-19 pandemic with a direct impact on Spine Oncology Surgery. Emergency surgery is still a priority, but in case of spinal tumors it should be better defined which conditions require emergency treatment. METHODS An expert panel with general spine surgeons, oncological spine surgeons, and radiation oncologists was formed to analyze the most frequent scenarios in spinal musculoskeletal oncology during Covid-19 pandemics. RESULTS Spine metastases can be found incidentally during follow-up or can clinically occur by increasing pain, pathologic fracture, and/or neurological symptoms. Primary spine tumors are much more rare and very rarely present with acute onset. The first step is to suspect this rare condition, to avoid to treat a primary tumor as it were a metastasis. Most complex surgery, like en bloc resection, associated with high morbidity and mortality rate for the treatment of low grade malignancy like chordoma or chondrosarcomas, if intensive care unit availability is reduced, can be best delayed some weeks, as not impacting on prognosis, due to the slow growth rate of these conditions. The currently accepted protocols for Ewing sarcoma (ES) and osteogenic sarcoma must be performed for local and systemic disease control. For ES, after the first courses of chemotherapy, radiotherapy can be selected instead of surgery, during Covid-19, to the end of the full course of chemotherapy. In immunocompromised patients, (treated by chemotherapy), it is necessary to avoid contact with affected or exposed people. CONCLUSION Even more than during normal times, a multidisciplinary approach is mandatory to share the decision to modify a treatment strategy. LEVEL OF EVIDENCE 5.
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Houten JK, Swiggett SJ, Hadid B, Choueka DM, Kinon MD, Buciuc R, Zumofen DW. Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury. World Neurosurg 2020; 143:374-388. [PMID: 32805465 DOI: 10.1016/j.wneu.2020.08.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- John K Houten
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.
| | - Samuel J Swiggett
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Bana Hadid
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David M Choueka
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Merritt D Kinon
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Razvan Buciuc
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Daniel W Zumofen
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
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Chang SY, Mok S, Park SC, Kim H, Chang BS. Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review. Asian Spine J 2020; 14:513-525. [PMID: 32791769 PMCID: PMC7435309 DOI: 10.31616/asj.2020.0379] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/29/2022] Open
Abstract
Metastatic spinal tumors are common, and their rising incidence can be attributed to the expanding aging population and increased survival rates among cancer patients. The decision-making process in the treatment of spinal metastasis requires a multidisciplinary approach that includes medical and radiation oncology, surgery, and rehabilitation. Various decision-making systems have been proposed in the literature in order to estimate survival and suggest appropriate treatment options for patients experiencing spinal metastasis. However, recent advances in treatment modalities for spinal metastasis, such as stereotactic radiosurgery and minimally invasive surgical techniques, have reshaped clinical practices concerning patients with spinal metastasis, making a demand for further improvements on current decision-making systems. In this review, recent improvements in treatment modalities and the evolution of decision-making systems for metastatic spinal tumors are discussed.
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Affiliation(s)
- Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sujung Mok
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sung Cheol Park
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
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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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Percutaneous Balloon Kyphoplasty and Short Instrumentation Compared with Traditional Long Instrumentation for Thoracolumbar Metastatic Spinal Cord Compression. World Neurosurg 2019; 130:e640-e647. [DOI: 10.1016/j.wneu.2019.06.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
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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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Ma J, Tullius T, Van Ha TG. Update on Preoperative Embolization of Bone Metastases. Semin Intervent Radiol 2019; 36:241-248. [PMID: 31435132 DOI: 10.1055/s-0039-1693120] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Shanghai Medical School of Fudan University, Shanghai, People's Republic of China
| | - Thomas Tullius
- Department of Radiology, The University of Chicago Medicine, Chicago, Illinois
| | - Thuong G Van Ha
- Department of Radiology, The University of Chicago Medicine, Chicago, Illinois
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Westbroek EM, Ahmed AK, Pennington Z, Goodwin ML, Xia Y, Boone C, Gailloud P, Sciubba DM. Hypervascular Metastatic Spine Tumor Angiographic Relationships with the Artery of Adamkiewicz and Other Radiculomedullary Arteries. World Neurosurg 2019; 126:e480-e485. [DOI: 10.1016/j.wneu.2019.02.075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 01/05/2023]
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Westbroek EM, Ahmed AK, Pennington Z, Goodwin ML, Xia Y, Boone C, Gailloud P, Sciubba DM. Atypical Vertebral Hemangiomas Are Frequently Associated with Radiculomedullary Arteries. World Neurosurg 2019; 127:e1215-e1220. [PMID: 31004857 DOI: 10.1016/j.wneu.2019.04.101] [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: 02/08/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Preoperative endovascular embolization of atypical hemangiomas of the spine can reduce intraoperative blood loss. One frequent concern raised about embolizing these tumors is a possible association with arteries feeding the spinal cord, such as the artery of Adamkiewicz. This study aimed to elucidate a relationship between spinal levels affected by atypical spinal hemangiomas and radiculomedullary arteries. METHODS This was a retrospective review of 8 patients undergoing preoperative embolization of atypical spinal hemangiomas. We evaluated 54 spinal levels by angiography during embolization procedures. Each spinal level was categorized on the basis of the presence or absence of tumor and radiculomedullary artery. RESULTS Six of 15 (40%) affected levels had an associated radiculomedullary artery. Four of 39 (10.2%) unaffected levels had an associated cord feeding artery. The relative risk of affected spinal levels having an associated radiculomedullary artery was 3.9 (95% confidence interval 1.28-11.91). The attributable risk was 0.40 (95% CI 0.12-0.76). The chi-squared statistic was 6.35, with a P value of 0.01. Six of 8 patients (75%) had a radiculomedullary artery at a level of disease and embolization. CONCLUSIONS In this study, spinal levels affected by atypical hemangiomas requiring surgery were associated with radiculomedullary arteries. When performing preoperative embolization, great care must be taken to identify and preserve arteries supplying the spinal cord.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine Boone
- Division of Interventional Radiology, University of California, San Diego School of Medicine, La Jolla, California, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Lung metastases regression with increased CD8+ T lymphocyte infiltration following preoperative spinal embolization and total en bloc spondylectomy using tumor-bearing frozen autograft in a patient with spinal metastatic leiomyosarcoma. 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 2018; 28:41-50. [PMID: 30465309 DOI: 10.1007/s00586-018-5831-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 11/12/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE To report systemic immunological enhancement following preoperative spinal embolization and total en bloc spondylectomy (TES) using tumor-bearing frozen autograft in a patient with spinal metastatic leiomyosarcoma. METHODS A 44-year-old woman with metastatic uterine leiomyosarcoma of the lung and L1 vertebra underwent TES following bilateral three-level preoperative segmental artery embolization. Resected tumor-bearing lamina was frozen using liquid nitrogen and used as tumor-bearing bone graft for spinal reconstruction. RESULTS Tumor necrosis and obstructing material used in preoperative embolization were detected in the resected specimen of L1. Five days after TES, chest computed tomography scan demonstrated decreased solitary lung mass size without adjuvant treatment. Lobectomy was performed for the lung metastasis 42 days after TES. Infiltration of CD8+ T lymphocyte into tumor tissue significantly increased in shrunk lung metastasis. On the other hand, slight infiltration in both the resected L1 and primary uterine lesion was observed. Six months after TES, activities of daily living were normal with no evidence of local recurrence or distant metastasis. One year after TES, however, lung CT revealed occurrence of another lung metastasis, and molecular-targeting therapy (pazopanib) was initiated. CONCLUSIONS There were no reports demonstrating metastasis regression with CD8+ T lymphocyte infiltration after TES. This case demonstrated that preoperative tumor embolization combined with TES using tumor-bearing autograft provided both a local radical cure and systemic antitumor immunological enhancement, although the long-term effect can be limited.
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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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Nasser R, Nakhla J, Echt M, De la Garza Ramos R, Kinon MD, Sharan A, Yassari R. Minimally Invasive Separation Surgery with Intraoperative Stereotactic Guidance: A Feasibility Study. World Neurosurg 2017; 109:68-76. [PMID: 28939543 DOI: 10.1016/j.wneu.2017.09.067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/10/2017] [Accepted: 09/11/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The treatment of spinal metastasis consists of algorithms combining surgical and radiation modalities. Recently the concept of separation surgery followed by stereotactic radiosurgery was shown to be a safe and effective treatment to achieve local tumor control. OBJECTIVE We examined a minimally invasive approach to separation surgery in a cadaveric study followed by a patient cohort with spinal metastasis using navigation to discuss our results and provide a technical note. METHODS A cadaveric study using minimally invasive access systems examined the feasibility of spinal cord decompression. Subsequently, 17 patients with spinal metastasis underwent minimally invasive separation surgery and instrumentation using navigation. All patients were at least 3/5 and pre- and post-operative CT scans were used to evaluate the decompression. Endpoints included neurologic function, operative time, estimated blood loss, duration of hospital stay, and complications. RESULTS The cadaveric study demonstrated adequate decompression of the spinal cord. For the operative cases, the post-operative imaging demonstrated excellent separation for safe stereotactic radiosurgery. The mean incision length was 4.9 cm. The average operative time was 6 hours and 48 minutes, the mean length of stay was 12.8 days and the mean surgical blood loss was 458 mL. The median Spine Instability Neoplastic Score score was 10 with a range of 6-16. All patients remained or improved their neurologic baseline with excellent pain control. One patient incurred a perioperative complication. CONCLUSIONS Minimally invasive separation surgery for spinal metastasis allows for circumferential decompression of the spinal cord and safe post-operative stereotactic radiosurgery. In addition, we demonstrated the efficacy of intra-operative navigation in guiding the resection.
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Affiliation(s)
- Rani Nasser
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jonathan Nakhla
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Murray Echt
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rafael De la Garza Ramos
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Merritt D Kinon
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alok Sharan
- WESTMED Spine Center, WESTMED Medical Group, Yonkers, New York, USA
| | - Reza Yassari
- Spine Research Group, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA; Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
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