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Thoracic spine metastasis with acute myelopathy


Introduction

Metastatic spine disease is one of the most feared complications of cancer with serious sequelae such as torturous pain, paralysis, and sphincter and sexual dysfunction. Approximately 30% of cancer patients develop symptomatic metastatic epidural spinal cord compression (MESCC) and a timely surgical decompression is the gold standard treatment. In this chapter, we present a case example to illustrate the clinical presentation and management of a patient with acute MESCC.

Example case

  • Chief complaint: new weakness

  • History of present illness: The patient is a 61-year-old male who presents to the emergency department with new-onset back pain and sudden-onset severe lower extremity weakness, sensory loss, and bowel and bladder incontinence. Thoracolumbar spine imaging showed a contrast-enhancing lesion involving the vertebral bodies of T8–10 and right pedicle and transverse process of T9, causing a T9 pathological fracture and severe spinal cord compression ( Fig. 51.1 ). The patient was afebrile and denies recent infection, renal insufficiency, or immune deficiency.

    Fig. 51.1, Preoperative magnetic resonance imaging (MRI). (A) Sagittal T2, (B) sagittal T1 with contrast, and (C) axial T2 images demonstrating a contrast-enhancing lesion involving the vertebral bodies of T8-10 (mostly T9) and causing a T9 vertebral body collapse. This extradural tumor causing significant ventral spinal cord compression and displacing the spinal cord to the left.

  • Medications: none

  • Allergies: no known drug allergies

  • Past medical history: hypertension, thyroid carcinoma, and squamous cell carcinoma of the lung

  • Past surgical history: none

  • Family history: noncontributory

  • Social history: none

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; full strength in bilateral upper extremities deltoids/triceps/biceps 5/5; interossei 5/5. Paraplegia with 0/5 strength in all lower extremity muscle groups. Sensory level at T11. No response on deep tendon reflex testing in patellar and Achilles tendons. Absent rectal tone.

  • Laboratories: all within normal limits

  • Amro F. Al-Habib, MD, MPH

  • Neurosurgery

  • King Khalid University Hospital

  • King Saud University

  • Riyadh, Saudi Arabia

  • Mark H. Bilsky, MD

  • Neurosurgery

  • Memorial Sloan Kettering Cancer Center

  • New York, New York, United States

  • Stefano Boriani, MD

  • Orthopaedic Surgery

  • IRCCS Istituto Ortopedico Galeazzi, Milan, Italy

Jang Yoon, MD Neurosurgery University of Pennsylvania Philadelphia, Pennsylvania, United States
Preoperative
Additional tests requested

  • CT T-spine

  • Chest x-ray

  • Blood cultures

  • Anesthesia evaluation

  • MRI complete spine

  • Bilateral lower extremity dopplers

  • Oncology evaluation

  • Family discussion

  • PET

  • CT C/T/L-spine

  • Spinal angiogram and selective arterial embolization

  • CT C/T/L-spine

  • CT chest/abdomen/pelvis

  • ESR/CRP

  • Blood cultures

  • Bence-Jones protein in urine

Surgical approach selected T8–9 laminectomy and costo-transversectomy and fusion T8–9 laminectomy, resection of epidural disease, PMMA augmentation, T8–9 fusion T8–9 laminectomy with posterior fusion and possible corpectomy pending preliminary pathology T8 partial corpectomy, T8–9 laminectomy, T6–11 posterior fusion
Goal of surgery Diagnosis, decompress neural elements, achieve adequate spinal stabilization Diagnosis, decompress spinal cord, stabilize spine, separation surgery for radiation treatment Diagnosis, decompress spinal cord Diagnosis, decompress spinal cord, stabilize spine
Perioperative
Positioning Prone on Jackson table, no pins Prone in pins Prone, no pins Prone on Jackson table, no pins
Surgical equipment

  • IOM (SSEP/MEP)

  • Surgical navigation

  • Fluoroscopy

  • Ultrasound

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • Surgical navigation

  • Ultrasound

Fluoroscopy Fluoroscopy
Medications MAP >80 Steroids, maintain MAP None Steroids
Anatomical considerations Pedicles Spinal cord Spinal cord Aorta, segmental vessels, artery of Adamkiewicz, thoracic spinal cord, lungs
Complications feared with approach chosen Spinal cord injury, neurological worsening Spinal cord injury Durotomy, bleeding from epidural veins Acute blood loss, wound complications, neurological worsening
Intraoperative
Anesthesia General General General General
Exposure T7–11 T8–9 T7-T11 T6-L2
Levels decompressed T8–9 T8–9 T8–9 T8-T10
Levels fused T7–11 T8–9 T8–9 T6-T11
Surgical narrative Position prone, level marking using anatomy landmarks and intraoperative navigation, adequate exposure, placement of navigation reference frame on most proximal spinous process, acquisition of images and connect them to the navigation system, placement of pedicle screws two levels above and below target segment, perform O-arm to confirm screw position, laminectomy and bilateral Position prone, fluoroscopy to confirm levels, incision, subperiosteal dissection, muscle retraction with forceps to avoid entering tumor, placement of pedicle screws with PMMA augmentation of pedicles, decompression by resecting entire spinous process of the index level and 50% of superior spinous process sparing interspinous ligament, matchstick is used to drill laminae to thin shell, ligamentum flavum Position prone, midline incision two levels above and below index level, wide T8-T9 laminectomy, sample tissue for frozen section, hemostasis of epidural vessels as soon as thecal sac fully exposed, place pedicle screws two levels above and below, complete fixation and graft if tumor Position prone, midline incision, subperiosteal dissection of paraspinal muscles and minimize charring of muscles, expose T6-T11, do not violate posterior tension band as well as facets, place bilateral pedicle screw at T6–7 and T10-T11 using anatomical landmarks, confirm position of screws with fluoroscopy, T8–9 laminectomy with medical facetectomy until pedicles can be palpated with a dissector, T8 transpedicular approach with removing both pedicles, confirm disease location, T7–8 and T8–9 discectomy, partial corpectomy
facetectomy of involved segment, intraoperative ultrasound to confirm level and assess spinal cord compression, removal of pedicle and rib head and achieve adequate decompression, send tissue for pathology and microbiology examination, another ultrasound to confirm decompression, apply rods and crosslink, close in layers with subfascial drain resected with #15 blade, medial bilateral pedicles and superior and inferior facet joints at index levels and superior joint at inferior level resected with drill to expose lateral dura, resection of tumor starting from normal dural planes, identify and spare nerve roots, partial resection of epidural tumor creating a defect in vertebral body, PLL-dural interface identified and PLL cut with scissors to create margin, ultrasound to confirm adequate decompression, decortication, placement of autograft, vancomycin in the wound, drain in epidural space, suprafascial flaps is radiosensitive, complete transpedicular corpectomy for gross total resection and reconstruction with PMMA or expandable cage if radioresistant, layered closure with subfascial drain and removal of the lesion with drill/curettes/osteotomes as needed, leave anterior cortex intact to minimize risk of vascular injury and pleural injury, remove cartilate from T7–8 and T8–9 to expose bony end plates, placement of expandable cage, preserve segmental vessel if concerned it is the artery of Adamkiewicz, confirm position of cage with fluoroscopy, place titanium rods bilaterally, vancomycin powder in the cavity, close with two subfascial drains
Complication avoidance Intraoperative navigation, two levels above and below fusion, ultrasound to assess level and decompression, costotransversectomy to achieve adequate decompression, crosslink for rods Muscle retraction with forceps, PMMA pedicle augmentation, spare interspinous ligament, avoid Kerrison punches, start tumor dissection from normal dural planes, identify and spare nerve roots, ultrasound to evaluate decompression, suprafascial flaps to minimize tension Hemostasis of epidural veins as soon as thecal sac fully exposed, avoid corpectomy and expandable cage if tumor is radiosensitive based on frozen pathology Minimize charring of muscles, maintain posterior tension band and facet capsules, bilateral transpedicular approach, leave anterior cortex of vertebral body intact to minimize risk of vascular injury, angiography to study artery of Adamkiewicz
Postoperative
Admission Stepdown unit ICU ICU ICU
Postoperative complications feared Neurological deterioration, infection Pseudoarthrosis, medical complications CSF leak, wound healing problems Instrumentation migration/failure, adjacent segment disease, medical complications
Anticipated length of stay 4 weeks 6 days 7 days 5–7 days
Follow-up testing

  • Physical therapy

  • MRI T-L spine 1 month after surgery

  • X-rays 1 month after surgery

  • MRI T-L spine 72 hours after surgery

  • Plain x-rays

  • Radiation oncology evaluation

  • MRI T-spine every 3–4 months for 2 years depending on pathology

  • Multidisciplinary team discussion pending pathology

  • Upright thoracic and lumbar x-rays 6 weeks after surgery

  • Radiation oncology evaluation

Bracing TLSO for 2 months None None None
Follow-up visits 1 month after surgery 3 weeks after surgery Every 3–4 months for 2 years depending on pathology 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery
CRP , C-reactive protein; CSF , cerebrospinal fluid; CT , computed tomography; EMG , electromyography; ESR , erythrocyte sedimentation rate; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; MRI , magnetic resonance imaging; PET , positron emission tomography; PLL , posterior longitudinal ligament; PMMA , polymethylmethacrylate; SSEP , somatosensory evoked potential; TLSO , thoracic lumbar sacral orthosis.

Differential diagnosis

  • ▪

    Metastatic spine disease

  • ▪

    Spinal stenosis

  • ▪

    Osteomyelitis

  • ▪

    Primary extradural spinal tumor

  • ▪

    Traumatic fracture

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