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Piña D, Kalistratova V, Boozé Z, Voort WV, Conry K, Fine J, Holland J, Wick J, Ortega B, Javidan Y, Roberto R, Klineberg E, Lipa S, Le H. Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine. J Am Acad Orthop Surg 2023; 31:e675-e684. [PMID: 37311424 DOI: 10.5435/jaaos-d-22-01147] [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: 12/12/2022] [Accepted: 04/11/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution. METHODS This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest. RESULTS Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables. DISCUSSION In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI. LEVEL OF EVIDENCE Retrospective case series, Level III evidence.
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Affiliation(s)
- Dagoberto Piña
- From the University of California, Davis School of Medicine, Sacramento, CA (Piña, Kalistratova, and Boozé), University of Louisville, School of Medicine, Louisville, KY (Holland), Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Piña, Voort, Conry, Wick, Ortega, Javidan, Roberto, Klineberg, and Le), Department of Public Health Sciences, University of California, Davis, Sacramento, CA (Fine), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Lipa)
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2
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Benato A, D'Alessandris QG, Murazio M, Pacelli F, Mattogno PP, Fernández E, Lauretti L. Integrated Neurosurgical Management of Retroperitoneal Benign Nerve Sheath Tumors. Cancers (Basel) 2023; 15:3138. [PMID: 37370749 DOI: 10.3390/cancers15123138] [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: 04/25/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Peripheral nerve sheath tumors (PNST) of the retroperitoneum are rare and are often treated by general surgeons dealing with retroperitoneal cancers. However, resection without the correct microsurgical technique can cause permanent neurological deficits and pain. Here, we discuss our interdisciplinary approach based on the integration of expertise from neurosurgery and abdominal surgery, allowing for both safe exposure and nerve-sparing microsurgical resection of these lesions. We present a series of 15 patients who underwent resection of benign retroperitoneal or pelvic PNST at our institution. The mean age of patients was 48.4 years; 67% were female. Tumors were 14 schwannomas and 1 neurofibroma. Eight patients (53%) reported neurologic symptoms preoperatively. The rate of complete resection was 87% (n = 13); all symptomatic patients showed improvement of their preoperative symptoms. There were no postoperative motor deficits; one patient (7%) developed a permanent sensory deficit. At a mean postoperative follow-up of 31 months, we observed no recurrences. To our best knowledge, this is the second-largest series of benign retroperitoneal PNST consistently managed with microsurgical techniques. Our experience confirms that interdisciplinary management allows for safe treatment of these tumors with good neurological and oncological outcomes.
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Affiliation(s)
- Alberto Benato
- Rome Campus, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | | | - Marino Murazio
- Rome Campus, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Fabio Pacelli
- Rome Campus, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Eduardo Fernández
- Rome Campus, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Liverana Lauretti
- Rome Campus, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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3
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Silva GGD, Britz JPE, Martins OG, Ferreira NP, Ferreira MP, Worm PV. IMPACT OF SURGERY ON AMBULATORY STATUS IN PATIENTS WITH SYMPTOMATIC NEOPLASTIC SPINAL CORD COMPRESSION IN SOUTHERN BRAZIL. COLUNA/COLUMNA 2022. [DOI: 10.1590/s1808-185120222103263573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Background: Spinal cord compression is a common complication of spine metastasis and multiple myeloma. About 30% of patients with cancer develop symptomatic spinal metastases during their illness. Prompt diagnosis and surgical treatment of these lesions, although palliative, are likely to reduce the morbidity and improve quality of life by improving ambulatory function. Study Design: Retrospective review of medical records. Objective: To evaluate postoperative functional recovery and the epidemiological profile of neoplastic spinal cord compression in two neurosurgical centers in southern Brazil. Methods: We retrospectively analyzed the data of all patients who underwent palliative surgery for symptomatic neoplastic spine lesion from metastatic cancer, in two neurosurgical centers, between January 2003 and July 2021. The variables age, sex, neurological status, histological type, affected segment, complications and length of hospitalization were analyzed. Results: A total of 82 patients were included. The lesions occurred in the thoracic spine in 60 cases. At admission, 95% of the patients had neurological deficits, most of which were Frankel C (37%). At histopathological analysis, breast cancer was the most common primary site. After surgery, the neurological status of 46 patients (56%) was reclassified according to the Frankel scale. Of these, 22 (47%) regained ambulatory capacity. Conclusion: Surgical treatment of metastatic spinal cord compression improved neurological status and ambulatory ability in our sample. Level of evidence II; Retrospective study.
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Colonna MR, Costa AL, Mastrojeni C, Rizzo V, Nirta G, Angileri FF, Ieni A, Milone E, Macrì A. Giant sacral schwannoma excised under intraoperative neuromonitoring in an elderly patient: case report. J Surg Case Rep 2021; 2021:rjab460. [PMID: 34733472 PMCID: PMC8560204 DOI: 10.1093/jscr/rjab460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/21/2021] [Indexed: 11/14/2022] Open
Abstract
Schwannomas are mainly benign tumors arising from the Schwann cells of the peripheral nerve sheath. These tumors can often be associated with non-specific symptoms, such as abdominal heaviness. In this article, we present a detailed description of the surgical management of a giant sacral schwannoma in an elderly patient, for which intraoperative neuromonitoring made it possible to distinguish easily the nerves of the sacral plexus from which the tumor originated and to remove it without complications. Treatment of these rare and symptomatic giant tumors is still a challenge for surgeons; to treat adequately these tumors; a multidisciplinary approach is required to ensure an optimal therapeutic approach to reduce the risk of recurrence and, on the other hand, is not associated with unnecessary iatrogenic neurological damage.
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Affiliation(s)
- Michele R Colonna
- Department of Human Pathology of the Adult, the Child and the Adolescent, University of Messina, Messina, Italy
| | - Alfio L Costa
- Department of Human Pathology of the Adult, the Child and the Adolescent, University of Messina, Messina, Italy
| | - Claudio Mastrojeni
- Unit of Vascular Surgery, CardioVascular and Thoracic Department, University of Messina, Messina, Italy
| | - Vincenzo Rizzo
- Department of Clinical and Sperimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Nirta
- U.O.C. Radiodiagnostic, University of Messina, Messina, Italy
| | - Filippo F Angileri
- Division of Neurosurgery, BIOMORF Department, University of Messina, Messina, Italy
| | - Antonio Ieni
- Departmant of Human Patology, Messina University Medical School Hospital, Messina, Italy
| | - Erica Milone
- Departmant of Human Patology, Messina University Medical School Hospital, Messina, Italy
| | - Antonio Macrì
- Departmant of Human Patology, Messina University Medical School Hospital, Messina, Italy
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Madhavan AA, Eckel LJ, Carr CM, Diehn FE, Lehman VT. Subdural spinal metastases detected on CT myelography: A case report and brief review. Radiol Case Rep 2021; 16:1499-1503. [PMID: 33981371 PMCID: PMC8082046 DOI: 10.1016/j.radcr.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/26/2022] Open
Abstract
Spinal metastases are most commonly osseous and may extend to the epidural space. Less commonly, spinal metastases can be subdural, leptomeningeal, or intramedullary. Among these, subdural metastases are the most rare, with few reported cases. While these lesions are now almost exclusively detected on MRI, they can rarely be apparent on other modalities. It is important to recognize subdural metastases on any modality, because they have a significant impact on patient prognosis and treatment. We report a case of renal cell carcinoma in a 68-year-old male initially presenting with subdural metastases detected on CT myelography, with subsequent confirmation by MRI. The case illustrates, to our knowledge, the first example of subdural metastatic disease seen on CT myelography.
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6
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Hardy J, Haywood A, Rickett K, Sallnow L, Good P. Practice review: Evidence-based quality use of corticosteroids in the palliative care of patients with advanced cancer. Palliat Med 2021; 35:461-472. [PMID: 33499759 DOI: 10.1177/0269216320986717] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It would be unusual for a patient with advanced cancer not to be prescribed corticosteroids at some stage of their disease course for a variety of specific and non-specific indications. AIM The aim of this practice review was to provide a pragmatic overview of the evidence supporting current practice and to identify areas in which further research is indicated. DESIGN A 'state-of-the-art' review approach was used to examine the evidence supporting the use of corticosteroids for the management of cancer-related complications and in symptom control, in the context of known risks and harms to inform quality use of this medicine. We developed 'Do', 'Do not', and 'Don't know' recommendations based on current literature and identified areas for future investigation and research. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane library from inception to 14th October 2020. Our initial search limited to reviews, reviews of reviews, randomised controlled trials (RCTs) and controlled trials was supplemented by supporting literature as appropriate. RESULTS Evidence to support common practice in the use of corticosteroids is lacking for most indications. This is in the context of strong evidence for the potential for significant toxicity and poor quality use of medicine. CONCLUSION Guidelines recommending the widespread use of corticosteroids should acknowledge the poor evidence base supporting much current dogma. Quality research is essential not only to define the role of corticosteroids in this context but to ensure good prescribing practice.
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Affiliation(s)
- Janet Hardy
- Mater Health, Brisbane, SEQ, Australia.,Mater Research Institute - University of Queensland (UQ), Brisbane, QLD, Australia
| | - Alison Haywood
- Mater Research Institute - University of Queensland (UQ), Brisbane, QLD, Australia.,School of Pharmacy and Pharmacology, Griffith University, Gold Coast, QLD, Australia
| | - Kirsty Rickett
- University of Queensland Library - Mater Misericordiae Hospital, Brisbane, QLD, Australia
| | - Libby Sallnow
- St Christopher's Hospice and UCL Marie Curie Palliative Care Department, London, UK.,St Vincent's Private Hospital Brisbane, Brisbane, QLD, Australia
| | - Phillip Good
- Mater Health, Brisbane, SEQ, Australia.,Mater Research Institute - University of Queensland (UQ), Brisbane, QLD, Australia.,St Vincent's Private Hospital Brisbane, Brisbane, QLD, Australia
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Leclerc A, Lebreton G, Huet A, Alves A, Emery E. Management of giant presacral schwannoma. Clinical series and literature review. Clin Neurol Neurosurg 2020; 200:106409. [PMID: 33341090 DOI: 10.1016/j.clineuro.2020.106409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/01/2020] [Accepted: 11/28/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Presacral schwannomas are rare tumors. Due to their benign nature and slow growth, these tumors are often giant and become difficult to treat. Their removal is a surgical challenge with different strategies reported in the literature. This study presents the consecutives cases of presacral schwannomas operated on in our institution, our surgical strategy and literature review. METHODS This retrospective study includes all consecutive patients operated on for a pre-sacral schwannoma in our department between 2006 and 2019, i.e. 6 patients. We report clinical features, pre and post-operative imaging, surgical data and post-operative outcomes. RESULTS All patients had symptoms before surgery (constipation, dysuria, radicular or lower back pain) with an average duration of 7.4 months. All patients underwent an MRI and a CT scan before the surgery. Five patients had type III schwannoma according to Klimo classification and one patient had a type II. The average size was 504,9 cm3 (range 53,1-1495,4). All the patients were operated on by an anterior approach in a double team with an mean duration of 246 min. Intraoperative bleeding was less than 500 ml for 4 patients, 2 patients had significant bleeding (2700 and 2900 mL). Excision was total or subtotal in all cases. One patient had an intraoperative complication (air embolism). Follow up at 3 months was excellent with a disappearance of symptoms for all patients except one patient who retained constipation. One patient had a late complication (bowel obstruction due to tissue adhesions). At last follow-up after phone interview, no patient had clinical symptoms that could suggest a recurrence. CONCLUSION The anterior approach with a double surgical team is a great option for the treatment of presacral schwannoma. Combined with adequate preoperative imaging and intraoperative stimulation, it reduces the risk of intra and postoperative complications.
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Affiliation(s)
- Arthur Leclerc
- CHU Caen, Department of Neurosurgery, Caen, F-14000, France; Université Caen Normandie, Medical School, Caen, F-14000, France.
| | - Gil Lebreton
- CHU Caen, Department of Digestive Surgery, Caen, F-14000, France
| | - Augustin Huet
- CHU Caen, Department of Imaging, Caen, F-14000, France; Université Caen Normandie, Medical School, Caen, F-14000, France
| | - Arnaud Alves
- CHU Caen, Department of Digestive Surgery, Caen, F-14000, France; INSERM, U1086 ANTICIPE Centre François Baclesse, 3 Avenue du Général Harris, 14000 Caen, France; Université Caen Normandie, Medical School, Caen, F-14000, France
| | - Evelyne Emery
- CHU Caen, Department of Neurosurgery, Caen, F-14000, France; INSERM, UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), GIP Cyceron, Caen, F-14000, France; Université Caen Normandie, Medical School, Caen, F-14000, France
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8
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Sasamura K, Suzuki R, Kozuka T, Yoshimura R, Yoshioka Y, Oguchi M. Outcomes after reirradiation of spinal metastasis with stereotactic body radiation therapy (SBRT): a retrospective single institutional study. JOURNAL OF RADIATION RESEARCH 2020; 61:929-934. [PMID: 32766715 PMCID: PMC7674683 DOI: 10.1093/jrr/rraa058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/14/2020] [Indexed: 06/11/2023]
Abstract
This study was aimed at assessing the feasibility and toxicity of using stereotactic body radiation therapy (SBRT) for reirradiation of spinal metastatic tumors. We conducted a retrospective review, from our institutional database, of the data of patients who received reirradiation, with overlap of some prescribed isodose lines to the vertebra from the initial radiation therapy, between 2007 and 2019. We identified 40 patients with spinal metastatic tumors, of whom 2 had 2 metastatic vertebral lesions each, totaling up to 42 target lesions. The median dose to spinal cord at the initial radiation therapy was 30 Gy. SBRT based on the intensity-modulated radiation therapy (IMRT) technique was used for reirradiation to spare the spinal cord. All patients received a prescription dose of 25 Gy in 5 fractions to the planning target volume (PTV). Among the 40 cases who had pain, pain relief was obtained in 24 (60%) after reirradiation. Neurologic improvement was obtained in 8 of 15 cases (53%). The adverse events were evaluated using the Common Terminology Criteria for Adverse Events Version 5.0. Reirradiation was well-tolerated, with only 2 patients experiencing adverse events ≥grade 2 in severity, including 1 patient with grade 3 pain, and another patient with grade 3 spinal fracture. None of the patients developed radiation myelopathy. Our data demonstrated that reirradiation of spinal metastasis using SBRT provided effective pain relief and neurologic improvement, with minimal toxicity.
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Affiliation(s)
- Kazuma Sasamura
- Radiation Oncology Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Ryoko Suzuki
- Radiation Oncology Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Takuyo Kozuka
- Department of Radiology, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Ryoichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yasuo Yoshioka
- Radiation Oncology Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Masahiko Oguchi
- Radiation Oncology Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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9
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Giant Sacral Schwannoma Causing Bilateral Hydronephrosis: Case Report and Review of the Literature. World Neurosurg 2020; 142:184-187. [PMID: 32634630 DOI: 10.1016/j.wneu.2020.06.213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Giant sacral schwannomas are very rare, and less than 1%-5% of spinal schwannomas are found in the sacral region. These frequently grow to considerable size because of permissive anatomic location and benign, slow growth of tumor. They can be unnoticed before reaching a huge size. CASE DESCRIPTION We report a rare case of a giant sacral schwannoma in a 46-year-old man. The patient presented with difficulty in passing urine, episodic constipation, and swelling of the right lower extremity for 6 months. Magnetic resonance imaging revealed 160 x 110 x 110 mm encapsulated heterogenous solid mass originated from left S1 spinal nerve extending into the pelvis and abdomen. Sigmoid colon and rectum were displaced to the right side, and bladder was displaced anteriorly. Left side of the S1 and S2 vertebral bodies, left S1 and S2 neural foramen were also eroded. It also compressed ureters causing bilateral hydronephrosis. The patient underwent a 2-stage procedure in which complete resection was achieved. CONCLUSIONS We report the second case of a completely resected giant sacral schwannoma with bilateral hydronephrosis in the literature. Performing a 2-stage procedure is important in giant sacral schwannomas. Morbidity can be minimized, and extent of resection can be maximized with the help of combined anterior/posterior approach.
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10
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Laratta JL, Weegens R, Malone KT, Chou D, Smith WD. Minimally invasive lateral approaches for the treatment of spinal tumors: single-position surgery without the "flip". JOURNAL OF SPINE SURGERY 2020; 6:62-71. [PMID: 32309646 DOI: 10.21037/jss.2019.12.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although primary tumors of the spine and neural elements are rare, metastatic disease to the spine is quite common. Traditionally, surgical treatment for spinal tumor patients involves open decompression with or without stabilization. The single-position minimally invasive (MIS) lateral approach, which has been recently described over the recent decade, allows simultaneous access to the anterior and posterior columns with the patient positioned in the lateral decubitus position. Herein, we review the application of single-position MIS lateral surgery for the treatment of spinal neoplasm. The aim was to review the evolution, operative technique, outcomes, and complications associated with MIS lateral approaches for spinal tumors. The history of spinal tumor diagnosis and management are reviewed and discussed as well as the author's experience and literature regarding spinal tumor treatment outcome and surgical complications, with particular attention to single-position, MIS lateral approaches. In addition, the author's surgical technique is outlined in detail for thoracic, thoracolumbar and lumbar tumors. Furthermore, there are specific indications and complications associated with the surgical treatment of spinal tumors, and the MIS, single-position lateral approach, when applied appropriately, allows for concurrent access to the anterior and posterior column while mitigating the complications associated with traditional, open posterior-based approaches. In the treatment of spinal neoplasms, the goals of surgery are dictated by a number of tumor-specific and patient-specific factors. Therefore, operative treatment of tumors in the future may be a consolidation of historical surgical techniques and MIS, single-position lateral approaches. Regardless, multidisciplinary management is imperative for the individualized treatment of the patient and optimization of outcome.
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Affiliation(s)
- Joseph L Laratta
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Ryan Weegens
- University of Louisville Medical Center, Louisville, KY, USA
| | - Kyle T Malone
- Clinical Resources, NuVasive, Inc., San Diego, CA, USA
| | - Dean Chou
- University of California San Francisco, San Francisco, CA, USA
| | - William D Smith
- Western Regional Center for Brain and Spine Surgery, Las Vegas, NV, USA.,University Medical Center of Southern Nevada, Las Vegas, NV, USA
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11
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Saadeh YS, Elswick CM, Fateh JA, Smith BW, Joseph JR, Spratt DE, Oppenlander ME, Park P, Szerlip NJ. Analysis of Outcomes Between Traditional Open versus Mini-Open Approach in Surgical Treatment of Spinal Metastasis. World Neurosurg 2019; 130:e467-e474. [DOI: 10.1016/j.wneu.2019.06.121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 10/26/2022]
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12
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Jung JM, Chung CK, Kim CH, Yang SH. Minimally Invasive Surgery without Decompression for Hepatocellular Carcinoma Spinal Metastasis with Epidural Spinal Cord Compression Grade 2. J Korean Neurosurg Soc 2019; 62:467-475. [PMID: 30919607 PMCID: PMC6616991 DOI: 10.3340/jkns.2018.0199] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/20/2018] [Indexed: 11/27/2022] Open
Abstract
Objective There is a lack of knowledge regarding whether decompression is necessary in treating patients with epidural spinal cord compression (ESCC) grade 2. The purpose of this study was to compare the outcomes of minimally invasive surgery (MIS) without decompression and conventional open surgery (palliative laminectomy) for patients with hepatocellular carcinoma (HCC) spinal metastasis of ESCC grade 2.
Methods Patients with HCC spinal metastasis requiring surgery were retrospectively reviewed. Patients with ESCC grade 2, medically intractable mechanical back pain, a Nurick grade better than 3, 3–6 months of life expectancy, Tomita score ≥5, and Spinal Instability Neoplastic Score ≥7 were included. Patients with neurological deficits, other systemic illnesses and less than 1 month of life expectancy were excluded. Thirty patients were included in the study, including 17 in the open surgery group (until 2008) and 13 in the MIS group (since 2009).
Results The MIS group had a significantly shorter operative time (94.2±48.2 minutes vs. 162.9±52.3 minutes, p=0.001), less blood loss (140.0±182.9 mL vs. 1534.4±1484.2 mL, p=0.002), and less post-operative intensive care unit transfer (one patient vs. eight patients, p=0.042) than the open surgery group. The visual analogue scale for back pain at 3 months post-operation was significantly improved in the MIS group than in the open surgery group (3.0±1.2 vs. 4.3±1.2, p=0.042). The MIS group had longer ambulation time (183±33 days vs. 166±36 days) and survival time (216±38 days vs. 204±43 days) than the open surgery group without significant difference (p=0.814 and 0.959, respectively).
Conclusion MIS without decompression would be a good choice for patients with HCC spinal metastasis of ESCC grade 2, especially those with limited prognosis, mechanical instability and no neurologic deficit.
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Affiliation(s)
- Jong-Myung Jung
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea.,Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.,Neuroscience Research Institute, Seoul National University Medical Research Center, Seoul, Korea.,Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
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Onoue K, Nishio M, Yakami M, Aoyama G, Nakagomi K, Iizuka Y, Kubo T, Emoto Y, Akasaka T, Satoh K, Yamamoto H, Isoda H, Togashi K. CT temporal subtraction improves early detection of bone metastases compared to SPECT. Eur Radiol 2019; 29:5673-5681. [PMID: 30888486 DOI: 10.1007/s00330-019-06107-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/05/2019] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare observer performance of detecting bone metastases between bone scintigraphy, including planar scan and single-photon emission computed tomography, and computed tomography (CT) temporal subtraction (TS). METHODS Data on 60 patients with cancer who had undergone CT (previous and current) and bone scintigraphy were collected. Previous CT images were registered to the current ones by large deformation diffeomorphic metric mapping; the registered previous images were subtracted from the current ones to produce TS. Definitive diagnosis of bone metastases was determined by consensus between two radiologists. Twelve readers independently interpreted the following pairs of examinations: NM-pair, previous and current CTs and bone scintigraphy, and TS-pair, previous and current CTs and TS. The readers assigned likelihood levels to suspected bone metastases for diagnosis. Sensitivity, number of false positives per patient (FPP), and reading time for each pair of examinations were analysed for evaluating observer performance by performing the Wilcoxon signed-rank test. Figure-of-merit (FOM) was calculated using jackknife alternative free-response receiver operating characteristic analysis. RESULTS The sensitivity of TS was significantly higher than that of bone scintigraphy (54.3% vs. 41.3%, p = 0.006). FPP with TS was significantly higher than that with bone scintigraphy (0.189 vs. 0.0722, p = 0.003). FOM of TS tended to be better than that of bone scintigraphy (0.742 vs. 0.691, p = 0.070). CONCLUSION Sensitivity of TS in detecting bone metastasis was significantly higher than that of bone scintigraphy, but still limited to 54%. TS might be superior to bone scintigraphy for early detection of bone metastasis. KEY POINTS • Computed tomography temporal subtraction was helpful in early detection of bone metastases. • Sensitivity for bone metastasis was higher for computed tomography temporal subtraction than for bone scintigraphy. • Figure-of-merit of computed tomography temporal subtraction was better than that of bone scintigraphy.
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Affiliation(s)
- Koji Onoue
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Mizuho Nishio
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan. .,Preemptive Medicine and Lifestyle-related Disease Research Center, Kyoto University Hospital, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Masahiro Yakami
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.,Preemptive Medicine and Lifestyle-related Disease Research Center, Kyoto University Hospital, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Gakuto Aoyama
- Medical Imaging System Development Center, R&D Headquarters, Canon Inc., 30-2, Shimomaruko 3-chome, Ohta-ku, Tokyo, 146-8501, Japan
| | - Keita Nakagomi
- Medical Imaging System Development Center, R&D Headquarters, Canon Inc., 30-2, Shimomaruko 3-chome, Ohta-ku, Tokyo, 146-8501, Japan
| | - Yoshio Iizuka
- Medical Imaging System Development Center, R&D Headquarters, Canon Inc., 30-2, Shimomaruko 3-chome, Ohta-ku, Tokyo, 146-8501, Japan
| | - Takeshi Kubo
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yutaka Emoto
- Kyoto College of Medical Science, 1-3 Imakita, Koyamahigashi-cho, Sonobe-cho, Nantan, Kyoto, 622-0041, Japan
| | - Thai Akasaka
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kiyohide Satoh
- Medical Imaging System Development Center, R&D Headquarters, Canon Inc., 30-2, Shimomaruko 3-chome, Ohta-ku, Tokyo, 146-8501, Japan
| | - Hiroyuki Yamamoto
- Medical Imaging System Development Center, R&D Headquarters, Canon Inc., 30-2, Shimomaruko 3-chome, Ohta-ku, Tokyo, 146-8501, Japan
| | - Hiroyoshi Isoda
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.,Preemptive Medicine and Lifestyle-related Disease Research Center, Kyoto University Hospital, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaori Togashi
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Uei H, Tokuhashi Y. Therapeutic Impact of Percutaneous Pedicle Screw Fixation on Palliative Surgery for Metastatic Spine Tumors. Indian J Orthop 2019; 53:533-541. [PMID: 31303669 PMCID: PMC6590019 DOI: 10.4103/ortho.ijortho_474_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Percutaneous pedicle screw (PPS) fixation has been introduced into palliative surgery for metastatic spine tumors; however, the therapeutic effects of PPS on the outcomes of multidisciplinary treatment for such tumors are unclear. Therefore, the therapeutic impact of PPS was investigated among patients with metastatic spine tumors and with revised Tokuhashi scores of ≤8. MATERIALS AND METHODS A total of 47 patients who underwent conventional palliative surgery (posterior decompression and stabilization, 33; posterior stabilization alone, 14) before the introduction of PPS and 38 patients who underwent PPS (posterior decompression and stabilization, 19; posterior stabilization alone, 19) were included. Surgical stress (operative time, blood loss, complications, etc.) and treatment outcomes (postoperative survival time, visual analog scale scores, Frankel classification, and the Barthel index at the final followup) were compared between the conventional and PPS groups. RESULTS The age of the indicated patients significantly increased after the introduction of PPS (P < 0.05). Regarding posterior decompression and stabilization, there were no significant intergroup differences in surgical stress or treatment outcomes. As for posterior stabilization alone, there were significant preoperative differences in various parameters between the conventional and PPS groups (P < 0.01) and also significant postoperative intergroup differences between surgical stress and treatment outcomes (P < 0.01). CONCLUSIONS For patients with early-stage metastatic spine tumors, the use of PPS-based posterior stabilization combined with multidisciplinary adjuvant therapy has changed the age range of the patients indicated for surgery and caused significant improvements in surgical stress, postoperative survival time, and Barthel index.
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Affiliation(s)
- Hiroshi Uei
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuaki Tokuhashi
- Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan,Address for correspondence: Prof. Yasuaki Tokuhashi, Department of Orthopaedic Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-Kamicho, Itabashi-Ku, Tokyo 173-8610, Japan. E-mail:
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Dubbs SB, Honasoge AP. Rapid Fire: Central Nervous System Emergencies. Emerg Med Clin North Am 2018; 36:537-548. [PMID: 30037440 DOI: 10.1016/j.emc.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Neurologic complications are unfortunately common in oncology patients, with many presenting to the emergency department for diagnosis and management. This case-based review provides a brief overview of the key points in pathophysiology, diagnosis, and management of 2 oncologic central nervous system emergencies: malignant spinal cord compression and intracranial mass.
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Affiliation(s)
- Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Akilesh P Honasoge
- Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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Abdelbaky A, Eltahawy H. Neurological Outcome Following Surgical Treatment of Spinal Metastases. Asian J Neurosurg 2018; 13:247-249. [PMID: 29682016 PMCID: PMC5898087 DOI: 10.4103/ajns.ajns_43_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Spinal metastases lead to bony instability and spinal cord compression resulting in intractable pain and neurological deficits which affect ambulatory function and quality of life. The most appropriate treatment for spinal metastasis is still debated. Objective: The aim of this study is to evaluate clinical outcome, quality of life, complications, and survival after surgical treatment of spinal metastases. Methods: Retrospective review of patients with spinal metastases surgically treated at our facility between March 2008 and March 2013 was performed. Evaluations include hospital charts, initial and interval imaging studies, neurological outcome, and surgical complications. Follow-up examinations were performed every 3 months after surgery. Results: Seventy patients underwent surgical intervention for treatment of spinal metastasis in our institution. There were 27 women and 43 men. The preoperative pain was reported in 65 patients (93%), whereas postoperative complete pain relief was reported in 16 patients (24%), and pain levels decreased in 38 patients (58%). Preoperative 39 patients were ambulant and 31 patients were nonambulant. Postoperative 52 patients were ambulant and 18 patients were nonambulant. Postoperative complications were experienced in 10 (14.2%) patients, and the patient survival rate was 71% (50 patients) at 3 months, 49% (34 patients) at 1 year. The postoperative 30-day mortality rate was 4.2%. Conclusion: Surgical decompression for a metastatic spinal tumor can improve the quality of life in a substantially high percentage of patients with acceptable complications rate.
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Affiliation(s)
| | - Hazem Eltahawy
- Department of Neurosurgery Surgery, Wayne State University, MI, USA
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17
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Pelegrini de Almeida L, Vidaletti T, Martins de Lima Cecchini A, Sfreddo E, Martins de Lima Cecchini F, Falavigna A. Reliability of Tokuhashi Score to Predict Prognosis: Comparison of 117 Patients. World Neurosurg 2017; 111:e1-e6. [PMID: 29175570 DOI: 10.1016/j.wneu.2017.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 11/04/2017] [Accepted: 11/07/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spinal metastatic disease compromises the quality of life and prognosis of the patients. Prognosis is an important factor for the decision-making process and needs to be precise in order to adjust the intensity of therapy. The Tokuhashi score is a universal instrument to determine the prognosis. The objective was to analyze the effectiveness of the Tokuhashi score in determining the prognosis of the patients with spine metastasis by comparing the expected survival time from the Tokuhashi score with the survival time observed among surgical patients. METHODS This retrospective study was performed from October 2008 to October 2015. The inclusion criteria were symptomatic patients with spinal metastasis who underwent spinal cord decompression and had a minimum of 1-year follow-up. The exclusion criteria were patients without histologic confirmation and were lost to follow-up. The Tokuhashi score was applied, and once the expected survival was defined, it was compared with the survival time observed in the follow-up. RESULTS The sample studied was 117 patients. The commonly female (58%) and breast spinal metastasis was often observed (25.6%). The patients were followed for a minimum period of 12 months. The actual survival was beyond that estimated by the Tokuhashi score (P < 0.05). CONCLUSION The Tokuhashi score was not reliable to predict the prognosis. Patients with lower scores that surgical treatment was not recommended by the Tokuhashi score had better quality of life and longer survival after surgery. Tokuhashi score is not a precise tool to establish the best therapy and survival in patients with spinal metastasis.
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Affiliation(s)
| | | | | | - Ericson Sfreddo
- Department of Neurosurgery, Cristo Redentor Hospital, Porto Alegre, Brazil
| | | | - Asdrubal Falavigna
- Department of Neurosurgery, Caxias do Sul University, Caxias do Sul, Brazil
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The safety, efficacy, and cost-effectiveness of intraoperative cell salvage in metastatic spine tumor surgery. Spine J 2017; 17:977-982. [PMID: 28323241 DOI: 10.1016/j.spinee.2017.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 02/09/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT Metastatic spine tumor surgery (MSTS) is associated with substantial blood loss, therefore leading to high morbidity and mortality. Although intraoperative cell salvage with leukocyte depletion filter (IOCS-LDF) has been studied as an effective means of reducing blood loss in other surgical settings, including the spine, no study has yet analyzed the efficacy of reinfusion of salvaged blood in reducing the need for allogenic blood transfusion in patients who have had surgery for MSTS. PURPOSE This study aimed to analyze the efficacy, safety, and cost-effectiveness of using IOCS-LDF in MSTS. STUDY DESIGN This is a retrospective controlled study. PATIENT SAMPLE A total of 176 patients undergoing MSTS were included in the study. METHODS All patients undergoing MSTS at a single center between February 2010 and December 2014 were included in the study. The primary outcome measure was the use of autologous blood transfusion. Secondary outcome measures included hospital stay, survival time, complications, and procedural costs. The key predictor variable was whether IOCS-LDF was used during surgery. Logistic and linear regression analyses were conducted by controlling variables such as tumor type, number of diseased vertebrae, approach, number and site of stabilized segments, operation time, preoperative anemia, American Society of Anesthesiologists (ASA) grade, age, gender, and body mass index (BMI). No funding was obtained and there are no conflicts of interest to be declared. RESULTS Data included 63 cases (IOCS-LDF) and 113 controls (non-IOCS-LDF). Intraoperative cell salvage with LDF utilization was substantively and significantly associated with a lower likelihood of allogenic blood transfusion (OR=0.407, p=.03). Intraoperative cell salvage with LDF was cost neutral (p=.88). Average hospital stay was 3.76 days shorter among IOCS-LDF patients (p=.03). Patient survival and complication rates were comparable in both groups. CONCLUSIONS We have demonstrated that the use of IOCS-LDF in MSTS reduces the need for postoperative allogenic blood transfusion while maintaining satisfactory postoperative hemoglobin. We recommend routine use of IOCS-LDF in MSTS for its safety, efficacy, and potential cost benefit.
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Comparison Between Minimally Invasive Surgery and Conventional Open Surgery for Patients With Spinal Metastasis: A Prospective Propensity Score-Matched Study. Spine (Phila Pa 1976) 2017; 42:789-797. [PMID: 27584676 DOI: 10.1097/brs.0000000000001893] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective propensity score-matched study. OBJECTIVE To compare the outcomes of minimal invasive surgery (MIS) and conventional open surgery for spinal metastasis patients. SUMMARY OF BACKGROUND DATA There is lack of knowledge on whether MIS is comparable to conventional open surgery in treating spinal metastasis. METHODS Patients with spinal metastasis requiring surgery from January 2008 to December 2010 in two spine centers were recruited. The demographic, preoperative, operative, perioperative and postoperative data were collected and analyzed. Thirty MIS patients were matched with 30 open surgery patients using propensity score matching technique with a match tolerance of 0.02 based on the covariate age, tumor type, Tokuhashi score, and Tomita score. RESULTS Both groups had significant improvements in Eastern Cooperative Oncology Group (ECOG), Karnofsky scores, visual analogue scale (VAS) for pain and neurological status postoperatively. However, the difference comparing the MIS and open surgery group was not statistically significant. MIS group had significantly longer instrumented segments (5.5 ± 3.1) compared with open group (3.8 ± 1.7). Open group had significantly longer decompressed segment (1.8 ± 0.8) than MIS group (1.0 ± 1.0). Open group had significantly more blood loss (2062.1 ± 1148.0 mL) compared with MIS group (1156.0 ± 572.3 mL). More patients in the open group (76.7%) needed blood transfusions (with higher average units of blood transfused) compared with MIS group (40.0%). Fluoroscopy time was significantly longer in MIS group (116.1 ± 63.3 s) compared with open group (69.9 ± 42.6 s). Open group required longer hospitalization (21.1 ± 10.8 days) compared with MIS group (11.0 ± 5.0 days). CONCLUSION This study demonstrated that MIS resulted in comparable outcome to open surgery for patients with spinal metastasis but has the advantage of less blood loss, blood transfusions, and shorter hospital stay. LEVEL OF EVIDENCE 3.
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Hansen-Algenstaedt N, Knight R, Beyerlein J, Gessler R, Wiesner L, Schaefer C. Minimal-invasive stabilization and circumferential spinal cord decompression in metastatic epidural spinal cord compression (MESCC). 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 2014; 22:2142-4. [PMID: 23989745 DOI: 10.1007/s00586-013-2959-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Nils Hansen-Algenstaedt
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany,
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Dodwad SNM, Savage J, Scharschmidt TJ, Patel A. Evaluation and treatment of spinal metastatic disease. Cancer Treat Res 2014; 162:131-150. [PMID: 25070234 DOI: 10.1007/978-3-319-07323-1_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
With the increased survival of oncologic patients, evaluation and management of patients with spinal metastasis is crucial to reducing morbidity and maximizing function. In this chapter, we present some guidelines for the initial systematic evaluation of patients with spinal lesions, as well as the risks, benefits, and alternatives to nonoperative and operative management of metastatic spinal disease, and the overall survival of these patients.
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Affiliation(s)
- Shah-Nawaz M Dodwad
- Northwestern Memorial Hospital, 676 N St Clair St, Suite 1350, Chicago, IL, 60611, USA
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Prise en charge par radiothérapie des métastases osseuses et de leurs complications : les standards. Bull Cancer 2013; 100:1175-85. [DOI: 10.1684/bdc.2013.1845] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Valesin Filho ES, de Abreu LC, Lima GHV, de Cubero DIG, Ueno FH, Figueiredo GSL, Valenti VE, Monteiro CBDM, Wajnsztejn R, Fujiki EN, Neto MR, Rodrigues LM. Pain and quality of life in patients undergoing radiotherapy for spinal metastatic disease treatment. Int Arch Med 2013; 6:6. [PMID: 23418821 PMCID: PMC3599966 DOI: 10.1186/1755-7682-6-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 02/08/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Radiotherapy is an important tool in the control of pain in patients with spinal metastatic disease. We aimed to evaluate pain and of quality of life of patients with spinal metastatic disease undergoing radiotherapy with supportive treatment. METHODS The study enrolled 30 patients. From January 2008 to January 2010, patients selection included those treated with a 20 Gy tumour dose in five fractions. Patients completed the visual analogue scale for pain assessment and the SF-36 questionnaire for quality of life assessment. RESULTS The most frequent primary sites were breast, multiple myeloma, prostate and lymphoma. It was found that 14 spinal metastatic disease patients (46.66%) had restricted involvement of three or fewer vertebrae, while 16 patients (53.33%) had cases involving more than three vertebrae. The data from the visual analogue scale evaluation of pain showed that the average initial score was 5.7 points, the value 30 days after the end of radiotherapy was 4.60 points and the average value 6 months after treatment was 4.25 points. Notably, this final value was 25.43% lower than the value from the initial analysis. With regard to the quality of life evaluation, only the values for the functional capability and social aspects categories of the questionnaire showed significant improvement. CONCLUSION Radiotherapy with supportive treatment appears to be an important tool for the treatment of pain in patients with spinal metastatic disease.
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Affiliation(s)
| | - Luiz Carlos de Abreu
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | | | | | | | | | - Vitor E Valenti
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
- Faculdade de Filosofia e Ciências, Universidade Estadual Paulista, UNESP. Av. Hygino Muzzi Filho, 737, 17.525-900, Marília, SP, Brazil
| | - Carlos Bandeira de Mello Monteiro
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
- Escola de Artes, Ciências e Humanidades da Universidade de São Paulo, São Paulo, Brazil
| | - Rubens Wajnsztejn
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Edison N Fujiki
- Hospital Estadual Mário Covas, Santo André, SP, Brazil
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Modesto Rolim Neto
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
| | - Luciano M Rodrigues
- Hospital Estadual Mário Covas, Santo André, SP, Brazil
- Laboratório de Delineamento de Estudos e Escrita Científica. Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Av. Príncipe de Gales, 821, 09060-650, Santo André, SP, Brazil
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Kim CH, Chung CK, Jahng TA, Kim HJ. Surgical outcome of spinal hepatocellular carcinoma metastases. Neurosurgery 2012; 68:888-96. [PMID: 21221023 DOI: 10.1227/neu.0b013e3182098c18] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Spinal hepatocellular carcinoma (HCC) metastases are increasing with improved survival of patients with HCC. However, its treatment outcome, particularly regarding functional outcome, has not been adequately investigated. OBJECTIVE To present the surgical outcome of spinal HCC metastases and demonstrate prognostic factors for survival and ambulation time. METHODS Thirty-three patients (30 males, 3 females) were retrospectively reviewed. Child-Pugh classification was used to assess hepatic function. Preoperatively, 19 patients could ambulate (group A) and 14 patients could not (group B). Preoperatively, 18 patients received conventional fractionated radiotherapy. RESULTS The spinal metastases were removed to achieve sufficient neural decompression. If destabilization developed, instrumentation and/or vertebroplasty were performed. Postoperatively, conventional radiotherapy was administered to 13 patients. Patients survived for 203 ± 31 days. Child-Pugh classification and preoperative/postoperative ambulatory ability were correlated with survival time, with Child-Pugh classification being the most significant factor (hazard ratio, 3.75; 95% confidence interval: 1.38-10.22). After the operation, ambulatory ability was maintained in all group A patients and was recovered in 4 in group B. Twenty-three patients could ambulate for 285 ± 62 days. Preoperative ambulatory status and Child-Pugh classification were correlated with a longer ambulatory period, with preoperative ambulatory status most significant (hazard ratio, 8.62; 95% confidence interval: 2.39-31.04). Patients died 81 ± 71 days after the loss of ambulatory ability, regardless of postoperative ambulatory status. CONCLUSION In spinal HCC metastasis, ambulatory status and hepatic function were significantly correlated with survival and ambulation time. Both ambulatory status and hepatic function should be considered in the selection of surgical candidates.
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Affiliation(s)
- Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
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Mattana JL, Freitas RRD, Mello GJP, Neto MA, Freitas Filho GD, Ferreira CB, Novaes C. STUDY ON THE APPLICABILITY OF THE MODIFIED TOKUHASHI SCORE IN PATIENTS WITH SURGICALLY TREATED VERTEBRAL METASTASIS. Rev Bras Ortop 2011; 46:424-30. [PMID: 27027033 PMCID: PMC4799287 DOI: 10.1016/s2255-4971(15)30257-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 10/18/2010] [Indexed: 11/26/2022] Open
Abstract
UNLABELLED To present the results obtained from surgical treatment of patients with vertebral metastases, comparing them with the modified Tokuhashi score in order to validate the applicability of this score for prognostic predictions and for choosing surgical treatments. METHODS This was a retrospective study on 157 patients treated surgically for spinal metastasis in Erastus Gaertner Hospital in Curitiba. The Tokuhashi score was applied retrospectively to all the patients. The patients' actual survival time was compared with the expected survival time using the Tokuhashi score. RESULTS There were 82 females and 75 males. The most frequent location of the primary tumor was the breast. The thoracic region was involved in 66.2%, lumbar region in 65.6%, cervical region in 15.9% and sacral region in 12.7%. All the patients underwent surgical treatment. The most frequent indication for treatment was intractable pain (89.2%). There was partial or complete improvement in a majority of the cases (52.2%). Out of 157 cases studied, 86.6% died. The maximum survival time was 13.6 years, the minimum was 3 days and the mean was 13.2 months. The following frequencies of Tokuhashi scores were found among the operated cases: up to 8 points, 111 cases; 9-11 points, 43 cases; and 12-15 points, three cases. The mean survival time in months for all 157 patients according to the Tokuhashi score was: 0-8 points, 15.4 months; 9-11 points, 11.4 months; and 12-15 points, 12 months. CONCLUSION Unlike the nonsurgical approach recommended by Tokuhashi for patients with lower scores, this group in our study was sent for surgery, with better results than those of non-operated patients reported by Tokuhashi.
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Affiliation(s)
- Jeferson Luis Mattana
- General Surgeon. Oncological Surgery Residents at Hospital Erasto Gaertner, Curitiba, PR, Brazil
| | - Rosyane Rena de Freitas
- General Surgeon. Oncological Surgery Residents at Hospital Erasto Gaertner, Curitiba, PR, Brazil
| | - Glauco José Pauka Mello
- Orthopedist in the Oncological Orthopedics Service, Hospital Erasto Gaertner, Curitiba, PR, Brazil
| | - Mário Armani Neto
- Orthopedist in the Oncological Orthopedics Service, Hospital Erasto Gaertner, Curitiba, PR, Brazil
| | - Geraldo de Freitas Filho
- Orthopedist in the Oncological Orthopedics Service, Hospital Erasto Gaertner, Curitiba, PR, Brazil
| | - Carolina Bega Ferreira
- Orthopedist in the Oncological Orthopedics Service, Hospital Erasto Gaertner, Curitiba, PR, Brazil
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Fattal C, Fabbro M, Gelis A, Bauchet L. Metastatic paraplegia and vital prognosis: perspectives and limitations for rehabilitation care. Part 1. Arch Phys Med Rehabil 2011; 92:125-33. [PMID: 21187215 DOI: 10.1016/j.apmr.2010.09.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate the vital prognosis of patients with metastatic epidural spinal cord compression (MESCC) to determine the relevance and duration of physical medicine and rehabilitation (PM&R) admission. DATA SOURCES Publications from 1980 to January 2010 selected from 3 databases. STUDY SELECTION Publications reporting data correlated with survival and prognosis factors, highlighting publications with level A scientific evidence (prospective randomized controlled studies with significant casuistry and relevant judgment criteria). The work focused on patients with MESCC below T1. DATA EXTRACTION Standardized reading grid. DATA SYNTHESIS Thirty-eight studies met the inclusion criteria. Most were retrospective. For survival rate at 1 year, they reported data ranging from 12% to 58%. The 12-month and median survival rates were the data reported most often in the articles. The median survival rate ranged from 2.4 to 30 months, and 12-month survival rates ranged from 12% to 58%. Of publications that chose this parameter, 95% reported 12-month survival rates less than 55.2% (95th percentile) regardless of patients' functional status and associated risk factors (eg, location of primary cancer, metastases spreading, pretreatment ambulatory status). CONCLUSIONS Despite major progress in cancer care, patients with MESCC still have a limited vital prognosis. The relevance and duration of PM&R care must be evaluated against the patient's functional need for rehabilitation while making time for family. The hypothesis of a 1-month stay extended only once appears reasonable for patients to adapt to their new functional status without taking precious time away from their loved ones.
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Affiliation(s)
- Charles Fattal
- Centre Mutualiste Neurologique Propara, Montpellier, France.
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Tumori spinali e intrarachidei. Neurologia 2011. [DOI: 10.1016/s1634-7072(11)70656-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Radiotherapy alone is the most common treatment for metastatic epidural spinal cord compression (MESCC). Decompressive surgery followed by radiotherapy is generally indicated only in 10-15% of MESCC cases. Chemotherapy has an unclear role and may be considered for selected patients with hematological or germ-cell malignancies. If radiotherapy alone is given, it is important to select the appropriate regimen. Similar functional outcomes can be achieved with short-course radiotherapy regimens and longer-course radiotherapy regimens. Longer-course radiotherapy is associated with better local control of MESCC than short-course radiotherapy. Patients with a more favorable survival prognosis (expected survival of ≥6 months) should receive longer-course radiotherapy, as they may live long enough to develop a recurrence of MESCC. Patients with an expected survival of <6 months should be considered for short-course radiotherapy. A recurrence of MESCC in the previously irradiated region after short-course radiotherapy may be treated with another short-course of radiotherapy. After primary administration of longer-course radiotherapy, decompressive surgery should be performed if indicated. Alternatively, re-irradiation can be performed using high-precision techniques to reduce the cumulative dose received by the spinal cord. Larger prospective trials are required to better define the appropriate treatment for the individual patient.
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Mak KS, Lee LK, Mak RH, Wang S, Pile-Spellman J, Abrahm JL, Prigerson HG, Balboni TA. Incidence and treatment patterns in hospitalizations for malignant spinal cord compression in the United States, 1998-2006. Int J Radiat Oncol Biol Phys 2010; 80:824-31. [PMID: 20630663 DOI: 10.1016/j.ijrobp.2010.03.022] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 03/10/2010] [Indexed: 12/27/2022]
Abstract
PURPOSE To characterize patterns in incidence, management, and costs of malignant spinal cord compression (MSCC) hospitalizations in the United States, using population-based data. METHODS AND MATERIALS Using the Nationwide Inpatient Sample, an all-payer healthcare database representative of all U.S. hospitalizations, MSCC-related hospitalizations were identified for the period 1998-2006. Cases were combined with age-adjusted Surveillance, Epidemiology and End Results cancer death data to estimate annual incidence. Linear regression characterized trends in patient, treatment, and hospital characteristics, costs, and outcomes. Logistic regression was used to examine inpatient treatment (radiotherapy [RT], surgery, or neither) by hospital characteristics and year, adjusting for confounding. RESULTS We identified 15,367 MSCC-related cases, representing 75,876 hospitalizations. Lung cancer (24.9%), prostate cancer (16.2%), and multiple myeloma (11.1%) were the most prevalent underlying cancer diagnoses. The annual incidence of MSCC hospitalization among patients dying of cancer was 3.4%; multiple myeloma (15.0%), Hodgkin and non-Hodgkin lymphomas (13.9%), and prostate cancer (5.5%) exhibited the highest cancer-specific incidence. Over the study period, inpatient RT for MSCC decreased (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.61-0.81), whereas surgery increased (OR 1.48, 95% CI 1.17-1.84). Hospitalization costs for MSCC increased (5.3% per year, p < 0.001). Odds of inpatient RT were greater at teaching hospitals (OR 1.41, 95% CI 1.19-1.67), whereas odds of surgery were greater at urban institutions (OR 1.82, 95% CI 1.29-2.58). CONCLUSIONS In the United States, patients dying of cancer have an estimated 3.4% annual incidence of MSCC requiring hospitalization. Inpatient management of MSCC varied over time and by hospital characteristics, with hospitalization costs increasing. Future studies are required to determine the impact of treatment patterns on MSCC outcomes and strategies for reducing MSCC-related costs.
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Stereotactic body radiotherapy: a review. Clin Oncol (R Coll Radiol) 2010; 22:157-72. [PMID: 20092981 DOI: 10.1016/j.clon.2009.12.003] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 11/02/2009] [Accepted: 11/30/2009] [Indexed: 12/13/2022]
Abstract
Stereotactic body radiotherapy (SBRT) combines the challenge of meeting the stringent dosimetric requirements of stereotactic radiosurgery with that of accounting for the physiological movement of tumour and normal tissue. Here we present an overview of the history and development of SBRT and discuss the radiobiological rationale upon which it is based. The published results of SBRT for lung, liver, pancreas, kidney, prostate and spinal lesions are reviewed and summarised. The current evidence base is appraised and important ongoing trials are identified.
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Mavrogenis AF, Papadopoulos EC, Starantzis K, Korres DS, Papagelopoulos PJ. Posterior decompression and stabilization, and surgical vertebroplasty with the vertebral body stenting for metastatic vertebral and epidural cauda equina compression. J Surg Oncol 2010; 101:253-8. [DOI: 10.1002/jso.21472] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Mavrogenis AF, Pneumaticos S, Sapkas GS, Papagelopoulos PJ. Metastatic epidural spinal cord compression. Orthopedics 2009; 32:431-9; quiz 440-1. [PMID: 19634817 DOI: 10.3928/01477447-20090511-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Andreas F Mavrogenis
- First Department of Orthopedics, Attikon General University Hospital, Athens, Greece
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Abstract
More than one-third of patients with cancer have vertebral metastases found at autopsy. Primary and metastatic tumors to the spinal column can lead to pain, instability, and neurologic deficit. Symptomatic lesions are most prevalent in the thoracic spine (70%), followed by the lumbar spine (20%) and cervical spine (10%). Lesions in larger vertebral bodies tend to be asymptomatic given the increased ratio between the diameter of the spinal canal and the traversing nerve roots.
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Affiliation(s)
- Todd Alamin
- Stanford University Department of Orthopaedic Surgery, Spinal Surgery Section, Stanford University School of Medicine, 300 Pasteur Drive, Stanford University Hospitals and Clinics, Room R171, Stanford, CA 94305, USA.
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Dy SM, Asch SM, Naeim A, Sanati H, Walling A, Lorenz KA. Evidence-Based Standards for Cancer Pain Management. J Clin Oncol 2008; 26:3879-85. [DOI: 10.1200/jco.2007.15.9517] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
High-quality management of cancer pain depends on evidence-based standards for screening, assessment, treatment, and follow-up for general cancer pain and specific pain syndromes. We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Providers should routinely screen for the presence or absence and intensity of pain and should perform descriptive pain assessment for patients with a positive screen, including assessment for likely etiology and functional impairment. For treatment, providers should provide pain education, offer breakthrough opioids in patients receiving long-acting formulations, offer bowel regimens in patients receiving opioids chronically, and ensure continuity of opioid doses across health care settings. Providers should also follow up on patients after treatment for pain. For metastatic bone pain, providers should offer single-fraction radiotherapy as an option when offering radiation, unless there is a contraindication. When spinal cord compression is suspected, providers should treat with corticosteroids and evaluate with whole-spine magnetic resonance imaging scan or myelography as soon as possible but within 24 hours. Providers should initiate definitive treatment (radiotherapy or surgical decompression) within 24 hours for diagnosed cord compression and should follow up on patients after treatment. These standards provide an initial framework for high-quality evidence-based management of general cancer pain and pain syndromes.
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Affiliation(s)
- Sydney M. Dy
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Steven M. Asch
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Arash Naeim
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Homayoon Sanati
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Anne Walling
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
| | - Karl A. Lorenz
- From Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California, Los Angeles, Los Angeles; RAND Health, Santa Monica; and University of California, Irvine, Irvine, CA
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Chaichana KL, Woodworth GF, Sciubba DM, McGirt MJ, Witham TJ, Bydon A, Wolinsky JP, Gokaslan Z. Predictors of ambulatory function after decompressive surgery for metastatic epidural spinal cord compression. Neurosurgery 2008; 62:683-92; discussion 683-92. [PMID: 18425015 DOI: 10.1227/01.neu.0000317317.33365.15] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. This study was designed to explore associations with maintaining and regaining ambulatory function after decompressive surgery for MESCC. METHODS Seventy-eight patients undergoing decompressive surgery for MESCC at an academic tertiary care institution between 1995 and 2005 were retrospectively reviewed. Fisher's exact analysis was used to compare preoperative ambulatory and nonambulatory patients. Multivariate Cox proportional hazards regression was used to identify associations with either maintaining or regaining the ability to walk. RESULTS Patients were followed for 7.1 +/- 1.6 (mean +/- standard deviation) months after surgery. Preoperative nonambulatory patients required more extensive surgery (increased operative spinal levels and number of laminectomies) and had more surgical site complications (wound dehiscences and cerebrospinal fluid leaks) compared with preoperative ambulatory patients. From the multivariate analysis, preoperative ability to walk (relative risk [RR], 2.320; 95% confidence interval [CI], 1.301-4.416; P < 0.01) independently increased the likelihood of ambulation at the last follow-up evaluation 2.3-fold. Pathological vertebral compression fracture at presentation (RR, 0.471; 95% CI, 0.235-0.864; P = 0.01) independently decreased the likelihood of ambulation at the time of the last follow-up evaluation 2.1-fold. For patients unable to walk at the time of surgery, preoperative radiation therapy (RR, 0.406; 95% CI, 0.124-0.927; P = 0.03) decreased the likelihood of regaining the ability to walk 2.5-fold. Symptoms present for less than 48 hours (RR, 2.925; 95% CI, 1.133-2.925; P = 0.02) and postoperative radiotherapy (RR, 2.595; 95% CI, 1.039-8.796; P = 0.04) independently increased the likelihood of regaining ambulatory ability 2.9- and 2.6-fold, respectively, by the time of last follow-up evaluation. CONCLUSION The identification of these associations with neurological outcome may help guide in the preservation or return of ambulation after surgery for patients with MESCC.
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Affiliation(s)
- Kaisorn L Chaichana
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Penas-Prado M, Loghin ME. Spinal cord compression in cancer patients: Review of diagnosis and treatment. Curr Oncol Rep 2008; 10:78-85. [DOI: 10.1007/s11912-008-0012-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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O'Toole JE, Eichholz KM, Fessler RG. Minimally Invasive Approaches to Vertebral Column and Spinal Cord Tumors. Neurosurg Clin N Am 2006; 17:491-506. [PMID: 17010899 DOI: 10.1016/j.nec.2006.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Minimally invasive approaches to spinal tumors have evolved rapidly over the past 15 to 20 years as clinicians seek to avoid the morbidity and long-term dysfunction associated with traditional open surgical procedures. We review the noninvasive, percutaneous, and minimally invasive surgical techniques currently available for the treatment of spinal column and intradural spinal tumors, including minimal access thoracic corpectomy and minimal access intradural tumor surgery. The various advantages and limitations of these approaches as well as their appropriate indications and uses are also presented here. A measured understanding of surgical objectives and iatrogenic effects on patients' quality of life allows the surgeon to implement such minimally invasive approaches in the design of individualized treatment plans that range from pure palliation to definitive cure.
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Affiliation(s)
- John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, 1725 West Harrison Street, Suite 970, Chicago, IL 60612, USA.
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Klimo P, Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol 2005; 7:64-76. [PMID: 15701283 PMCID: PMC1871618 DOI: 10.1215/s1152851704000262] [Citation(s) in RCA: 224] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 07/29/2004] [Indexed: 12/22/2022] Open
Abstract
Radiotherapy has been the primary therapy for managing metastatic spinal disease; however, surgery that decompresses the spinal cord circumferentially, followed by reconstruction and immediate stabilization, has also proven effective. We provide a quantitative comparison between the "new" surgery and radiotherapy, based on articles that report on ambulatory status before and after treatment, age, sex, primary neoplasm pathology, and spinal disease distribution. Ambulation was categorized as "success" or "rescue" (proportion of patients ambulatory after treatment and proportion regaining ambulatory function, respectively). Secondary outcomes were also analyzed. We calculated cumulative success and rescue rates for our ambulatory measurements and quantified heterogeneity using a mixed-effects model. We investigated the source of the heterogeneity in both a univariate and multivariate manner with a meta-regression model. Our analysis included data from 24 surgical articles (999 patients) and 4 radiation articles (543 patients), mostly uncontrolled cohort studies (Class III). Surgical patients were 1.3 times more likely to be ambulatory after treatment and twice as likely to regain ambulatory function. Overall ambulatory success rates for surgery and radiation were 85% and 64%, respectively. Primary pathology was the principal factor determining survival. We present the first known formal meta-analysis using data from nonrandomized clinical studies. Although we attempted to control for imbalances between the surgical and radiation groups, significant heterogeneity undoubtedly still exists. Nonetheless, we believe the differences in the outcomes indicate a true difference resulting from treatment. We conclude that surgery should usually be the primary treatment with radiation given as adjuvant therapy. Neurologic status, overall health, extent of disease (spinal and extraspinal), and primary pathology all impact proper treatment selection.
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Affiliation(s)
- Paul Klimo
- Departments of Neurosurgery (P.K., J.R.W.K., M.H.S.) and Family & Preventive Medicine (C.S.T.) and Spinal Oncology Service, Huntsman Cancer Institute (M.H.S.), University of Utah, Salt Lake City, UT 84108, USA
| | - Clinton J. Thompson
- Departments of Neurosurgery (P.K., J.R.W.K., M.H.S.) and Family & Preventive Medicine (C.S.T.) and Spinal Oncology Service, Huntsman Cancer Institute (M.H.S.), University of Utah, Salt Lake City, UT 84108, USA
| | - John R.W. Kestle
- Departments of Neurosurgery (P.K., J.R.W.K., M.H.S.) and Family & Preventive Medicine (C.S.T.) and Spinal Oncology Service, Huntsman Cancer Institute (M.H.S.), University of Utah, Salt Lake City, UT 84108, USA
| | - Meic H. Schmidt
- Departments of Neurosurgery (P.K., J.R.W.K., M.H.S.) and Family & Preventive Medicine (C.S.T.) and Spinal Oncology Service, Huntsman Cancer Institute (M.H.S.), University of Utah, Salt Lake City, UT 84108, USA
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Schmidt MH, Larson SJ, Maiman DJ. The lateral extracavitary approach to the thoracic and lumbar spine. Neurosurg Clin N Am 2004; 15:437-41. [PMID: 15450878 DOI: 10.1016/j.nec.2004.04.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The LECA is a technically challenging procedure with a steep learning curve. It is one of the most versatile approaches to the spine, however,with a logical sequence of maneuvers that can be combined to adapt the LECA for many different spinal procedures that need to be performed for decompression of the spinal cord and reconstruction of the spinal column in cancer patients.
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Affiliation(s)
- Meic H Schmidt
- Division of Spinal Oncology, Department of Neurosurgery, University of Utah School of Medicine, 30 North 1900 East, Suite 3B-409, Salt Lake City, UT 84132, USA.
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Klimo P, Dailey AT, Fessler RG. Posterior surgical approaches and outcomes in metastatic spine-disease. Neurosurg Clin N Am 2004; 15:425-35. [PMID: 15450877 DOI: 10.1016/j.nec.2004.04.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Spinal cord compression represents a major cause of morbidity and suffering in cancer patients. Surgery should be considered a form of primary therapy in many of these patients. The goals of surgery and the approach used are functions of a number of variables, including the surgeon's preference, the location of disease within the spine (cervical, thoracic, or lumbar),the extent of disease within each vertebra, the number of levels affected, and the patient's medical health and overall prognosis. Currently,the goals of any major debulking surgery are to decompress the spinal cord, prevent local recurrence, reconstruct the spine, and provide immediate stabilization with the use of fixation devices. Posterior approaches, starting with the decompressive laminectomy, have traditionally been the most common surgical procedures for metastatic spine disease. The laminectomy should only be used for disease isolated to the dorsal spine without evidence of concomitant instability. A laminectomy combined with instrumentation has been shown to provide superior results but should be reserved for those patients who cannot tolerate or would not benefit from more aggressive surgery. Various posterolateral approaches have been devised to access more ventrally placed lesions. These include the transpedicular approach, the costotransversectomy, and the lateral extracavitary/parascapular approach. Each of these allows adequate spinal cord decompression anteriorly and posteriorly and the ability to reconstruct and stabilize with acceptable peri-operative risk. It must be remembered that surgery for this disease is almost always palliative.Thus, surgery should be a means to maximize the patient's quality of life while minimizing the risk of suffering surgical complications.
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Affiliation(s)
- Paul Klimo
- Department of Neurosurgery, University of Utah School of Medicine, 30 North 1900 East, Suite 3B409, Salt Lake City, UT 84132, USA.
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Klimo P, Kestle JRW, Schmidt MH. Clinical trials and evidence-based medicine for metastatic spine disease. Neurosurg Clin N Am 2004; 15:549-64. [PMID: 15450889 DOI: 10.1016/j.nec.2004.04.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Treatment of metastatic epidural spinal disease has undergone significant changes over the last 20 years. No longer is indiscriminate decompressive laminectomy offered as the only surgical treatment. It carries all the risks associated with an invasive procedure and offers the patient little benefit unless it is used to remove disease isolated to the posterior elements. The existing literature suggests that surgery that frees the spinal cord at the site of compression in addition to reconstructing and stabilizing the spinal column is more effective at preserving and regaining neural function, notably ambulatory function and sphincter function, than conventional radiotherapy. It is also highly effective in relieving pain. The preliminary results ofa recent RCT provide the first class I evidence to support a reversal in the current philosophy of primary treatment for many patients with meta-static disease. Conventional radiotherapy has a clearly defined role as adjuvant therapy and as primary therapy in those who are unable to tolerate or benefit significantly from surgery. The role of nonconventional radiation therapy, such as IMRT and SRS, remains to be elucidated.
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Affiliation(s)
- Paul Klimo
- Department of Neurosurgery, University of Utah School of Medicine, 30 North 1900 East, Suite 3B-409 SOM, Salt Lake City, UT 84132-2303, USA.
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Abstract
The management of patients with metastatic disease of the spine should be highly individualized and depends on several factors, including the clinical presentation, duration of symptoms, tu-mor type, anticipated radiosensitivity, tumor lo-cation, extent of extraspinal disease, integrity of the spinal column, and medical fitness and life expectancy of the patient. Early diagnosis and intervention are of paramount importance in improving the likelihood of functional neurologic recovery, with the maintenance of ambulation as the primary goal. Effective management of axial spinal pain involves reconstruction and stabilization of the spinal column. Although the ideal therapy has not been established, a wide range of management options is currently available.
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Affiliation(s)
- Adam S Wu
- Division of Neurosurgery, Royal University Hospital, 103 Hospital Drive, University of Saskatchewan, Saskatoon, Saskatchewan S7N 0W8, Canada
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Abstract
Metastatic spread to the spinal column is a growing problem in patients with cancer. It can cause a number of sequelae including pain, instability, and neurologic deficit. If left untreated, progressive myelopathy results in the loss of motor, sensory, and autonomic functions. Except in rare circumstances, treatment is palliative. Traditionally, conventional fractionated external beam radiotherapy has been the treatment of choice. "Surgery" for metastatic spinal disease was, and generally continues to be, equated with laminectomy by many physicians. However, there has been a remarkable evolution in surgical techniques over the last 20 years. Today, the goal of surgery is to achieve circumferential decompression of the neural elements while reconstructing and immediately stabilizing the spinal column. This has been made possible by the use of different surgical approaches and the exploitation of a burgeoning array of internal fixation devices. More recently, minimally invasive surgical techniques, such as endoscopy, kyphoplasty/vertebroplasty, and stereotactic radiosurgery, have been added to the surgeon's armamentarium. As the number of treatment options for metastatic spinal disease grows, it has become clear that effective implementation of treatment can only be achieved by a multidisciplinary approach. This will provide the surest means of maximizing the quality of the remainder of the patient's life.
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Affiliation(s)
- Paul Klimo
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132-2303, USA
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