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Spinal metastasis with kyphotic deformity


Introduction

Primary tumors may spread to the spine in 20% to 40% of cancer patients, and approximately 20% of these patients will be symptomatic from their tumors. Their symptomatology may be related to compression of the spinal cord, leading to pain and weakness, mechanical back pain from spinal instability, or a combination of these two. The presence of mechanical back pain should prompt consideration for stabilization of the spine, as this pain may be partially or completely resolved if instability is the true etiology of their pain. There is ample evidence to suggest that surgical decompression plus radiation is the management of choice for patients with spinal metastatic disease and epidural compression. However, there is no clear consensus as to when patients undergoing surgery will require stabilization. These decisions were typically made according to factors such as patient symptoms, patient health and life expectancy, and tumor histology, but there was a lack of evidence-based guidelines for determination of spinal stability. The Spinal Instability in Neoplastic disease Score (SINS) is a tool to guide clinicians who are evaluating patients with spinal metastatic disease to help determine the need for surgical stabilization ( Table 48.1 ). There are six components to this scoring system, including location, presence of mechanical pain, spinal alignment, whether the tumor is lytic or blastic, amount of vertebral body collapse, and tumor involvement of posterior elements. A score is given according to each component, and the cumulative score determines whether the patient will require stabilization. In this chapter, we present a patient with metastatic disease for which this score may be applied.

Example case

  • Chief complaint: neck pain and radiculopathy

  • History of present illness: This is a 65-year-old female with a history of breast cancer status post chemoradiation on remission. She presents with several months of back pain. Over the past few days, she reports worsening pain, balance dysfunction, leg weakness, and numbness. She underwent imaging and there was concern for cord compression ( Figs. 48.1–48.2 ).

    Fig. 48.1, Preoperative magnetic resonance images. (A) T2 sagittal, (B) T1 sagittal with contrast, and (C) T1 axial with contrast images demonstrating pathological involvement of the T2 and T3 vertebral body and circumferential cord compression.

    Fig. 48.2, Preoperative computed tomography images. (A) Sagittal and (B) axial images demonstrating pathological involvement of the T2 and T3 vertebral body.

  • Medications: melatonin, metoprolol

  • Allergies: iodinated contrast

  • Past medical history: breast cancer, hypertension

  • Family history: noncontributory

  • Social history: nonsmoker

  • Physical examination: awake, alert, and oriented x 3; cranial nerves CNII–XII intact; bilateral deltoids/triceps/biceps/interossei 5/5; iliopsoas 4/5; knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 3+ in bilateral biceps/triceps/brachioradialis with positive Hoffman; 3+ in bilateral patella/ankle; positive clonus and Babinski; sensation intact to light touch

  • Laboratories: basic metabolic panel, heme-8, coagulation all within normal limits

  • Andres Almendral, MD

  • Neurosurgery

  • Clinica Hospital San Fernando

  • Panama City, Panama

  • Takeshi Hara, MD

  • Neurosurgery

  • Juntendo University

  • Hongo, Bunkyo-ku, Tokyo, Japan

  • Maziyar A. Kalani, MD

  • Neurosurgery

  • Mayo Clinic

  • Phoenix, Arizona, United States

  • Khoi D. Than, MD

  • Neurosurgery

  • Duke University

  • Durham, North Carolina, United States

Preoperative
Additional tests requested

  • DEXA

  • Cardiothoracic surgery

  • Oncology evaluation

  • Radiation oncology evaluation

  • Anesthesia evaluation

  • CTA C-spine

  • CT T-spine

  • MRI T-spine

  • Bone scintigram

  • MRI complete spine

  • CT T-spine

  • Cardiothoracic surgery

  • Oncology evaluation

  • Radiation oncology evaluation

  • MRI complete spine

  • Oncology evaluation

  • Radiation oncology evaluation

  • CT chest/abdomen/pelvis

Surgical approach selected

  • Stage 1: T3-4 laminectomy and C5-T7 posterior fusion

  • Stage 2: T2-4 corpectomy via midline sternotomy

  • Stage 1: T2-4 corpectomy via midline sternotomy

  • Stage 2: T2-4 posterior decompression and C7-T6 posterior fusion

If prognosis is reasonable (> several months), C6-T6 posterior instrumented fusion with T2-4 laminectomy, possible T2-3 corpectomies with T1-4 interbody fusion
Goal of surgery Decompress the spinal cord, stabilize spine Relieve neck pain, improve quality of life Decompress the spinal cord, correction of kyphosis, stabilize the spine Decompress the spinal cord, stabilize the spine
Perioperative
Positioning Prone with pins Prone with pins Stage 1: supineStage 2: prone on Jackson table, no pins Prone with pins
Surgical equipment

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • Surgical navigation

  • IOM (MEP)

  • Fluoroscopy

  • O-arm

  • Surgical navigation

  • IOM

  • Fluoroscopy

  • Cardiothoracic surgery

  • Chest tube

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • O-arm/surgical navigation

Medications Steroids, maintain MAP None Steroids, MAP >85 MAP >80
Anatomical considerations Vertebral bone anatomy Vertebral arteries, aorta

  • Stage 1: heart, great vessels, trachea, lungs, esophagus

  • Stage 2: spinal cord

Spinal cord, T2-3 nerve roots, pleura
Complications feared with approach chosen Blood loss, spinal compression, spinal instability Major vessel injury, spinal cord and/or nerve root injury Major vessel injury, spinal cord injury, injury to artery of Adamkiewicz Neurological deficit
Intraoperative
Anesthesia General General General General
Exposure C4-T6 C7-T7

  • Stage 1: anterior T2-4

  • Stage 2: C7-T6

C6-T6
Levels decompressed

  • Stage 1: T3-4

  • Stage 2: T2-4

T2-4

  • Stage 1: T2-4

  • Stage 2: T2-4

T2-4
Levels fused

  • Stage 1: C5-T7

  • Stage 2: T2-4

C6-T7

  • Stage 1: T2-4

  • Stage 2: C7-T6

C6-T6
Surgical narrative

  • Stage 1: Preflip IOM, position prone after placing Mayfield pins, keep in neutral position, postflip IOM to confirm stability, midline incision, subperiosteal dissection exposing C4 to T6, fluoroscopic or surgical navigation guidance to place pedicle screws at T1-T2/T5-7/C7 and lateral mass screws at C5-6, T3-4 laminectomy, epidural tumor resection, layered closure with drain

  • Stage 2 (same day): cardiothoracic surgery to perform midline sternotomy, T2-4 corpectomy, insertion of expandable cage and plate, layered closure

Preflip IOM, position prone with pin, keep neutral position, midline incision, subperiosteal dissection exposing from C7 to T7, place C7 pedicle pilot holes with surgical navigation as well as T1/T4-6 pedicles, T2-3 laminectomy, place C7/T1/T4-5 pedicle screws, confirm placement with x-rays, place cobalt chromium alloy rods, layered closure

  • Stage 1: position supine, cardiothoracic surgery to perform exposure via midline sternotomy, intraoperative x-ray to identify correct level, annulotomy at T1-2 and T4-5, discectomy to remove cartilaginous end plates off inferior end plate of T1 and superior end plate of T5, midline marked based on where discs drop off laterally, corpectomy in piecemeal fashion, use discectomies to evaluate depth, remove posterior cortex of bone with upgoing curettes, remove any soft tissue from epidural space, titanium cage filled with allograft and place in space, apply buttress screws to secure cage into end plates of T1 and T5, cardiothoracic closure with chest tube

  • Stage 2 (3 days later): preflip IOM, position prone, postflip IOM, x-ray to confirm anterior cage is not dislodged, midline incision from C7 to T6, subperiosteal dissection, intraoperative x-ray to confirm levels, freehand placement of bilateral pedicle screws at C7/T1/T5/T6, final rods placed to avoid spinal translation and movement of cage, T2-4 laminectomy, final x-rays, closure in layers with subfascial drain

Positioned prone with Mayfield pins, neutral anatomical alignment, fluoroscopy to localize level, midline incision, subperiosteal dissection, instrumentation with lateral mass screws at C6, pedicle screws at C7/T1/T4-T6, T2-4 en bloc laminectomy with high-speed drill, removal of ligamentum flavum, wide bony removal at T2-3 similar to costotransversectomy, bilateral T2-3 nerve roots are identified and ligated, T2-3 corpectomies with osteotome and curettage working lateral to the spinal cord, tissue sent to pathology, size corpectomy defect, insertion of appropriate sized interbody device filled with allograft, O-arm spin to confirm accuracy of instrumentation, rods contoured appropriated and placed in screw heads, set screws placed and final tightened after fluoroscopy, remained bone between C6 and T6 decorticated and allograft is laid, wound closed in layers with drain
Complication avoidance Preflip IOM, possible surgical navigation, two-staged approach, cardiothoracic for anterior exposure Preflip IOM, surgical navigation for pedicle screws Two-staged approach, cardiothoracic for anterior exposure, use discectomies to evaluate depth, preflip IOM prior to starting second stage, early placement of rods to prevent spinal translation and dislodgement of cage En bloc laminectomy, work lateral to spinal cord for corpectomy
Postoperative
Admission ICU ICU ICU ICU
Postoperative complications feared Blood loss, spinal compression, spinal instability Infection, instrument failure, aortic injury Major vessel injury, spinal cord injury, injury to artery of Adamkiewicz Neurological deficit
Anticipated length of stay 4–6 days 10 days 5–7 days 5 days
Follow-up testing

  • CT C-T spine within 48 hours of surgery

  • Oncology evaluation

Radiation oncology evaluation

  • Standing AP/lateral scoliosis x-rays 6 weeks, 6 months, 1 year after surgery

  • Radiation oncology evaluation

  • Scoliosis films

  • CT myelogram for radiation planning

Bracing None Soft collar for 3 months TLSO for 6 weeks CTO for 6 weeks
Follow-up visits 2 weeks, monthly after surgery 1 week, every 1–2 months after surgery 2 weeks, 6 weeks, 6 months, 1 year after surgery 3 weeks after surgery
AP , Anteroposterior; CT , Computed tomography; CTA , computed tomography angiography; CTO , cervical thoracic orthosis; DEXA , duel-energy x-ray absoprtiometry; EMG , electromyography; ESI , epidural spinal injections; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; SSEP , somatosensory evoked potentials; TLSO , thoracic lumbar sacral orthosis.

Table 48.1
Spinal Instability in Neoplastic disease Score (SINS)
Location Junctional (occiput-C2, C7-T2, T11-L1, L5-S1) 3
Mobile spine (C3-C6, L2-L4) 2
Semirigid (T3-T10) 1
Rigid (S2-S5) 0
Mechanical Pain Yes 3
Pain present but not mechanical 1
No pain 0
Type Of Bone Lesion Lytic 2
Mixed 1
Blastic 0
Spinal Alignment Subluxation/translation 4
Kyphosis/scoliosis 2
Normal alignment 0
Vertebral Body >50% collapse 3
Colapse <50% collapse 2
No collapse with >50% body involved 1
None of the above 0
Involvement Of Bilateral 3
Posterolateral Unilateral 1
Elements None 0
0 to 6 indicates stability, scores of 7 and greater warrant surgical intervention

Differential diagnosis

  • ▪

    Metastatic disease

  • ▪

    Multiple myeloma

  • ▪

    Primary bone tumor such as chordoma

  • ▪

    Osteomyelitis

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