Life expectansy Operative treatment Complications

1. Metastatic Tumors
of the
Spinal Column:
Diagnosis and Treatment
GEORGE SAPKAS
PROFESSOR OF ORTHOPAEDICS
Metropolitan Hospital Athens

2. Epidemiology
Pneumon’s metastasis

3. Συχνότητα άνα περιοχή
Metastasis
 CA- breast 45-85%
 CA- lung 35-60%
 CA-kidney 35-40%
 CA- prostate 35-85%
 CA- thyroid 30-60%
Skull 35%
Cervical spine 22%
Humerus 10%
Ribs 57%
Thoracic spine 37%
Lumbar spine 53%
Sacrum 6%
Pelvis 19%
Femur 22%
Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

4. The most common
location for skeletal
metastasis:
 Thoracolumbar region
~ 70%
 Lumbar and sacral
spine ~ 20%
 Cervical spine ~ 10%
Gilbert R.W. et al.
Ann. Neural. 1998 Pneumon’s metastasis

5. European Review for medical and Pharmacological sciences 2004

6. Vertebral metastases are
the first sign of malignant
disease in 12% to 20% of
the cases.
Schick V. et al.
Neurosurg. Rev. 2001
Schiff D. et al.
Neurology 1997
Pneumon’s metatstasis

7. Clinical
symptoms of
spinal metastasis
Pain
Neurologic deficit

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The spinal pain may be due:
In destruction of the anatomic
vertebral elements as a result
of metastases
Resulting spinal instability
The pain is possible to occur
as a result of:
compression
or
infiltration of the spinal
cord – nerves from neoplasmatic
masses.
Pain

9. Pathologic spinal
fracture
Spinal pain
Instability Compression
of the neural
tissues
Neurologic
deficit

10. Diagnosis of
spinal metastases
M.K.
F 81
2yrs POP
Thyroid metastasis
L3
L3
T12
T12

11. CT
3-D

12. Kidney’s metastasis
M.R.I.

13. Tc 99 MDP
SCANNING

14. Lung’s metastasis
P.E.T.

15.  Graig’s trocar
 C.T. – guided
percutaneous
needle - trocar
Biopsy of the spine

16. Breast adenocarcinoma : spinal metastasis

17. Treatment
Medical treatment
Chemotherapy
Hormone therapy
Immunotherapy
Radiotherapy
Operative

18. Medical treatment
Chemotherapy
Anti-tumor medication
Steroids
Bi-phosphonates

19. Chemotherapy
Highly sensitive
Childhood cancers like
acute lymphocytic leukemia
Wilms tumor
Ewing’s tumor
Retinoblastoma
Rhabdomyosarcoma
Hodgkin’s lymphoma.
Carcinoma of the testis.
Choriocarcinoma.
Burkitts tumor.
Acute promyelocytic leukemia.
Costachescu E. et al 2010

20. Chemotherapy
Moderately sensitive
Adenocarcinoma of breast.
Non-Hodgkin’s lymphoma.
Lung cancer.
Osteosarcoma.
Adult myeloid and lymphocytic leukemia.
Carcinoma of the prostate.
Colorectal carcinoma.
Female cancers of the ovary, endometrium,
and cervix.
Costachescu E. et al 2010

21. Chemotherapy
Minimally sensitive
Endocrine gland cancers.
Malignant melanoma.
Hepatocellular carcinoma.
Renal carcinoma.
Pancreatic carcinoma.
Costachescu E. et al 2010

22. Bi-phosphonates
Tend to inhibit osteoclast
re-absortion of bone matrix and
decrease bone turnover.
There are three generations of
bi-phosphonate currently
available.
Costachescu E. et al 2010

23. Radiotherapy
Relevant contraindication : Neurologic deficit
Absolute contraindication : Vertebral collapse
Indications
• Palliative
• Post-operative

24. Radiosensitivity of metastatic
lesions
Squamous cell carcinomas
Lymphomas
Adenocarcinomas
Sarcomas
Melanoma

25. Radiotherapy
EXPECTED LIFE TIME
QUALITYOFLIFE
WITHOUT
THERAPY
PALLIATIVE
THERAPY
Spinal metastasis

26. ARTERIAL EMBOLISM
IN
SPINAL METASTASIS

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CA Νεφρού - Μετάσταση

28. Cervical Spine
Courtesy Dr George Magoufis
Interventional Radiologist

29. RT TH 10,11 RT TH 9 LT TH 8
LT TH 9
LT TH 9
S1E4
Thorasic Spine
Courtesy Dr George Magoufis
nterventional Radiologist

30. 1. Spinal instability
2. Pain resistible to conservative
treatment (radiotherapy –
chemotherapy)
3. Incomplete neurologic deficit
resistible to any type of
conservative treatment
4. Rapid deterioration of the
neurologic deficit
Indications for operative treatment

31. 5. Recurrence of tumor in
an area that has been
already submitted in
radiotherapy (at the
maximum permitted
levels)
6. Ambiguous histological
diagnosis

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The biology of the tumor
The location
The pain
The neurologic deficit
The spinal instability
Life expectancy
Overall condition of the
patient
Aboulafia A. Levine A., OKU Spine 2, 2004
Factors for evaluation:

33.  Tokuhashi
scoring system
 Tomita surgical staging
 Karnofsky performance status
scale definitions rating (%) criteria
Methods of evaluation

34. Tokuhashi’s Evaluation System for
prognosis of metastatic spinal tumors
Symptoms 0 1 2
General condition
performance status
Poor
(PS 10% to 40%)
Moderate
(50% to 70%)
Good
(80% to 100%)
No of extraspinal
skeletal metastases
>3 1 to 2 0
Metastases to
internal organs
Unremovable Removable No metastases
Primary site of
tumor
Lung stomach Kidney liver uterus
unknown
Thyroid prostate
breast rectum
Number of
metastases
>3 2 1
Spinal cord palsy Complete Incomplete None
Tokuhashi, Y. et al, Spine 1990
Total score versus survival period:
9 to 12 points > 12 months survival
0 to 5 points < 3 months survival

35. Tokuhashi’s criteria allow the
definition of a pre-operative strategy
and therefore considerable variability
in the choice of treatment ranging:
excisional operation should be performed
on those who scored above 9 points
a palliative operation should be
performed on those who scored under 5
points
Tokuhashi Y. et al.
Spine 1990

36. Simpler system of preoperative
evaluation based on only three
parameters:
the degree of malignacy
the presence of visceral metastases
the presence of bony metastases.
Tomita K. et al.
Spine 2001
Bauer H. et al.
Spine 2002

37. Tomita’s classification system
Intra-compartmental Extra-compartmental Multiple skip
lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site
(1 or 2 or 3)
Anterior or posterior
Lesion in situ
Site
(1 +2 or 3 + 2)
Extension to pedicle
Site
(1 +2 +r 3)
Anterio-posterior
development
(any site + 4)
Epidural extension
(any site + 5)
Paravertebral
development
Involvement to
adjacent vertbra

39. Life expectansy
1 yr Adrenal glands
1 yrLung cancer
2 yrs Breast
3 yrs Multiple myeloma
Differentiated
Thyroid cancer
5 yrs

40. Operative treatment

41. Types of operative treatment
Decompression
Decompression–
spondylodesia
Debulking
Piecemeal excision

42. Boriani S. et al Spine 1997

43. Up to three
vertebral
metastases
Anterior procedure

44. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

45. Breast’s metastasis
 Vertebrectomy
 Vertebral substitution
by cylinder
and
 Stabilization

47. .

48. Posterior procedure
1. Vertebrae
2. Posterior vertebral
elements involvement
3. Poor general condition

49. Posterior decompression
±
stabilization
Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004

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LevelBilateral Mastectomy 35 yrs ago

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Posterior decompression
±
Occiput-Cervical stabilization

53. Breast’s metastasis
Posterior decompression
±
stabilization
Thoracic spine

54. Posterior decompression
and
stabilization

55. Combined procedures
(anterior – posterior)
Breast metastasis

56. Pneumon Metastasis
N(+)

58. Combined
Anterior - Posterior decompression
±
Cervical stabilization

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60. Combined
Anterior - Posterior decompression
±
Thoracic stabilization

61. Breast’s metastasis

62. Global Spine Tumor Study Group

63. Gasbarrini A. et al European Review for medical and Pharmacological sciences 2004
Total en block Vertebrectomy

64. Total vertebrectomy
Stener 1971
Stener and Johnsen 1971
Sundaresan et al 1988
Roy-Camille et al 1990
Boriani et al 1994
Tomita et al 1994
Total en Bloc spondylectomy (TES)
for solitary spinal metastases
Int. Orthopedics, 1994

65. Total Vertebrectomy
according to Tomita

66. Total en Bloc Spondylectomy (TES)
Harmful
Not useful
Useful
Asymptomatic, Inactive aneurysmal bone
cyst T11 , 65 yrs
Primary osteosarcoma L3, 40 yrs
Meta Ca Lung,
T4, T7, meta liver,
>72 yrs, Karnofsky 20

67. En Block Vertebrectomy
Indications
Primary malignant tumors stage Ι - ΙΙ
Aggressive benign tumors stage 3 (GCT)
Isolated metastasis with long life expectancy

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Anatomical
restrictions
• Anterior longitudinal ligament
• Posterior longitudinal ligament
• Periosteum of spinal canal
• Ligament flavum
• Periosteum of lamina
• Periosteum of spinal process
• Intrespinous ligament
• Spinous ligament
• End plate
• Nucleous polposus

69. Anatomical restrictions for
Total En Block Vertebrectomy

70. Uncontrollable hemorrhage
Injury of great vessels
Spinal cord injury
Dissemination of cancerous cells
Total instability
Total En block Vertebrectomy
(TEBV)
intra-operative complications

71. Local recurrence due to remaining malignant and
dispersion cancerous cells intra-operatively
Talac et al, Relationship between surgical margins and local
recurrence in sarcomas of the spine, CORR 397:127 - 132
Tomita et al,J Orthop Sci (2006) 11:3–12

72. Revision due to local recurrence
Extremely difficult
Postoperative scars with adhisions
to nearby sensitive anatomical
stractions
 meninges
 Aorta
 vena cava
Therefore the first operation should
be and the final
Talac et al, Relationship between surgical margins and local
recurrence in sarcomas of the spine, CORR 397:127 - 132

73. Material
(open procedures)
 2006 - 2018
 45 patients :
28 women and 17 men
 Age: 58.8 yrs (range 22-72)
 Neurologic deficit 20 pts

74. Material
The primary tumors were:
Breast 12 pts
Lung 11 pts
Thyroid 4 pts
Colon 2 pts
Kidney 4 pts
Uterus 5 pts
Lymphoma 4 pts
Gastric 2 pts
Hepatocellular 1 pt

75. The main lesion of the
spinal metastases were
located in the:
Thoracic spine: 38 pts
Lumbar -//-: 5 pts
Cervical -//-: 2 pts
Material
Breast’s metatstasis

76. Operative
treatment
 Spondylectomy 32 pts
 Decompression
& Stabilization 13 pts

77. Results

78. Follow-up:
62 months ( 6 - 115 ).

79.  Operative time:
 one session: 13½ h (9 - 21)
 two stages: 11 h (9 - 14)
Combined
Procedures
 blood loss: 1500 ± 500 ml

80. A. Pain
B. Neurological
status - paresis
C. Gait
Clinical evaluation

81. Clinical results of prosthetic replacement surgery. The
improvement rate was 94% for pain, 82% for motor
function and 73% for ambulation.
Prosthetic replacement of spinal metastasis

82. Posterior stabilization
Clinical results of posterior stabilization. The positive
recovery rate was 52% for ambulation, 50% for motor
function and 84% for pain.

83. Neurologic Evaluation:
Improvement in 80%
of the patients.

84. Complications
Intra-operative
Early postoperative < 3wks
Late postoperative > 3 wks

85. Major
Intra-operative
complications
N(-)ve

86. Early post-operative
complications
< 3weeks
Wound dehiscence
Neurologic deterioration
Implants dislodgement
infections

87. Late post-operative
complications
> 3 weeks
Wound dehiscence
Neurologic deterioration
Implants dislodgement or broken
infections

88. Late post-operative instability
(spinal destabilization)
Breast’s metatstasis

89. Late post-operative instability
(implants failure)
Breast’s metatstasis

90. Post-operative
complementary
treatment
Radiation therapy
of spinal metastases
Tombolini Y. et al 1994
Ortho - Athens
Best to start
> 3wks post - op

91. CA Thyroid to 1st lumbar vertebra
Post – Radiotherapy following Kyphoplasty
Radiotherapy of the spine

92. Vertebroplasty -
Kyphoplasty
Minimal invasive
techniques

93. Vertebral fractures
(compression ± burst)
Osteoporotic fractures
(compression ± burst)
Pathologic fractures of the
spinal vertebra (metastasis)
Haemangioma of the vertebra
Multiple myeloma
Pneumon’s metastasis
Vertebroplasty – Kyphoplasty
Indications

94. Destruction of the posterior spinal
elements
Burst fractures (±)
Neurologic compression
syndromes
(due to dislocated bony fragments)
Destruction of dorsal structures
(vertebral arch and facet joints)
Vertebra plana
Spinal infection
Allergy
(methylmethacrylate etc)
Coagulopathy
Untreated cardiovascular
disturbances Thyroid metastasis
Vertebroplasty – Kyphoplasty
Contraindications

95. 18 cases
Vertebroplasty

96. Kyphoplasty
(single level)
kidney’s metastasis
10 cases

97. Kyphoplasty
(multiple levels)
21 cases
Pneumon’s metastasis

98. Conclusions:

99. is treated successfully only
by operative procedure
Breast’s metatstasis
Spinal instability
and
neurologic deficit
due to metastasis

100. Prosthetic replacement
is indicated for
metastasis up to three
consecutive vertebrae

101. Pneumon’s metatstasis
Posterior
stabilization is
recommended:
 For multiple
metastases
 Poor general
condition
 Short life
expectancy

102. Anterior vertebral replacement
and
anterior – posterior stabilization
1. Is indicated in excessively
unstable spine
and
2. It gives the best overall
results

103. For the metastatic spinal lesions:

104. The minimal invasive techniques
(Verterboplasty – Kyphoplasty)
are recommended methods of
treatment.