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Spine metastasis
Introduction
Metastatic spine disease occurs in approximately 20% of cancer patients, with an estimated 20,000 new cases each year. Most malignancies have the ability to spread to the spine, but the most common primary sites are lung, breast, prostate, and kidney. Chemotherapy and immunotherapies have become more efficacious; thus cancer patients are living longer, leading to an ever-growing number of patients with spinal metastasis. Historically, surgical management of spinal metastatic disease was controversial, with typical treatment paradigms consisting of steroids and radiation. The Patchell et al. trial that was published in 2005 provided level 1 evidence that surgical decompression plus radiotherapy is superior to radiotherapy alone for patients with spinal cord compression secondary to metastatic disease. This trial excluded patients with radiosensitive tumors, complete paraplegia for >48 hours, and multiple noncontiguous levels of disease; therefore, these patients are typically not considered for surgery. Radiation is a critical component of treatment, and there have been significant advances in the delivery methods for these tumors. The advent of stereotactic body radiotherapy (SBRT) has revolutionized the treatment of these lesions, allowing for excellent conformality and precision of treatment doses with minimal spillover to the spinal cord. Despite advances in surgical and radiation treatment, decision making for patients with spinal metastatic disease remains controversial. The neurological, oncological, mechanical, and systemic (NOMS) framework can be used to help guide this decision making. NOMS is an acronym for neurological, oncological, mechanical, and systemic disease. Each component of this framework must be considered when deciding which treatment strategy would be most ideal for a particular patient. The International Spine Oncology Consortium also published an algorithm to assist with decision making for these patients. Algorithms and guidelines like these must be used when deciding which treatment strategy would be best for cases like the one presented below.
Example case
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Chief complaint: neck pain and radiculopathy
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History of present illness: This is a 75-year-old male with a history of cholangiocarcinoma diagnosed 6 months ago and status post chemoradiation. He started having incapacitating left shoulder and neck pain. The pain radiates into his scapula and is not relieved with pain medications. He also has mild left-hand weakness and paresthesia and denies bowel/bladder dysfunction. He underwent imaging that was concerning for metastatic spine disease ( Figs. 44.1–44.2 ).
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Medications: amlodipine, apixaban, lorazepam, mirtazapine, oxycodone
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Allergies: iodinated contrast
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Past medical history: reflux, cholangiocarcinoma, hypertension, deep vein thrombosis, Barrett’s esophagus, hyperlidpiemia, back pain
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Family history: noncontributory
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Social history: nonsmoker
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Physical examination: awake, alert, and oriented x 3; cranial nerves CNII–XII intact
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Motor: Bilateral deltoids/triceps/biceps 5/5; right interossei 5/5; left interossei 4+/5. iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle no clonus or Babinski; sensation intact to light touch
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Laboratories: basic metabolic panel, heme-8, coags all within normal limits
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| Preoperative | ||||
| Additional tests requested |
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C-spine x-rays | Anesthesia evaluation |
| Surgical approach selected | Posterior C5-T4 instrumented fusion, T1 decompression if survival expected greater than 6 months | Minimally invasive T1 hemilaminectomy, left facetectomy, percutaneous C7-T2 fusion | T1 corpectomy and C7-T2 anterior plate | T1 corpectomy |
| Goal of surgery | Decompress C7-T1 and stabilize across cervicothoracic junction | Decompress left T1 nerve root, stabilization | Tumor debulking, stabilization | Decompression of spinal cord, tumor resection |
| Perioperative | ||||
| Positioning | Prone with Mayfield clamps | Prone with Mayfield clamps | Supine, no pins | Supine, no pins |
| Surgical equipment |
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Fluoroscopy |
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| Medications |
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None | None |
| Anatomical considerations | Traversing and exiting nerve rootsCentral canal | C7 and T2 pedicles, left T1 facet and pedicle, left T1 nerve root | Right sternocleidomastoid, carotid sheath, thyroid gland | Carotid artery, esophagus/trachea |
| Complications feared with approach chosen | Pseudoarthrosis, CSF leak | Postoperative pain, wound infection | Recurrent laryngeal nerve injury, thyroid gland injury, esophageal injury, carotid injury | Nerve root injury |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | C5-T4 | C7-T2 | C7-T2 | C7-T2 |
| Levels decompressed | C7-T2 laminectomy | T1 | T1 | T1 |
| Levels fused | C5-T4 | C7-T2 | C7-T2 | C7-T2 |
| Surgical narrative | Head is pinned, placed prone, incision, subperiosteal dissection from C5 to T4, bilateral lateral mass screws from C5 to 7 and pedicle screws T2-4 with navigation is available, secure with rods, wide laminectomy from C7-T2, posterolateral fusion with allograft, subfascial drain | Position prone with Mayfield pins, neck in neutral position, place spinous clamp and register navigation, intraoperative CT, percutaneous placement of C7 and T2 pedicle screws, connect rods, place expandable retractor through left C7 screw incision and doc on left T1 lamina, hemilaminectomy/facetectomy/pedicle removal under microscopic visualization, full decompress left T1 nerve root, standard closure | Position supine, lower anterior skin incision above medial border of right sternocleidomastoid muscle, approach anterior spinal column in standard fashion based on preoperative CT, limited manubriotomy with 1 cm of the central part of the manubrium with preservation of muscle attachment if needed after gentle mobilization of thyroid gland, ligate significant thyroid vessels on one side, T1 corpectomy, remove all tumor until thecal sac, remove cartilaginous end plates of C7 and T2, place PMMA spacer with plate fixed to spacer with two screws, augment C7 and T2 vertebral body with PMMA through the holes in the plate, fix screws quickly into cemented vertebral body, place synthetic strip-like bone substitute to promote lateral fusion laterally to plate, wound closure with drain | Right-sided incision at C6-7 level, blunt dissection between vessels and trachea/esophagus, confirm level with fluoroscopy, black belt retractor, continue with microscope, incision of C7-T1 and T1-T2 discs, removal of the uncus bilaterally, insertion of expandable PEEK cage, plate from C7 to T2 |
| Complication avoidance | Several levels above and below to prevent instability, neuronavigation | Surgical navigation, percutaneous screw placement, minimally invasive laminectomy | Avoid posterior approach, limited manubriotomy, use of PMMA spacer, augment C7 and T2 vertebral bodies, place synthetic strip-like bone substitute to promote fusion | Anterior approach, blunt dissection between vessels and trachea/esophagus |
| Postoperative | ||||
| Admission | ICU | Floor | ICU | Floor |
| Postoperative complications feared | Hematoma, hardware failure, medical complications | Tumor recurrence, misplaced screws, pain control | Vessel injury, laryngeal nerve paresis, thyroid gland and esophageal injury | Bleeding, hardware failure, tumor progression |
| Anticipated length of stay | 3–4 days | 2–3 days | 3–5 days | 23 hours |
| Follow-up testing | C-spine upright AP/lateral x-rays |
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C-spine x-rays after drain removal | CT C-spine after surgery and per oncology |
| Bracing | Cervical collar when out of bed | None | Hard collar for 6 weeks | None |
| Follow-up visits | 2 weeks for wound check; 3, 12, and 24 months | 3–4 weeks, 3 months after surgery | 3 months, 6 months, 12 months, 18 months, 24 months after surgery | 3 months after surgery |
AP , Anteroposterior; CSF , cerebrospinal fluid; CT , computed tomography; ICU , intensive care unit; IOM , intraoperative monitoring; MRI , magnetic resonance imaging; PEEK , polyetheretherketone; PET , positron emission tomography; PMMA , polymethylmethacralate.
Differential diagnosis
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Metastatic disease
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Multiple myeloma
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Primary bone tumor such as chordoma
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Osteomyelitis
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