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Multiple spine metastasis with one level symptomatic


Introduction

Spinal metastatic disease is seen in almost 40% of cancer patients, and up to 20% of those patients will have spinal cord compression. The American Cancer Society found that there were 1.7 million new cases of cancer diagnosed in the United States in 2017. As patients are living longer due to improved cancer therapies, there has been an increased incidence of metastatic disease. The treatment of patients with solitary spinal metastasis and compression of the spinal cord has been validated with level 1 data and there is a clear consensus on the benefit of surgery for this group of patients. However, the guidelines are not as clear when patients have multiple noncontiguous areas of disease. The randomized clinical trial by Patchell et al. excluded patients with multiple noncontiguous levels of tumor, so there is no high-level evidence for this group of patients. The treatment goal for these patients with multiple spinal metastases has primarily been centered around the goal of palliation. However, there have been multiple reports and series showing that tumor resection in these patients can lead to improvement in quality of life, although the surgery itself will not be curative. A prospective multicenter study found that surgical treatment of patients with oligometastatic disease will have improved survival compared with survival management of patients with polymetastatic disease. Both groups, however, had improved quality of life after surgical decompression of the symptomatic lesion. Prior to consideration for surgery, patients should be assessed by a multidisciplinary team to determine their estimated survival, as patients with a short life expectancy may not benefit from surgical management of their tumors and may be better served by less invasive strategies for pain control.

Example case

  • Chief complaint: back and leg pain with leg weakness

  • History of present illness: This is a 78-year-old male with a history of renal cell carcinoma who presents with a 3-month history of back pain and 3 weeks of leg pain. He has not been ambulatory due to leg weakness and pain. The patient had magnetic resonance imaging (MRI), which revealed evidence of a tumor compressing his thecal sac at L2, as well as evidence of disease elsewhere ( Fig. 49.1 ).

    Fig. 49.1, Preoperative imaging. (A) , Axial T1 with contrast magnetic resonance imaging (MRI); (B) , sagittal T2 MRI demonstrating an expansile destructive L2 metastasis with involvement of the spinous process, lamina, pedicles, and majority of the vertebral body. The vertebral body demonstrates mild pathological collapse of the superior end plate on the left side. There is marked expansion of the pedicles and posterior elements by the soft tissue involvement with posterolateral epidural extension producing severe compression of the thecal sac and crowding of the cauda equina roots. (C) , Positron emission tomography/computed tomography scans of the whole body demonstrating a hypermetabolic right upper lobe pulmonary nodule and multiple mediastinal and hilar lymph nodes with increased metabolic activity, concerning for neoplastic processes. There is also evidence of multiple lytic lesions seen within the sternum, spine, and left parietal calvarium, some of which demonstrate increased metabolic activity suggestive of metastatic lesions from patient’s known left renal primary.

  • Medications: aspirin 325 mg

  • Allergies: no known drug allergies

  • Past medical history: renal cell carcinoma

  • Past surgical history: nephrectomy

  • Family history: noncontributory

  • Social history: previous smoker

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension 3/5, 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 intact to light touch

  • Laboratories: all within normal limits

  • Rafid Al-Mahfoudh, MBChBh

  • Neurosurgery

  • Brighton and Sussex University Hospitals

  • Brighton, United Kingdom

  • Manoj Phalak, MCh

  • Neurosurgery

  • All India Institute of Medical Sciences

  • New Delhi, India

  • Khoi D. Than, MD

  • Neurosurgery

  • Duke University

  • Durham, North Carolina, United States

  • Anand Veeravagu, MD

  • Neurosurgery

  • Stanford University

  • Palo Alto, California, United States

Preoperative
Additional tests requested

  • MRI complete spine

  • CT lumbar spine

  • CT chest/abdomen/pelvis CT

  • Oncology evaluation

  • Cerebral angiogram with embolization

  • DEXA

  • CT lumbar spine

  • Oncology evaluation

  • Radiation oncology evaluation

  • Anesthesia evaluation

  • CT lumbar spine

  • Oncology evaluation

  • Radiation oncology evaluation

  • MRI complete spine

  • Standing lumbar spine x-rays (AP and lateral)

Surgical approach selected L2 decompression and fusion and resection of tumor L1-3 decompression and tumor resection with T10-L4 posterior fusion If prognosis is reasonable (> several weeks), minimally invasive L2 laminectomy If patient has minimal systemic disease, L2 corpectomy, L2-3 laminectomy, T11-L5 instrumented fusion
Goal of surgery Decompress neural elements, stabilize spine Maximal tumor resection, stabilization to reduce pain Decompress neural elements Decompress neural elements, separate neurological elements to allow for radiotherapy
Perioperative
Positioning Prone on Jackson or Allan table Prone on Allan table Prone on Wilson frame Prone on Jackson table
Surgical equipment

  • Fluoroscopy

  • Surgical microscope

  • Ultrasonic bone scalpel

  • IOM (MEP/SSEP)

  • Surgical navigation

  • Ultrasonic aspirator

  • Fluoroscopy

  • Tubular retractor

  • Surgical microscope

  • Fluoroscopy

  • IOM

  • Surgical navigation

Medications Tranexamic acid, steroids Maintain MAP None Possible tranexamic acid, steroids
Anatomical considerations Thecal sac, pedicles Iliopsoas, lumbar plexus, aorta, renal artery, inferior vena cava, ureter Thecal sac, nerve roots Thecal sac, nerve roots
Complications feared with approach chosen Blood loss, prolonged hospital stay Injury to blood vessels, ureteral injury, pseudoarthrosis, CSF leak, infection CSF leak, recurrent stenosis Conus injury, nerve root injury, CSF leak
Intraoperative
Anesthesia General General General General
Exposure L2 T10-L4 L2 T11-L4
Levels decompressed L2 L1-3 L2 L2-3
Levels fused T12-L4 T10-L4 None T11-L4
Surgical narrative Position prone, AP x-ray to ensure good visualization of pedicles using K-wire held against skin, paramedian stab incisions, Jamshidi needles progressed through pedicles with x-ray control, two levels above and below, K-wire inserted through Jamshidi needles, Jamshidi needles removed, percutaneous dilators, tap then pedicle screws inserted under x-ray, rods measured and tunneled, rods reduced and set screws applied, midline incision at L2, bilateral muscle dissection with tranexamic soaked swabs, McCulloch retractors placed, microscope brought in, L2 spinous process removed, laminectomy with high-speed drill, remove remained of thinned lamina with upcuts with flavectomy, lateral recess decompression with ultrasonic bone scalpel, debulk the extradural portion of tumor to achieve good clearance from the theca, pedicle removal to gain and aid access to lateral/anterolateral aspect of theca, apply hemostatic agent to reduce excessive blood loss, closure in layers with vancomycin and subfascial drain if necessary Position prone on Allen table, baseline IOM, preparation of iliac crest for bone graft, T10-L4 incision, subperiosteal dissection making sure to not violate tumor, place pedicle screws T10-L4 and including T10-11 because of assumed compression fracture, place temporary rod on right, L1-3 laminectomy with excision of transverse process and intralesional resection, gently create lateral and ventral plane to vertebral body with malleable retractor, detach psoas and crus of diaphragm, excision L1-2 and L2-3 discs, remove pedicle off of tumor, mobilize remaining tumor, maximal tumor removal and decompression, place titanium mesh with iliac crest autograft, decorticate exposed bone posteriorly and use remaining iliac crest graft to help with fusion, layered wound closure with drains Position prone on Wilson frame, Wilson frame cranked open to provide kyphosis to open interlaminar spaces, midline spinous process marked, 1 cm lateral to midline planned, spinal needle placed aimed directly at L2-3 disc space based on lateral fluoroscopy, 2 cm incision made where needle enters skin, dissect through lumbar muscular fascia with cauterization, gradually increased dilator tubes docked to inferior L2 lamina, 18 mm wide tubular retractor and location confirmed with fluoroscopy, microdissection with microscope, muscles overlying L2 lamina removed, L2 laminectomy down to ligamentum flavum, rostral attachment dissected from underlying thecal sac with curved curette, ligamentum flavum is removed with Kerrison rongeurs, tumor sent to pathology, contralateral decompression with angled tubular retractor, remove bone/ligamentum flavum/tumor as needed, confirm adequate decompression with Woodson elevator, wound closed in layers Position prone, O-arm for intraoperative navigation, place pedicle screws T11-12 and L1 and L3–4, perform L2-3 laminectomy, transpedicular decompression, resect L1-2 and L2-3 discs, place temporary rod, complete L2 corpectomy, place expandable titanium cage, insert final rods from T11 to L4, fusion with allograft across laminectomy defect site, multilayer closure with two subfascial drains
Complication avoidance Embolization, AP x-ray to confirm location of pedicles, percutaneous screws under fluoroscopy, tranexamic soaked swabs, remove tumor to good clearance from dura, remove pedicle if necessary to gain better visualization Possible staged procedure for blood loss or hemodynamic instability, if this occurs, iliac crest for bone grafting, avoid violating tumor during dissection, incorporate compression fracture levels into construct Minimally invasive laminectomy, confirm adequacy of decompression with Woodson elevator Surgical navigation, incorporate T12 vertebral body fracture, separation surgery
Postoperative
Admission Floor ICU Floor Floor
Postoperative complications feared Excessive bleeding Injury to blood vessels, ureteral injury, pseudoarthrosis, CSF leak, infection CSF leak, wound infection, recurrent stenosis Wound complication, CSF leak, failure of fusion
Anticipated length of stay 3–5 days 10 days 2–3 days 4 days
Follow-up testing

  • Lumbar x-rays within 24 hours of surgery

  • Oncology evaluation

  • T-L spine x-ray after surgery

  • CT T-L spine 3 months after surgery

  • MRI lumbar spine after surgery

  • Chemoradiation per oncology 3 weeks after surgery

  • MRI and CT lumbar spine within 1 month of surgery

  • Lumbar x-rays 1 month, 3 months, 6 months, 12 months after surgery

Bracing None None None TLSO for 8 weeks
Follow-up visits 6–8 weeks after surgery 14 days and 3 months after surgery 2 weeks after surgery 2 weeks, 1 month, 3 months, 6 months, 1 year after surgery
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; EMG , electromyography; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; SSEP , somatosensory evoked potential; TLSO , thoracic lumbar sacral orthosis.

Differential diagnosis

  • ▪

    Metastatic disease

  • ▪

    Lumbar stenosis

  • ▪

    Multiple myeloma

  • ▪

    Primary bone tumor such as chordoma

  • ▪

    Osteomyelitis

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