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Diffuse mets to spine with lumbar stenosis


Introduction

The skeleton is the third most common site of metastatic disease, with the spinal column being the most common location. Metastatic spinal disease can be found in 20% to 30% of patients with primary malignancies and leads to significant morbidity secondary to compression of the spinal cord, pain related to spinal instability, or neural compression. Concomitant degenerative spinal disease will be found in a significant portion of patients with spinal metastasis, as it tends to occur in patients over 60 years of age. In addition, many patients with symptomatic degenerative spine disease will have radiographic evidence of spinal metastasis as primary cancers are becoming more common. Thus, it is not uncommon to have patients with symptomatic spinal stenosis secondary to degenerative changes and concomitant spinal metastatic disease, which may or may not be symptomatic. The decision-making strategy should be derived from a multidisciplinary discussion including the oncology team to determine the overall disease status of the patient. Patients with well-controlled systemic disease and a life expectancy of at least 3 months will likely benefit from surgical decompression of their symptomatic stenosis. Consideration can sometimes be made for palliative, minimally invasive decompression for patients who may have poor life expectancy but are still able to tolerate surgery. Although there is no high-level evidence for management of patients with spinal metastatic disease and concomitant stenosis, this chapter presents a patient with these concomitant pathologies.

Example case

  • Chief complaint: leg pain

  • History of present illness: This is a 73-year-old male with a history of prostate cancer and known spinal metastasis presenting with bilateral leg pain when walking. He denies any weakness or bowel or bladder incontinence. Metastatic disease has been controlled after chemotherapy and spinal radiation. The patient underwent magnetic resonance imaging (MRI), which revealed evidence of known metastatic disease but with lumbar stenosis ( Fig. 45.1 ).

    Fig. 45.1, Preoperative magnetic resonance imaging (MRI). (A) Sagittal T2, (B) axial T2 at the level of L4/5, and (C) sagittal T2 thoracic images demonstrating postradiation T2 hyperintensity at L1-5 and T2-7. There is evidence of multilevel lumbar spondylosis with severe L4-5 central canal stenosis secondary to disc bulge, ligamentum flavum thickening, and facet hypertrophy.

  • Medications: aspirin 81 mg

  • Allergies: no known drug allergies

  • Past medical history: prostate cancer s/p chemotherapy and spinal radiation

  • Past surgical history: transurethral resection of the prostate (TURP), IR-guided vertebral body biopsy

  • Family history: none

  • Social history: former smoker

  • Physical examination: awake, alert, and oriented x 3; CNII–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral, biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation is intact to light touch

  • Laboratories: all within normal limits

  • Carlos A. Bagley, MD

  • Neurosurgery

  • University of Texas Southwestern

  • Dallas, Texas, United States

  • Mohamed El-Fiki, MBBCh, MS, MD

  • Neurosurgery

  • Alexandria University

  • Alexandria, Egypt

  • Tong Meng, MD

  • Orthopaedic Surgery

  • Shanghai General Hospital

  • Shanghai Jiaotong University

  • Shanghai, China

  • Meic H. Schmidt, MD, MBA

  • Neurosurgery

  • University of New Mexico

  • Albuquerque, New Mexico, United States

Preoperative
Additional tests requested

  • L-spine standing x-rays

  • Physical therapy

  • Physiatrist of lumbar injections

  • Geriatrics evaluation

  • PET

  • CT chest

  • Creatinine level

  • Lower extremity Dopplers

  • Electrophysiological evaluation

  • MRI L-spine

  • CT L-spine

  • PET

  • Oncology evaluation

  • Urology evaluation

Anesthesia evaluation
Surgical approach selected If fails conservative measures, L4 laminectomy and bilateral foraminotomies L4-5 endoscopic discectomy and bilateral foraminotomy If survival greater than a year, L4-5 TLIF Left MIS L4-5 bilateral decompression
Goal of surgery Nerve root decompression Nerve root decompression Nerve root decompression Nerve root decompression
Perioperative
Positioning Prone on Jackson table Prone Prone Prone on Wilson frame
Surgical equipment Fluoroscopy

  • Fluoroscopy

  • Surgical microscope

  • Endoscope

  • Ultrasonic bone scalpel

  • Electrical drill

  • Fluoroscopy

  • Fluoroscopy

  • Surgical microscope

  • Electric drill

  • Tubular retraction system

Medications Pregabalin None Steroids None
Anatomical considerations Thecal sac, nerve roots, facet joints Lumbar nerve roots Lumbar nerve roots Lumbar nerve roots, dura
Complications feared with approach chosen Spinal instability CSF leak, nerve root injury CSF leak, nerve root injury CSF leak, spinal instability
Intraoperative
Anesthesia General General General General
Exposure L4-5 L4-5 L4-5 Left L4-5 lamina
Levels decompressed L4-5 L4-5 L4-5 Left L4-5 lamina and bilateral foraminotomies
Levels fused None None L4-5 None
Surgical narrative Position prone, localize intercristal line, make 1-inch incision at intercristal line, subperiosteal dissection to expose spinous process and proximal lamina, x-ray to confirm level, adjust incision ½ or less if necessary, place retractors, remove spinous process and superficial lamina of L4 with Leksell rongeur, drill away remnants of L4 lamina, define plane between dura and ligamentum flavum, remove ligamentum and wide laminectomy with Kerrison rongeur, undercut overgrown facets with Kerrison, generous foraminotomies bilaterally, probe foramen and obtain final x-ray in L4-5 foramen, irrigate with bacitracin lactated ringers, multilayer closure Position prone, confirm level with x-ray, midline skin incision over L4-5 space and dissect down to lamina, confirm level with x-ray, introduce microscope or use endoscopy with tube directed toward inferior border of L4, sequential dilation, then lock endoscope, remove soft tissue from posterior border of laminofacet junction, proceed to base of spinous process, drill lower 1.5 cm of the L4 lamina until junction with inferior articular facet, remove ligamentum flavum on inner surface of L4, remove 0.5 cm of lower L5 lamina, remove ligamentum until expose shoulder of nerve root, perform adequate foraminotomy so annulus seen with slight medial retraction of nerve root, open annulus and evacuate disc material, additional foraminotomy until nerve root is lax and pulsating, maintain integrity of facets, continue drilling medially to remove base of spinous process and cross to opposite side, decompress contralateral root, contralateral foraminotomy, apply vancomycin in wound, layered closure with drain Position prone, posterior midline incision, place L4-5 pedicle screws, L4-5 laminectomy, expose and remove ligamentum flavum, facetectomy, resect posterior bony elements, mobilize dural and neural elements to access posterior annulus and disc space without any dural tension, distract with triple distraction technique, enlarge a window on the disc to protect exiting and traversing nerve roots, resect disc, place appropriate sized interbody cage packed with bone graft, confirm location by fluoroscopy, restore lordosis, perform contralateral facetectomy, closure in layers Position prone with maximum lumbar flexion, fluoroscopy to determine level, left paraspinal muscle dissection down to lamina, place tubular retractor, laminectomy to ligamentum flavum under microscope, ipsilateral ligamentum flavum removed, ipsilateral foraminotomy, view contralateral side and resect contralateral ligamentum flavum, contralateral foraminotomy
Complication avoidance No fusion, target radicular nerve pain, undercut overgrown facets, generous foraminotomies MIS, endoscopy, partial laminectomy, additional foraminotomy until nerve root is lax and pulsating, maintain integrity of facets, unilateral approach to decompress bilaterally Mobilize dura and neural elements, distract with triple distraction technique, bilateral facetectomy Ipsilateral approach for bilateral decompression
Postoperative
Admission Floor Floor Floor Floor
Postoperative complications feared Infection, hematoma, medical complication CSF leak, neurological deficit, infection, medical complication CSF leak, neurological deficit CSF leak, spinal instability
Anticipated length of stay 1 day 1–2 days 4–5 days 23 hours
Follow-up testing None L-spine x-ray every 3 months for 1 year after surgery

  • Lumbar x-rays 1 day, 3 months, 6 months after surgery

  • MRI L-spine 3 days after surgery

Upright AP/lateral L-spine x-rays
Bracing None None Lumbar support for 3–4 weeks None
Follow-up visits 6 weeks after surgery 2 weeks, every 1 month for 1 year after surgery 3 and 6 months after surgery 3, 6, 12 months with x-rays after surgery
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; ICU , intensive care unit; IOM , intraoperative monitoring; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; PET , positron emission tomography.

Differential diagnosis

  • ▪

    Lumbar spinal stenosis

  • ▪

    Metastatic spine disease with possible epidural compression

  • ▪

    Synovial cyst

  • ▪

    Postradiation myelopathy

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