Spine Surgery in Patients with Metastatic Breast Cancer: A Retrospective Analysis

What is the Optimal Management of Metastatic Spine Patients With Intermediate Spinal Instability Neoplastic Scores: To Operate or Not to Operate?

STUDY DESIGN

Systematic review.

OBJECTIVE

In patients with extradural metastatic spine disease, we sought to systematically review the outcomes and complications of patients with intermediate Spinal Instability Neoplastic Score (SINS) lesions undergoing radiation therapy, percutaneous interventions, minimally invasive surgeries, or open spinal surgeries.

METHODS

Following PRISMA guidelines for systematic reviews, MEDLINE, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews and the Cochrane Center Register of Controlled Trials were queried for studies that reported on SINS intermediate patients who underwent: 1) radiotherapy, 2) percutaneous intervention, 3) minimally invasive, or 4) open surgery. Dates of publication were between 2013-22. Patients with low- or high-grade SINS were excluded. Outcome measures were pain score, functional status, neurological outcome, ambulation, survival, and perioperative complications.

RESULTS

Thirty-nine studies (n = 4554) were included that analyzed outcomes in the SINS intermediate cohort. Radiotherapy appeared to provide temporary improvement in pain score; however, recurrent pain led to surgery in 15%-20% of patients. Percutaneous vertebral augmentation provided improvement in pain. Minimally invasive surgery and open surgery offered improvement in pain, quality of life, neurological, and ambulatory outcomes. Open surgery may be associated with more complications. There was limited evidence for radiofrequency ablation.

CONCLUSION

In the SINS intermediate group, radiotherapy was associated with temporary improvement of pain but may require subsequent surgery. Both minimally invasive surgery and open spinal surgery achieved improvements in pain, quality of life, and neurological outcomes for patients with spine metastases. Open surgery may be associated with more complications.

Open Kyphoplasty for Metastatic Spine Disease: A Retrospective Clinical Series

OBJECTIVE

Symptomatic metastatic spine disease (MSD), is a challenging disease involving 3%-20% of patients with bone metastases. Different surgical options are available and must be tailored to the general and neurologic conditions of the patients. Open kyphoplasty (OKP) refers to decompressive hemilaminectomy, associated with a contralateral percutaneous kyphoplasty, and in some cases, to a posterior stabilization. The aim of the study was to critically review our experience during the last decade with OKP in patients with cancer.

METHODS

Fifty-three patients with cancer underwent OKP for symptomatic MSD. The Tokuhashi score and Spinal Instability Neoplastic Score were calculated for each patient. Length of hospital stay, perioperative complications, incidence of adjacent-level fractures, and median survival after surgery were evaluated. Karnofsky Performance Status, visual analog scale, and Dennis Pain Score were calculated preoperatively, postoperatively, and at last follow-up.

RESULTS

Median Tokuhashi score and Spinal Instability Neoplastic Score were 10 and 10, respectively. The mean volume of filling material inserted was 3.6 mL. Median operative time was 180 minutes. Complications included 8 leakages (15%), 2 permanent motor deficits (3.8%), and 2 asymptomatic pulmonary embolisms (3.8%). Mean length of hospital stay was 7 days. A significant improvement was observed in Karnofsky Performance Status, visual analog scale score, and Dennis Pain Score (P < 0.0001). Median follow-up was 16 months and overall survival 22 months.

CONCLUSIONS

OKP was an effective treatment of symptomatic MSDs in selected oncologic patients with low Tokuhashi scores. It relieved lateral epidural compressions, expanded indications of palliative surgery in patients who were not otherwise surgical candidates, and rapidly dealt with cement leakages.

Risk for surgical complications after previous stereotactic body radiotherapy of the spine

OBJECT

Stereotactic body radiotherapy (SBRT) for vertebral metastases has emerged as a promising technique, offering high rates of symptom relief and local control combined with low risk of toxicity. Nonetheless, local failure or vertebral instability may occur after spine SBRT, generating the need for subsequent surgery in the irradiated region. This study evaluated whether there is an increased incidence of surgical complications in patients previously treated with SBRT at the index level.

METHODS

Based upon a retrospective international database of 704 cases treated with SBRT for vertebral metastases, 30 patients treated at 6 different institutions were identified who underwent surgery in a region previously treated with SBRT.

RESULTS

Thirty patients, median age 59 years (range 27-84 years) underwent SBRT for 32 vertebral metastases followed by surgery at the same vertebra. Median follow-up time from SBRT was 17 months. In 17 cases, conventional radiotherapy had been delivered prior to SBRT at a median dose of 30 Gy in median 10 fractions. SBRT was administered with a median prescription dose of 19.3 Gy (range 15-65 Gy) delivered in median 1 fraction (range 1-17) (median EQD2/10 = 44 Gy). The median time interval between SBRT and surgical salvage therapy was 6 months (range 1-39 months). Reasons for subsequent surgery were pain (n = 28), neurological deterioration (n = 15) or fracture of the vertebral body (n = 13). Open surgical decompression (n = 24) and/or stabilization (n = 18) were most frequently performed; Five patients (6 vertebrae) were treated without complications with vertebroplasty only. Increased fibrosis complicating the surgical procedure was explicitly stated in one surgical report. Two durotomies occurred which were closed during the operation, associated with a neurological deficit in one patient. Median blood loss was 500 ml, but five patients had a blood loss of more than 1 l during the procedure. Delayed wound healing was reported in two cases. One patient died within 30 days of the operation.

CONCLUSION

In this series of surgical interventions following spine SBRT, the overall complication rate was 19%, which appears comparable to primary surgery without previous SBRT. Prior spine SBRT does not appear to significantly increase the risk of intra- and post-surgical complications.

Advanced Neuroimaging in the Evaluation of Spinal Cord Tumors and Tumor Mimics: Diffusion Tensor and Perfusion-Weighted Imaging

Spinal cord tumors are an important component of pathologic diseases involving the spinal cord. Conventional magnetic resonance (MR) imaging only provides anatomical information. MR diffusion tensor imaging (DTI) and MR perfusion-weighted imaging (PWI) may detect microstructure diffusion and hemodynamic changes in these tumors. We review recent application studies of MR DTI and PWI in spinal cord tumors. Overall, MR DTI and MR PWI are promising imaging tools that are especially useful in improving differential diagnosis between spinal cord tumors and tumor mimics, preoperative evaluation of resectability, and providing assistance in surgical navigation.