[Translated article] Epidemiology and clinic of vertebral metastasis

Cancer is in Spain the second cause of death in women (22%) and the first in men (31%). In this chapter, we describe the most frequent types of spinal metastases, their most frequent locations within the spine, as well as their clinical behaviour. We also analyse the neurological conditions most frequently associated with spinal metastases: root compression, spinal cord compression, cauda equina, and spinal cord involvement.

Critical evaluation of the literature on decision-making in spinal metastases

Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.

Role of radiotherapy in the management of spine metastases

Spine metastases are a common cause of pain in the oncologic patient which can generate functional limitation, in addition to complications derived from spinal cord compression, radicular compression and fractures. A complex approach to these metastases is required due to the risk of permanent sequelae. With the increase in survival rates due to new emerging treatments, the possibilities of presenting vertebral metastases are increasing, therefore, the management of these lesions should be aimed at pain relief and maintenance of ambulation. Radiotherapy has a fundamental role in the management of these lesions, and technological advances in recent years have made it possible to improve the quality and intentionality of the treatments, going from having a palliative intent to proposing treatments that improve local control. In this article we describe how the stereotactic body radiotherapy (SBRT) technique, in selected patients, can improve local control and its value in oligometastatic patients and after surgery.

[Translated article] Role of radiotherapy in the management of spine metastases

Spine metastases are a common cause of pain in the oncologic patient which can generate functional limitation, in addition to complications derived from spinal cord compression, radicular compression and fractures. A complex approach to these metastases is required due to the risk of permanent sequelae. With the increase in survival rates due to new emerging treatments, the possibilities of presenting vertebral metastases are increasing, therefore, the management of these lesions should be aimed at pain relief and maintenance of ambulation. Radiotherapy has a fundamental role in the management of these lesions, and technological advances in recent years have made it possible to improve the quality and intentionality of the treatments, going from having a palliative intent to proposing treatments that improve local control. In this article, we describe how the stereotactic body radiotherapy (SBRT) technique, in selected patients, can improve local control and its value in oligometastatic patients and after surgery.

Epidemiology and clinic of vertebral metastasis

Cancer is in Spain the second cause of death in women (22%) and the first in men (31%). In this chapter we describe the most frequent types of spinal metastases, their most frequent locations within the spine, as well as their clinical behavior. We also analyze the neurological conditions most frequently associated with spinal metastases: root compression, spinal cord compression, cauda equina, and spinal cord involvement.

[Translated article] Critical evaluation of the literature on decision-making in spinal metastases

Decision-making in patients with vertebral metastases is highly complex. Different factors of the patient, their cancer disease and treatment options are involved in it. Treatment schemes and strategies have been modified with the evolution of knowledge and treatment of disseminated oncological disease. This paper analyzes the bibliography that has been used for decision-making in the last three decades, as well as the evolution to the schemes that we could consider contemporary.

[Treatment of thoracic disc herniation. Case report]

BACKGROUND

Herniated thoracic intervertebral disc is a rare cause of spinal cord compression. Its frequency varies from 0.15% to 1.7% of all disc herniations, and produces symptoms in 0.5% to 0.8%.

CLINICAL CASES

Case 1. A 50-year-old woman, with pain and burning sensation in left hemithorax of four months of onset. It was treated as a herpetic syndrome, with no improvement. She was seen after thirteen days of exacerbation of clinical symptoms. The physical examination showed asymmetric paraparesis, lower left pelvic limb 1/5, and right pelvic limb 3/5¸ sensory level T8, with left Babinski positive. A thoracic disc herniation in space T8-T9 was diagnosed.

CASE 2

A 55-year-old patient with a history of presenting pain in lumbar area of 5 years onset. She also had radicular pain that radiated to the right pelvic limb, with intensity 10/10 on a Visual Analogue Scale. Her physical examination showed muscle strength 5/5, with normal sensitivity in all dermatomes and tendon reflexes, and a positive right Babinski. Thoracic disc herniation T7-T8 level was diagnosed.

DISCUSSION

Due to anatomical conditions that define this type of hernia, the extracavitary posterolateral approach should be the recommended surgical procedure when the simultaneously performed anterior decompression and fixation with posterior instrumentation are the treatments proposed.

CONCLUSION

Despite the different anatomical structures of this special area, it was possible to obtain satisfactory results for both clinical cases.

[Clinical presentation of a dorsal epidural arachnoid cyst after an epidural anesthesia]

BACKGROUND

Arachnoid cysts are dural diverticula with liquid content similar to cerebrospinal fluid, with 1% occurring in the spinal cord. They locate mainly in the dorsal region of the thoracic spine, and are unusual causes of spinal cord compression.

CLINICAL CASE

The case is presented of a previously healthy 15-year-old boy, with a 20-month history of spastic paraparesis that started apparently after epidural block for ankle osteosynthesis. There was decreased sensitivity and strength of the pelvic limbs and gradually presented with anaesthesia from T12 to L4 dermatomes, L5 and S1 bilateral hypoaesthesia and 4+/5 bilateral strength, in the L2 root and 2+/5 in L3, L4, L5, S1, hyperreflexia, Babinski and clonus, but with no alteration in the sacral reflexes. In the magnetic resonance it was diagnosed as an extradural arachnoid cyst from T6 to T9. The patient underwent a T6 to T10 laminotomy, cyst resection, dural defect suture, and laminoplasty. One year after surgery, the patient had recovered sensitivity, improvement of muscle strength up to 4+/5 in L2 to S1, and normal reflexes.

CONCLUSIONS

After the anaesthetic procedure, increased pressure and volume changes within the cyst could cause compression of the spinal cord, leading to symptoms. Despite being a long-term compression, the patient showed noticeable improvement.

Spontaneous spinal epidural haematoma: a retrospective study of a series of 13 cases

INTRODUCTION

Spontaneous spinal epidural haematoma (SSEH) has an estimated incidence of one per million inhabitants. It is classified as spontaneous when no identifiable cause can be linked to its onset.

OBJECTIVE

To describe a sample of patients with SSEH and analyse variables related to its functional prognosis.

PATIENTS AND METHODS

Retrospective study carried out in patients diagnosed with SSEH between 2001 and 2013 in our hospital.

RESULTS

We included 13 subjects (7 men) with a mean age of 71 years. Of the total, 62% had hypertension and 54% were treated with oral anticoagulants; of the latter, 57% had an International Normalised Ratio above 3. The most frequent manifestation was spinal column pain (85%). Nearly all subjects presented an associated neurological deficit, whether sensory-motor (70%), pure motor (15%), or pure sensory (7%). Five patients underwent surgical treatment and 8 had conservative treatment. After one year, 3 of the patients treated surgically and 4 of those on conservative treatment had a score of 2 or lower on the modified Rankin Scale. Poorer prognosis was observed in patients with anticoagulant therapy, large haematomas, location in the lumbar region, and more pronounced motor disability at onset.

CONCLUSIONS

Old age, hypertension, and anticoagulant therapy are the main risk factors for SSEH. The typical presentation consists of back pain with subsequent motor deficit. In patients with established motor symptoms, surgical treatment within the first 24hours seems to be the best option.