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AOSpine Masters Series

Metastatic Spinal Tumors


AOSpine Masters Series
Metastatic Spinal Tumors

Series Editor:
Luiz Roberto Vialle, MD, PhD
Professor of Orthopedics, School of Medicine
Catholic University of Parana State
Spine Unit
Curitiba, Brazil

Guest Editors:
Ziya L. Gokaslan, MD, FACS
Donlin M. Long Professor
Professor of Neurosurgery, Oncology, andOrthopaedic Surgery
Director, Neurosurgical Spine Program
Vice Chair, Department of Neurosurgery
Johns Hopkins University School of Medicine
Baltimore, Maryland

Charles G. Fisher, MD, MHSc, FRCSC


Professor and Head
Division of Spine Surgery
Department of Orthopaedic Surgery
University of British Columbia
Vancouver, British Columbia

Stefano Boriani, MD
Unit of Oncologic and Degenerative Spine Surgery
Rizzoli Orthopedic Institute
Bologna, Italy

Thieme
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54321
ISBN 978-1-62623-046-0

Also available as an e-book:


eISBN 978-1-62623-048-4
AOSpine Masters Series
Luiz Roberto Vialle, MD
Series Editor

Volume 1 Metastatic Spinal Tumors

Volume 2 Primary Spinal Tumors

Volume 3 Cervical Degenerative Conditions

Volume 4 Adult Spinal Deformities

Volume 5 Spinal Trauma 1, Cervical

Volume 6 Spinal Trauma 2, Pitfalls on Thoracolumbar

Volume 7 SCI and Regeneration

Volume 8 Back Pain

Volume 9 Pediatric Spinal Deformities

Volume 10 Spinal Infection


Contents

Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Jeffrey C. Wang
Series Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Luiz Roberto Vialle
Guest Editors Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Charles G. Fisher, Stefano Boriani, and Ziya L. Gokaslan

1 Evaluation and Decision Making for Metastatic Spinal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1


Yan Michael Li, Michael S. Dirks, Claudio E. Tatsui, and Laurence D. Rhines

2 Neoplastic Spinal Instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14


Daryl R. Fourney and Charles G. Fisher

3 Major Complications Associated with Stereotactic Ablative Radiotherapy


for Spinal Metastasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Simon S. Lo, Arjun Sahgal, and Eric L. Chang

4 En Bloc Resection in the Treatment of Spinal Metastases: Technique and Indications. . . . . . . 34


Ilya Laufer, Jean-Paul Wolinksy, and Mark H. Bilsky

5 Region-Specific Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Ioan Adrian Lina, Patricia L. Zadnik, and Daniel M. Sciubba

6 Spinal Reconstruction and Fixation/Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61


Rajiv Saigal and Dean Chou

7 Minimally Invasive Surgery for Metastatic Spine Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73


Meic H. Schmidt

8 Vertebral Augmentation for Metastatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84


Ehud Mendel, Eric C. Bourekas, and Paul Porensky

9 Surgical Complications and Their Avoidance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94


Michelle J. Clarke

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Foreword

With the large number of publications, journals, format for spine surgeons to approach the dis-
and textbooks available to the spine practi- eases of the spine. The foundation for treat-
tioner, it is refreshing to see a novel publication ments of the disease process is presented, with
in a new format that has a specific focus on clinical pearls and complications avoidance, and
relevant and important contemporary topics. an update on the current literature and key ar-
With the introduction of the AOSpine Masters ticles. I am especially excited for young spine
Series and the first volume focused on meta- surgeons and for residents and fellows in train-
static spinal tumors, new ground is broken on ing programs, because this textbook will enable
an innovative collection of educational mate- them to learn about spine surgery in a unique
rial from the worlds experts in the spine sur- way that will provide them with a better under-
gery field. standing of the current status of our knowledge
I congratulate all the editors and the authors of the spine.
of AOSpine Masters Series and the inaugural The authors are all knowledgeable experts
volume for their unique vision in creating this who are world-renowned in their field. The
series that collects the vast knowledge of the editors who have created this vision should be
top experts in the field. The AOSpine Masters congratulated and very proud of this very im-
Series addresses current topics, targeting not pressive collection of experts and the unique
only our large spine surgeon membership, but method of presentation. The entirety of the
also spine practitioners on a global basis. It is chapters come together to form an educational
not a journal or a conventional book, but a treatment focus on the individual topics. The
publication for the worlds experts to share entire collection forms an amazing series of
their personal views and recommendations on truly masters level information that is unpar-
a given topic. The goal of this series is to con- alleled. I am very excited by the AOSpine Mas-
tribute to an evolving, dynamic model of an ters Series and look forward to future volumes.
evidence-based medicine approach to spine care.
Not only is the information contained in this Jeffrey C. Wang, MD
series and in the first volume new, but the pre- Chairman, AOSpine International
sentation of the material is truly revolutionary. Chief, Orthopaedic Spine Service
The process involves a synthesis of best avail- Co-Director USC Spine Center
able evidence and consensus expert opinions Professor of Orthopaedic Surgery and
to arrive at appropriate recommendations for Neurosurgery
patient care. There is no other source that com- USC Spine Center
bines this information or presents it in such a Los Angeles, California

978-1-62623-048-4c0FM.indd 9 7/2/14 1:15 PM


Series Preface

Spine care is advancing at a rapid pace. The vehicle for sharing their experiences and exper-
challenge for todays spine care professional tise and providing links to the literature. Each
isto quickly synthesize the best available evi- volume focuses on a current compelling and
dence and expert opinion in the management sometimes controversial topic in spine care.
of spine pathologies. The AOSpine Masters The unique and efficient format of the
Series provides just thateach volume in the Masters Series volumes quickly focuses the
series delivers pathology-focused expert opin- attention of the reader on the core informa-
ion on procedures, diagnosis, clinical wisdom, tion critical to understanding the topic, while
and pitfalls, and highlights todays top research encouraging the reader to look further into the
papers. recommended literature.
To bring the value of its masters level edu Through this approach, AOSpine is advanc-
cational courses and academic congresses to a ing spine care worldwide.
wider audience, AOSpine has assembled inter-
nationally recognized spine pathology leaders Luiz Roberto Vialle, MD, PhD
to develop volumes in this Masters Series as a
Guest Editors Preface

To practice evidence-based spine surgery, a tients to live longer, thus changing traditional
spine surgeon must combine a rigorous and decision aids for metastatic spine patients, es-
critical approach to the evaluation of the sci- pecially for lung and renal cancer patients. Or-
entific literature with clinical expertise and ganizing and understanding all of these new
astrong commitment to patient centeredness concepts and technologies from a decision-
and humanistic values. Patients with meta- making perspective is one of the major goals of
static disease of the spine are a very unique this book.
patient entity for spine surgeons or any care The chapters have been researched and writ-
providers; these patients are dying, and their ten by key opinion leaders in spine oncology
quality of life for their remaining time is a very and range from evaluation and decision-making
precious and personal process. Shared decision principles to a spectrum of nonoperative and
making in the care of these patients is essen- operative treatment options that hich have been
tial, and often these decisions are agonizing as evolving at a rapid pace, especially over the last
the physician strives to do the best, without decade. The three guest editors have reviewed
doing too much. From palliative or hospice each chapter to ensure consistency and the
care to major surgery, the goal of this book is necessary synthesis of the best-available lit
to provide guidance for clinicians to make the erature and expert opinion. Furthermore, a
right decisions and direct the best level of care conscious and very necessary effort to ensure
possible for metastatic spine patients. multidisciplinary appraisal and input has been
In metastatic spine disease, technologic ad- taken. In fact, the input of the medical and
vancements and high-quality literature on neu- radiation oncologists and radiology interven-
rologic recovery, cost-effectiveness, stability, tionalists, along with that of the spine surgeon,
and health-related quality of life (HRQOL) have is emphasized throughout this book, just as
strengthened surgerys role in its manage- itshould be in the day-to-day care of spine
ment; however, choosing the correct treatment metastases patients. Multiple authors were en-
remains a challenge. Similarly on the oncology couraged for each chapter to ensure the most
side, new radiation technologies, such as ste- balanced, transparent, and comprehensive rep-
reotactic radiosurgery have changed the treat- resentation possible.
ment paradigm; formally radioresistant tumors Currently, there is a true paradigm shift oc-
are now radiosensitive, negating the need for curring in the management of metastatic spine
high-risk surgical procedures. New, targeted disease. Successful treatment must accomplish
molecular drugs are allowing metastatic pa- pain palliation, preservation, or recovery of
xiv Guest Editors Preface

neurological function and spine stability. Fur- cal expertise, and patient preferences, will help
thermore, with increased life expectancy, local ensure that this goal is achieved as manage-
control is gaining importance. The ultimate goal ment continues to evolve at an exciting pace.
in the treatment of this fragile patient popula-
tion is related to improvement in HRQOL, while Charles G. Fisher, MD, MHSc, FRCSC
limiting adverse events. We hope this guide Stefano Boriani, MD
framed around best available literature, clini- Ziya L. Gokaslan, MD, FACS
Contributors

Mark H. Bilsky, MD Dean Chou, MD


Department of Neurosurgery Associate Professor
Memorial Sloan-Kettering Cancer Center Department of Neurosurgery
New York, New York Spine Center
University of CaliforniaSan Francisco
Stefano Boriani, MD San Francisco, California
Unit of Oncologic and Degenerative Spine
Surgery Michelle J. Clarke, MD
Rizzoli Orthopedic Institute Assistant Professor
Bologna, Italy Department of Neurosurgery
Mayo Clinic
Rochester, Minnesota
Eric C. Bourekas, MD
Associate Professor, Radiology, Neurology, Michael S. Dirks, MD
andNeurological Surgery Neurosurgery Resident
Chief of Neurosurgery, Department of Walter Reed Army Medical Center
Radiology Washington, DC
Wexner Medical Center
Ohio State University Charles G. Fisher, MD, MHSc, FRCSC
Columbus, Ohio Professor and Head
Division of Spine Surgery
Eric L. Chang, MD Department of Orthopaedic Surgery
Professor and Chair University of British Columbia
Department of Radiation Oncology Vancouver, British Columbia
Keck School of Medicine of University of
Southern California Daryl R. Fourney, MD, FRCSC, FACS
University of Southern California Norris Assistant Professor
Comprehensive Center Division of Neurosurgery
LAC+USC Medical Center Royal University Hospital
Keck Hospital University of Saskatchewan
Los Angeles, California Saskatoon, Saskatchewan
xvi Contributors
Ziya L. Gokaslan, MD, FACS Paul Porensky, MD
Donlin M. Long Professor Neurosurgical Resident
Professor of Neurosurgery, Oncology, Wexner Medical Center
andOrthopaedic Surgery Ohio State University
Director, Neurosurgical Spine Program Department of Neurological Surgery
Vice Chair, Department of Neurosurgery Columbus, Ohio
Johns Hopkins University School
of Medicine
Laurence D. Rhines, MD
Baltimore, Maryland
Professor
Department of Neurosurgery
Ilya Laufer, MD
Division of Surgery
Department of Neurosurgery
University of Texas
Memorial Sloan-Kettering Cancer Center
M.D. Anderson Cancer Center
Department of Neurological Surgery
Houston, Texas
Weill Cornell Medical College
New York, New York
Arjun Sahgal, MD
Yan Michael Li, MD, PhD Associate Professor
Neurosurgical Fellow and Staff University of Toronto
M.D. Anderson Cancer Center Department of Radiation Oncology
Houston, Texas Sunnybrook Health Sciences Centre and the
Princess Margaret Cancer Centre
Ioan Adrian Lina, MD Toronto, Ontario
Medical Student
University of Maryland School of
Medicine Rajiv Saigal, MD, PhD
Department of Neurosurgery Department of Neurological Surgery
Johns Hopkins University School University of CaliforniaSan Francisco
of Medicine San Francisco, California
Baltimore, Maryland
Meic H. Schmidt, MD, MBA, FAANS, FACS
Simon S. Lo, MD
Professor of Neurosurgery and Vice Chair
Associate Professor
for Clinical Affairs
Department of Radiation Oncology
Ronald I. Apfelbaum Endowed Chair in
University Hospitals Seidman
Spine and Neurosurgery
Cancer Center
Director, Spinal Oncology Service,
Case Comprehensive Cancer Center
Huntsman Cancer Institute
Cleveland, Ohio
Director, Neurosurgery Spine
Fellowship
Ehud Mendel, MD, FACS
Clinical Neurosciences Center
Tina Skestos Endowed Chair
University of Utah
Professor, Neurosurgery, Oncology,
Salt Lake City, Utah
Orthopedics, and Integrated Spine
Fellowship Program
Vice Chair, Neurosurgery Clinical Affairs Daniel M. Sciubba, MD
Wexner Medical Center Associate Professor of Neurosurgery,
James Cancer Center Oncology & Orthopaedic Surgery
Ohio State University Johns Hopkins University
Columbus, Ohio Baltimore, Maryland
Contributors xvii
Claudio E. Tatsui, MD Jean-Paul Wolinsky, MD
Assistant Professor Associate Professor
Department of Neurosurgery Neurosurgery and Oncology
Division of Surgery Department of Neurosurgery
University of Texas Johns Hopkins University
M.D. Anderson Cancer Center Baltimore, Maryland
Houston, Texas
Patricia L. Zadnik, BA
Jeffrey C. Wang, MD Spinal Oncology Research Fellow
Chairman, AOSpine International Sciubba Lab
Chief, Orthopaedic Spine Service Johns Hopkins Medicine
Co-Director USC Spine Center Baltimore, Maryland
Professor of Orthopaedic Surgery and
Neurosurgery
USC Spine Center
Los Angeles, California
1
Evaluation and Decision Making
forMetastatic Spinal Tumors
Yan Michael Li, Michael S. Dirks, Claudio E. Tatsui,
and Laurence D. Rhines

Introduction cluding hematogenous spread, direct extension


or invasion, and seeding of the cerebrospinal
Every year, more than 1.6 million new cases fluid. The thoracic spine is the most common
ofcancer are diagnosed in the United States.1 site of involvement (70%), followed by the lum
Roughly half of these patients eventually die bar spine (20%), cervical spine, and sacrum.
from their disease, frequently due to compli The vertebral body is involved in 80% of cases,
cations from metastasis. The bone is the third with the posterior elements being affected in
most common site of metastases following lung 20%. Most metastases are osteolytic (95%), with
and liver,2 and the spine is the most common breast and prostate carcinomas accounting for
site for bone metastasis. As many as 30 to 70% most of the osteoblastic metastases. Occasion
of cancer patients are found to have spinal ally both osteoblastic and osteolytic metasta
metastases on autopsy studies.3 Symptomatic ses occur in the same patient. Almost invariably,
secondary metastases are estimated to occur in metastatic tumors do not involve the dura (i.e.,
approximately 10 to 20% of all cancer patients.3,4 they are epidural), but certain sarcomas and
The highest incidence of spinal metastases is recurrent metastatic tumors after radiotherapy
found in individuals 40 to 65 years of age, cor can violate the dural barrier.
responding to the period of highest cancer risk; With improvements in chemotherapy and
5 to 10% of patients with cancer develop spinal hormonal therapy, and with the advent of novel
cord compression.3 Up to 50% of spinal metas targeted agents, medical oncologists have an
tases require some form of treatment, and 5 to increased number of therapeutic options and
10% require surgical management.5 Moreover, survival times have improved over the years.
as survival rates for many primary cancers con Radiotherapeutic techniques have also evolved.
tinue to improve, it is likely that the prevalence Spinal stereotactic radiosurgery and intensity-
of spinal metastases will increase. modulated radiation therapy (IMRT) techniques
The common tumors that spread to the are enabling the delivery of high-dose confor
spine in adults are breast, lung, prostate, renal, mal radiation to spinal tumors, erasing some of
melanoma, thyroid, and colorectal cancers, as the distinction between radiosensitive and ra
well as hematologic malignancies.69 Multiple dioresistant tumor histologies. Lastly, advances
myeloma has the highest tendency for spinal in surgical techniques now enable the surgeon
metastases of all tumors. Spine tumors in chil to treat spinal metastases more effectively than
dren are represented by various forms of neuro before. Spine surgery can correct mechanical
blastoma and sarcomas.7 There are several ways instability, relieve neurologic compression,
in which tumors disseminate to the spine in and improve pain.9,10 Increasingly, this can be
2 Chapter 1

achieved through minimally invasive tech procedure and approach. Nonsurgical treat
niques that entail less morbidity and enable ments, such as conventional radiation therapy
faster recovery.11,12 or radiosurgery, or minimally invasive spinal
The increasing number, and complexity of, procedures, such as percutaneous vertebral aug
treatment modalities available for patients with mentation, may be appropriate for patients with
spinal metastases can complicate the decision significant medical risks or limited prognosis.
making, so the evaluation of these complex pa
tients must be multidisciplinary, and the deci
sion to perform surgery must be based on four
key aspects of the patients status: medical fit Clinical Presentation
ness, clinical presentation, oncological status,
and feasibility of surgical treatment. This eval The second key consideration in the manage
uation scheme is detailed in the remainder of ment of metastatic spinal disease is the patients
this chapter. It is not meant to be an algorithm clinical presentation. Patients with spinal me
but rather a consideration of these four key tastases typically present with neurologic symp
aspects when developing a treatment plan for toms, pain, or signs of mechanical instability.
the patient with spinal metastasis and when It is important to recognize that the nature of
determining the role of surgery. the clinical presentation and the severity of the
clinical findings have an impact on the choice
of treatment modality.

Medical Fitness Neurologic Function


The first fundamental consideration in man Neurologic dysfunction is a common finding in
aging patients with metastatic spinal disease patients with metastatic disease of the spine.
is their overall medical condition. Many cancer Acareful neurologic assessment must look for
patients have received prior chemotherapy or sensory and motor disturbance, autonomic dys
radiation, as well as steroids, and they may be function, as well as long tract signs. The main
malnourished from their treatment or from focus of the neurologic assessment is on local
the disease. This may have an impact on their izing the potential lesion and determining the
ability to tolerate surgical intervention. clinical extent of the myelopathy or the func
General patient factors such as overall health, tional radiculopathy. This clinical information is
nutritional status, and medical comorbidities then combined with the radiological evaluation
should all be considered in deciding whether to assess the degree of epidural spinal cord com
to recommend surgery.10 Patient factors that pression (ESCC) or nerve root compression.
have been found to be related to poor surgical Approximately 5 to 10% of patients with
outcome include advanced age, obesity, mal metastatic spine tumors develop metastatic
nutrition, diabetes, low bone mineral density, epidural spinal cord compression (MESCC). His
chronic corticosteroid use, and bone marrow torically, treatment of MESCC by decompressive
suppression.13 Hematologic status, such as leu laminectomy alone did not provide substantial
kopenia, thrombocytopenia, or coagulopathy clinical benefit beyond that of conventional
conditions common among cancer patients radiation, and it frequently further compro
receiving chemotherapy or radiation therapy mised spinal stability.14,15 The development of
must also be considered. improved surgical approaches and spinal in
As a general rule, the more extensive the strumentation to treat instability has resulted
surgical procedure, the healthier the patient in better surgical techniques for spinal decom
needs to be in order to survive the surgery and pression and stabilization.4 Using techniques
enjoy durable benefits. The patients medical of circumferential decompression and stabili
fitness may be considered not only in deciding zation, Patchell et al10 conducted a randomized
whether to recommend surgery or not, but prospective trial of 101 patients with MESCC.
also in the selection of the appropriate surgical They conclusively showed that early surgical
Evaluation and Decision Making for Metastatic Spinal Tumors 3
decompression and stabilization followed by tion with the neurologic examination and tumor
postoperative radiotherapy is superior to treat histology to help guide treatment.
ment with radiotherapy alone for patients with For patients with highly radiosensitive or
spinal cord compression caused by metastatic chemosensitive tumors, nonsurgical treatment
cancer. It should be noted that this study did may be adequate even in cases of high-grade
not include patients with highly radiosensitive/ spinal cord compression due to the rapid re
chemosensitive tumors such as myeloma, lym sponse of these tumors to radiation or chemo
phoma, and small cell lung cancer. Significantly therapy. For other solid metastatic tumors, the
more patients in the surgery group (84%) than Patchell study suggests that high-grade (grade
in the radiotherapy group (57%) could ambu 2 or 3) MESCC is best treated with surgical de
late after treatment (odds ratio [OR], 6.2; 95% compression and stabilization followed by ra
confidence interval [CI], 2.019.8; p = 0.001). diation therapy. For patients who do not have
These patients were able to maintain their am significant myelopathy or functional radiculop
bulation for a greater durationa median of athy with low-grade MESCC (grade 1c or less),
122 days in the surgical group compared with surgery may not be necessary (unless there is
13 days in the radiotherapy group (p = 0.003). significant spinal instability; see below). In this
The need for corticosteroids and opioid anal case chemotherapeutic or radiotherapeutic
gesics was significantly reduced in the surgical options (including spinal radiosurgery for ra
group. dioresistant histologies) can be utilized. The
The degree of MESCC at the time of clinical nature and severity of the neurologic and ra
presentation is highly variable amongst pa diological findings clearly influence the choice
tients. The selection criteria in the Patchell of treatment.17
study included only patients with true defor
mation of the spinal cord. The Spine Oncology
Study Group (SOSG) has developed and vali
Pain
dated a six-point grading system to describe Metastatic spine tumors most commonly come
the degree of ESCC based on axial T2-weighted to attention with the development of pain. This
magnetic resonance imaging (MRI) at the site occurs in 83 to 95% of patients and typically
of most severe compression (Fig. 1.1).16 This ra precedes the development of other neurologic
diological assessment can be used in combina symptoms.18 It is important to recognize that

Fig. 1.1ac Schematic representation of the cord compression but cerebrospinal fluid (CSF) is
6-point epidural spinal cord compression (ESCC) visible. (c) Grade 3, spinal cord compression without
grading scale16. Grade 0, tumor is confined to bone visible CSF. Grades 0, 1a, and 1b are considered for
only. (a) Grade 1, tumor extension into the epidural radiation as first treatment in the lack of mechanical
space without deformation of the spinal cord. This is instability. Grades 2 and 3 define high-grade ESCC.
further divided into 1a, epidural impingement but Note: Used with permission from Bilsky MH, Laufer I,
no deformation of the thecal sac; 1b, deformation Fourney DR, et al. Reliability analysis of the epidural
ofthe thecal sac without spinal cord abutment; and spinal cord compression scale. J Neurosurg Spine
1c, deformation of the thecal sac with spinal cord 2010;13(3):324328.
abutment but no compression. (b) Grade 2, spinal
4 Chapter 1

there are different types of pain caused by ical integrity of the spine, and therefore are un
metastatic spine tumors, and the nature of the likely to provide durable relief of mechanical
pain may impact decision making. There are pain. Patients with mechanical pain typically
three types of pain that affect patients with require a treatment aimed at strengthening the
symptomatic spinal metastases: local or bio affected spinal region, such as cement augmen
logical, radicular, and mechanical. tation or spinal stabilization.
Local pain is thought to result from perios
teal stretching, elevation of endosteal pressure,
or inflammation caused by tumor growth.19 The
Mechanical Instability
pain can be localized, is often constant, and The final component of the clinical evaluation
presents in the evenings and mornings. It is is to recognize the patient presenting with spi
described as a deep gnawing or aching pain nal instability. The SOSG has defined neoplastic
atthe site of disease; it does not worsen with spinal instability as the loss of spinal integrity
movement and may improve with activity. This as a result of a neoplastic process that is associ
type of pain is quite responsive to anti-inflam ated with movement-related pain, symptomatic
matory or corticosteroid medications, and ra or progressive deformity, and/or neural com
diation therapy can relieve it by shrinking the promise under physiologic loads.20 Mechani
tumor and decreasing the production of in cal instability due to spinal metastasis is an
flammatory mediators. indication for surgical stabilization or percuta
Radicular pain is caused by nerve root im neous vertebral augmentation, regardless of the
pingement, which occurs when a spinal metas ESCC grade or the chemo/radiosensitivity of the
tases compresses the exiting nerve root within tumor. Although effective for local tumor con
the spinal canal, within the neuroforamen, or trol, chemotherapy and radiation therapy have
outside the foramen. The radicular pain follows little or no impact on spinal stability. As a re
a dermatomal distribution and is described as sult, patients with gross neoplastic spinal insta
sharp, shooting, or stabbing in nature. It is bility generally require a surgical intervention.
often constant and may or may not be relieved The assessment of spinal instability is based
with changing position. As with local pain, ra on a combination of both clinical and radio
dicular pain may respond to therapies that can graphic information. The SOSG has proposed
reduce the effective size of the tumor, includ a set of criteria, the Spine Instability Neoplas
ing corticosteroids, chemotherapy, and radia tic Score (SINS) (Table 1.1),20 to help clinicians
tion therapy. evaluate instability. This grading scheme is
Mechanical pain is severe and movement- based on six parameters: location of the lesion,
related. It typically worsens with loading of the presence and type of pain, radiographic align
spine as a patient moves from lying down to ment, nature of the lesion (lytic or blastic),
sitting and from sitting to standing. Bending vertebral body collapse, and posterior element
often exacerbates the pain, and it is relieved involvement. Each parameter receives a numer
with recumbency. It is typically associated with ical score. Metastatic spine lesions with a low
vertebral collapse, as the weakened vertebra is SINS (06) are generally considered stable and
no longer able to support the mechanical loads do not require surgical intervention, whereas
placed on it. It is important when assessing ahigh SINS (1318) suggests instability that is
spine tumor patients to evaluate their pain likely to require surgical stabilization. Inter
when they are sitting or standing, because mediate SINS (712) tumors are considered po
mechanical pain might not be noted in patients tentially unstable and represent the middle of
lying in bed. Mechanical pain must be distin the instability spectrum. The SINS does not rec
guished from local and radicular pain. It is often ommend any specific treatment but is a guide
refractory to anti-inflammatory medications, to help both surgeons and nonsurgeons recog
chemotherapy, and radiation. Although these nize those patients who might be at risk for
modalities may treat the underlying tumor, progressive vertebral collapse and deformity.
they are not effective at restoring the mechan The SINS demonstrated near perfect inter- and
Evaluation and Decision Making for Metastatic Spinal Tumors 5
Table 1.1 The Spinal Instability Neoplastic Score (SINS)

SINS Component Description Score

Location Junctional (occiput-C2, C7-T2, T11-L1, L5-S1) 3


Mobile spine (C3-C6, L2-L4) 2
Semi-rigid (T3-T10) 1
Rigid (S2-S5) 0
Paina Yes 3
Occasional pain but not mechanical 1
Pain-free lesion 0
Bone lesion Lytic 2
Mixed (lytic/blastic) 1
Blastic 0
Radiographic spinal alignment Subluxation/translation present 4
De novo deformity (kyphosis/scoliosis) 2
Normal alignment 0
Vertebral body collapse > 50% collapse 3
< 50% collapse 2
No collapse with > 50% body involved 1
None of the above 0
Posterolateral involvement of spinal elementsb Bilateral 3
Unilateral 1
None of the above 0
aPainimprovement with recumbency and/or pain with movement/loading of the spine.
bFacet,pedicle or costovertebral joint fracture or replacement with tumor.
Source: From Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease:
an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine 2010;35:E1221E1229.
Reproduced with permission.

intraobserver reliability in determining the Histology


three clinically relevant categories of stability:
It is critical to identify the tumor histology be
stable (SINS 06), potentially unstable (SINS
cause it provides important information about
712), and unstable (SINS 1318). The sensi
the patients prognosis. In fact, the histology
tivity and specificity for detecting potentially
ofthe primary tumor is the single strongest
unstable or unstable lesions were 95.7% and
predictor of postoperative survival in patients
79.5%.13
undergoing surgery for spinal metastases.21,22
According to Tomita et al,21 tumor histologies can
be stratified into three groups: slow-growing
Oncological Status tumors, including breast, prostate, thyroid, and
carcinoid tumors; moderately growing tumors,
The third key element of the evaluation of the including those arising from the kidney and
patient with spinal metastatic disease is onco uterus; and rapidly growing tumors, including
logical status. Most importantly this includes tumors of the lung, liver, stomach, esophagus,
recognition of the specific tumor histology. In pancreas, bladder, sarcoma, and tumors of un
addition, the extent of metastatic disease (bone, known origin. In general, the more aggressive
visceral) and the extent and nature of prior the histology, the worse the prognosis.
treatment also have an impact on the manage Knowledge of the tumor histology also pro
ment of the spine metastasis. vides critical information regarding the respon
6 Chapter 1

siveness of the spinal metastasis to nonsurgical Finally, it is important to identify the tumor
therapies such as chemotherapy and radiation type, as certain histologies are particularly
therapy. The impact of chemotherapy and hypervascular. Metastases from renal cell, thy
radiotherapy varies considerably with tumor roid, hepatocellular, melanoma, and giant cell
type.23,24 Chemotherapy is generally reserved tumors can all bleed substantially during tumor
for asymptomatic or minimally symptomatic resection. Preoperative embolization can be
lesions because its effects typically take time very effective in reducing intraoperative blood
to manifest and this may be problematic for loss.28 One must identify hypervascular tu
symptomatic patients. The obvious exceptions mors preoperatively in order to take advan
to this are the hematologic malignancies or tage of this procedure.
Ewings sarcoma, which may respond rapidly to To confirm the histology in a patient with a
chemotherapy. In patients without neurologic spinal tumor, percutaneous biopsy may be re
deficit or spinal instability, it may be perfectly quired. This is not generally necessary when
reasonable to utilize systemic therapy for sen apatient with a known primary and active
sitive histologies. Breast and prostate cancers, metastatic disease presents with a new spinal
for example, can be quite sensitive to hormonal lesion. However, when there is no known pri
therapies.25,26 mary or when a patient with a known primary
With regard to radiation, tumors have tradi has been without active disease for a prolonged
tionally been considered radiosensitive or ra interval, biopsy should be strongly considered
dioresistant depending on their response to in order to confirm the diagnosis, to exclude a
conventional radiation therapy (CRT).23,24 With second primary, or to rule out a primary bone
out precise conformal technique, the dosing of tumor. This may be particularly true in patients
CRT is limited by spinal cord tolerance, as the who have a history of prior chemotherapy or
cord is within the radiation field that is used to radiation, which may increase the chance of a
treat the tumor. Hence, a tumor that responds second malignancy.
favorably to doses limited by cord tolerance is
considered radiosensitive, whereas those that Extent of Metastatic Disease/
do not respond favorably to these doses are
considered radioresistant. In cases where the
Systemic Staging
tumor is in close proximity to the spinal cord, In addition to the type of tumor, the presence
it may be impossible to radiate the tumor with and extent of extraspinal metastatic disease
out radiating the cord, and the radiosensitivity have an impact on decision making. The pres
of the tumor, therefore, will determine whether ence of additional visceral and bone metasta
this modality can be used effectively. Most au ses adversely affects survival, which in turn
thors consider lymphoma, myeloma, and sem may have an impact on the choice of treat
inoma to be highly radiosensitive and treatable ment.21,22 This is the basis for the well-known
with CRT even in cases of spinal cord com Tomita scoring system, which assigns point
pression. Of the solid tumors, breast, prostate, values to these three factors to generate a
ovarian, and neuroendocrine carcinomas are score, which in turn determines the aggressive
considered to be radiosensitive, whereas renal, ness of treatment. Grade of malignancy (slow
thyroid, hepatocellular, nonsmall-cell lung, growth, 1 point; moderate growth, 2 points;
colon, melanoma, and sarcoma are considered rapid growth, 4 points), visceral metastases
radioresistant.17 Spinal stereotactic radiosurgery (no metastasis, 0 points; treatable, 2 points:
(SRS), which can be used to deliver highly con untreatable, 4 points), and bone metastases
formal doses of radiation to spinal tumors while (solitary or isolated, 1 point; multiple, 2 points)
avoiding the spinal cord, has been shown to are used to generate a score from 2 to 10. A
provide excellent tumor control in a histology- prognostic score of 2 to 3 points indicates a
independent manner.13,24,27 However, this tech wide or marginal excision for long-term local
nique is limited when the tumor and spinal control; 4 to 5 points indicates marginal or in
cord are in close proximity. tralesional excision for middle-term local con
Evaluation and Decision Making for Metastatic Spinal Tumors 7
trol; 6 to 7 points indicates palliative surgery high in patients within each score range (08,
for short-term palliation; and 8 to 10 points 911, or 1215), 86.4% in the 118 patients
indicates nonoperative supportive care for end evaluated prospectively after 1998, and 82.5%
of life. Cancer therapies have evolved consider in all 246 patients evaluated retrospectively.
ably since the publication of this paper. As a The prognostic criteria scoring system were
result the treatments recommended based on useful for predicting the prognosis irrespective
the prognostic score may no longer be optimal. of treatment modality or local extension of the
Nonetheless, the impact of these prognostic lesion.
factors on survival is clear. Patients with exten
sive systemic disease have a poorer survival
Extent of Previous Treatment
and are less likely to benefit from major sur
gical procedures. Moreover, the increased dis The final component of the patients oncologi
ease burden may cause comorbidities (e.g., cal status is the nature and extent of the prior
decreased pulmonary function from lung me therapy. This is not easy to stratify or quantify,
tastasis, coagulopathy from liver metastasis), and it needs to be evaluated on a patient-by-
that render the patient less able to tolerate patient basis; however, the concept is relatively
larger procedures. Therefore, staging is man self-evident. Simply put, when considering
datory and should be performed in all patients treatment options for a patient with spinal
prior to surgery, if possible. metastatic disease, the choice will be influ
It is worth noting the aforementioned prog enced by what therapies have already been
nostic factors characterized by Tomita; tumor utilized and the relative efficacy of the remain
histology, visceral metastasis, and bone metas ing treatment strategies. As an illustrative ex
tasis, are also components of the well-known ample, a patient has metastatic breast cancer
Tokuhashi scoring system. In their system, and a midthoracic lesion that is abutting the
Tokuhashi et al22 consider six key prognostic cord, causing some mild radiculopathy but
factors: general condition, number of extraspi noneurologic dysfunction. If this patient is
nal bone metastases, number of metastases in therapy nave, treatment options may include
the vertebral body, presence or absence of me conventional radiotherapy, hormonal/chemo
tastases to major internal organs, site of the pri therapy (depending on receptor status), or sur
mary lesion, and severity of palsy. In addition gery. But if this lesion has been previously
to the primary site of the cancer (tumor histol irradiated and the patient is receiving third-
ogy), they evaluate presence of metastases to line chemotherapy, nonsurgical options may
the major internal organs and score these as be limited, and surgery may be necessary if the
irremovable, removable, and none. They sepa prognosis is reasonable. The presence and
rate bone metastases into extraspinal and ver proximity of prior radiation fields is often a
tebral classifying the former as 3, 1 to 2, or 0, determining factor regarding the efficacy or
and the latter as 3, 2, or 1. Finally, they strat feasibility of subsequent radiation due to is
ify the general condition of the patient (Kar sues of spinal cord tolerance. Spinal SRS may
novsky Performance Status) as poor (1040), help to minimize cord toxicity but requires
moderate (5070), or good (80100), and the that there be some degree of spatial separation
presence of spinal cord palsy as complete, in between the tumor and the neurologic struc
complete, or none. Each parameter is then as tures.24,29 Clearly, patients who have received
signed a range of scores to provide a maximum multiple prior therapies may be further along
total of 15. The score is then used to determine in their overall disease trajectory. This may re
how aggressive a treatment to select. Patients flect a decreased overall prognosis that must be
with lower scores are recommended for more considered prior to surgery.17,18 Collaboration
conservative approaches, with higher scoring among the medical oncology, radiation oncol
patients receiving excisional surgeries. The con ogy, and surgical teams is necessary to develop
sistency rate between the criteria for predicted optimal treatment plans for these complicated
prognosis and the actual survival period was patients.
8 Chapter 1

Feasibility of the Second, the surgeon must consider the sur


SurgicalPlan gical approach. Often this is a matter of indi
vidual preference; however, there are certainly
The final factor that must be considered before regional anatomic constraints that may influ
intervening surgically for a spinal metastasis ence this decision, and these are discussed in
is the feasibility of the surgical plan. The goal asubsequent chapter.13,34 There may also be
of treatment for spinal metastatic disease is factors related to the individual patient that
palliation. Surgery must be able to reduce pain, influence the choice of surgical approach. For
restore and protect neurologic function, and example, the surgeon may wish to avoid oper
restore spinal stability in a manner that is du ating in a previously radiated or operated site in
rable over the remaining life expectancy of the order to reduce wound healing complications
patient and with acceptable morbidity. Qual and make the dissection easier.31 Alternatively,
ity of life should be enhanced. There is ample it may not be feasible to consider a transtho
evidence to suggest that surgery can help to racic approach in a patient with compromised
achieve these goals, and in certain circum pulmonary function. It is imperative for the sur
stances, particularly in the case of MESCC, may geon to consider whether an access surgeon
be the superior treatment option. In the case of with additional expertise might provide a safer
high-grade MESCC, when combined with post and more satisfactory surgical approach.
operative radiation, surgery provides far supe Third, the surgeon must consider the strat
rior outcomes than does radiation alone.9,10,30 egy for spinal reconstruction and stabilization.
Moreover, surgery may be the only means of cor There are numerous devices, materials, and
recting symptomatic spinal instability. Lastly, techniques that are available for rebuilding the
surgery may be the best option in cases where spine following resection of a spinal metasta
chemotherapeutic and radiotherapeutic strat sis. It is beyond the scope of this chapter to re
egies have failed or are otherwise limited. view this topic or the biomechanical principles
However, surgery also tends to be among the of spinal reconstruction. However, there is one
most invasive treatments for spinal metastases important point that the spine surgeon must
and carries significant potential for complica contemplate in the spinal metastasis patient
tions. This is particularly relevant in a patient the quality of the patients bone. The stability
population that may have substantial comor of a spinal reconstruction and stabilization
bidities related to advanced age; underlying relies on the implants contacting and fixating
disease; prior treatment with chemotherapy, into bone of satisfactory quality. When this is
radiation therapy, or steroids; and poor nutri not the case, implants can loosen and fixation
tional status.7,31,32 can be compromised, leading to spinal instabil
In short, it is the responsibility of the spinal ity. The presence of tumor in adjacent or nearby
surgeon to carefully consider the surgical plan vertebra is one factor that can impact fixation.
prior to taking a patient to the operating room. Imaging studies should be scrutinized to make
First, the surgeon must consider the strategy sure that there is limited tumor burden in
for resection of the metastasis. Will the resec vertebra that is being relied on to provide ad
tion be intralesional or en bloc? Given the pal equate structural support. In addition, osteo
liative nature of surgery for metastatic disease, penia and osteoporosis are common among
most resections are performed in a piecemeal cancer patients.35 This may be a by-product of
fashion. However, there are some circumstances advanced age, female sex, or treatments for the
(indolent histology, solitary spinal metastasis, underlying cancer including steroids, chemo
long predicted survival) where a more aggres therapy, hormonal therapy, and radiotherapy.
sive en bloc resection may be considered.33 In Poor nutritional status may also lead to bone
addition, for hypervascular histologies, a pre loss. The spine surgeon must recognize this
operative embolization should be considered potential problem and avoid surgery, alter the
to reduce intraoperative blood loss.28 reconstruction plan technique, or consider
Evaluation and Decision Making for Metastatic Spinal Tumors 9
the adjunctive use of vertebral augmentation not all patients will fit neatly within any pro
to improve the strength of the vertebra and cedural framework. Moreover, each institution
fixation. will base its algorithm on the treatment mo
Lastly, the spine surgeon must consider dalities available within that center. Nonethe
wound healing. A palliative spine surgery that less, it is instructive to see how the key factors
decompresses the neurologic elements and sta described above are integrated into two of the
bilizes the spine is not successful if the patient most commonly utilized treatment algorithms
is left with a nonhealing wound. This can lead for patients with metastatic disease to the
to a prolonged hospital stay and, more impor spine. These are the Algorithm for Spinal Me
tantly, can delay the administration of much- tastases (Fig. 1.2) developed and prospectively
needed systemic therapy. It is incumbent upon applied by Borianis group in Bologna since
the surgeon to recognize factors that will im January 2002,3840 and the neurologic, onco
pede healing. These include prior radiation or logical, mechanical, and systemic (NOMS) de
surgery, chemotherapy, steroids, and malnu cision framework (Fig. 1.3) utilized during
trition. Obviously, if previous radiation and thepast 15 years at Memorial Sloan-Kettering
surgical fields can be avoided, this is advanta Cancer Center.17
geous.31 However, this is often not the case. If In both treatment paradigms, a critical ini
the surgery is elective, there may be time to tial assessment is the overall medical status of
discontinue chemotherapy or steroids and im the patient. In the Boriani algorithm, this is
prove the nutritional status of the patient. Un referred to as operability, and in the NOMS it
fortunately, most surgeries for spinal metastatic is the systemic assessment. Those patients un
disease are done under more urgent circum able to tolerate surgery are referred for radia
stances. Therefore, the surgeon is frequently tion or medical therapy. The next critical factor
left with a situation that requires surgery, but is the clinical presentation. In both frameworks
presents wound healing challenges. In these the degree of neurologic compromise (mea
situations, we strongly recommend collabora sured either neurologically or by the degree of
tion with a plastic surgeon for immediate flap spinal cord compression) directs a patient to
reconstruction at the time of the surgical re ward surgery unless the histology is highly
section and stabilization.36,37 The utilization of sensitive to chemotherapy or conventional ra
local muscle advancement flaps, rotational flaps, diation. Similarly, the presence of spinal insta
and even free tissue transfer at the time of the bility (risk of pathological fracture in Boriani)
initial spine surgery can dramatically reduce leads the patient toward a surgical remedy. The
complications related to wound healing. oncological status of the patient is tightly inter
Consideration of these aforementioned fac twined with the clinical presentation. In par
tors when planning surgery for spinal meta ticular, the impact of the tumor histology on
static disease will help avoid poorly conceived response to radiation and chemotherapy is a
operations, reduce complications, and lead to critical factor. Chemo- and radiosensitive his
improved patient outcomes. tologies are more likely to be managed with
nonsurgical modalities as long as there is no
worsening neurologic compromise or spinal in
stability. Resistant histologies are directed to
Treatment Algorithms ward surgery by Borianis algorithm. In NOMS,
these tumors may be treated by spinal SRS (not
Utilizing the principles of evaluation and deci available in Bologna) if the degree of cord com
sion making outlined in this chapter, several pression is low grade. For high-grade compres
authors and institutions have developed algo sion with radioresistant histology, separation
rithms for the management of patients with surgery to remove the compressive portion of
spinal metastases. Obviously, treatment deci the tumor and stabilize the spine, followed by
sions must be made on an individual basis and radiosurgery to the remaining disease, is rec
10 Chapter 1

Fig. 1.2 Borianis Treatment algorithm for spinal vertbroplasty. (From Cappuccio M, Gasbarrini A,
metastasis. ASA, American Society of Anesthesiolo- VanUrk P, Bandiera S, Boriani S. Spinal metastasis:
gists; CHT, chemotherapy; CT, computed tomogra- aretrospective study validating the treatment
phy; E.B., en bloc; Frankel, Frankel grading system; algorithm. Eur Rev Med Pharmacol Sci 2008;12:
METS, metastases; NMR, nuclear magnetic reso- 155160. Reproduced with permission.)
nance; PT., patient; RXT, radiation therapy; VP,
Evaluation and Decision Making for Metastatic Spinal Tumors 11

Fig. 1.3 Schematic description of the neurologic, (Adapted from Laufer I, Rubin DG, Lis E, et al. The
oncological, mechanical, and systemic (NOMS) NOMS framework: approach to the treatment of
decision framework.17,29 cEBRT, conventional spinal metastatic tumors. Oncologist 2013;18:
external beam radiation; ESCC, epidural spinal 744751.)
cordcompression; SRS, stereotactic radiosurgery.

ommended.29 Implicit in both of these frame presenting symptoms, including pain, neuro
works is that the surgeons carefully consider logic dysfunction, and mechanical instability.
the feasibility of any treatment plan in advance This chapter also discussed evaluation of a pa
of its execution. tients oncologic status and the feasibility of
surgery as part of the treatment plan. Com
monly used management algorithms were re
viewed. After reading this chapter, the reader
Chapter Summary should have a basic understanding of the many
factors that need to be taken into consideration
The appropriate management of patients with when developing a plan to manage a patient
metastatic spinal disease requires an appreci with metastatic spinal disease.
ation for the complexity of this challenging
clinical condition. Spine surgeons who treat
patients with tumors not only need to be ex Pearls
perts in the technical aspects of performing
Manage spine tumor patients as part of a multi-
spinal surgery, but also must have an under
disciplinary team.
standing of oncological principles and nonsur Understand what you are treating. Whenever
gical treatments available for these patients. possible, obtain a tissue diagnosis before operat-
This chapter reviewed the literature that serves ing on a spine tumor.
as the basis for evaluation and decision making Have a well-thought-out operative plan. Consider
factors such as the need to stage procedures, the
in the management of patients with metastatic
need for approach surgeons, and the need for
spinal disease. The factors relevant to a patients plastic surgeons. Have a plan for spinal recon-
medical fitness to undergo surgery were dis struction and stabilization.
cussed, as was evaluation of common clinical
12 Chapter 1

Pitfalls Operating without a tissue diagnosis: Tumor his-


tology provides critical information regarding
Unnecessary or excessive surgery: Understand the prognosis, availability of adjuvant therapies, type
patients prognosis and other treatment options of surgery required, and need for embolization.
available. Avoid major operations on patients with Most patients who present with metastatic spine
limited life expectancy or potential for recovery. tumors do not need emergent surgery. Most will
Problems with wound healing: Consider using a achieve significant relief of symptoms with ste-
plastic surgeon for local flap reconstruction. Use roids. In the vast majority of cases there is time
drains when necessary. Pay attention to nutrition to establish the tissue diagnosis, obtain appro-
in the postoperative period. Implement a mobili- priate multidisciplinary evaluation, and carefully
zation strategy to avoid pressure ulcers. plan surgery.

References
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2
Neoplastic Spinal Instability
Daryl R. Fourney and Charles G. Fisher

Introduction difficult for the nonsurgeon (radiologist, oncol-


ogist), potentially leading to inappropriate re-
Restoration or maintenance of spinal stability ferrals or patients with instability being under
is an important objective in the surgical treat- treated, risking pain, deformity, or neurologic
ment of spinal metastasis, but is often ne- deterioration.
glected in settings of neurologic compromise. This chapter reviews some of the principles
Indeed, a prospective randomized trial has of biomechanics as they relate to patterns of in-
demonstrated the superiority of surgery and stability and deformity that occur in neoplastic
radiation therapy compared to radiation ther- disease, describes and applies the SINS in illus-
apy alone in the management of high-grade trative cases, and discusses the unique anatomic
spinal cord compression for solid tumors.1 Spi- and biomechanical features of the different re-
nal instability is a common and distinct indica- gions of the spine and options for management.
tion for surgery or vertebral augmentation with
vertebroplasty or kyphoplasty.2 However, it has
not been studied as rigorously as spinal cord Principles
compression. This reflects the controversy that
exists regarding tumor-related instability. The Definition of Tumor-Related
biomechanical and clinical literature in this
area is remarkably limited.3 Prior to the Spinal
SpineInstability
Instability Neoplastic Score, there were few Unlike the appendicular skeleton, the spine
clinical criteria published, and none had been presents a very complex environment in which
tested for reliability or validity. The lack of to judge tumor-related instability. Metastatic
standardized criteria led to significant varia- cancer alters both the material and geometric
tion with regard to diagnosis and treatment properties of the bonethe two entities that
indications. In essence if the problem was not form the structural property rigidity. Although
clearly defined, it was very difficult to study. these properties determine the resistance to
The concept of spinal instability, however, re- axial bending and twisting loads in bone, the
mains a critical and essential component in the bone or vertebras resistance to load in the
surgical decision-making process. spine is unique and significantly influenced by
Most often, spine surgeons rely on clinical the region and adjacent anatomy. Indeed, there
experience to determine if instability is pres- can be fracture or collapse in the spine, but no
ent. Although challenging for the spine sur- clinical symptoms, deformity, or fracture pro-
geon, the diagnosis of instability is even more gression. The infinite complexity has led to a
Neoplastic Spinal Instability 15
simpler approach in trying to define and pre- ligaments working under tension. The well-
dict spinal in stability in the setting of meta- vascularized vertebral bodies are the most
static disease. The Spine Oncology Study Group common sites of tumor involvement, with
(SOSG) defines spine instability as loss of spi- posterior vertebral elements being much less
nal integrity as a result of a neoplastic process frequently affected. In general, the dorsal liga-
that is associated with movement-related pain, mentous complex is less commonly disrupted
symptomatic or progressive deformity, or neu- by neoplasm as compared with high-velocity
ral compromise under physiological loads.4 trauma.5 Iatrogenic destruction of posterior
elements by laminectomy is probably more
common than disruption by the tumor itself.
Basic Biomechanical Principles in Destruction of the facet joints by tumor is also
Spine Tumors Versus Trauma rarer than in trauma, but when it is present, it
Tumor-related instability is very distinct from may result in significant translational or rota-
high-energy traumatic injuries in the pattern of tional deformity.
bony and ligamentous involvement, neurologic
manifestations, and bone quality. In addition,
the ability of the spine to heal is compromised Impending Collapse
by the tumor, systemic therapies, irradiation, The biomechanical effects of spinal metastases
and the general biological compromise of these are poorly defined. As a result, there are no
patients.5 standards for predicting the risk of pathologi-
cal fracture, even when lesions have been iden-
Principle 1: Load Sharing tified and characterized with modern imaging
studies. Theoretically, vertebral body collapse
Disease that involves the cancellous core of the
may be prevented by radiation therapy or sys-
vertebral body with preservation of the corti-
temic therapies if the tumor is sensitive to one
cal bony support may not result in instability.
of those treatments and its growth (and there-
Taneichi et al6 analyzed radiological and clini-
fore lytic destruction of the vertebra) can be
cal data from patients with thoracic and lumbar
arrested. Once the tumor reaches a critical size,
metastases and created a multivariate logistic
which may be defined as impending collapse,
regression model to identify the probability of
only surgical prophylactic stabilization (e.g.,
collapse under various states of tumor involve-
percutaneous cement, pedicle screws) can pre-
ment. They found that in the thoracic spine,
vent fracture. Unfortunately, a reliable method
destruction of the costovertebral joint was a
to predict impending collapse does not exist
more important risk factor for collapse than
due to the regional biomechanical and ana-
the size of the metastatic lesion within the ver-
tomic issues. Therefore, treatment of instabil-
tebral body, presumably related to loss of stiff-
ity should generally be on the basis of actual
ness and strength normally provided by the rib
clinical instability rather than asymptomatic or
cage. In the thoracolumbar and lumbar spine,
relatively asymptomatic radiological findings
the most important factor for collapse was the
that imply the potential for instability in the
size of the vertebral body defect. Involvement
future.
of the pedicle had a much greater influence on
vertebral collapse compared with the thoracic
spine. Other studies have suggested that bone
Spinal Instability Neoplastic Score
mineral density is more important than defect
size in predicting fracture threshold. In the SINS classification system, tumor-related
instability is assessed by adding together six
individual component scores: spine location,
Principle 2: Tension Band
pain, lesion bone quality, radiographic align-
Anterior compressive forces are balanced by ment, vertebral body collapse, and postero
aposterior system composed of muscles and lateral involvement of the spinal elements
16 Chapter 2

(see Table 1.1). Each component of SINS has Treatment of Instability by


demonstrated clinically acceptable reliability.7 SpinalRegion
The minimum score is 0 and the maximum
is 18. Total SINS scores have near-perfect inter- Craniovertebral Junction
and intraobserver reliability when collapsed into Metastasis in this region rarely cause myelop-
three clinically relevant assessments of tumor- athy because the upper cervical canal is large,
related instability, which can be described as and because tumors in this region typically
stability (06), indeterminate instability (poten- present with severe mechanical neck pain be-
tially unstable) (712), and instability (1318). fore they become large enough to significantly
Surgical consultation is recommended for pa- compress the spinal cord. Therefore, ventral
tients with SINS scores 7. Examples of scoring tumor resection (via a transoral or extraoral
are presented in Figs. 2.1, 2.2, and 2.3. approach) is rarely indicated, and our surgical
Content and face validity of the SINS was fa- management strategy has focused on posterior
cilitated by integrating the best evidence pro- spinal stabilization.10 We favor occipitocervical
vided by two systematic reviews with expert fixation over short-segment approaches be-
consensus from members of the SOSG.4 At the cause it protects the patient against the poten-
time of this writing, there are no prospective tial loss of stability due to progression of the
studies that have assessed SINS. However, a destructive process. Our goal is to obtain a
retrospective validity analysis found that the durable construct so that the use of any cum-
false-negative rate was low (4.3%), and all of bersome and poorly tolerated external orthoses
these type II errors were due to distinguishing (e.g., rigid collar or halo vest) can be avoided.
stable from potentially unstable cases (not
stable vs unstable).7
Subaxial Cervical Spine
From C3 through C6, corpectomy reconstructed
When Is Vertebroplasty or with a cage and plate is the most common
Kyphoplasty Sufficient for approach. A combined anterior/posterior sta-
bilization is often necessary for multilevel dis-
Stabilization?
ease, circumferential tumor involvement, severe
Assigning a numerical grade to instability (SINS instability/deformity, and poor bone quality.
018) is attractive because it recognizes that, Supplemental posterior stabilization is often
unlike in trauma, spinal stability due to tumor required at the C7/T1 junction.11
is not lost suddenly in an all-or-none fashion.
Instead, it is gradual process that at a certain
Thoracic and Lumbar Spine
point results in pathological fracture. By being
able to reliably define the severity of instability Anterior approaches are not feasible in most
we may come closer to understanding the indi- patients from T2 to T5, due to the great vessels
cations for less invasive forms of stabilization and the heart. Posterolateral approaches (cos-
such as vertebroplasty or kyphoplasty. We pro- totransversectomy or lateral extracavitary ap-
pose that patients with intermediate grades proach) are recommended for this region, and
of instability (SINS 712) are more likely to are also increasingly popular from T6 through
beappropriate candidates for percutaneous L5 (as compared with anterior approaches),
cement, whereas those with higher scores may because they allow removal of the tumor and
be better treated with spinal instrumentation.8 the application of spinal instrumentation as
Vertebral augmentation is particularly useful in asingle-stage operation.12 Regardless of the
patients with limited life expectancy, patients approach used, the vertebral body may be re-
who are too medically frail to have open sur- constructed with various materials, including al-
gery, and patients with very poor bone quality lograft bone, polymethylmethacrylate (PMMA),
(e.g., myeloma bone disease).9 or metal cages. The latter include distractible
Neoplastic Spinal Instability 17

a b c

d e

Fig. 2.1ae Computed tomography (CT) images of Instability Neoplastic Score (SINS) is calculated
(a) select left parasagittal view, (b) select midline asfollows: mobile spine location (L2), 2 points;
sagittal view, (c) select right parasagittal view, pain-free lesion, 0 points; mixed lytic/blastic lesion,
(d)representative coronal view, and (e) axial view 1 point; normal spinal alignment, 0 points; no
atL2 of a 42-year-old woman with known meta- vertebral body collapse but > 50% body involve-
static breast cancer who had an asymptomatic L2 ment, 1 point; no posterolateral spinal element
lesion identified as an incidental finding on CT involvement, 0 points. Total SINS = 2 + 0 + 1 + 0 + 1
imaging. She denies any back pain. The Spine + 0 = 4 (stable lesion).
18 Chapter 2

a b

c d

Fig. 2.2ae Computed tomography (CT) images


of(a) select left parasagittal view, (b) select midline
sagittal view, (c) select right parasagittal view,
(d)representative coronal view, and (e) axial view
ofa L5 lesion in a 49-year-old man with multiple
myeloma who presents with mild low back pain
thatis not aggravated by activities or movement.
The SINS is calculated as follows: junctional location,
3points; pain but not mechanical, 1 point; lytic,
2points; spinal alignment preserved, 0 points; <
50% vertebral body collapse, 2 points; unilateral
replacement of right pedicle with tumor, 1 point.
Total SINS = 3 + 1 + 2 + 0 + 2 + 1 = 9 (potential
e instability, surgical referral recommended).
Neoplastic Spinal Instability 19

a b c

d e

Fig. 2.3ae Computed tomography (CT) images of application of a cervical collar. The SINS is calculated
(a) select left parasagittal view, (b) select midline as follows: mobile spine location, 2 points; mechani-
sagittal view, (c) select right parasagittal view, cal pain, 3 points; lytic lesion, 2 points; kyphotic
(d)representative coronal view, and (e) axial view deformity, 2 points; > 50% collapse, 3 points;
ofa C4 lesion in a 54-year-old woman with known bilateral posterolateral involvement, 3 points. Total
metastatic sarcoma who presents with neck pain SINS = 2 + 3 + 2 + 2 + 3 + 3 = 15 (instability, surgical
exacerbated by any movement and improved with referral recommended).

or telescoping varieties. Polymethylmethacry- approach, anterior column reconstruction and


late is biologically compatible and very stable stabilization with a plate without supplemen-
in compression, but usually requires anchoring tary posterior stabilization may be sufficient,
with Steinmann pins or a chest tube. If verte- except in certain circumstances: significant ky-
brectomy has been performed via an anterior phosis or deformity, such as translation; thora-
20 Chapter 2

columbar junction zone; significant adjacent vertebral joint, facet, pedicle), kyphoscoliosis
chest wall resection (e.g., Pancoast tumor or may be seen. Occasionally, shearing forces may
locally invasive sarcoma); vertebrectomy span- lead to spondylolisthesis.
ning two or more levels; vertebrectomy caudal A second feature of neoplastic deformities is
to L4 (anterior fixation devices are difficult to that they are usually flexible. The majority may
apply in this region); and poor bone quality.13 be corrected by careful positioning of the pa-
tient on the operating room table. After verte-
brectomy, a distractible cage is a simple tool to
Lumbosacral Junction and Sacrum
correct most kyphotic deformities. Another op-
Tumors in this region, in our experience, sel- tion under the right conditions is to shorten
dom cause spondylolisthesis or other obvious the spine by compressing on normal bone once
deformity because the strong ligamentous sup- the tumor is removedanalogous to a pedicle
port structures and the L5-S1 facet complex, subtraction osteotomy. Exceptions are certain
which confer most of the stability in this re- upper cervical deformities (e.g., pathological
gion, are seldom completely disrupted by tumor. dens fracture with translation, rotatory atlan-
Although significant deformity is unusual, clin- toaxial subluxation), which may require the
ical instability with mechanical pain is not un- application of cervical traction.
common, as this region experiences the largest
loads encountered in the entire spine. As with Is Bone Fusion Necessary?
the cervicothoracic and thoracolumbar regions,
the lumbosacral junction is a high-stress re- Bony fusion per se is unlikely to be achieved
gion. Relatively abrupt changes in anatomy and inmany cancer patients, due to (1) limited life
regional mechanics between the mobile lum- expectancy, (2) adjuvant chemotherapy or ra-
bar and fixed sacral segments increase the risk diation therapy that further compromises the
of fracture and instability and present chal- chance of successful fusion, or (3) poor general
lenging problems in terms of spinal stabiliza- fitness (bone quality, nutrition, or general
tion. Although sacral instability is uncommon,14 frailty). Our goal is to provide an immediately
when it is present the construct demand is stable construct that minimizes or eliminates
high and we generally recommend providing axial pain and helps to prevent neurologic de-
more stability than less. We recommend large- terioration during the remaining life span. In
diameter pedicle screws at S1 (7 to 8 mm), sup- line with these principles, bracing is generally
plemented with additional sacral alar screws or avoided as well. Allograft is often applied after
iliac screws, favoring the later. With significant stabilization in order to promote fusion for the
involvement of the sacrum and sacroiliac (SI) occasional long-term survivor. However, we
joints, percutaneous iliosacral or transsacral do not favor the use of autograft because of
screws should be used. These can often be sup- the potential for graft-site morbidity and the
plemented with cement through a small open occurrence of unrecognized metastatic disease
incision. within the iliac crest bone of some patients.

Correction of Spinal Deformity


Potential Problems
In general, spinal deformities that arise as a re-
sult of metastasis are secondary to collapse of
the vertebral body. Therefore, with the excep-
Mechanical Pain
tion of the upper cervical spine, where trans- Even in the absence of obvious vertebral body
lational and rotational deformities may occur, collapse or deformity, some clinical instability
neoplastic deformity is usually a kyphotic de- is assumed to be present when the syndrome
formity. With significant chest wall disruption, of mechanical pain is present. This type of pain
or the loss of posterolateral elements (costo- is characteristically aggravated by movements
Neoplastic Spinal Instability 21
and improved or relieved at rest. It is important Chapter Summary
to distinguish this from local (biological) pain,
which does not characteristically change with Many of the criteria used to define spinal sta-
movement. Often biological pain and mechan- bility after trauma may not be valid in the set-
ical pain occur together in metastatic disease. ting of oncology. Patients who develop spinal
instability have, or are at high risk of having, a
neurologic deficit, severe pain, and progressive
Vertebral Compression Fractures deformity. An understanding of the mechani-
After Radiosurgery cal integrity of the spine is a key component of
treatment decision making in patients with
Radiation therapy has developed new treatment metastatic disease, along with tumor histology,
paradigms over the last decade. In patients neurologic status, prognosis, and medical fit-
with minimal epidural disease, stereotactic ness for surgery. Prior to the development of
body radiation therapy (SBRT) can be used to the SINS, there were no accepted evidence-
deliver radiation more precisely to the tumor, based guidelines for the classification of neo-
significantly reducing the dose to the spinal plastic spine instability. The SINS is the only
cord, and allowing greater dose-delivery per grading system for neoplastic stability in the
fraction. This advance allows durable tumor spine that has been shown to be reliable and
control rates independent of tumor histology- valid. It is hoped that it can be used to study
specific radiosensitivity to conventional exter- outcomes in an effort to clarify indications for
nal beam radiation therapy (cEBRT). In other surgical and nonsurgical treatment, especially
words, historically radioresistant tumors such for the intermediate grades of instability, where
as renal cell carcinoma may be treated with there is currently significant variation in prac-
SBRT. As well, SBRT may be used in patients in tice. Because the SINS can be reliably rated by
whom cEBRT has failed. nonsurgeons (e.g., radiologists, radiation oncol-
Higher doses produce superior local con- ogists), it is hoped that it will facilitate appro-
trol but may be associated with late toxicities priate referral patterns for surgical assessment
not associated with cEBRT, including vertebral and thus prevent unnecessary suffering and
compression fracture (VCF). Radiation myelop- catastrophic collapse and neurologic injury.
athy is still a rare toxicity unlike the reported
data for VCF after SBRT. A series from the Me-
morial Sloan-Kettering Cancer Center first re- Pearls
ported a fracture progression rate of 39% of
Understand the definition of tumor-related insta-
71sites treated.15 The M.D. Anderson Cancer
bility and basic biomechanical principles in spine
Center later reported a rate of 20% of 123 sites tumors.
treated.16 Conversely, the risk of fracture after Consider impending collapse.
conventional cEBRT is only 2.8% with frac- Utilize the Spine Instability Neoplastic Score
tionated short-course radiation therapy (rang- (SINS).
Appreciate when vertebral augmentation alone
ing most commonly from approximately 20 Gy
is sufficient for stabilization.
in five fractions to approximately 30 Gy in 10 Be aware of approaches and instrumentation for
fractions).17 Cunha et al18 recently reported treatment of instability in each spine region.
that patients treated with SBRT of 20 Gy or
greater in a single fraction are at a higher risk Pitfalls
of VCF. Vertebral augmentation with or with-
Not recognizing that mechanical pain alone may
out pedicle screw supplementation has been
be the only sign of clinical instability.
advocated to prevent fracture, but it is unclear High rate of vertebral compression fractures after
which patients should receive prophylactic radiosurgery.
stabilization.
22 Chapter 2

References
Five Must-Read References
1. Patchell RA, Tibbs PA, Regine WF, et al. Direct decom- 10. Fourney DR, York JE, Cohen ZR, Suki D, Rhines LD, Go-
pressive surgical resection in the treatment of spinal kaslan ZL. Management of atlantoaxial metastases
cord compression caused by metastatic cancer: a with posterior occipitocervical stabilization. J Neuro
randomised trial. Lancet 2005;366:643648 PubMed surg 2003;98(2, Suppl):165170 PubMed
2. Berenson J, Pflugmacher R, Jarzem P, et al; Cancer 11. Fehlings MG, David KS, Vialle L, Vialle E, Setzer M,
Patient Fracture Evaluation (CAFE) Investigators. Vrionis FD. Decision making in the surgical treat-
Balloon kyphoplasty versus non-surgical fracture ment of cervical spine metastases. Spine 2009;34(22,
management for treatment of painful vertebral body Suppl):S108S117 PubMed
compression fractures in patients with cancer: a mul- 12. Polly DW Jr, Chou D, Sembrano JN, Ledonio CG,

ticentre, randomised controlled trial. Lancet Oncol Tomita K. An analysis of decision making and treat-
2011;12:225235 PubMed ment in thoracolumbar metastases. Spine 2009;
3. Weber MH, Burch S, Buckley J, et al. Instability and 34(22, Suppl):S118S127 PubMed
impending instability of the thoracolumbar spine in 13. Fourney DR, Gokaslan ZL. Use of MAPs for deter-
patients with spinal metastases: a systematic review. mining the optimal surgical approach to metastatic
Int J Oncol 2011;38:512 PubMed disease of the thoracolumbar spine: anterior, poste-
4. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classi- rior, or combined. Invited submission from the Joint
fication system for spinal instability in neoplastic Section Meeting on Disorders of the Spine and Pe-
disease: an evidence-based approach and expert con- ripheral Nerves, March 2004. J Neurosurg Spine
sensus from the Spine Oncology Study Group. Spine 2005;2:4049 PubMed
2010;35:E1221E1229 PubMed 14. Nader R, Rhines LD, Mendel E. Metastatic sacral tu-
5. Fourney DR, Gokaslan ZL. Spinal instability and de- mors. Neurosurg Clin N Am 2004;15:453457 PubMed
formity due to neoplastic conditions. Neurosurg Focus 15. Rose PS, Laufer I, Boland PJ, et al. Risk of fracture after
2003;14:e8 PubMed single fraction image-guided intensity-modulated
6. Taneichi H, Kaneda K, Takeda N, Abumi K, Satoh S. radiation therapy to spinal metastases. J Clin Oncol
Risk factors and probability of vertebral body col- 2009;27:50755079 PubMed
lapse in metastases of the thoracic and lumbar spine. 16. Boehling NS, Grosshans DR, Allen PK, et al. Vertebral
Spine 1997;22:239245 PubMed compression fracture risk after stereotactic body ra-
7. Fourney DR, Frangou EM, Ryken TC, et al. Spinal in- diotherapy for spinal metastases. J Neurosurg Spine
stability neoplastic score: an analysis of reliability 2012;16:379386 PubMed
and validity from the spine oncology study group. 17. Chow E, Harris K, Fan G, Tsao M, Sze WM. Palliative
JClin Oncol 2011;29:30723077 PubMed radiotherapy trials for bone metastases: a systematic
8. Paton GR, Frangou E, Fourney DR. Contemporary review. J Clin Oncol 2007;25:14231436 PubMed
treatment strategy for spinal metastasis: the LMNOP 18. Cunha MV, Al-Omair A, Atenafu EG, et al. Vertebral
system. Can J Neurol Sci 2011;38:396403 PubMed compression fracture (VCF) after spine stereotactic
9. Fourney DR, Schomer DF, Nader R, et al. Percutane- body radiation therapy (SBRT): analysis of predictive
ous vertebroplasty and kyphoplasty for painful ver- factors. Int J Radiat Oncol Biol Phys 2012;84:e343
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2003;98(1, Suppl):2130 PubMed
3
Major Complications Associated
with Stereotactic Ablative
Radiotherapy for Spinal Metastasis
Simon S. Lo, Arjun Sahgal, and Eric L. Chang

Introduction trials. The fear is not so much acute toxicity


but rather long-term toxicity, such as radiation
During the past decade stereotactic ablative myelopathy arising from overdosing the spinal
radiotherapy (SABR), which is also known cord, which is a delayed event and a devastating
asstereotactic body radiotherapy (SBRT), has one for the patient, leading to paralysis, inconti-
evolved as a high-dose targeted treatment nence, and potentially death. This chapter sum-
aimed at local tumor control for various tumor marizes the literature on adverse events with
sites such as the lung, the liver, and, now, the spine SABR, as several reviews have focused on
spine.1 With respect to spinal metastases, it clinical outcomes.24
was initially developed for the re-treatment
indication, as further conventional radiation
was limited by the cumulative tolerance of the Major Adverse Events
spinal cord, and spine SABR enables carving of
the radiation dose around and away from the
spinal cord to maintain safe dose limits while
Radiation Myelopathy
dose escalating the vertebral tumor segment. Radiation myelopathy (RM) has been observed
This technique has become a primary therapy after spinal SABR in both unirradiated and re
for selected patients in the upfront setting irradiated patients. The work by Sahgal et al57
and as postoperative therapy, and it is rapidly at the University of Toronto has resulted in safe
emerging as a commonly practiced alternative dose limits for both clinical situations based on
to low-dose conventional radiotherapy.2,3 Mul- the multi-institutional pooling of cases of RM
tiple series have shown promising results with and controls with no RM. For patients with no
regard to local control and pain control3; how- history of radiation, Sahgal et al7 recently re-
ever, as yet there are no randomized controlled ported on nine cases of RM after spinal SABR
trials completed to confirm superior outcomes. and provided an unprecedented detailed dose-
Radiation Therapy Oncology Group (RTOG) 0631 volume histogram (DVH) analysis. The DVH
is an ongoing trial comparing 8 Gy in one frac- data were compared for the nine RM patients
tion delivered conventionally to 16 to 18 Gy in and 66 controls, and the spinal cords were con-
one fraction delivered with SABR. toured based on the thecal sac as a surrogate
One of the major issues with this technique for the true cord. This contouring approach was
is the toxicity profile, which has not been ex- done to factor in potential sources of error in
tensively studied with phase 1 trials, and, more- assuming that the dose to the contoured true
over, there are limited prospective phase 2 cord is in reality the dose that is delivered.
24 Chapter 3

Sources of error include physiological spinal within thecal sac volumes ranging from a point
cord motion, intrafraction patient motion, maximum (Pmax) to 2 cc. The most significant
variation in spinal cord delineation, potential result was observed for the Pmax volume, cor-
errors in magnetic resonance imaging (MRI) roborating the notion that the spinal cord is a
and computed tomography (CT) image fusion, serial organ.
the treatment planning calculation algorithm, With respect to reirradiation, Sahgal et al6
the image-guidance system, treatment couch also reported a case-control analysis based on
motions, gantry rotation precision, and micro- five cases of RM and 16 controls. Once again, the
multileaf collimator (mMLC) leaf position cali- thecal sac was used as a surrogate for the spinal
bration. Basing the dose limits on the thecal cord. The cumulative nBED, which was defined
sac essentially provides a margin of safety on as the sum of the nBED from the first course of
the true cord that was anatomic as opposed conventional radiotherapy and the Pmax nBED
toa fixed expansion. The authors acknowledge from the SABR retreatment course for each pa-
that this approach is roughly equivalent to a tient was then calculated (using an/ of 2 for
1.5-mm margin expansion beyond the cord. All the spinal cord). Based on the analysis, the au-
patients received SABR over one to five frac- thors recommended that the cumulative nBED
tions, with fraction sizes 5 Gy. Although one to the thecal sac Pmax should not exceed 70
patient with RM had been treated with boost Gy2/2, which was most applicable when the ini-
SABR 6 weeks after external beam radiother- tial conventional radiotherapy nBED ranged from
apy, the cumulative biologically effective dose 30 to 50 Gy2/2, and that the thecal sac (surro-
(BED) was calculated. The median follow-up gate of spinal cord) Pmax nBED from reirradia-
times for patients with and without RM was tion with SABR should not exceed 25 Gy2/2. In
23 and 15 months, respectively, and the me- addition, the model suggested that the thecal
dian time to RM was 12 months (range, 315 sac SABR Pmax nBED/cumulative Pmax nBED
months). In this study, all doses were converted ratio should not exceed 0.5, and the minimum
to an equivalent BED in 2-Gy fractions, which time interval between the two treatment courses
was termed the normalized 2-Gy equivalent be at least 5 months. Based on the data of this
BED (nBED), and the / used for the spinal study, Sahgal et al have made recommenda-
cord was 2 (hence, the dose unit is Gy2/2). This tions on absolute dose limit for the thecal sac
is also known as the equivalent dose in 2 Gy for re-treatment of spinal tumors with SABR
fractions (EQD2). Ultimately, a model was cre- (Table 3.2). Their colleagues atthe University of
ated to yield 1%, 2%, 3%, 4%, and 5% probabilities Toronto follow these recommendations strictly
of RM based on linear regression analysis. The in their high-volume centers and have not ob-
doses are listed in Table 3.1. The authors also served RM in their patients (unpublished in-
reported a detailed analysis of the effect of dose formation provided by Arjun Sahgal).

Table 3.1 Predicted Pmax Volume Absolute Doses in Gy for 1 to 5 SABR Fractions that Result in 1% to
5% Probability of Radiation Myelopathy

1 Fraction 2 Fractions 3 Fractions 4 Fractions 5 Fractions


Pmax Limit Pmax Limit Pmax Limit Pmax Limit Pmax Limit
(Gy) (Gy) (Gy) (Gy) (Gy)

1% probability 9.2 12.5 14.8 16.7 18.2


2% probability 10.7 14.6 17.4 19.6 21.5
3% probability 11.5 15.7 18.8 21.2 23.1
4% probability 12.0 16.4 19.6 22.2 24.4
5% probability 12.4 17.0 20.3 23.0 25.3

Abbreviation: Pmax, maximum point dose.


Source: From Sahgal A, Weinberg V, Ma L, et al. Probabilities of radiation myelopathy specific to stereotactic body radiation
therapy to guide safe practice. Int J Radiat Oncol Biol Phys 2013;85:341347. Reproduced with permission from Elsevier.
Stereotactic Ablative Radiotherapy for Spinal Metastasis 25
Table 3.2 Reasonable Reirradiation SABR Doses to the Thecal Sac Pmax Following Common Initial
Conventional Radiotherapy Regimens*

1 Fraction: 2 Fractions: 3 Fractions: 4 Fractions: 5 Fractions:


Conventional SABR Dose SABR Dose SABR Dose SABR Dose SABR Dose
Radiotherapy to Thecal to Thecal to Thecal to Thecal to Thecal
(nBED) Sac Pmax Sac Pmax Sac Pmax Sac Pmax Sac Pmax

0 10 Gy 14.5 Gy 17.5 Gy 20 Gy 22 Gy
20 Gy in 5 fractions 9 Gy 12.2 Gy 14.5 Gy 16.2 Gy 18 Gy
(30 Gy2/2)
30 Gy in 10 fractions 9 Gy 12.2 Gy 14.5 Gy 16.2 Gy 18 Gy
(37.5 Gy2/2)
37.5 Gy in 15 9 Gy 12.2 Gy 14.5 Gy 16.2 Gy 18 Gy
fractions
(42 Gy2/2)
40 Gy in 20 fractions N/A 12.2 Gy 14.5 Gy 16.2 Gy 18 Gy
(40 Gy2/2)
45 Gy in 25 fractions N/A 12.2 Gy 14.5 Gy 16.2 Gy 18 Gy
(43 Gy2/2)
50 Gy in 25 fractions N/A 11 Gy 12.5 Gy 14 Gy 15.5 Gy
(50 Gy2/2)

Abbreviations: N/A, not applicable; nBED, normalized biologically effective doses; SABR, stereotactic ablative radiotherapy.
*These dose limits are based on a prior publication by Sahgal et al. for spinal cord tolerance in patients treated with SABR
and no prior history of radiation.
Source: From Sahgal A, Ma L, Weinberg V, et al. Reirradiation human spinal cord tolerance for stereotactic body radiother-
apy. Int J Radiat Oncol Biol Phys 2012;82:107116. Reproduced with permission from Elsevier.

Controversy Vertebral Compression Fracture


The recommendations of Sahgal et al were based Vertebrae bearing metastases are prone to
on BED modeling to convert the various dose- pathological fractures due to the replacement
fractionation schemes into a single number, as it
of healthy bone with tumor. Lytic disease is
represents at this time the easiest model to apply
inthe clinic with the least number of assumptions. inherently weaker than sclerotic disease; how-
However, the linear-quadratic (LQ) model has re- ever, both increase the risk of skeleton-related
cently been challenged in its ability to accurately events. Radiotherapy, frequently used as a treat-
estimate the BED in the ablative dose range (> 15 ment for bone metastasis, can increase the risk
Gy/fraction) as used in SABR. Wang et al8 have pro-
of fracture, but the risk is thought to be low
posed a generalized LQ (gLQ) model, which pro-
vides a natural extension across the entire dose with conventional palliative doses. However,
range. This model was independently validated for SABR is based on ablative doses of radiation and
tumor response in in-vitro studies at Thomas Jef- delivered to the clinical target volume (CTV),
ferson University, but it had not been employed to which typically includes the entire vertebral
model toxicities in normal tissues9 until Huang et
body; hence, tumor and normal bone tissue are
al10 reanalyzed the data from the above discussed
paper on spinal cord tolerance for reirradiation with exposed. It is only recently that vertebral com-
SABR by Sahgal et al, using the gLQ model. It was pression fracture (VCF) after spinal SABR has
also determined that no RM was observed when the been reported in the literature in detail.1113
cumulative Pmax nBED to the thecal sac was 70 Researchers at Memorial Sloan-Kettering
Gy2/2 based on conversions using the gLQ model.10
Cancer Center (MSKCC) first reported their
However, with the scarcity of clinical data, the gLQ
model must be approached with extreme caution, observation of VCF following SABR for spinal
and clinical validation is necessary. metastases. The dose regimen used was 18 to
24 Gy in one fraction, with a majority of pa-
26 Chapter 3

tients receiving 24 Gy in one fraction. They ob- lying mechanism of the fracture, which again
served progressive VCF in 39% of the vertebrae makes radiobiological sense.14 However, there
treated at a median time of 25 months.13 The was a discrepancy of the time frame within
location of spinal metastasis (above T10 vs T10 which VCF occurred between the MSKCC study
or below), the nature of the spinal metastasis and the MDACC and University of Toronto
(lytic vs sclerotic and mixed), and the percent- studies. The much later median time to VCF
age of vertebral body involvement were iden- reported by the MSKCC group at 25 months
tified as predictors of VCF. versus 3 and 2 months by the MDACC and Uni-
Compared to the study from MSKCC, research- versity of Toronto1113 may imply that with fur-
ers at M.D. Anderson Cancer Center (MDACC)11 ther follow-up the risk of VCF may continue to
and the University of Toronto12 reported much rise or that the pathological processes may be
lower rates of VCF and at an earlier time-course different.
post-SABR (median time ranging from 2 to 3.3
months). In the MDACC study, the incidence of
new or progressive VCF in 93 patients with 123
Pain Flare
spinal metastases treated with SABR was 20%. Pain flare, defined as a transient increase in
Unlike the MSKCC study where a single-fraction pain during or shortly after radiotherapy, has
regimen was used for SABR for all patients, ap- been observed after conventional radiotherapy
proximately two thirds of the patients in the for bone metastasis. So far, there has been only
MDACC cohort received either 27 Gy in three one study addressing pain flare specific to
fractions or 20 to 30 Gy in five fractions. Fac- spine SABR. Chiang et al15 at the University of
tors predicting development of VCF included Toronto performed a prospective study exam-
age > 55 years, a preexisting fracture, and base- ining the incidence of pain flare and the pre-
line pain. Obesity was found to have a protective dictive factors of the complication. A total of
effect. The median time to fracture progression 41 steroid-nave patients were enrolled, and
was 3 months after SBRT. Similarly, the study pain was assessed using the Brief Pain Inven-
from the University of Toronto, which included tory (BPI) at baseline, during SABR, and for 10
90 patients with 167 spinal metastases treated days after SABR. The investigators recorded the
with SABR, also included patients treated with use of pain medications with dosages converted
two to five fractions in addition to those treated to an oral morphine equivalent dose (OMED),
with a single fraction. The identified risk fac- and the use of steroids, daily during the study
tors for VCF included the presence of kyphosis/ period.
scoliosis, lytic appearance, primary lung and Pain flare was defined as
hepatocellular carcinoma, and a dose per frac-
1. a 2-point increase of worst pain score on BPI
tion 20 Gy. The crude rate of VCF was 11% and
with no change in oral morphine equivalent
the 1-year fracture-free probability was 87.3%.
dose;
The median time to fracture after SBRT was
2. a 25% increase in oral morphine equivalent
2months.
dose with no decrease in worst pain score; or
The much higher rate of VCF observed in the
3. any initiation of steroid therapy.
MSKCC study was likely related to the very ag-
gressive regimen of 24 Gy in one fraction used In terms of SABR dose, 18 patients received 20
for the majority of the patients in that study.13 to 24 Gy in a single fraction and 23 patients re-
This corroborated with the finding from the ceived 24 to 35 Gy in two to five fractions to
University of Toronto study that a dose per their spinal metastases. Pain flare was observed
fraction of 20 Gy was associated with an in- in 28 (68.3%) of 41 patients, with eight (28.6%)
creased risk of VCF,12 which implies that the of 28 patients experiencing pain flare the day
radiation has an independent effect on the risk after SABR completion. Fifteen (53.6%) of 28
of VCF. Moreover, a clinicopathological study patients had a 2-point increase in worst pain
from the University of Toronto found that ra score with no change in analgesic intake, five
diation necrosis of the bone is likely the under- (17.9%) needed a 25% increase in analgesic in-
Stereotactic Ablative Radiotherapy for Spinal Metastasis 27
take with no decrease in worst pain score, and 8 to 12 Gy 2 fractions, 8 Gy 3 fractions, 6 to
eight (28.6%) needed initiation of dexametha- 12.5 Gy 4 fractions, and 5 to 10 Gy 5 frac-
sone. With respect to risk factors associated with tions. Three of 31 patients developed esopha-
pain flare, none of the dosimetric or tumor- geal toxicities and two of them died of either a
specific factors were predictive of pain flare. tracheoesophageal fistula or esophageal perfo-
Only the Karnofsky Performance Scale (KPS) ration (grade 5). Dosimetric parameters exam-
and the location of the index vertebra (cervical ined included D5cc, D2cc, D1cc, and Dmax. When
and lumbar) were predictive. Rescue dexameth- the LQ model was used to convert the dose to a
asone at 4 mg orally once daily for the remain- single fraction, the D5cc, D2cc, D1cc, and Dmax for
der of the course of SABR, or for 5 days after the three patients ranged from 10.7 to 16.5 Gy,
SABR either during or within 10 days from com- 13.7 to 18.2 Gy, 15.7 to 19 Gy, and 18.5 to
pletion of SABR, was found to effectively treat 22.8Gy, respectively. When the universal sur-
the pain flare. vival curve (USC) model was used to convert
the dose to single fraction, the corresponding
numbers were 11.9 to 16.5 Gy, 17.4 to 18.2 Gy,
Esophageal Toxicity 19 to 22.5 Gy, and 21 to 37.3 Gy, respectively.
The esophagus is located immediately in front Further data and modeling are required before
of the spinal column, especially for the thoracic hard dose limits are known, but both these
segments, and is susceptible to injury by abla- studies suggest keeping the maximum dose
tive doses of radiation delivered to the spine. 20 Gy.
There is limited literature specific to esopha-
geal toxicity from SABR. In a large study from Radiation Plexopathy/
MSKCC in which 182 patients with 204 spinal
metastases abutting the esophagus were treated
Radiculopathy
with single-fraction SBRT to a dose of 24 Gy, Given the close proximity of the spinal nerves
esophageal toxicity was scored according to and nerve plexuses to the vertebrae, these
the National Cancer Institute Common Toxicity structures are susceptible to injury by ablative
Criteria for Adverse Events version 4.0.16 There doses of radiation delivered through SABR.
were 31 (15%) acute and 24 (12%) late esopha- Although rare, radiation radiculopathy or plex-
geal toxicities during the median follow-up opathy has been observed. In a phase I/II trial
interval of 12 months. Grade 3 or higher acute of single-dose SABR for radiation nave spinal
or late toxicities were observed in 14 (6.8%) pa- metastases from MDACC, where doses of 16 to
tients. For grade 3 or higher esophageal toxici- 24 Gy were given, of 61 patients treated, 10 de-
ties, the median splits for D2.5cm3 (the minimum veloped mild (grade 1 or 2) numbness and tin-
dose to the 2.5 cm3 receiving the highest dose), gling and one developed grade 3 radiculopathy
V12 (the volume receiving at least 12 Gy), V15, at L5.18 Researchers at Beth Israel Deaconess
V20, and V22 were 14 Gy, 3.78 cc, 1.87 cc, 0.11 cc, Hospital (Boston, MA) observed four cases of
and 0 cc, respectively. They also note the max- persistent or new radiculopathy in their cohort
imum point dose should be kept below 22 Gy. of 60 patients with recurrent epidural spinal
Importantly, the seven patients who developed metastases treated with SABR. All of those pa-
grade 4 or higher toxicities either had radiation tients had radiological progression of disease,
recall reactions after chemotherapy with doxo- and it is unclear whether the complications
rubicin or gemcitabine, or iatrogenic esophageal were caused by tumor progression, radiation
manipulation, such as biopsy, dilatation, and injury of the spinal nerves, or a combination of
stent placement. both.19 Investigators from MDACC observed two
In a study from Stanford University, 31 pa- cases of grade 3 lumbar plexopathy in their
tients treated with SABR for lung or spinal tu- study on reirradiation with SBRT for recurrent
mors < 1 cm from the esophagus were reviewed spinal metastases in 59 patients.20
to determine esophageal tolerance.17 Treatment The tolerance of the brachial plexus to SABR
regimens included 16 to 25 Gy in one fraction, has been investigated in a study from Indiana
28 Chapter 3

University, where 36 patients with 37 apical may result in overdosing of those structures,
primary lung cancers were treated with a dose leading to catastrophic neurologic complica-
of 30 to 72 Gy in three or four fractions.21 Seven tions.5 When a linear-accelerator (LINAC)-based
cases of grade 2 to 4 brachial plexopathy was system is used for SABR, the use of the BodyFIX
observed. The cutoff dose was determined to (Elekta, Stockholm, Sweden) near-rigid body
be 26 Gy in three or four fractions, which is in immobilization system has been demonstrated
keeping with the constraint of 24 Gy in three by researchers at the University of Toronto to be
fractions used in the RTOG trials. The 2-year more robust in minimizing intrafraction mo-
rates of brachial plexopathy were 46% and 8% tions as compared to a simple vacuum cushion
when the maximum brachial plexus dose was system, limiting the set-up error to 2 mm.23
> 26 Gy and 26 Gy, respectively. One caveat of Intrafraction patient motion occurs despite
the study is that the subclavian/axillary ves- the application of advanced technology to its
sels, which served as a surrogate for brachial fullest extent, especially when the treatment
plexus, instead of the full brachial plexus were time is anticipated to be long. Investigators from
contoured. University of Toronto evaluated their LINAC-
based system and showed that there could be
intrafraction motion of 1.2 mm and 1 degree
Avoiding Complications with near-rigid body immobilization (BodyFIX),
To minimize the risks of serious complications image-guidance with kilovoltage cone-beam
caused by spinal SABR, all relevant organs at risk CT (CBCT), and a robotic couch capable of ad-
(OARs) such as the spinal cord, cauda equina, justing shifts with 6 degrees of freedom.24 To
nerve plexuses and roots, and esophagus should maintain this level of precision, it was concluded
be contoured and the dose constraint for each that intrafraction repeat cone-beam CT is nec-
OAR should be respected. For critical neural essary to check for any positional variation and
structures such as the spinal cord and cauda at an interval of approximately every 20 min-
equina, MRI is required for very accurate con- utes. Newer technologies like volumetric mod-
touring.22 Fusion of the spinal MRI (axial T1 ulated arc therapy (VMAT) and the high dose
and T2 sequences) with the treatment planning rate flattening filter-free feature can drastically
CT should be performed to facilitate the pro- reduce treatment time and may render intra-
cess. The quality of the fusion should be care- fraction cone-beam CT unnecessary. With the
fully checked before the image sets are used for use of a CyberKnife unit, which is capable of
delineation of the neural structures. In patients real-time intrafraction imaging with in-room
who cannot undergo a spinal MRI or in the stereoscopic kV x-ray and providing feedback
postoperative setting where there is significant to a mini-LINAC mounted on a robotic arm, a
metallic artifacts on MRI obscuring the visual- positioning accuracy of 1.0 mm and 1.0 degree
ization of the spinal cord, a CT myelogram can can be achieved.25 Near-rigid body immobiliza-
be used for delineation of the spinal cord. It is tion may not be necessary for this system as the
crucial that the window leveling is correct be- CyberKnife is unique in its ability to reposition
cause inaccurate window leveling will lead to the LINAC while treatment is being delivered
inaccurate cord contouring, which in turn will with tight tolerances. Apart from intrafraction
result in inaccurate determination of cord dose. patient motion, physiological spinal cord mo-
Universal to SABR for all body sites and par- tion can also contribute to uncertainties or er-
ticularly for spinal tumors, robust immobiliza- rors in the estimation of true spinal cord dose
tion is of the utmost importance. Most OARs from SABR.5 Taking into account all the above-
including critical neural structures like the spi- mentioned factors, it is prudent to create a Plan-
nal cord and nerve roots are in very close prox- ning organ-at-risk volume (PRV) for the spinal
imity to the spinal CTVs, and the dose gradient cord to decrease the risk of RM caused by po-
between the spinal cord and spinal CTV is typ- tential errors that can lead to overdosing of
ically very steep in SABR for spinal metastases the spinal cord. Although some institutions and
such that even slight deviations in positioning RTOG do not use a PRV to set a dose constraint
Stereotactic Ablative Radiotherapy for Spinal Metastasis 29
for spinal cord, the authors routinely use the metastasis. Therefore, it is crucial to contour
thecal sac or a 1.5- to 2.0-mm margin around the esophagus as an OAR and to respect its
the MRI/myelogram delineated cord to set the tolerance in order to minimize the risk of seri-
dose constraint for spinal cord. ous complications. Data from MSKCC showed
Sahgal et al6,7 have made recommendations that the maximum dose tolerated was volume-
on spinal cord dose constraints using the the- dependent, as mentioned above.16 Other fac-
cal sac as a surrogate in a radiation-nave situ- tors that increase the risk of severe esophageal
ation and a reirradiation setting (Tables 3.1 and toxicity such as post-SABR doxorubicin- or
3.2). As mentioned above, one of the authors gemcitabine-based chemotherapy or surgical
(Sahgal), who follows these recommendations esophageal manipulation should be avoided if
strictly, has not observed any incident of RM, possible. The use of a multiple session regimen
having treated at least 500 targets over the last (three to five fractions) may also decrease the
5 years. Alternatively, spinal cord dose con- risk of esophageal injury by SABR if the dose
straints of 10 Gy in five fractions and 9 Gy in constraint cannot be met in one fraction.
three fractions have been used by the other Nerve plexuses and nerve roots are suscep-
two authors (Lo and Chang) in the reirradiation tible to injury by ablative radiation.1820 To spare
setting, with prior conventional radiotherapy these structures, they need to be carefully and
dose 45 Gy (1.82.0 Gy per fraction), and RM accurately contoured. These structures can be
has not been observed. The reanalysis of the better visualized on MRI, which can be fused
data on spinal cord tolerance for reirradiation with treatment planning CT. Best efforts must
with SABR using the gLQ model has yielded be made to respect the dose constraints of these
interesting results, which are different from neural structures, especially at levels where
those of the original study.10 However, exten- the nerves roots or nerve plexuses are respon-
sive clinical validation is necessary to guide sible for motor function of the extremities.
safe treatment. Currently, the data from the The contouring atlas of brachial plexus is avail-
original study by Sahgal et al. represent the best able at the RTOG website (http://www.rtog.org/
clinical data available.6 CoreLab/ContouringAtlases/BrachialPlexus-
As mentioned above, several risks factors ContouringAtlas.aspx).
have been identified, predicting VCF after SABR Table 3.3 lists the constraints used by RTOG
for spinal metastases. It seems to be prudent trials for the spinal cord, esophagus, cauda
to avoid using a single fraction of 20 Gy,12 es- equina, and nerve plexuses. Note that the con-
pecially for patients with the above-mentioned straints in the table have not been tested clini-
risk factors. In patients with preexisting frac- cally, and their use outside of a clinical trial
tures, prophylactic kyphoplasty or vertebro- setting is not authorized by RTOG.
plasty before SABR can be offered and may
reduce the risk of further fracture and palliate
the mechanical pain to enable the patient to tol-
erable subsequent SABR. For pain flare, rescue Chapter Summary
steroids are effective, and the use of prophylac-
tic steroids may be best, subject to a further The major complications that have been ob-
study at the University of Toronto. Medrol Pak served after SABR for spinal metastases include
Oral (Pfizer, Brooklyn, NY) is a commercially RM, VCF, pain flare, esophageal toxicity, and
available prepacked version of methylprednis- nerve injury.6,7,1120 Given the proximity of
olone that is more convenient for patients to those relevant OARs to the vertebrae, these
use during SABR. complications are not unexpected. Every effort
The esophagus is immediately anterior to the must be made to spare those structures from
vertebral column mostly in the lower cervical doses beyond their tolerance. Robust near-rigid
and thoracic regions, and it is expected that immobilization and strategies to manage intra-
some portions of the esophagus will receive a fraction patient motion are crucial steps in safe
proportion of the dose delivered to the spinal delivery of SABR. Apart from near-rigid immo-
30 Chapter 3

Table 3.3 Normal Tissue Constraints used by RTOG trials (www.rtog.org)*

Organ at Risk 1 Fraction 3 Fractions 4 Fractions 5 Fractions

Spinal cord RTOG 0631 and RTOG 0236 and RTOG 0915: 26 RTOG 0813: 30 Gy
0915: 14 Gy 0618: 18 Gy (maximum)/ (maximum)/
(<0.03 cc or (maximum) 20.8 (< 0.35 22.5 Gy (< 0.25
maximum)/10 RTOG 1021: cc)/13.6 cc)/13.5 Gy
Gy (< 0.35 cc)/ 21.9Gy (<1.2 cc) (< 0.5 cc)
7 Gy (<1.2 cc) (maximum)/
(only for RTOG 18 Gy (< 0.35
0915) cc)/12.3 Gy
(< 1.2 cc)
Brachial plexus RTOG 0631 and RTOG 0236 and RTOG 0915: RTOG 0813: 32 Gy
0915: 17.5 Gy 0618: 24 Gy 27.2Gy (maximum)/
(<0.03 cc or (maximum) (maximum)/ 30 Gy (< 3 cc)
maximum)/ RTOG 1021: 24 Gy 23.6 Gy (< 3 cc)
14 Gy (< 3 cc) (maximum)/
20.4 Gy (< 3 cc)
Cauda equina RTOG 0631: 16 Gy Not available Not available Not available
(< 0.03 cc)/
14 Gy (< 5 cc)
Sacral plexus RTOG 0631: 18 Gy Not available Not available Not available
(< 0.03 cc)/
14.4 Gy (< 5 cc)
Esophagus RTOG 0631: 16 Gy RTOG 0236 and RTOG 0915: 30 Gy RTOG 0813:
(< 0.03 cc)/ 0618: 27 Gy (maximum)/ 105% of PTV
11.9 Gy (< 5 cc) (maximum) 18.8 Gy (< 5 cc) prescription
RTOG 0915: 15.4 RTOG 1021: 25.2 (maximum)/
Gy (maximum)/ Gy (maximum)/ 27.5 Gy (< 5 cc)
11.9 Gy (< 5 cc) 17.7 Gy (< 5 cc)

*These dose constraints have not been thoroughly tested clinically, and the authors do not assume responsibility for the
use of these dose limits.

bilization, intrafraction CBCT and the use of PRV for planning or simply the utilization of
newer technologies such as VMAT and the high the thecal sac contours as a surrogate for the
dose rate flattening filter-free mode to drasti- spinal cord.3,5,22 The current recommendations
cally reduce treatment time can also tackle for spinal cord constraints were derived based
intrafraction patient motion. on the use of thecal sac as a surrogate.
To facilitate accurate contouring of the spinal Vertebral compression fracture occurs more
cord, a spinal MRI or a CT myelogram should be commonly in patients with certain risk fac-
fused with the treatment planning CT.22 Be- tors.1113 The most important treatment factor
cause of various sources of potential error, in- is the dose per fraction; the prescribed dose is
cluding inherent technical uncertainties and 20 Gy/fraction,12 which in essence is the dose
physiological spinal cord motion, there is a risk used for a single fraction regimen. Therefore, it
of overdosing of the spinal cord given the steep is recommended that one should avoid using a
dose gradient from the spinal CTV. Although single dose of 20 Gy for SABR for spinal me-
many institutions and RTOG use only the spi- tastasis, especially in patients with risk factors
nal cord contours to set dose constraints, it is for VCF. Pain flare is a common acute compli-
prudent to create a safety margin for the spinal cation of spinal SABR and it can be prevented
cord during treatment planning. Common prac- with the use of a short course of prophylactic
tices include an expansion of a 1.5- to 2.0-cm dexamethasone or methylprednisolone.15 Se-
margin around the cord contour to generate a vere esophageal toxicities have been observed
Stereotactic Ablative Radiotherapy for Spinal Metastasis 31
in patients who have undergone doxorubicin-
and providing feedback to a mini-LINAC mounted
or gemcitabine-based chemotherapy or surgical
on a robotic arm, and a positioning accuracy of
esophageal manipulation after single fraction 1.0 mm and 1.0 degree can be achieved.
SABR.16 One should avoid those treatments or To account for physiological cord motion, a PRV
procedures after SABR, if possible. If doxoru for the spinal cord is created to decrease the risk
bicin- or gemcitabine-based chemotherapy is of RM caused by potential errors that can lead to
overdosing of the spinal cord.
necessary as part of the treatment plan, it is
The published data and guidelines on spinal cord
recommended that it should be given before constraints based on real patients may be used to
spinal SABR. The use of a multisession SABR guide treatment planning.6,7,10
regimen may also decrease the risk of esopha- Alternatively, spinal cord dose constraints of 10 Gy
geal injury. Nerve plexuses and nerve roots are in five fractions and 9 Gy in three fractions have
been used by two of the authors (Lo and Chang)
susceptible to injury by ablative radiation as
in the reirradiation setting, with prior conven-
delivered in spinal SABR.1820 To spare these tional radiotherapy dose 45 Gy (1.82.0 Gy per
structures, they need to be carefully and accu- fraction), and RM has not been observed.
rately contoured. A contouring atlas is available It is prudent to avoid using a single fraction of
at the RTOG website (http://www.rtog.org/ 20 Gy for SABR for spinal metastasis, especially
for patients with risk factors for VCF.
CoreLab/ContouringAtlases/BrachialPlexus
For pain flare, rescue steroids are effective and the
ContouringAtlas.aspx). use of prophylactic steroids may be considered.
The Radiation Therapy Oncology Group has It is crucial to contour the esophagus as an OAR
a set of dose constraints for OARs for their and to respect its tolerance in order to minimize
SABR trials (www.rtog.org), but they are largely the risk of serious complications from spinal
SABR.
unvalidated. More clinical data are needed be-
Post-SABR doxorubicin- or gemcitabine-based
fore they can be adopted in routine practice. chemotherapy or surgical esophageal manipula-
tion should be avoided if possible.
Pearls The use of a multiple session regimen (three to
five fractions) may also decrease the risk of
All relevant organs at risk (OARs) such as the spi- esophageal injury by SABR if the dose constraint
nal cord, cauda equina, nerve plexuses and roots, cannot be met in one fraction.
and esophagus should be contoured and the dose To spare the nerve plexuses and nerve roots,
constraint for each OAR should be respected. they need to be carefully and accurately con-
Fusion of the spinal MRI (axial T1 and T2 se- toured, preferably on MRI fused with treatment
quences) with the treatment planning CT should planning CT.
be performed to facilitate the process. Best efforts must be made to respect the dose
In patients who cannot undergo a spinal MRI or in constraints of the nerve plexuses and nerve roots,
the postoperative setting where there is signifi- especially at levels where the nerves roots or nerve
cant metallic artifacts on MRI obscuring the visu- plexuses are responsible for motor function of
alization of the spinal cord, a CT myelogram can the extremities.
be used for delineation of the spinal cord. The dose constraints used in SABR trials of RTOG
The quality of the fusion should be carefully are largely unvalidated and should be approached
checked before the image sets are used for de- with extreme caution.
lineation of the neural structures.
It is crucial that the window leveling of CT myelo- Pitfalls
gram be correct.
Robust immobilization is crucial for safe delivery If OARs such as the spinal cord, cauda equina,
of SABR for spinal metastasis, and this is best nerve plexuses and roots, and esophagus are not
achieved with the use of a device that has a dou- contoured during treatment planning for spinal
ble vacuum system. SABR, inadvertent injury to those structures may
Intrafraction positional variation can be minimized occur, leading to serious complications if dose
by the use of intrafraction repeat cone-beam CT constraints of those OARs are exceeded.
and the reduction of treatment time by using Accurate delineation of the spinal cord and cauda
VMAT and the high dose rate flattening filter-free equina, which is crucial to safe delivery of spinal
feature. SABR, can be difficult without fusion of appropri-
A CyberKnife unit is capable of real time intrafrac- ate scans such as MRI of the spine with the treat-
tion imaging with in-room stereoscopic kV X-ray ment planning CT.
32 Chapter 3

Metallic artifacts can interfere with delineation of nave and a reirradiation setting, and these pose
spinal cord on MRI. challenges to spinal SABR practitioners.
Poor-quality image fusion and improper window- Vertebral compression fracture and pain flare,
ing can lead to inaccurate cord contouring, which both very undesirable complications, can occur
in turn will result in inaccurate determination of with SABR for spinal metastasis.
cord dose. The esophagus is immediately anterior to the
Intrafraction patient motion and physiological vertebral column mostly in the lower cervical and
spinal cord motion can lead to significant uncer- thoracic regions and is susceptible to toxicity from
tainty in the actual radiation dose delivered in the ablative doses of radiation delivered by SABR.
spinal cord. Nerve plexuses and nerve roots are susceptible
There are significant uncertainties regarding the toinjury by ablative radiation delivered by SABR
spinal cord constraints for spinal SABR in a radiation- given their proximity to the vertebrae.

References
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radiation therapy to guide safe practice. Int J Radiat 86:638642 PubMed
Oncol Biol Phys 2013;85:341347 PubMed 16. Cox BW, Jackson A, Hunt M, Bilsky M, Yamada Y.
8. Wang JZ, Huang Z, Lo SS, Yuh WT, Mayr NA. A gener- Esophageal toxicity from high-dose, single-fraction
alized linear-quadratic model for radiosurgery, ste- paraspinal stereotactic radiosurgery. Int J Radiat
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9. Ohri N, Dicker AP, Lawrence YR. Can drugs enhance tolerance to high-dose stereotactic ablative radio-
hypofractionated radiotherapy? A novel method of therapy. Dis Esophagus 2012;25:623629 PubMed
Stereotactic Ablative Radiotherapy for Spinal Metastasis 33
18. Garg AK, Shiu AS, Yang J, et al. Phase 1/2 trial of 22. Lo SS, Sahgal A, Wang JZ, et al. Stereotactic body ra-
single-session stereotactic body radiotherapy for pre- diation therapy for spinal metastases. Discov Med
viously unirradiated spinal metastases. Cancer 2012; 2010;9:289296 PubMed
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19. Mahadevan A, Floyd S, Wong E, Jeyapalan S, Groff M, neau D. Impact of immobilization on intrafraction
Kasper E. Stereotactic body radiotherapy reirradia- motion for spine stereotactic body radiotherapy using
tion for recurrent epidural spinal metastases. Int J cone beam computed tomography. Int J Radiat Oncol
Radiat Oncol Biol Phys 2011;81:15001505 PubMed Biol Phys 2012;84:520526 PubMed
20. Garg AK, Wang XS, Shiu AS, et al. Prospective evalua- 24. Hyde D, Lochray F, Korol R, et al. Spine stereotactic
tion of spinal reirradiation by using stereotactic body body radiotherapy utilizing cone-beam CT image-
radiation therapy: The University of Texas MD An- guidance with a robotic couch: intrafraction motion
derson Cancer Center experience. Cancer 2011;117: analysis accounting for all six degrees of freedom. Int
35093516 PubMed J Radiat Oncol Biol Phys 2012;82:e555e562 PubMed
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PubMed
4
En Bloc Resection in the
Treatmentof Spinal Metastases:
Technique and Indications
Ilya Laufer, Jean-Paul Wolinsky, and Mark H. Bilsky

Introduction principles in the treatment of spinal tumors.


The majority of spinal metastatic solid tumors
The principles of primary musculoskeletal originate from the osseous structures of the
tumor excision were thoroughly detailed by vertebrae, with the dorsal vertebral body being
William Enneking et al.1 Although treatment the most common tumor site.3 The discussion
concepts applicable to primary and metastatic of a single vertebra as an individual surgical
tumors differ, the Enneking system elucidates compartment requires clear understanding of
the concept of surgical margin and may pro- the surrounding tissues that may prevent tumor
vide the historic context for the development spread and that are the most likely routes of
of metastasis-specific surgical concepts. The tumor spread outside of the vertebra.4 The bar-
Enneking system recommends radical or wide rier tissues surrounding the vertebra include
margin en bloc resection in cases of primary ligaments (anterior longitudinal ligament [ALL],
high-grade malignant tumors. The goal of en posterior longitudinal ligament [PLL], ligamen-
bloc resection is to remove the tumor in one tum flavum, interspinous ligament, and supra-
piece without entering the margin. Radical spinous ligament), periosteum (lateral to the
margin surgery requires the excision of the en- vertebral body, surrounding the spinal canal,
tire anatomic compartment that harbors the and dorsal and lateral to the lamina and spi-
tumor. Wide margin resection preserves nor- nous process), and intervertebral disk (cartilag-
mal tissue around the entire tumor, whereas inous end plate, annulus fibrosus, and nucleus
amarginal margin resection is carried through pulposus).
the reactive zone of the tumor. The residual re- Examination of en bloc surgical specimens
active tissue after a marginal margin surgery demonstrated the highest degree of tumor in-
may contain satellite tumor cells and both vasion in the PLL and lateral periosteum.3 The
marginal and wide margin dissection cannot ALL, ligamentum flavum, and intervertebral
eliminate the risk of residual skip lesions. Thus, disk appeared to act as good barriers to tumor
in the absence of radical margin, Enneking rec- penetration. Further analysis of tumor spread
ommended adjuvant therapy in cases of high- pattern showed that the lateral PLL was the
grade malignant tumors in order to treat the skip most likely route of vertical extension in meta-
lesions and minimize the risk of recurrence.1,2 static tumors, followed by the central PLL. The
The complex anatomy of the surrounding strong longitudinal central attachment of the
structures and the central location of the spinal PLL compared with the thinner ligament lat-
cord within the spinal column present unique erally provides an explanation for this spread
challenges to the application of the Enneking pattern. The presence of a fibrous reactive mem-
En Bloc Resection in the Treatment of Spinal Metastases 35
brane was noted in several specimens even after body into 12 radial zones, similar to a clock face,
extension outside of these anatomic barriers. and into five concentric zones, thereby provid-
The presence of such a capsule implies the ing a systematic description of the extent and
possibility of a marginal margin resection ac- location of the tumor around the spinal cord
cording to the Enneking principles. However, and its extraosseous extension6 (Fig. 4.2). Both
the high likelihood of satellite microscopic dis- systems were developed in order to provide a
ease outside of the capsule has to be considered common language when describing the loca-
in cases of malignant tumors, which includes tion and extent of the tumor and to determine
all metastases. what type of surgical margin would be feasible.
In 1997, two systems aimed at translating Although a radical margin, or resection of the
the resection principles of the Enneking system entire spinal compartment, is not feasible, cer-
into the spine-specific context were proposed. tain tumors may be amenable to wide or mar-
The Surgical Classification of the Vertebral Tu- ginal margin resection.
mors developed by Tomita et al5 (Fig. 4.1) and
applicable to metastases, divides the tumors into
intracompartmental (confined to the vertebra),
extracompartmental (extraosseous extension), Surgical Technique
and multifocal skip lesions, and classifies them
also based on the extent of dorsal extension Vertebrectomy, sagittal resection, and poste-
along the vertebra (vertebral body only, ex- rior arch resection represent the three main
tension into pedicle and then lamina). The methods of en bloc resection in the spine.6 Tu-
Weinstein, Boriani, and Biagini (WBB) Surgical mors centered in the vertebral body may be
Staging System, applicable to primary spinal removed en bloc by carrying out a vertebrec-
tumors, divides the axial plane of the vertebral tomy or excision of the entire vertebral body.

Fig. 4.1 Tomita classification of vertebral tumors. surgical techniques and related basic background.
(From Kawahara N, Tomita K, Murakami H, DemuraS. Orthop Clin North Am 2009;40:4763. Reproduced
Total en bloc spondylectomy for spinal tumors: with permission from Elsevier.)
36 Chapter 4

Fig. 4.2 Weinstein-Boriani-Biagini surgical staging surgical staging. Spine 1997;22:10361044.


system. (From Boriani S, Weinstein JN, Biagini R. Reproduced with permission from Wolters Kluwer
Primary bone tumors of the spine. Terminology and Health.)

Tumors arising from the pedicle, transverse pro- Embolization of three levels significantly re-
cess, or eccentrically located in the vertebral duced the intraoperative blood loss compared
body may be removed en bloc using sagittal with embolization of only the level with tumor
osteotomy through the posterior elements and invasion. Preoperative embolization also helps
the vertebral body. Tumors arising from poste- to define segmental arteries that anastomose
rior elements may be removed en bloc by sec- with the anterior spinal artery, including the
tioning the pedicles and removing the posterior artery of Adamkiewicz.8 Although sacrifice of
arch in one piece.2 Any method of total spon- the artery of Adamkiewicz is generally avoided,
dylectomy must include the opening of the spi- Murakami et al9 reported a series of 15 total
nal canal in order to permit safe passage of the spondylectomies where the artery of Adam-
spinal cord through the opening. Therefore, in kiewicz was ligated during tumor resection
cases of a tumor that begins to encircle the spi- without neurologic deterioration.
nal cord, deliberate transgression of the tumor The location of the tumor dictates the ap-
is likely required. proach. En bloc resection can be carried out
Prior to en bloc resection of spinal tumors, using a single posterior or anterior approach,
embolization may be undertaken in order to or a combination of the posterior and anterior
decrease intraoperative blood loss. Kawahara approaches. The combined approaches may
et al7 recommend embolization of bilateral seg- be performed on the same day or as two sepa-
mental arteries at the excision levels in order rate operations. The extent of tumor invasion
to facilitate the separation of the artery from of the surrounding structures and the level and
the vertebral body and along with the cephalad the extent of required spinal reconstruction de-
and caudal levels. Such embolization may re- termine the optimal combination of approaches.
duce blood loss in cases where intentional or Generally, a combination of anterior and poste-
unintentional tumor transgression takes place. rior approaches is required in order to perform
En Bloc Resection in the Treatment of Spinal Metastases 37
an en bloc resection of lumbar tumors. When portance. This artery is usually located lateral
invasion of the major vessels, segmental ar- to the pedicle. The spinal branch of the seg-
teries, and thoracic or abdominal organs is sus- mental artery must be identified and ligated.
pected, an anterior dissection may be performed In the thoracic spine, the nerve roots can gen-
during the first stage of the operation, followed erally be safely sacrificed below T1, which elim-
by the posterior approach for the en bloc exci- inates the risk of evulsion and facilitates the
sion. The order of the anterior and posterior circumferential exposure and dissection. The
approaches has to be tailored to specific level surrounding pleura or iliopsoas muscle are
and tumor anatomy and determined individu- bluntly dissected off the vertebral body, with
ally for each case. care being taken to control the segmental ar-
The posterior approach should expose two tery at all times. The bilateral segmental arter-
or three levels above and below the tumor. Lat- ies are followed to the aorta, which is carefully
erally, approximately 4 to 5 cm of the bilateral dissected off the left ventral surface of the ver-
ribs or the entire transverse process must be tebral body. The segmental arteries are clipped,
exposed at the levels involved by tumor and at coagulated, and sectioned in order to prevent
least one level adjacent to the tumor. Superi- evulsion of these arteries off the aorta. This
orly the spinous process and the inferior artic- dissection is completed in the cephalocaudal
ulating processes of the level above the tumor direction until all of the vertebral bodies that
and inferiorly the ligamentous attachment of will be removed en bloc are separated from the
the spinous process and the superior articulat- surrounding lateral and ventral structures. Mal-
ing processes of the level below the tumor must leable retractors are used to maintain the sepa-
be sectioned in order to release the posterior ration and to protect the paraspinal structures.
elements of tumor. In the thoracic spine, the The vertebrae involved by tumor are gener-
3- to 4-cm segments of the ribs distal to the ally separated from the remaining spinal col-
costovertebral junction are removed in order umn at the cephalad and caudal disk spaces.
to expose the pedicles of the tumor level. The This can be carried out using a thread-wire
neurovascular bundle running along the infe- saw or osteotomes.7,8 Various devices have been
rior edge of the rib is identified and separated developed to facilitate this step. If a lateral di-
or sacrificed prior to removal of the rib. Perios- rection of the cut is chosen, the surgeon must
teal dissection is carried out along the pars in- remember the concave shape of the dorsal sur-
terarticularis and pedicles in order to allow a face of the vertebral body and create a safe
safe osteotomy through the pedicles. channel for the saw prior to stretching it in
Posterolateral pedicle fixation is carried out order to avoid dural damage. The anterior and
two or three levels above the excision. Only posterior longitudinal ligaments must also be
one rod is placed at this time, on the side oppo- sectioned in order to complete the release of
site the direction of the rotation of the final en the tumor, and the epidural venous plexus dor-
bloc specimen. Only temporary tightening of sal to the PLL must be fully coagulated in order
the screw rod construct should be carried out to minimize the bleeding. Finally, the ventral
because distraction and compression maneu- dural surface must be separated from the ver-
vers may be required. The osteotomy may be tebrectomy segment and Hoffmans ligaments
carried out using a thread-wire saw, an osteo- must be carefully sectioned. This can be car-
tome, or a drill. Once the pedicles are sectioned ried out through blunt dissection using angled
and the posterior elements are released from dissectors. At this point the vertebrectomy spec-
the levels above and below the tumor, the imen is entirely mobilized and can be rotated
pedicle, transverse process, lamina, and spi- around the spinal cord in order to complete
nous process complex of the levels involved by the removal. Anterior column reconstruction
tumor may be removed in one piece. is completed using a distractible or mesh ti
Identification of the segmental artery at the tanium cage; alternatively, a distractible poly-
level of the vertebrectomy is of paramount im- etheretherketone (PEEK) cage may be used.
38 Chapter 4

Axial loading of the anterior construct is en- ried out with the patient placed in the lateral
sured with compression of the posterolateral position.12
instrumentation. Autologous rib graft may be
used to maximize the chances of osseous fusion
during the reconstruction of the anterior and
posterior columns. Irrigation of the resection Local Control
cavity with distilled water and high-concen-
tration cisplatinum can be performed to locally En bloc excision of spinal metastases provides
treat microscopic residual tumor. excellent neurologic outcomes and reliable local
If anterior release of the tumor from vital tumor control (Fig. 4.3), with only a few recur-
thoracic or abdominal structures is required rences reported (Table 4.1). Murakami et al13
prior to the posterior approach, a thoracotomy examined the neurologic function after tho-
may be used or a retroperitoneal approach to racic en bloc tumor resection in 79 patients,
L2-L4 and a transperitoneal approach to the L5 with 53 of these patients undergoing surgery
level. An approach surgeon may be consulted, for metastatic tumors. Within the entire group,
depending on the preference and experience 46 patients had a neurologic deficit, and 25 of
of the surgeon and institutional practice. These them experienced an improvement of at least
procedures can be carried out using traditional one Frankel grade, whereas the remaining pa-
open techniques or a mini-open or thoraco- tients experienced an improvement in neuro-
scopic approach.10 Thoracoscopy provides a logic symptoms even if it did not translate into
minimally invasive alternative to ventral liga- a full Frankel grade improvement.
tion of the segmental arteries and does not Tomita et al5 reported no recurrences in 20
require a postoperative chest tube.11 The com- patients who underwent en bloc resection for
bined posterior-anterior approach may be car- a variety of metastatic tumor histologies. The

b c

Fig. 4.3ac Case example of a 58-year-old man tumor, and carbon fiber cage and allograft recon-
with (a) solitary renal metastasis to the T6 and T7 struction of the anterior column. Adjuvant conven-
levels with chest wall invasion on the right. (b) The tional external beam radiation was administered.
patient underwent preoperative embolization of the Hismost recent follow-up, 3 years and 3 months
tumor followed by T6 and T7 spondylectomy with after surgery, shows no evidence of local recurrence
right-sided chest wall resection for en bloc tumor and no evidence of systemic disease. (Courtesy of
resection. (c) The stabilization was carried out using Jean-Paul Wolinsky, MD, Johns Hopkins University.)
pedicle fixation three levels above and below the
En Bloc Resection in the Treatment of Spinal Metastases 39
Table 4.1 Summary of Publications Describing the Outcome of Spondylectomy for En Bloc Resection
of Metastases in at Least 10 Patients

Number Surgical
of Time
Study Patients Recurrence EBL (cc) (Hours) Complications

Tomita et al (1994) 20 0 1,650 7.8 10% major


Fourney et al (2001) 15 0 2,100 10.6 27% major
Sakaura et al (2004) 12 17% 1,925 7.3 N/A
Melcher et al (2007) 12 0 15 PRBC, 20 FFP 9.2 1 infection, 1 wound
Li et al (2009) 32 3% 1,536 7.7 18.75% major,
9.4 % minor
Demura et al (2011) 10 10% 1,713 9.1 2 pleural effusion,
1 chylothorax
Fang et al (2012) 17 0 1,720 6.7 12%
Huang et al (2013) 14 0 2,300 7.2 N/A

Abbreviations: EBL, estimated blood loss; FFP, fresh frozen plasma; N/A, not available; PRBC, packed red blood cells.

median follow-up in this group was 9 months, bloc resection in 32 patients with spinal me-
with nine patients alive at the completion of tastases, with most of the tumors originating
the analysis and a range of 8- to 30-month in the kidney. Twenty-six of the patients un-
follow-up among survivors. Fifteen metastatic derwent a vertebrectomy, three underwent a
tumors, mostly metastatic renal cell carcinoma, sagittal resection, and three had a posterior re-
were resected using a simultaneous anterior- section. The median survival was 40.1 months
posterior approach with the patient placed in (range, 1666 months) with only one patient
the lateral position. No recurrences were ob- having a local recurrence. Fang et al10 performed
served after a median follow-up of 6 months, en bloc resection in 17 patients with spinal
with two patients surviving over 2 years with- metastatic tumors with an average follow-up
out local recurrence. Sakaura et al14 reported of 15.3 months. No recurrences were observed,
the outcome of en bloc resection in 12 patients, with 59% of the patients dying with an aver-
mostly with metastatic breast, thyroid, and age survival of 12 months. Finally, Huang et al8
renal cell carcinoma metastases. The overall performed en bloc resection in 14 patients,
survival was 58%, with median follow-up of 61 with no evidence of local recurrence. The
months in survivors and 23 months in patients mean follow-up was 14 months (range, 323
who died. The authors observed two local re- months), with five patients dying during the
currences 25 months after surgery, both in pa- study period.
tients with tumors with paraspinal extension. Several patient series report the results of en
Eight patients had tumor progression at other bloc resection in patients with specific histolo-
sites at a median of 5 months after surgery. gies. Demura et al16 and Matsumoto17 exam-
Melcher et al11 performed en bloc resection ined the results of en bloc resection in patients
on 12 patients with solitary metastases, with with metastatic thyroid carcinoma. Demura
median survival of 29 months. No local recur- et al treated six patients with follicular, three
rences were observed with follow-up ranging with papillary, and one with medullary thy-
from 2 to 75 months. Four patients developed roid carcinoma with median follow-up of 54
distant metastases at an average of 5.3 months, months. They reported one local recurrence at
with two of these patients dying. Of note, eight about 3 years after surgery. Three patients died
patients were reported to have no evidence of of disease, five are alive with disease, and two
disease. Li et al15 reported the outcome of en have no evidence of disease. The 5-year survival
40 Chapter 4

in this group was 90%. Matsumoto et al per- minor vascular injury, asymptomatic deformity,
formed en bloc resection in six patients with retrograde ejaculation, and acute renal failure.
follicular and two with papillary thyroid carci- The use of combined surgical approaches was
noma. Two patients experienced local recur- associated with increased risk of minor and
rence 3.3 and 8 years after surgery, with one of major complications, and the risk of major com-
the patients undergoing intralesional resection plications increased with the number of resec-
of the recurrence. All of the patients in this tion levels.
series were alive with a mean follow-up of 6.4
years, and five patients had no evidence of
disease.
Murakami et al18 reported the results of en Indications
bloc resection in six patients with metastatic
lung adenocarcinoma. Four surviving patients The treatment goals of spinal metastases in-
were followed for an average of 46 months clude local control, preservation, and restora
without evidence of local recurrence. Several tion of neurologic function and spinal stability
case reports describe long-term local control and pain control. These goals are accomplished
after en bloc resection of metastatic para using various combinations of surgery, radia-
ganglioma, pheochromocytoma, and myxoid tion, and chemotherapy. Surgical indications
liposarcoma. include stabilization of a mechanically unstable
spinal column, decompression of the neural
elements, and optimization of local tumor
control. The prospective study conducted by
Complications Patchell et al20 found that in patients with spi-
nal cord compression secondary to solid meta-
En bloc excision of spinal tumors is a chal- static tumors surgery followed by radiation
lenging operation that may be associated with therapy provides superior functional out-
significant intraoperative and early and late comes compared with radiation therapy alone.
postoperative morbidity. The reported average However, in this study patients underwent a
operative times range between 6.7 and 10.6 broad range of operative interventions, which
hours, with major series reporting a mean precludes any conclusions about the optimal
estimated blood loss ranging from 1.5 to 2.3 surgical method. To date, a randomized study
L5,8,1012,14,15 (Table 4.1). The reported compli- comparing various types of surgery has not
cation rates range from 10 to 27%. Boriani et been conducted. The available retrospective
al19 critically examined the morbidity of en studies are difficult to compare due to a great
bloc spinal surgery in 134 patients, 44 of whom variety of chemotherapy and radiation options
had metastatic tumors. The complications were available in the neoadjuvant and adjuvant set-
classified as minor and major, with complica- tings, and due to the extremely heterogeneous
tions that significantly affected the expected patient population.
postoperative recovery course classified as Surgeons have developed several scoring sys-
major. The authors reported 70 complications tems and decision frameworks to help guide de
in 47 patients (35.1%). A total of 41 major com- cision making in patients with metastatic spine
plications occurred in 26 patients, including tumors. The Tokuhashi and Tomita scoring sys-
vena cava and aortic injuries, massive intra tems focus on the expected survival in order to
operative hemorrhage, myocardial infarction, guide surgical strategy.21,22 The Tomita scoring
pulmonary embolism, renal failure, subdural system looks at the primary tumor histology,
hematoma, paraplegia due to postoperative the extent of visceral metastases, and the num-
hematoma, deep wound infections, and pos- ber of osseous metastases in order to determine
terior instrumentation revision. Three deaths the treatment goal.22 The treatment goal cate-
(2%) occurred due to the surgical complica- gories include long-, middle-, and short-term
tions. Minor complications included durotomies, palliation, and terminal care. For patients with
En Bloc Resection in the Treatment of Spinal Metastases 41
the goal of long-term palliation, wide or mar- dramatic change with implementation of ste-
ginal excision is recommended, and for patients reotactic radiosurgery (SRS). The majority of
with the goal of middle-term palliation, mar- solid tumor metastases, with the exception
ginal or intralesional excision is recommended. of breast and prostate histology, are resistant
Among the 28 patients for whom, according to conventionally fractionated radiation, which
to their scoring system, long- or middle-term has been available for decades and has served
palliation was recommended and who under- as the determinant of tumor sensitivity to radi-
went en bloc excision with a wide or marginal ation.24 However, spinal SRS overcomes this
margin, 26 had no evidence of local recurrence, resistance in the majority of cases, providing
with an average survival of 38.2 months. effective local tumor control even in tumors
The Tokuhashi scoring system considers the that exhibit resistance to conventional external
performance status, number of spinal and ex- beam radiation therapy (cEBRT). SRS may be
traspinal bone metastases, extent of visceral safely employed as the single-treatment option
metastases, primary tumor histology, and the in patients who do not require surgical stabili-
neurologic status in order to divide the patients zation or decompression or as a postoperative
into groups with expected survival of less than adjuvant. It can also be administered in previ-
6 months, between 6 months and 1 year, and ously radiated tumors in cases of recurrence.
longer than 1 year.21 Based on these survival In a series of 500 patients treated with radio-
categories, conservative treatment, palliative surgery, Gerszten et al25 reported radiographic
surgery, or excisional surgery is recommended. control in 88% of the tumors with a median
However, only 22 out of 246 patients who were follow-up of 21 months. Garg et al26 also re-
included in the analysis had scores that quali- ported an actuarial 18-month local tumor con-
fied them for excisional surgery and only five trol of 88% in 63 tumors treated with single-
of them underwent en bloc excision. Although fraction SRS. Furthermore, tumor control has
both of these scoring systems capture some of been shown to be dose dependent, and the risk
the vital considerations in predicting the pa- of local radiographic tumor progression after
tients expected survival, they omit the con- high-dose single-fraction radiation (24 Gy) was
sideration of systemic and radiation therapy as estimated to be 4% with 3-year follow-up.27 Fi-
treatment options for spinal metastases, plac- nally, when SRS was used as the primary form
ing great emphasis on surgery. of tumor control in patients who underwent cir-
The treatment algorithm implemented by cumferential decompression of the spinal cord
Gasbarrini et al23 takes the sensitivity of the and resection of the epidural tumor extension
tumor to radiation therapy, chemotherapy, hor- without resection of the tumor-infiltrated ver-
monal therapy, and immunotherapy into con- tebral body or paraspinal tumor, the risk of local
sideration in order to guide the treatment of tumor progression at 1 year after treatment
spinal metastases. They recommend that pa- was 9% after single-fraction radiotherapy and
tients with metastases that are resistant to 4% after high-dose hypofractionated radiother-
radiation and systemic therapy undergo exci- apy.28 The neurologic, oncological, mechanical,
sional surgery, with en bloc resection sug- and systemic (NOMS) paradigm integrates spi-
gested for patients with isolated metastases nal SRS into the decision-making process, plac-
and debulking surgery suggested for patients ing greater emphasis on the role of radiotherapy
with multiple metastases. Thus, in this algo- in local tumor control while recommending
rithm, the decision to undergo surgery largely surgery for patients who require stabilization
hinges on the sensitivity of the tumor to radia- or spinal cord decompression.29
tion and systemic therapy, with en bloc resec- Local tumor control for the duration of the
tion recommended for patients whose tumors patients life represents one of the primary goals
cannot effectively be controlled with radiation of treatment of spinal metastases. The survival
or systemic therapy. prediction can often present a challenge, espe-
During the past decade the concept of radi- cially with the rapid evolution of systemic ther-
ation sensitivity of tumors has undergone a apy options. Although several scoring systems
42 Chapter 4

facilitate this estimation by highlighting the metastases and no or minimal epidural tumor
primary considerations, each treatment deci- extension. Currently, this recommendation
sion must be tailored to the modern thera- can be extended to most metastases, based on
peutic options and patient-specific medical and accumulating data describing histology-inde-
social factors. In the overwhelming majority pendent durable control provided by SRS.
of patients with spinal metastases, treatment In most cases without spinal cord compres-
goals remain palliative and must be made in sion, en bloc resection can be reserved for tu-
the context of expected survival ranging from a mors that progress in spite of previous optimal
few months to a few years and the importance radiation therapy. On the other hand, in patients
of expedient continuation or commencement with spinal cord compression by solid tumors,
of systemic therapy. Thus, the penalty of post- surgery followed by radiation therapy contin-
operative complication may be devastating if it ues to be the recommended treatment. In these
leads to delay in systemic therapy and if dis- cases and in carefully selected patients, en bloc
ease progression cannot be controlled, and the resection may provide effective local tumor
risk of complication must be weighed against control; however, intralesional resection of the
the benefit of local tumor control. epidural tumor component with circumferen-
The reported local recurrence rates after tial spinal cord decompression provides a less
enbloc excision of spinal metastases are ex- invasive alternative and has been shown to
tremely low, with only three recurrences (2%) also provide effective local tumor control when
reported among the 122 patients studied in followed by high-dose radiation therapy.28
the seven series that include more than 10 pa-
tients.5,8,1012,14,15 The long follow-up reported
for some of the series emphasizes the impor-
tance of careful patient selection for this oper- Chapter Summary
ation. However, the variability of follow-up
methods for assessing tumor recurrence and Local tumor control represents one of the pri-
the retrospective nature of most studies limit mary goals in the treatment of spinal metastases.
the strength of evidence presented by the sur- The importance of tumor margin preservation
gical series. Furthermore, these operations are and wide margin excision was shown in pa-
challenging, and a complication rate as high as tients with primary musculoskeletal tumors
35% has been reported even from one of the and subsequently incorporated into some of the
worlds leading centers in en bloc spinal tumor treatment systems for spinal metastases.5,6 The
excision. technique of spinal en bloc resection generally
The potential for significant hemodynamic requires a circumferential dissection around the
stress during surgery even after embolization vertebral column without violating the tumor
and the long-term survival requirement in margin, followed by instrumented stabiliza-
order to justify en bloc excision exclude the tion.7 Depending on the level and the degree
majority of patients with metastatic cancer. of paraspinal extension, anterior, posterior, or
The reliable local control provided by high- combined approaches may be required. The
dose SRS provides a low-morbidity alternative local control rates after en bloc tumor resection
to en bloc excision and has gained prominence have been outstanding, whereas some series
as more medical centers integrate spinal radio- report a high risk of perioperative complica-
surgery into their treatment paradigms. Review tions. In the metastatic spine tumor patient
of treatment results in patients with solitary population the risk of complication must be
renal metastases after SRS compared with en weighed against the importance of long-term
bloc resection showed comparable local con- tumor control in the setting of generally limited
trol.30 Although the strength of the recommen- survival. Although a select patient population
dation was limited by the quality of available with long expected survival may be considered
evidence, SRS was recommended as first-line for en bloc tumor excision, spinal SRS provides
treatment in patients with solitary spinal renal an effective alternative to aggressive tumor re-
En Bloc Resection in the Treatment of Spinal Metastases 43
section in most patients while avoiding the po-
Spinal SRS can provide comparable local control
tential morbidity of extensive surgery.
to en bloc resection with a significantly lower
complication risk and therefore may represent a
better option for tumor control.
Pearls
Pitfalls
The Weinstein-Boriani-Biagini Surgical Staging
System and the Tomita Surgical Classification of
Careful examination of ventral epidural space is
the Vertebral Tumors can be used to describe the
mandatory because the most common route of
location and intra- and extraosseous extension of
tumor spread is between the PLL and the verte-
spinal tumors.
bral body.
En bloc resection options include vertebrectomy,
Hoffmans ligaments must be ligated in order to
sagittal resection, posterior arch resection, and
separate the en bloc specimen from the dura.
spondylectomy for en bloc resection of tumor.
The concave shape of the dorsal aspect of the
Preoperative embolization decreases intraopera-
vertebral body and the dural convexity at their
tive blood loss during intralesional surgery.
interface must be taken into consideration when
Segmental arteries must be carefully dissected
performing the osteotomy in the dorsal third of
and ligated.
the vertebral body or intervertebral disk space.
En bloc tumor excision provides durable local
control in carefully selected patients.

References
Five Must-Read References
1. Enneking WF, Spanier SS, Goodman MA. A system for affect neurologic function? Spine 2010;35:E1187
the surgical staging of musculoskeletal sarcoma. Clin E1192 PubMed
Orthop Relat Res 1980;153:106120 PubMed 10. Fang T, Dong J, Zhou X, McGuire RA Jr, Li X. Compari-
2. Enneking WF. A system of staging musculoskeletal son of mini-open anterior corpectomy and posterior
neoplasms. Clin Orthop Relat Res 1986;204:924 total en bloc spondylectomy for solitary metastases
PubMed of the thoracolumbar spine. J Neurosurg Spine 2012;
3. Sasagawa T, Kawahara N, Murakami H, et al. The 17:271279 PubMed
route of metastatic vertebral tumors extending to 11. Melcher I, Disch AC, Khodadadyan-Klostermann C, et
the adjacent vertebral body: a histological study. al. Primary malignant bone tumors and solitary
JOrthop Sci 2011;16:203211 PubMed metastases of the thoracolumbar spine: results by
4. Fujita T, Ueda Y, Kawahara N, Baba H, Tomita K. Local management with total en bloc spondylectomy. Eur
spread of metastatic vertebral tumors. A histologic Spine J 2007;16:11931202 PubMed
study. Spine 1997;22:19051912 PubMed 12. Fourney DR, Abi-Said D, Rhines LD, et al. Simultane-
5. Tomita K, Kawahara N, Baba H, Tsuchiya H, Nagata S, ous anterior-posterior approach to the thoracic and
Toribatake Y. Total en bloc spondylectomy for soli- lumbar spine for the radical resection of tumors fol-
tary spinal metastases. Int Orthop 1994;18:291298 lowed by reconstruction and stabilization. J Neuro-
PubMed surg 2001;94(2, Suppl):232244 PubMed
6. Boriani S, Weinstein JN, Biagini R. Primary bone tu- 13. Murakami H, Kawahara N, Demura S, Kato S, Yosh-
mors of the spine. Terminology and surgical staging. ioka K, Tomita K. Neurological function after total en
Spine 1997;22:10361044 PubMed bloc spondylectomy for thoracic spinal tumors. J
7. Kawahara N, Tomita K, Murakami H, Demura S. Total Neurosurg Spine 2010;12:253256 PubMed
en bloc spondylectomy for spinal tumors: surgical 14. Sakaura H, Hosono N, Mukai Y, Ishii T, Yonenobu K,
techniques and related basic background. Orthop Yoshikawa H. Outcome of total en bloc spondylectomy
Clin North Am 2009;40:4763, vi PubMed for solitary metastasis of the thoracolumbar spine. J
8. Huang L, Chen K, Ye JC, et al. Modified total en bloc Spinal Disord Tech 2004;17:297300 PubMed
spondylectomy for thoracolumbar spinal tumors via 15. Li H, Gasbarrini A, Cappuccio M, et al. Outcome of
a single posterior approach. Eur Spine J 2013;22:556 excisional surgeries for the patients with spinal me-
564 PubMed tastases. Eur Spine J 2009;18:14231430 PubMed
9. Murakami H, Kawahara N, Tomita K, Demura S, 16. Demura S, Kawahara N, Murakami H, et al. Total en bloc
KatoS, Yoshioka K. Does interruption of the artery spondylectomy for spinal metastases in thyroid carci-
of Adamkiewicz during total en bloc spondylectomy noma. J Neurosurg Spine 2011;14:172176 PubMed
44 Chapter 4

17. Matsumoto M. Total en bloc spondylectomy for spi- the options, indications, and outcomes? Spine 2009;
nal metastasis of differentiated thyroid cancers: a 34(22, Suppl):S78S92 PubMed
long-term follow-up. J Spinal Disord Tech 2012; 25. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Ra-
10/17:1 PubMed diosurgery for spinal metastases: clinical experience
18. Murakami H, Kawahara N, Demura S, Kato S, Yosh- in 500 cases from a single institution. Spine 2007;
ioka K, Tomita K. Total en bloc spondylectomy for 32:193199 PubMed
lung cancer metastasis to the spine. J Neurosurg Spine 26. Garg AK, Shiu AS, Yang J, et al. Phase 1/2 trial of
2010;13:414417 PubMed single-session stereotactic body radiotherapy for pre-
19. Boriani S, Bandiera S, Donthineni R, et al. Morbidity viously unirradiated spinal metastases. Cancer 2012;
of en bloc resections in the spine. Eur Spine J 2010; 118:50695077 PubMed
19:231241 PubMed 27. Yamada Y, Cox BW, Zelefsky MJ, et al. An analysis of
20. Patchell RA, Tibbs PA, Regine WF, et al. Direct decom- prognostic factors for local control of malignant spine
pressive surgical resection in the treatment of spinal tumors treated with spine radiosurgery. Paper pre-
cord compression caused by metastatic cancer: a ran- sented at the International Journal of Radiation On-
domised trial. Lancet 2005;366:643648 PubMed cology, Biology, Physics, October 1, 2011
21. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A 28. Laufer I, Iorgulescu JB, Chapman T, et al. Local disease
revised scoring system for preoperative evaluation of control for spinal metastases following separation
metastatic spine tumor prognosis. Spine 2005;30: surgery and adjuvant hypofractionated or high-dose
21862191 PubMed single-fraction stereotactic radiosurgery: outcome
22. Tomita K, Kawahara N, Kobayashi T, Yoshida A, analysis in 186 patients. J Neurosurg Spine 2013;18:
Murakami H, Akamaru T. Surgical strategy for spinal 207214 PubMed
metastases. Spine 2001;26:298306 PubMed 29. Laufer I, Rubin DG, Lis E, et al. The NOMS framework:
23. Gasbarrini A, Li H, Cappuccio M, et al. Efficacy evalu- approach to the treatment of spinal metastatic tu-
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24. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and the treatment of metastatic spine disease. Spine 2009;
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5
Region-Specific Approaches
Ioan Adrian Lina, Patricia L. Zadnik, and Daniel M. Sciubba

Introduction For highly vascularized tumors, such as renal


carcinoma, a preoperative angiogram with em-
The spine is the third most common location of bolization should be considered to reduce the
secondary metastases, after the lung and liver, risk of intraoperative tumor bleeding during
occurring in up to one third of all metastatic resection.5 In all pathologies, surgery with ra-
cancer patients.1 Further, in a review of au- diation should be considered if the patient is
topsy studies, it was reported that up to 70% of expected to live for longer than 3 months.6 In
cancer patients had evidence of metastatic dis- the landmark randomized controlled clinical
ease in the spinal column at the time of death.2 trial of radiation alone versus radiation with
Anatomically, an overwhelming majority of surgery, Patchell and colleagues7 found that
spinal metastases originate from the vertebral patient survival increased and the use of mor-
body rather than from the posterior elements.3 phine and corticosteroids decreased with radi-
Patients with symptomatic spinal metasta- ation and surgery compared with surgery alone.
ses most commonly present with pain or neu- Several scoring systems help to guide surgi-
rologic dysfunction. A systemic workup with a cal decision making. The Tokuhashi score has
computed tomography (CT) scan of the chest, been used to identify if an excision or palliative
abdomen, and pelvis for cancer staging may strategy should be offered.8 Treatment goals
be necessary to guide surgical decision mak- can be tailored to the patients visceral and bony
ing, and in patients without a known primary disease burden and grade of the malignancy as
tumor, a fine-needle biopsy under CT guidance proposed in the Tomita score.9 The Spinal In-
should be performed. Patients with metastatic stability Neoplastic Score (SINS) was proposed
epidural spinal cord compression should be by the Spine Oncology Study Group (SOSG) to
given high-dose dexamethasone, and in pa- incorporate multiple variables to determine the
tients who respond to this therapy, radiation stability, pending instability or gross instabil-
will likely provide relief.4 Tumor pathology dic- ity caused by a primary or metastatic lesion in
tates the appropriateness of adjuvant therapy, the spine.10
as radiosensitive tumors such as small-cell lung Complex approaches requiring prolonged
carcinoma, lymphoma, and multiple myeloma recovery times are contraindicated if the life
rarely require open decompression, as radiation expectancy of the patient does not exceed 3
alone provides effective palliation for patients months, and radiation therapy may be offered
at the end of life. Intermediately radiosensi- for palliative treatment of pain.6 For patients
tive tumors include breast and prostate cancer, with widespread metastases in the spinal col-
whereas melanoma is relatively radioresistant. umn, direct decompressive surgery (i.e., lami-
46 Chapter 5

nectomy) with adjuvant radiotherapy improves plex, particularly the transverse ligament, de-
neurologic outcomes and reduces the need for termines the stability of the C1/C2 vertebral
steroids and opioid analgesics.7 It should also bodies. The wider spinal canal in the atlanto-
be taken into account that surgical interven- axial spine reduces the risk of metastatic epi-
tion delays radiation treatment due to the dural spinal cord compression, and as a result
additional time needed for wound healing. En anterior atlantoaxial subluxation is a more
bloc resection for metastatic disease has been common cause of canal stenosis at this level.14
debated in the literature. Oncological cure is Lateral flexion-extension radiographs of the
unlikely for metastatic disease, as widespread spine can help identify the degree of spondy-
microscopic tumor foci are likely present; how- lolisthesis and ultimately identify regions of
ever, patients may survive many years beyond instability in the cervical spine.
surgery. In a systemic review of the literature, When assessing a patient with a cervical
Cloyd and colleagues11 found 5-year survival metastasis, take a thorough history and per-
rates of 37.5% for patients undergoing en bloc form a physical examination to confirm the
spondylectomy for metastatic cancer in the spi- patients chief complaint. Cervical myelopathy,
nal column. Aside from the technical demand characterized by weakness in the hands and
of the surgery, the major risks of en bloc re- relative preservation of lower extremity func-
section include nerve damage, excessive bleed- tion, may be the result of degenerative disease
ing, spinal cord ischemia or stroke, and tumor in the cervical spine unrelated to the meta-
spillage with disruption of the capsule or in- static process. Although vertebral body involve-
tralesional curettage. When planning en bloc ment from a metastatic lesion may be the most
resection, the patient must be consulted to de- radiographically impressive element of the pa-
termine his or her preferences and goals of care. tients imaging, it may not be the sole cause
This chapter reviews the approaches used ofthe neurologic impairment. Loss of cervical
for surgical resection of metastatic tumors in lordosis, degenerative disk disease with multi-
specific regions of the spine (Fig. 5.1), and de- level stenosis, or congenital stenosis may be
scribes patient positioning and approaches as the main cause of a patients symptoms and
well as the common complications associated should be considered when planning surgery.
with each surgical intervention. Complications In patients with a loss of lordosis, posterior re-
are summarized in Table 5.1. duction and fixation alone will not restore an-
atomic alignment, and an anterior approach is
recommended.

Cervical Spine Posterior Approach


The cervical spine comprises only 10 to 20% Posterior laminectomy or hemilaminectomy
ofmetastatic spine disease cases; however, in- with instrumented fixation is frequently used
stability due to cervical metastases can lead to for patients with preserved cervical lordosis
profound morbidity.12 More than 90% of pa- suffering from metastatic disease in the cervi-
tients with metastatic disease in the cervical cal spine. Although the posterior elements are
spine present with nonmechanical neck pain rarely involved in metastatic cervical tumors,
as their chief complaint.13 Patients may also decompressive laminectomy or foraminotomy
report referred pain in the shoulders. Biome- are less invasive surgical procedures to provide
chanically, in the subaxial spine, lytic invasion relief of myelopathy or cervical radiculopathy.
of metastatic tumor in the cancellous bone of Instrumented fusion reduces the pain asso
the vertebral body increases the risk of collapse ciated with subluxation and instability. Bone
and subsequent loss of lordosis. At the atlanto- quality should also be taken into consideration
axial level, involvement of the C1 lateral mass in order to assess the patients risk of instru-
leads to pain on rotational head movements. mentation failure, and cement can be used to
Stability of the atlantoaxial ligamentous com- reinforce screw purchase.
Region-Specific Approaches 47

Fig. 5.1 Schematic depicting region-specific for cross-junctional access. Black dashed arrows
approaches to the spine for resection of metastatic demonstrate approaches commonly used at
tumors. Approaches between regions are effective multiple regions.
48 Chapter 5

Table 5.1 Complications Associated with Each Surgical Intervention

Spinal
Approach Levels Advantages Complications

Laminectomy All levels Well known to spinal Risk of vertebral artery injury
surgeons Cannot reduce anterior cord
Low risk of complications compression
Complications from improper
screw placement
Transoral C0-C3 Anterior access to upper High learning curve
cervical spine Extensive recovery time
High prevalence of
comorbidities
Smith-Robinson C3-T1 Generous exposure Risk of esophageal and tracheal
Multilevel access injury
Postoperative edema may
necessitate tracheostomy
Anterior neck dissection C4-T3 Access to the cervicotho- Risk of pulmonary injury and
and sternotomy racic transition zone damage to the great vessels
Surgically challenging

Trapdoor exposure T3-T4 Optimal surgical window Risk of hemopericardium and


for accessing anterior pulmonary injury
pathologies Violation of the thoracic cavity

Transpedicular T1-L5 Circumferential Interbody cage placement may


decompression necessitate nerve root ligation
posteriorly Limited operative field
Higher risk of durotomy and
CSF leaks

Thoracotomy T5-T11 Superior visualization of Risk of pneumo- and


vertebral elements hemothorax
Minimizes spinal cord Air leaks, pulmonary complica-
manipulation tions such as atelectasis
Thoracoabdominal T11-L1 Access to the thoraco- Diaphragm is incised
lumbar transition zone circumferentially
Risk of injury to the spleen (left
side) and kidney

Retroperitoneal L1-L5 Minimal violation of Risk of injury to the ureter and


critical structures genitofemoral nerve

The patient is placed prone on the operating when weighing treatment options. Lateral mass
table with the head in a Mayfield fixator. A screws may be used from C3 to C6, along with
midline incision is made to provide adequate a fitted rod to mimic natural cervical lordosis.
exposure of the level of interest. The paraspinal Intractable subluxations can warrant the place-
musculature is divided, and subperiosteal dis- ment of occipitocervical fusion (OCF) hardware,
section facilitates direct visualization of the which requires a more extensive exposure and
lamina. Although the C1 and C2 nerve roots is beyond the scope of this chapter.
can be sacrificed safely, subsequent nerve root One of the primary risks associated with sur-
damage to C3-C7 results in significant patient gical intervention in the cervical spine is verte-
morbidity and should always be considered bral artery (VA) injury. Wright and Lauryssen14
Region-Specific Approaches 49
found that 4.1% of a cohort of 1,318 patients the high risk of complications. Posterior fixation
receiving transarticular screws incurred VA in- is highly recommended following the transoral
jury. Patients with tumor in this region or a approach due to an increase in mechanical in-
history of radiation to the area may have dis- stability caused by the possible disruption of
torted anatomy or scar tissue, further increas- the alar, transverse, and anterior longitudinal
ing the risk of vertebral artery injury. As a ligaments.16 As a result, treatment of the atlan-
result, a preoperative three-dimensional (3D) toaxial spine often results in OCF; however, if
CT angiogram should be considered prior to the occipitoaxial joint remains stable, a limited
placing instrumentation in the craniovertebral C1-C2 fixation should be considered to preserve
junction. If a VA is injured intraoperatively, re- motion.17
call that the lateral mass screw acts to tampon- The most common complications associated
ade the vessel. Avoid removing the screw in the with the transoral approach include injury to
VA and do not place the contralateral screw, as the hypoglossal and lingual nerves with subse-
bilateral VA injury will lead to devastating neu- quent speech and swallowing difficulties. A na-
rologic consequences. Perform an angiography sogastric tube may be placed intraoperatively,
immediately, if possible, to assess if endovas- or a percutaneous endoscopic gastrostomy
cular repair via balloon occlusion, coil emboli- (PEG) may be placed to provide adequate nu-
zation, or stent deployment is feasible and to trition for the patient in the immediate post-
assess the patency of the contralateral VA. operative period. As with most spinal surgeries,
cerebrospinal fluid (CSF) leak secondary to
incidental durotomy can lead to devastating
Transoral Approach complications and should be managed with a
The transoral approach allows visualization of direct repair when possible, or a CSF diverting
the anterior aspect of C1-C3 with 15 to 20 mm lumbar drain or shunt as necessary. Patients
of lateral exposure from the midline.15 It is un- with CSF leak may complain of headaches, and
commonly performed in metastatic tumor pa- are at risk of meningitis.16 The splitting of the
tients, yet may be indicated for patients with soft palate is also known to cause velopalatine
significant anterior compression of the spinal incompetence, or the inability to completely
cord involving the upper cervical vertebrae. For close the soft palate resulting in nasal regurgi-
this approach, the patient is positioned supine tation of liquids during swallowing.18
with the neck in 10 to 15 degrees of extension
in a three-point Mayfield headholder. Intra- Smith Robinson/Anterolateral
operative fluoroscopy with a C-arm is recom-
mended for localization. A preoperative lateral
Approach
radiograph of the hyperextended neck is rec- First described by Smith and Robinson,19 the
ommended to evaluate instability at the cranio- anterolateral approach to the cervical spine
cervical junction that may be aggravated with enables anterior access to C3-T1. On the right
patient positioning. Preoperative and intraop- side, the recurrent laryngeal nerve crosses me-
erative antibiotics should be given to cover an- dially at C6/C7, thus a left-sided approach is
aerobes and oral flora. Intubation via an awake recommended at this level. For this approach,
fiberoptic endotracheal intubation may be used the head of the bead is elevated 30 degrees and
or tracheostomy to provide ventilation with- the patient is positioned supine with the head
out disrupting the operative field. fixed in a Mayfield clamp and rotated away
If necessary, the soft palate can be split at from the incision, with a towel placed trans-
the midline to increase the operative field. Al- versely under the scapula to allow for neck ex-
though greater extension of the surgical field is tension. The head is rotated about 15 degrees
possible via maxillary osteotomy or mandibu- to the contralateral side. Nasotracheal intuba-
lotomy approaches, they should be used with tion allows complete closure of the mandible
extreme caution in metastatic tumor patients and improves the exposure. A 3- to 5-cm inci-
due to prolonged patient recovery times and sion is made along the midline to the posterior
50 Chapter 5

Fig. 5.2ac Surgical markings for various ap- and sternotomy approach with a T-shaped incision.
proaches. (a) A hockey stick incision for the (c) The trapdoor approach, which extends into the
anterolateral (Smith-Robinson) approach to the fourth interspace, allowing for retraction of the
subaxial cervical spine. (b) Anterior neck dissection chest wall.

sternocleidomastoid for adequate exposure of formed followed by the placement of a cage


two or three disk levels corresponding to the with allograft and anterior plate fixation. Con-
relevant pathology (Fig. 5.2a). The platysma comitant posterior fixation is required for multi
isthen divided at the anterior border of the level anterior corpectomy performed at three
sternocleidomastoid. Deep dissection proceeds or more vertebral levels in order to ensure ade-
with division of the pretracheal fascia to open quate construct stabilization. Traction may be
the plane between the carotid sheath and the used if the patient has a severe kyphotic defor-
trachea and esophagus. Care should be taken mity in the cervical spine or if subluxation is
to ensure the protection of the trachea, esoph- present.
agus, and recurrent laryngeal nerve during dis- The anterolateral approach to the subaxial
section. Once adequate exposure is obtained, cervical spine represents a relatively atraumatic
anterior corpectomy and resection can be per- spinal dissection with a generous exposure
Region-Specific Approaches 51
allowing for access to a wide range of spinal will often lead to a higher incidence of adja-
pathologies. An intraoperative tracheostomy, cent level degeneration due to added mechan-
PEG, or nasogastric (NG) tube may be placed, ical stress. As a result, this approach facilitates
as postoperative edema can compress the air- good visualization and proper screw and plate
way and esophagus. Additional care should be placement across the cervicothoracic junction.
given for patients who previously received ra- The presence of an anterolateral soft tissue
diation treatments because scarring and tissue mass is viewed as a contraindication for such
deterioration can significantly increase the risk an approach due to the already limited opera-
of complications. Esophageal erosion from an- tive space available. Considering the relatively
terior plate hardware is a rare but serious com- small operative field and the anatomic com-
plication with a reported incidence of 1.49%, plexity of the upper thoracic cavity, this ap-
and the patient should be monitored long term proach presents a challenge to most spinal
for any symptoms of instrumentation failure.20 surgeons. Patients must be made aware of the
possibility of an intraoperative tracheostomy
and gastrostomy, pulmonary injury, the risks
of recurrent laryngeal nerve palsy, and the po-
Thoracic Spine tential for damage to the great vessels.22

Metastatic tumors in the thoracic region repre-


sent 70% of metastatic disease in the spine.3 Case Illustration
One of the primary anatomic advantages for A 39-year-old woman presented with breast
surgical resection of tumors in the thoracic cancer with diffuse skeletal and spinal metas-
region is that, if necessary, nerve roots can be tases despite chemotherapy (Fig. 5.3a). The lytic
easily ligated without severe functional deficit. nature of the lesions at C6 and C7 resulted in
In addition, the thoracic spine is more stable vertebra plana, with complete loss of the verte-
than other spinal regions because it is mechan- bral body height. She developed paraplegia, and
ically reinforced by the ribs and sternum. underwent radiation therapy and external im-
mobilization and recovered the ability to am-
Anterior Neck Dissection bulate with some assistance. A staged surgical
procedure was offered. The patient underwent
andSternotomy preoperative reduction with 35 pounds of trac-
First described by Rosen et al,21 this approach tion with gradual correction of her deformity.
provides the most direct access to the cervi- The first stage of the surgery included a left
cothoracic junction (as high as C4) and to the anterior cervical approach and median sternot-
superior aspect of the T3 vertebral body. The omy to gain access to the left cervicothoracic
patient is positioned supine with towels under junction. The anterior corpectomy was per-
the scapula to extend the neck slightly. A formed through an aortocaval window above
T-shaped incision is made 1 cm above the clav- the pulmonary artery and below the innomi-
icle with a vertically oriented medial incision nate vein. The vertebral bodies of C6-T1 were
over the sternum (Fig. 5.2b). Once exposure removed using a high-speed diamond bur. De-
isestablished, a rectangular block of sternum compression of the C6-T1 nerve roots was also
is resected along with about one third of the performed. An anterior cage and plate were
clavicle on the operative side. Although entry placed extending from C5 to T2. Four days later,
from the left is preferred due to the risk of in- a C5-T1 bilateral total laminectomy and a C2-T8
jury to the right recurrent laryngeal nerve, the posterior fixation completed the second stage
approach should also be dictated by the side of the procedure (Fig. 5.3b). Her clinical course
with the greatest extravertebral tumor exten- was complicated by facial edema, bilateral
sion. Instrumentation following low cervical/ pleural effusions, and hospital-acquired pneu-
high thoracic vertebrectomy that does not ex- monia. She was discharged to rehabilitation
tend across the cervicothoracic transition zone and survived 3 years after surgery.
52 Chapter 5

a b
Fig. 5.3a,b Metastatic lesion at the cervicothoracic anterolisthesis. Intraoperatively, the vertebral bodies
junction. (a) Composite cervical and thoracic of C6-T1 were removed using a high-speed diamond
preoperative computed tomography (CT) scan bur. (b) An anterior cage and plate were placed
froma patient with metastatic breast cancer in the extending from C5-T2. Four days later, C5-T1
cervicothoracic junction demonstrating vertebra bilateral laminectomy and C2-T8 posterior fixation
plana of C6-C7 with focal kyphosis and grade 4 completed the second stage of the procedure.

The Trapdoor Approach Unlike other anterior approaches, the trap-


door exposure preserves the clavicle and ster-
The trapdoor exposure can be performed bi-
noclavicular junction. Due to the manipulation
laterally and differs from the above transsternal
of the great vessels and violation of the tho-
approach by providing extended visualization
racic cavity, great attention should be given
of the T3-T4 region. Anatomically, the T3-T4
postoperatively to monitoring the patient for
region rests behind the great vessels and
symptoms of hemopericardium, particularly
heart, which makes it inaccessible from the
following previous irradiation. Symptoms in-
approaches described above. As a result, the
clude cardiac tamponade, shortness of breath,
trapdoor approach provides a more lateral ex-
and chest pain. Treatment consists of the in-
posure by further opening the thoracic cavity
sertion of a needle into the pericardial window
to enable the mobilization of anterior elements.
for pericardial drainage. Although the increased
The patient is positioned supine similarly to
risk of morbidity and the lengthy postopera-
the sternotomy approach. The initial incision is
tive care are potential contraindications for the
made along the medial border of the sterno-
treatment of metastases, this approach provides
cleidomastoid muscle to the sternal notch and
the best anterior visualization of the T3-T4
is then extended ventrally over the fourth in-
vertebral bodies. Alternatively, an anterolateral
terspace (Fig. 5.2c). Although this approach is
approach can be performed to gain access to
similar to the transsternal approach in that the
the same spinal region and is preferred by some
neck is fully dissected, it differs in that there is
surgeons.23
no need for the clavicle to be transected. Signif-
icant retraction is placed on the sternal retrac-
tor so as to open the trapdoor and provide Thoracotomy (Transthoracic
access to the thoracic cavity. Dual lobe intuba-
tion is required to allow the ipsilateral lung to
Approach)
be deflated, exposing the C4-T4 vertebral bodies By providing a wide anterior surgical field, the
for cage placement if necessary (Fig. 5.4a). thoracotomy or transthoracic approach provides
Region-Specific Approaches 53

Fig. 5.4ad Methods for approaching the thoracic and plate fixation. (c) Posterior decompression
spine. (a) Anterior access to the upper thoracic vialaminectomy followed by instrumentation.
spine via the trapdoor or transsternal approach. (d)Posterior vertebrectomy using the transpedicular
(b)Thoracotomy (transthoracic) approach for approach with subsequent cage placement.
anterior decompression followed by anterior cage

access to the ipsilateral pedicle, the thoracic chosen based on the tumor pathology; how-
vertebral bodies, the nerve roots, and the spinal ever, the left side is anatomically preferable be-
canal. Compared with the posterior approach, cause the spleen is easier to retract than the
the transthoracic approach affords a wider view liver and the aorta easier to repair than the vena
and permits maximal decompression while cava. In patients who have undergone previous
minimizing manipulation of the spinal cord chest surgery, it is preferable to choose the nave
for access to ventral pathology. side in order to avoid pleural adhesions that
The patient is placed in a lateral decubitus may increase the risk of postoperative pneumo-
position with the arm extended outward in and hemothorax.
order to elevate the scapula off the chest wall. For lesions involving T5-T6, the rib corre-
The rhomboids and trapezius muscles are then sponding to the tumor level is removed. Given
incised on the lower edge of the scapula en- the curvature of the ribs, at the T7-T8 levels,
abling visualization of the underlying ribs. This the rib one level above the tumor is removed.
approach can be divided into two techniques Likewise for the T9-T10 levels, the rib that
based on the anatomic considerations of the istwo levels above the tumor is removed to
thoracic spine, namely high (T5-T7) and low provide adequate visualization of the vertebral
thoracotomy (T7-T10). For a high thoracot- body.23 Once the rib is resected, the parietal
omy, the scapula must be mobilized. As with pleura is exposed and the ribs are spread using
other approaches, the operative side should be a self-retaining retractor. Intubation with a
54 Chapter 5

dual-lumen endotracheal tube enables com- quate space for expandable cage and allograft
plete or partial deflation of a single lung. The insertion (Fig. 5.4d). It is important to com-
pleural space provides a plane of dissection pletely remove any cartilaginous tissue from
and the surgeon can gently retract the lung and both end plates to ensure proper cage fixation.
parietal pleura away from the surgical field. Posterior fixation with pedicle screws and fit-
This will provide exposure of the affected ver- ted rods is then performed to support the ante-
tebral body, which may be resected piecemeal rior construct and prevent forward translation
or en bloc with the use of a Tomita saw. A cage of the superior adjacent vertebral body.
may then be placed if reconstruction is neces- The separation of the PLL from the dura via
sary (Fig. 5.4b). Air leaks may be assessed by the posterior approach should be performed
filling the thoracic cavity with saline and ex- with extreme caution. Unintended durotomy
amining for air bubbles. Upon completion of may result if the tumor is calcified or if adja-
the surgery, two chests tubes may be placed: cent disk herniations are calcified, compromis-
the inferior chest tube is placed at the poste- ing the plane between the PLL and dura. If a
rior corner of the diaphragm to collect blood, CSF leak results and a CSF fistula or pseudome-
and the other tube is placed at the apex of the ningocele forms, a lumbar drain can be placed
lung to allow trapped air to escape. to divert CSF flow. In the case of an epidural
Pulmonary compromise resulting from lung hematoma from spinal cord manipulation, im-
metastases is a relative contraindication to tho- mediate evacuation should be performed. In
racotomy. Complications include pneumonia, addition, the placement of the interbody cage
airway obstruction, atelectasis, pneumothorax, can often be challenging due to the restricted
pleural effusion, and hemothorax. The risk of operative window available.
these complications is substantially increased
in elderly patients, and careful assessment of
preoperative lung function is necessary before
Thoracoabdominal Approach
surgery. This approach combines a low posterolateral
thoracotomy with the retroperitoneal approach
for visualization of the thoracolumbar region
Transpedicular Approach (T11-L1). A left-sided approach is preferred.
The transpedicular approach utilizes posterior The patient is placed in a lateral decubitus po-
exposure to access anterior pathology. This sition and an incision is made over the 10th rib,
can reduce the size of the incision and enable extending from the paraspinous muscles ante-
circumferential decompression and cage place- riorly to the costal cartilage (Fig. 5.5a,b). Be-
ment when bilateral transpedicular approaches cause the diaphragm attaches to the 11th and
are used. The patient is place prone and a mid- 12th ribs, if resection of these ribs is warranted,
line incision is made extending up to two levels the diaphragm is incised circumferentially leav-
above and below the level of the tumor. The ing a 2-inch cuff of tissue to facilitate closure.
length of the incision is dictated by the planned The ipsilateral lung is deflated using a dual-
instrumentation. Laminectomies are performed lumen endotracheal tube and is retracted, en-
to provide posterior decompression of the cord abling access to the retroperitoneal cavity,
(Fig. 5.4c). The facet joints, the proximal trans- which can be navigated with blunt dissection
verse processes, and the pedicles are subse- to the diaphragmatic crus (Fig. 5.5c). Incision of
quently removed, providing access to the rostral the proximal attachment of the ipsilateral psoas
and caudal intervertebral disk. Once the plane can provide additional exposure of the verte-
between the posterior longitudinal ligament bral body. Although breach of the peritoneal
(PLL) and the dura is identified, the PLL in in- cavity is preferably avoided, if it occurs, the tear
cised at the disk space above and below the should be either closed or extended so as to
origin of disease. The tumor and vertebral body prevent the strangulation of the bowel via hia-
are then resected piecewise until there is ade- tal hernia formation. In addition to the risks
Region-Specific Approaches 55

Fig. 5.5ad Thoracoabdominal approach for access providing access to the T12 vertebral body (bright
to T12. (a) The patients arm is extended and an yellow). (d) Sagittal CT scan demonstrating cage
incision is made over the 10th rib. (b) Once expo- and place placement following T12 vertebral body
sure of the diaphragm is granted, the ipsilateral lung resection in a patient with metastatic colon
is deflated. (c) Retroperitoneal fat, which lies behind carcinoma.
the diaphragm, is retracted along with peritoneum

posed to the thoracotomy approach, the thora- the T12 vertebral body until the PLL was visibly
coabdominal approach also risks injury to the decompressed. The cage was then placed be-
spleen, kidney and ureters. tween T11 and L1 to restore anatomic align-
ment (Fig 5.5d). The cage was packed with
allograft bone from the 10th rib and a plate
Case Illustration
was placed extending from T11 to L1. A single
A 47-year-old man presented with intractable chest tube was placed and the diaphragm was
back pain requiring daily treatment with a high- closed using 1-0 Prolene. Postoperatively, the
dose fentanyl patch. The patient had a past patient complained of decreased lung capacity
medical history of metastatic colon carcinoma and feeling winded, and he died 3 months after
and had received chemotherapy and radiation surgery.
to a lesion at T12. He had a mass in the left
lung, suspicious for a pulmonary metastasis.
Surgery was offered when imaging demon-
strated a progressive kyphosis at the T12 level Lumbar Spine
and a wedge deformity of the T12 vertebral
body. Intraoperative imaging was used to iden- Approximately one in every five spine tumor
tify the 10th rib, and an overlying incision was cases occurs in the lumbar region.3 The lumbar
made. The rib was excised and the chest cavity spine is unique in that, inferior to the conus
was entered. The diaphragm was detached from medullaris, the cord becomes the branched
the chest wall, a rectangular incision was made cauda equina. In patients with metastases to
in the parietal pleura, and the iliopsoas was mo- the lumbar spine, preexisting lumbar degener-
bilized. T11-12 and T12-L1 diskectomies were ative scoliosis and disk disease may complicate
performed, followed by piecemeal resection of the surgical approach and planning. In patients
56 Chapter 5

with a greater than 30-degree Cobb angle, with both nerve roots and reduces the risk of radic-
lateral translation of the vertebral bodies, or ular pain caused by root compression.
severe spondylolisthesis, simple decompression Care should be taken to avoid entering either
alone may worsen their degenerative lumbar the perirenal fat or the retropsoas spacetwo
spine disease. Clinical assessment and surgical regions that are commonly incurred instead of
planning should take comorbid pathology into the plane in front of the quadratus lumborum
account. Flexion and extension radiographs are and psoas muscles.23 Both the ureter and gen-
advised if spondylolisthesis is suspected. itofemoral nerve should be protected from
excessive retraction. Unlike the thoracic spine,
anterior approaches to the lumbar spine pose
Posterior Approach (Laminectomy) an additional challenge because the nerve roots
A posterior approach to the lumbar spine can should be preserved whenever possible. For
be sufficient for palliative care of anterior pa- approaches involving the lower lumbar spine,
thologies. Posterior decompression via laminec- it should be taken into consideration that the
tomy or foraminotomy with posterior fixation aorta bifurcates into the common iliac vessels
is one of the best known surgical techniques at L4. Mobilization of the great vessels by a vas-
with a very low rate of postoperative complica- cular access surgeon may be required for expo-
tions. However, there is growing evidence that sure of L3-L4.
suggests that laminectomy alone for decom-
pression is no more effective than radiation in
treating neurologic pain.24
Sacral Approaches
Retroperitoneal Approach Although rare, malignant tumors of the sacral
The retroperitoneal approach provides anterior spine present a complex array of challenges.
access to the lumbar spine in tumor cases to Due to the delayed onset of symptoms, patients
enable effective resection and to restore ante- often present with large tumors with some
rior column stability. The patient is placed in a degree of adjacent structure invasion at the
semilateral (45-degree) decubitus position and time of their diagnosis. If resection constitutes
the table is arched so as to widen the space be- greater than 50% of the sacroiliac (SI) joint, re-
tween the hip and ribs. An oblique flank inci- construction with a transiliac bar, femoral graft,
sion is made between the 12th rib and the iliac iliac, and pedicle screws is necessary.25
crest centered at the tumor level. The internal Sacrectomy has proven effective in treating
oblique and the transversus abdominis muscle a number of sacral tumors; however, the litera-
layers are divided in line with the skin incision, ture describing sacral tumor resection includes
exposing retroperitoneal fat, which is then re- a majority of patients with primary spinal tu-
tracted anteriorly along with peritoneum. Once mors. The degree of sacrectomy (low, middle,
the vertebral level is confirmed, ligation of the high, or total) is dependent on a number of fac-
segmental vessels enables mobilization of the tors including the tumor pathology, the nerve
aorta to facilitate exposure of the anterior part roots involved, and subsequent goals of sur-
of the vertebral body. A corpectomy can then gery. Knowledge of sacral vascular anatomy is
be performed using a diamond bur for circum- crucial for sacrectomy approaches. The aorta
ferential decompression of the spinal cord. In- bifurcates to form the common iliac arteries
complete resection of the contralateral pedicle at the level of the L3-4 disk, and the common
can be avoided by further tilting the patient so iliac arteries become the internal and external
as to enhance visualization. Once the anterior iliacs at the lumbosacral articulation. Bilaterally,
vertebral body and adjacent vertebral disks are the common iliacs are transversed by the ure-
removed, the PLL should be carefully dissected ter. The common iliacs give off the medial and
away from the cord. This facilitates exposure of lateral sacral arteries, which commonly supply
Region-Specific Approaches 57
presacral tumors. The superior and inferior glu- fied Galveston L-rod technique for spinopelvic
teal arteries also traverse the sacrum. Signifi- reconstruction.27 Autograft and demineralized
cant bleeding can result from injury to these bone are placed in the defect to promote fu-
arteries. sion, and the rectus abdominis flap is used to
Because the majority of tumors occur ante- reconstruct the defect. Gluteal flaps are also
riorly, sacrectomies are typically performed in mobilized medially to serve as additional pro-
a two-stage, anterior then posterior, fashion. tection. The single-stage posterior approach
The principal aims of the anterior approach are has also been successfully used for sacrectomy,
to expose the anterior aspects of the tumor, reducing the wound size and reducing the po-
dissect adhesions to the bowel and abdominal tential risk for vascular complications.28 Fur-
viscera, and ligate the main vessels.26 The pa- ther, if the tumor does not violate more than
tient is placed in a supine position and a midline 50% of the SI joint, the caudal extent of the sa-
incision is made extending from the umbilicus crum may be removed without any spinopelvic
to the symphysis pubis to expose the anterior reconstruction.
lumbosacral region. The ureters and iliac vessels There are a number of possible complica-
are carefully dissected and preserved. A vascu- tions associated with sacrectomy. Impairment
lar access surgeon may assist in mobilization of of the sacral nerve roots often results in uro-
the great vessels. If necessary, a colostomy can logic, anorectal, and sexual function issues. In
be performed at this stage of the operation to one study, Todd et al29 reported that the pres-
protect the bowel from later radiation or if the ervation of at least one S3 nerve root preserves
bowel is invaded by the tumor. satisfactory bowel and bladder function in most
The periosteum is then identified and dis- patients. Preservation of bilateral S1 is required
sected. Midline osteotomies may be scored into for normal ambulation. In addition, reconstruc-
the bone following exposure. The lumbar trunk tion of the spinopelvis can result in loss of am-
and lumbosacral plexus are then identified and bulation and vertical and rotation instability
preserved along the lateral aspect of the sacral of the lower spine. There is also an increased
ala. Lateral to the plexus, the sacroiliac joint risk of deep wound infections and major wound
can be identified, and bilateral sacroiliac oste- dehiscence.
otomies are performed if total sacrectomy is
merited. The L5-S1 disk and annulus are then
incised. A Silastic sheath may be placed poste-
rior to the vascular structures and the rectum Role of Minimally
to prevent adhesions. If a large sacral defect is InvasiveSurgery
planned, a myocutaneous flap, such as a ven-
tral rectus abdominis myocutaneous (VRAM) Minimally invasive surgery (MIS) has emerged
flap is then prepared, fed by the inferior epi- as an approach for patients with metastatic
gastric vessels. spine disease to reduce blood loss, operative
High-volume blood loss may complicate the time, and complication rates, although class I
anterior procedure, and, if necessary, the pos- evidence is lacking.30 Several common MIS ap-
terior approach may be performed several days proaches such as endoscopy, thoracoscopy, and
after the first operation. For this approach, the laparoscopy can provide effective access for
patient is placed prone and a midline incision vertebroplasty, corpectomy, and percutaneous
is made extending from L2 inferiorly past the screw placement throughout the spine. MIS
coccyx. A laminectomy is performed at L5 and has great potential for reducing postoperative
S1 to expose the cauda equina and nerve roots. pain and complications such as wound dehis-
Lateral sacroiliac osteotomies are performed, cence.21,30 Specifically, for patients with spinal
meeting the anterior osteotomies. Although metastases who are eligible for adjuvant ther-
there is little reported in the literature, several apy, MIS techniques result in smaller wounds
groups have reported success using the modi- and may decrease wound healing time. This can
58 Chapter 5

decrease the time from surgery to adminis surgical outcomes are greatly dependent on the
tration of chemotherapy or radiation therapy. experience of the surgical team. Knowledge of
However, there is a steep learning curve with spinal anatomy and how to properly address
these approaches, and the exposure can be lim- intraoperative complications is critical for pa-
ited compared with that of open techniques. tient success.
Furthermore, few reports have demonstrated
success using MIS to provide circumferential
spinal cord decompression and stabilization for Pearls
the treatment of tumors. As a result, MIS may
be a useful technique in a carefully selected Prior to any intervention for spinal metastatic dis-
population of patients. ease, review the patients anatomy to determine
the role of comorbid degenerative pathology.
For anterior approaches to the cervical spine, con-
sider preoperative tracheostomy and PEG or NG
tube placement to provide ventilation and nutri-
Chapter Summary tion in the event of severe perioperative airway
edema.
To a large extent, treatment for patients with A misplaced lateral mass screw in a single verte-
metastatic cancer often remains palliative due bral artery will tamponade the damaged vessel
until endovascular repair is available.
to the presence of lesions at multiple foci. When
Intubation with a dual-lumen endotracheal tube
considering surgical intervention, there are four allows deflation of a single lung for thoracic tumor
primary objectives: reduction of intractable approaches.
pain; preservation/improvement of neurologic In the thoracic spine, sacrifice of nerve roots re-
function; correction of mechanical instability; sults in minimal patient morbidity and improved
exposure.
and oncological control. In general, approaches
For thoracolumbar approaches, the aorta is more
to the spine can be divided into three catego- difficult to injure and easier to repair than the vena
ries: anterior, posterior, or combined. Although cava; thus, a left-sided approach is preferred.
metastatic tumors primarily originate anteriorly, Resection of greater than 50% of the SI joint re-
direct access to the anterior spine presents a quires its reconstruction with femoral or fibular
strut allograft with transiliac rods and iliac screws.
number of operative challenges including lim-
ited access, increased risk of comorbidity, and Pitfalls
extended hospital recovery time. In the past,
the workhorse technique of most metastatic Esophageal perforation is a rare, late complica-
lesions was posterior decompression via lami- tion following anterior cervical plating.
nectomy and instrumented fixation. However, Never place a screw in the contralateral lateral
mass following injury to the vertebral artery.
several posterior/posterolateral approaches have
Hemo- and pneumothorax are common compli-
been developed to address the issue of circum- cations following thoracotomy approaches, and
ferential decompression of the spinal cord. As postoperative chest tube placement helps to de-
nonsurgical treatments continue to improve, crease these risks.
patients will continue to demonstrate longer Cardiac tamponade from hemopericardium is a
rare but life-threatening complication following
median survival times that will facilitate the
sternal approaches and can be temporarily man-
use of en bloc resection for long-term pain re- aged with a pericardial window for drainage of
lief. Although several of the techniques men- blood.
tioned are considered technically demanding,
Region-Specific Approaches 59
References
Five Must-Read References
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tumors of the cervical spine and first two thoracic soral approaches to the cervical spine. Neurosurgery
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2. Galasko CS. Skeletal metastases. Clin Orthop Relat 16. Hannallah D, Lee J, Khan M, Donaldson WF, Kang JD.
Res 1986;210:1830 PubMed Cerebrospinal fluid leaks following cervical spine
3. Perrin RG, McBroom RJ. Anterior versus posterior de- surgery. J Bone Joint Surg Am 2008;90:11011105
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J Neurol Sci 1987;14:7580 PubMed 17. Bhatia R, Desouza RM, Bull J, Casey AT. Rigid occipito-
4. Cavaliere R, Schiff D. Epidural spinal cord compres- cervical fixation: indications, outcomes, and compli-
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cord compression caused by metastatic cancer: a after anterior cervical surgery. J Spinal Disord 2000;
randomised trial. Lancet 2005;366:643648 PubMed 13:7784 PubMed
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9. Tomita K, Kawahara N, Kobayashi T, Yoshida A, 510 PubMed
Murakami H, Akamaru T. Surgical strategy for spinal 22. Resnick DK. Anterior cervicothoracic junction cor-
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10. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classi- Neurosurg Focus 2002;12:E7 PubMed
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disease: an evidence-based approach and expert thoracolumbar metastatic spine tumors. Neurosurg
consensus from the Spine Oncology Study Group. Clin N Am 2004;15:443451 PubMed
Spine 2010;35:E1221E1229 PubMed 24. Klimo P Jr, Dailey AT, Fessler RG. Posterior surgical
11. Cloyd JM, Acosta FL Jr, Polley MY, Ames CP. En bloc approaches and outcomes in metastatic spine-disease.
resection for primary and metastatic tumors of the Neurosurg Clin N Am 2004;15:425435 PubMed
spine: a systematic review of the literature. Neuro 25. Gunterberg B, Romanus B, Stener B. Pelvic strength
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PubMed mental study. Acta Orthop Scand 1976;47:635642
12. Fehlings MG, David KS, Vialle L, Vialle E, Setzer M, PubMed
Vrionis FD. Decision making in the surgical treat- 26. Fourney D, Gokaslan Z. Surgical approaches for the
ment of cervical spine metastases. Spine 2009;34(22, resection of sacral tumors. In: Dickman C, Fehlings
Suppl):S108S117 PubMed M, Gokaslan Z, eds. Spinal Cord and Spinal Column
13. Molina CA, Gokaslan ZL, Sciubba DM. Diagnosis and Tumors: Principles and Practice. New York: Thieme
management of metastatic cervical spine tumors. Medical, 2006:632648
Orthop Clin North Am 2012;43:7587, viiiix viiiix 27. Gokaslan ZL, Romsdahl MM, Kroll SS, et al. Total sa-
PubMed crectomy and Galveston L-rod reconstruction for ma-
14. Wright NM, Lauryssen C; American Association of lignant neoplasms. Technical note. J Neurosurg 1997;
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29. Todd LT Jr, Yaszemski MJ, Currier BL, Fuchs B, Kim 30. Molina CA, Gokaslan ZL, Sciubba DM. A systematic
CW, Sim FH. Bowel and bladder function after major review of the current role of minimally invasive
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3639 PubMed disease. Int J Surg Oncol 2011;2011:598148 PubMed
6
Spinal Reconstruction and
Fixation/Fusion
Rajiv Saigal and Dean Chou

Introduction pins7 or chest tubes8 to the more modern use


of expandable titanium cages.9 Here we dis-
Surgery for metastatic spinal tumors was once cuss clinical issues and preoperative planning,
a controversial topic, due to meager outcomes and summarize the key points and supporting
from decompressive laminectomy and unclear data for each of these methods.
benefits compared to radiation alone.13 How-
ever, as surgical practice advanced to include
metastatic tumor resection and spinal fixation/
stabilization,4 neurologic outcome and pain Preoperative Planning
results began to improve.1 The landmark 2005
Patchell et al5 study definitively changed man- Preoperative planning for spinal reconstruction
agement, establishing that circumferential sur- cases is vital to ensure operative success. Plan-
gical decompression plus adjuvant radiation is ning includes acquiring adequate imaging, de-
a favorable therapeutic strategy for patients ciding whether to use an approach surgeon and
with neurologic deficit from epidural spinal whether to complete the procedure as a single
cord compression and an expected survival of stage or in multiple stages, considering preop-
at least 3 months. erative tumor embolization, and scheduling the
Strategies for spinal reconstruction and fix- required equipment, including implanted hard-
ation have only grown in importance since, ware systems and neuromonitoring.
with around 25,000 new cases of metastatic
epidural spinal cord compression yearly in the
United States.6 After pulmonary and hepatic
Imaging Modalities
sites, the skeletal system is the next most com- Magnetic resonance imaging (MRI), computed
mon site of metastasis, and the spinal column tomography (CT), and plain film X-rays provide
is the most common skeletal site.6 When the unique, complementary information in prepa-
pathological vertebral body is removed, the spi- ration for metastasis removal with spine recon-
nal column must be reconstructed in order to struction. As part of cancer staging, positron
provide structural support. Reconstruction after emission tomography (PET) or nuclear scintig-
resection of metastasis can generally be under- raphy scans may often provide the first diagno-
taken from an anterior, posterior, or combined sis of metastatic spinal cord compression, but
approach. Techniques for vertebral body re- generally they do not provide adequate resolu-
construction vary widely, from the early use tion for preoperative planning.6 A contrast MRI
of polymethylmethacrylate with Steinmann scan helps to delineate the tumor boundaries
62 Chapter 6

and the degree of epidural spinal cord com- safety. Region-specific approaches are discussed
pression. MRI can clarify whether a metastatic in greater detail in Chapter 5.
tumor is confined to the vertebral body or ex-
tends to the posterior elements. CT best defines
the bony anatomy; in addition to assessing the
Staging
pathological bone invaded by tumor, the sur- For cases that involve expected long operative
geon can assess bone quality at adjacent seg- time or multiple anatomic approaches, some
ments. Preoperative measurement of pedicle surgeons would consider staging in order to
size and anatomy enables optimization of ped- facilitate patient tolerance and to reduce sur-
icle screw diameter, length, and trajectory. CT geon fatigue. However, there is growing evi-
myelogram may be performed in patients with dence to suggest that performing anterior and
contraindications to MRI, such as implanted posterior fusions on separate days is not ben-
pacemakers or deep brain stimulators, but it eficial. A single-stage procedure may entail
carries the downside of being an invasive pro- decreased overall operative time, lower blood
cedure with its own intrinsic risks. Standing or loss, better deformity correction, and shorter
sitting spine X-rays demonstrate the effects of hospital stay.1113 In a recent study of the Na-
load-bearing, information unavailable from the tionwide Inpatient Sample, a 28% complication
standard supine spine MRI or CT scan. Sagittal rate was observed with staged anterior-posterior
and coronal balance should also be measured on surgeries, a significant increase over the 22%
weight-bearing X-rays (if possible), not on su- rate for same-day surgeries.12 With staging,
pine MRIs or CTs, in order to establish a preop- there were increased rates of venous throm-
erative baseline. bosis and acute respiratory distress syndrome
Presurgical planning also involves deciding with no mortality benefit.
what type of intraoperative imaging to order.
Anteroposterior (AP) and lateral C-arm fluo-
roscopy is used for localization in most cases.
Angiography and Embolization
Intraoperative CT (when available) and navi- Thoughtful consideration should be given to
gation can be used for real-time image-guided the option of preoperative angiogram with
implant placement or for ensuring proper place- embolization in highly vascular lesions. A neu-
ment of implants. rointerventional radiologist or endovascular
neurosurgeon should be consulted for lesions
deemed amenable to angiography or emboli-
The Surgical Team zation. Angiography alone may be valuable to
It is sometimes beneficial to utilize an approach identify the segmental level and side of the
surgeon an approach surgeon who has exper- artery of Adamkiewicz, especially when con-
tise in anterior or lateral approaches. If anterior sidering anterior or lateral approaches between
access to the upper cervical spine (C1-2) is re- T9 and L2.14,15 However, magnetic resonance
quired, an otolaryngologisthead and neck sur- (MR) or CT angiography should be considered
geon may be required for transoral approaches as less invasive methods to obtain the same an-
with or without mandible splitting. A thoracic atomic information. For certain hypervascular
surgeon is required for sternotomy for anterior tumors, such as renal cell carcinoma, thyroid car-
access to the thoracic spine and may be benefi- cinoma, hepatocellular carcinoma, or heman-
cial for lateral thoracic approaches.10 A general giopericytoma, preoperative embolization may
or vascular surgeon may provide anterior ret- minimize blood loss, enhancing safety and re-
roperitoneal access to the lumbosacral spine. ducing operative time. However, embolization
Even for spine surgeons who are trained in an- itself carries the risk of neurologic compromise.
terior and lateral approaches, it may be advan- In one series, three of 12 patients (25%) suffered
tageous to arrange the services of an approach neurologic deficits after preoperative emboli-
surgeon who has experience dealing with un- zation.8 Therefore, risks and benefits must be
expected occurrences and maximizing patient carefully weighed prior to proceeding.
Spinal Reconstruction and Fixation/Fusion 63
Neuromonitoring neck dissection with partial sternotomy and
anterolateral thoracotomy enables trapdoor
Intraoperative neuromonitoring is commonly
entry to the chest cavity.8 T5-10 is less favorable
used for spine reconstruction with implants,
for a pure anterior approach due to anatomic
although there is a paucity of data showing
location of the heart, aortic arch, and great
effect on neurologic outcomes. For cases with
vessels; a right-sided thoracotomy is favored.6
partial or no preoperative motor or sensory
At T11-L1, an anterior thoracotomy or anterior
deficit, motor evoked potentials (MEPs) and
retroperitoneal approach may be necessary.
somatosensory evoked potentials (SSEPs) pro-
Retroperitoneal approaches are generally used
vide important feedback to the surgeon about
in the lumbar spine.16
whether any surgical manipulations nerve roots,
Prior to commencing the vertebrectomy,
albeit with the inherent risk of false negatives.
segmental vessels should be identified, ligated,
An exception would be the case of complete
and transected. The intervertebral disks ros-
spinal cord injury from metastatic spinal cord
tral and caudal to the pathological segments(s)
compression. Even in such cases, some clini-
should be removed with an annulotomy knife,
cians would consider using preoperative MEPs
rongeurs, and curettes. After removing cartilag-
and SSEPs to confirm a suspected complete spi-
inous layers, care should be taken to minimize
nal cord injury based on neurologic exam. For
the removal of subchondral cortical bone.9 Re-
unstable spine lesions, preoperative supine MEPs
moval of end-plate bone increases the risk of
and SSEPs are imperative to establish whether
graft subsidence. Vertebrectomy and removal
patient positioning causes any departure from
of metastatic tissue then follows. The use of
baseline before the surgery commences. Addi-
Leksell rongeurs at the outset enables the re-
tionally, direct stimulation of implanted screws
moval of larger pieces of diseased tissue and
intraoperatively may alert the surgeon to the
relative structural preservation in specimens
presence of an unexpected breach from the in-
sent to the pathology lab for diagnosis. A high-
tended trajectory.
speed drill with a round or matchstick drill bit
is necessary to remove posterior vertebral body
tissue, particularly when nearing the posterior
Approaches longitudinal ligament. An ultrasonic aspirator
can be used to assist with tumor removal. The
posterior longitudinal ligament is often opened
Anterior Approach to facilitate visualization of the underlying spi-
Anterior approaches have long been used for nal cord dura and exiting nerve roots. A thor-
resection of vertebral body metastasis with re- ough decompression can only be ensured with
construction of the anterior column. An estab- direct visualization.
lished technique in the thoracic spine entails Options for anterior column reconstruction
anterior vertebrectomy, decompression, and include auto- or allograft bone, static and ex-
reconstruction. The main benefits of an ante- pandable cages, polyetheretherketone (PEEK)
rior approach are direct access to the diseased cages, and polymethylmethacrylate (PMMA)
segment(s), improved wound healing, biome- augmented with Steinmann pins. Prior to the
chanical strength from weight-bearing column widespread availability of mesh cages, PMMA
reconstruction, and fixation of fewer segments.8 was often used to fill in the vertebrectomy
There are various options for vertebral body re- defect, historically combined with either a

construction supplemented with locking plate Steinmann pin or a chest tube as a scaffold.
and screws. Toaccomplish the latter, a cylindrical defect
The anterior approach requires careful con- was drilled into the superior and inferior ver-
sideration of anatomic restraints and generally tebrae. A chest tube was cut to size and filled
requires assistance of an approach surgeon. with PMMA.8 In an exothermic polymeri
AtT1-2, a combined anterior neck dissection zation process, PMMA can heat surrounding
and sternotomy is favored.8 At T3-4, an anterior tissues, so irrigation with lukewarm saline is
64 Chapter 6

beneficial.8 PMMA provides large surface area of a substantial amount of rib with pleural dis-
coverage of the end plate to minimize subsid- section in order to access the spine. Costo-
ence and is extremely stable and strong in transversectomies involve removal of the rib
compression. head in approaching the spine. Transpedicular
A more modern method of anterior column corpectomies are performed entirely through
reconstruction entails the use of an expand- the pedicle and do not require removal of the
able titanium cage.9 Expandable cages are in- rib head nor pleural dissection. More com-
creasingly employed due to their facility of use, monly today these three approaches have been
restoration of vertebral height, and improve- combined into one posterolateral approach;
ment in sagittal alignment and mechanical essentially whatever bone is needed to be re-
strength. Correction of sagittal alignment is a moved to accomplish the surgical goals of de-
major advantage over methylmethacrylate, but compression and reconstruction is removed.
higher cost is a disadvantage. For placement of methylmethacrylate supple-
After anterior column reconstruction, sup- mented with Steinmann pins, a thin rim of
porting instrumentation is implanted. An an- cortical bone if often left as a mold.21 Modern
terior locking plate with screws prevents techniques generally involve placement of an
distraction and stabilizes implants.8 In patients expandable titanium cage from the postero-
with poor bone quality or significant kyphosis, lateral direction. The previously used Luque
anterior fixation alone does not restore sta rectangles and sublaminar cables have been
bility comparable to healthy segments in the replaced by pedicle screws as the standard
thoracolumbar spine,17 and additional poste- posterior fixation.
rior supplementation should be considered in
patients with extended life expectancy. When
operating in the thoracic cavity, chest tubes
Lateral Extracavitary Approach
are left in place during the early postoperative In the thoracic spine, lateral extracavitary ap-
period. proaches garnered greater interest prior to the
Although providing direct access, anterior era of transpedicular corpectomy.14 For these
thoracotomy approaches carry the highest com- approaches, the patient is positioned prone or
plication rate: 39% (including 3.5% reoperation three-quarters prone. The lesion is localized with
rate and 1.5% mortality); lateral extracavitary preoperative fluoroscopy. Hockey-stick (mid-
and costotransversectomy approaches carry line handle with lateral blade) or crescent-
lower morbidity rates of 17% and 15%, respec- shaped incisions are surgical options. Skin and
tively.18 Despite the high complication rate, fascia are first opened at the midline. A lateral
76% of patients with neurologic compromise fascial incision at the injury level exposes the
at presentation improved in some series.8 erector spinae, which are then elevated and re-
tracted. The medial ribs, costotransverse joints,
and costovertebral joints at the lesion level are
Posterior-Only Approaches dissected and cut/disarticulated. Removal of the
Costotransversectomy, transpedicular, and ex- rib requires careful dissection from the pari-
tracavitary approaches are viable options for etal pleura. Nerve roots are followed to the fo-
posterior-only reconstruction in the lumbar19 ramina. After removal of the ipsilateral pedicle,
and thoracic20 spine. They offer the benefit of a vertebrectomy and diskectomy can be per-
anterior column reconstruction and posterior formed and the diseased level(s) addressed with
supplementation from a single approach. In the spinal cord under direct lateral visualiza-
addition, comorbidities or anatomic tumor bur- tion.14 An expandable cage or other graft (in-
dens may preclude an anterior thoracic or ab- cluding the harvested rib segment) can then
dominal approach and thus require a posterior- be placed to reconstruct the anterior column.
only approach. The three approaches differ in Finally, pedicle screws and rods can be placed
the degree of rib removal involved. The stan- from the same approach due to dorsal expo-
dard extracavitary approach requires removal sure and access. Unfortunately, the lateral ex-
Spinal Reconstruction and Fixation/Fusion 65
tracavitary approach carries a high morbidity navigation. Generally, three levels above and
of up to 55% in the thoracic spine and might below the pathological vertebral body are in-
be best reserved for lesions inaccessible from strumented, although two levels above and
other routes. below can also be done in patients with excel-
lent bone quality. It is critical to remember that
rigid, durable fixation is essential for optimal
Transpedicular Corpectomy pain relief and for preserving quality of life in
For transpedicular corpectomies, pedicle screw patients with metastatic disease.
insertion can be completed via an open, mini- Although pedicle screws can be placed in
open, or percutaneous technique.22 In the open amini-open or percutaneous fashion, trans-
case, the fascia is fully opened, and paraspinal pedicular corpectomy requires a midline fas-
muscles fully dissected off the midline in the cial opening. Paraspinal muscles are dissected
subperiosteal plane. They are retracted later- and retracted laterally to the rib. After lami-
ally to expose pedicle screw entry sites under nectomy, the pedicle is removed with a ron-
direct visualization. For mini-open cases, skin is geur or drill. Vertebrectomy is then performed
opened at the midline, but fascia is preserved. using rongeurs and drills until reaching the an-
Pedicle screw placement then proceeds under terior longitudinal ligament. A matchstick drill
either fluoroscopy or image-guidance with bit is recommended in order to minimize the
intraoperative O-arm CT scan. risk to ventral tissues. Complete removal of the
For fluoroscopy-guided pedicle screw place- vertebra is not always necessary and depends
ment, Jamshidi needles are placed into the on the surgical goals. Before completing the
lateral margins of the pedicles under AP fluo- corpectomy, a temporary rod should be placed
roscopy guidance, using the same technique as on the contralateral side. A Woodson or down-
for percutaneous screw placement. They are angle curette is used to dissect the posterior
then advanced about 10 mm under AP guid- vertebral body off of the spinal cord or thecal
ance, taking care not to violate the pedicle me- sac and advance it ventrally.21 The posterior ver-
dially or inferiorly. A lateral view is taken to tebral body and posterior longitudinal ligament
ensure correct trajectory at this point. Again may contain tumor and should be removed.
under AP guidance, the Jamshidi is advanced This is also necessary in order to achieve cir-
to 20 mm, and a lateral image then confirms cumferential decompression.21 The ipsilateral
whether the needle has passed through the nerve root is ligated and transected pregangli-
posterior cortex of the vertebral body. Blunt- onically to create an entry path for the cage.
tip Kirschner wires (K-wires) are inserted into The posterior longitudinal ligament is dissected
the Jamshidi needles and advanced to a depth free and opened, and the ventral and caudal
of approximately 75% of the vertebral body. disks are removed. Then a pathway along the
The Jamshidi is then removed and a cannulated rib head must be opened. The rib head can
pedicle screw is advanced over the K-wire. Ex- be removed or opened in a trapdoor fashion.
treme caution and frequent imaging should be The latter option avoids pleural dissection and
used to avoid inadvertent ventral migration of the rib head can temporarily be swung open
the K-wire. to allow placement of the cage.23 A trial sizer
For image-guided pedicle screw placement, should be placed to determine the largest pos-
a single midline skin incision is made, again sible safe cage placement. Finally, an expand-
not opening the fascia. An intraoperative CT able cage is passed into the corpectomy defect
scan is performed with a reference marker on and expanded. The position is verified with an
one of the caudal spinous processes. Then using X-ray. Final rods and set screws are placed. In
intraoperative image navigation, a pilot hole is the open case, posterior arthrodesis is per-
drilled with the navigated drill guide and drill. formed with auto- or allograft bone chips sub-
A navigated tap is used to prepare the entry jacent to the rod if life expectancy longer than
site, and the appropriate screw size is mea- 6 months is expected. An illustrative case is
sured. The pedicle screw is then advanced under shown in Figs. 6.1, 6.2, 6.3, 6.4, 6.5, 6.6.
66 Chapter 6

a b c

d e f

Fig. 6.1af Preoperative imaging in a 58-year-old enhancement in the T6 and T7 vertebral bodies
woman with metastatic melanoma causing epidural aswell as a posterior T6-7 enhancing mass lesion
spinal cord compression. The patient had an in- contributing to epidural spinal cord compression.
ability to ambulate and profound neurologic deficit. (d) Axial T1 postgadolinium MRI scan at T6 shows
(a) Sagittal T2 magnetic resonance imaging (MRI) circumferential epidural spinal cord compression.
shows T6 pathological fracture with epidural spinal (e) Sagittal CT T-spine and (f) upright lateral chest
cord compression. (b) Sagittal T1 precontrast scan. X-ray scan better demonstrate the pathological
(c) Postgadolinium T1 sagittal MRI scan shows collapse and kyphosis at T6.
Spinal Reconstruction and Fixation/Fusion 67

Fig. 6.2 Image-guided pedicle screw placement. fixed reference arc (four gray spheres on blue frame)
The surgeon views the live monitor to verify correct isattached to a caudal spinous process prior to
trajectory while drilling a pilot hole. The drill guide obtaining the intraoperative computed tomography
isattached to infrared sensors (four gray spheres on (CT) scan.
pink frame) to determine its position in space. The

In a single-institution study of 80 patients obstruct the surgical trajectory. Anterior re-


with thoracolumbar spine surgery, there was construction can be done from a lateral mini-
no difference in estimated blood loss (EBL), mally invasive approach, and this is discussed
operative time, and complication rates when in greater detail in Chapter 7.
comparing single-level transpedicular with an-
terior-only corpectomies.20 However, combined
anterior-posterior corpectomies, had a higher Combined Approaches
complication rate, higher EBL, and increased
Biomechanics
operative time compared with the single-staged
transpedicular corpectomy approach. Combined anterior and posterior fixation may
increase stiffness by approximately 50% com-
pared with anterior cage placement and poste-
Lateral Approaches rior fixation alone.17 For anteriorly placed grafts
True lateral approaches for vertebrectomy and or cages, posterior supplementation should
reconstruction are particularly well suited to almost always be considered when tumor in-
the midlumbar spine (L2-L4), where rib dissec- vades the posterior elements, to provide neces-
tion is unnecessary and the iliac crest does not sary biomechanical instability, and to avoid late
68 Chapter 6

Fig. 6.3 Mini-open image-guided pedicle screw The right screen shows parasagittal view. The
placement. After drilling a pilot hole, the pedicle traversing pedicle tap (violet) and the current
and vertebral body are tapped under image trajectory (green hatched line) are shown.
navigation. Axial view is shown on the left screen.

Fig. 6.4 Mini-open image-guided pedicle screw shows parasagittal view. The traversing pedicle
placement. After tapping the hole, the pedicle screw (pink), the screwdriver (blue), and the current
screw is advanced under image navigation. Axial trajectory (green hatched line) are shown.
view is shown on the left screen. The right screen
Spinal Reconstruction and Fixation/Fusion 69

Fig. 6.5 Image-guided pedicle screw placement. sensors (four gray spheres on dark gray frame) to
The surgeon views the live monitor to determine determine its position in space. The fixed reference
the correct trajectory while advancing the pedicle arc (four gray spheres on blue frame) is attached to a
screw. The screwdriver is attached to infrared caudal spinous process (bottom left).

construct failures. In cases of pathological ky- Single-Stage Combined Approach


phosis, junctional levels, or multiple adjacent
vertebrectomies, posterior supplementation is When tumor invades both anterior and poste-
essential.5 rior columns, combined approaches are often
Posterior supplementation is more biome- advantageous.16,25 Lateral positioning is one op-
chanically stable than the native healthy mo- tion for such combined approaches to lesions at
tion segment or anterior fixation alone.17,24 T5-L4 and offers the benefit of reduced intra-
There is no biomechanical difference between abdominal pressure relative to prone position-
static and expandable cages when combined ing and simultaneous exposure for separate
with anterolateral vertebral body plating alone.24 surgical teams working ventrally and dorsally.25
When combined with posterior supplementa- Separate thoracotomy and midline thoraco-
tion, some studies found that expandable cages lumbar incisions are opened. If tumor extends
are more biomechanically stable for axial rota- to the ribs, these are transected laterally.16 Lam-
tion, extension, and lateral bending than static inectomies expose any epidural tumor, which
mesh cages,24 whereas others found no biome- is then dissected off of the dura or nerve roots.
chanical difference.17 Additionally, design vari- Segmental vessels are ligated to reduce vascu-
ations in expandable cages do not appear to lar supply to the tumor, but not bilaterally in
offer structural differences.17 order to preserve spinal cord perfusion. Special
70 Chapter 6

Fig. 6.6a,b Postoperative imaging. Anteroposterior


(a) and lateral (b) standing X-rays demonstrate
good hardware placement. The expandable
titanium cage is seen at the center of the construct.
Pedicle screws were placed three levels above and
below the level of the transpedicular corpectomy. b

care must be taken near the artery of Adam- thecal sac is decompressed circumferentially.
kiewicz. Ventral tissues and blood vessels are In a retrospective study by Fourney et al, the
shifted away from the tumor. The spine must anterior column was reconstructed with meth-
be stabilized posteriorly prior to performing ylmethacrylate using the chest tube technique,
the spondylectomy. Posterior instrumentation followed by placement of an anterior locking
can be placed with the patient in the lateral plate and screws.16 Patients with metastatic
position or the patient can be rotated prone if spinal tumors survived a mean 22.5 months
positioned on a mobile table with appropriate after surgery.16 The presence of extraspinal me-
padding.25 Removal of the pathological verte- tastasis was a predictor of a shorter survival
bral body and surrounding tumor then pro- (amean of 17 months vs 47 months for no
ceeds from posterior to anterior diagonally, near extraspinal metastasis); 62% of patients with
the pedicle, using a high-speed drill and ultra- preoperative neurologic deficit showed post-
sonic aspirator as needed.4 The spinal cord or operative improvement, and 96% of patients had
Spinal Reconstruction and Fixation/Fusion 71
significant improvement in pain at 1 month
Circumferential surgical decompression with ad-
follow-up, with the median visual analogue
juvant radiotherapy is indicated for patients with
scale (VAS) pain score decreasing to zero at metastatic epidural spinal cord compression, neu-
1year follow-up.16 rologic deficit (including pain), and expected sur-
vival of at least 3 months.5 The minimum expected
survival time needed to undergo surgery may
shorten as minimally invasive techniques evolve.
Chapter Summary Hypervascular tumors should be assessed for
preoperative embolization.
Patients with metastatic spinal tumors may often
For patients with spinal metastatic tumors,
have poor bone quality related to the primary
spine reconstruction and fixation/fusion can cancer, poor nutritional status, and adjuvant che-
be performed from an anterior, posterior, lat- motherapy and radiation.9 It is thus imperative
eral, or combined approach. For carefully se- toreconstruct the spine with constructs of ade-
lected patients with neurologic deficits related quate biomechanical strength.
In patients who undergo a destabilizing spon-
to tumor invasion, instability, and life expec-
dylectomy, options for vertebral body recon-
tancy of approximately three months, tumor struction include auto- or allograft bone,
resection combined with spine reconstruction polymethylmethacrylate, static mesh cages, and
affords improvements in neurologic function, expandable titanium cages.
pain, quality of life, and possibly longevity.5 An- For anterior approaches to vertebral body recon-
struction, posterior supplementation is advised
terior options include anterior cervical corpec-
for kyphotic lesions, junctional lesions, multilevel
tomy, transthoracic corpectomy, and abdominal vertebrectomies, and in patients with extended
retroperitoneal lumbar corpectomy. Anterior life expectancy.
reconstruction and plating are satisfactory in For patients with metastatic spinal tumors, the goal
single-level, nonjunctional, and minimal defor- of surgical reconstruction is generally palliative.
Surgery should be planned to preserve neurologic
mity cases. Combined anterior and posterior
function, alleviate pain, and correct instability.16
fixation provides for the greatest biomechani-
cal stiffness and stability.17 Posterior options Pitfalls
include extracavitary or transpedicular (pos-
terolateral) corpectomy with expandable cage Patients with poor overall functional state and
placement. The latter provides access for an- significant comorbidities must not be operated
on without careful preoperative evaluation. Pa-
terior column reconstruction and posterior in-
tients who are poor candidates for spinal recon-
strumentation from a single approach. Tumors struction with fixation and fusion may still qualify
with both anterior and posterior involvement for percutaneous cement augmentation (see Chap-
can be approached from a single posterolateral ter 8) or radiation therapy.
approach or single lateral position using a si- Radiosensitive tumors such as lymphoma and
myeloma may be best treated with radiation
multaneous combined approach.
first,6 if stability is not an issue.
Anterior reconstruction without posterior supple-
mentation is likely inadequate in cases of multi-
Pearls level vertebrectomy, involvement of the cervico-
thoracic or thoracolumbar junction, significant
Seventy percent of cases involve the thoracic kyphotic deformity, or tumor involvement of the
spine, 20% the lumbar spine, and 10% the cervical posterior elements.
spine, with most metastases going to the ver Transpedicular corpectomy is highly destabilizing.
tebral bodies rather than to the posterior ele- At least two levels above and below the corpec-
ments.8 The anatomic differences of each region tomy should be instrumented, and a cross linker
necessitate different surgical approaches for sur- should be placed. In cases of poor bone quality,
gical reconstruction and fusion (see Chapter 5 for such as osteoporosis, three levels above and below
further details). are recommended.
72 Chapter 6

References
Five Must-Read References

1. Bilsky MH, Lis E, Raizer J, Lee H, Boland P. The dia- operative complications. Neurosurgery 1998;43:796
gnosis and treatment of metastatic spinal tumor. On- 802, discussion 802803 PubMed
cologist 1999;4:459469 PubMed 15. Charles YP, Barbe B, Beaujeux R, Boujan F, Steib JP.
2. Young RF, Post EM, King GA. Treatment of spinal epi- Relevance of the anatomical location of the Adam-
dural metastases. Randomized prospective compari- kiewicz artery in spine surgery. Surg Radiol Anat
son of laminectomy and radiotherapy. J Neurosurg 2011;33:39 PubMed
1980;53:741748 PubMed 16. Fourney DR, Abi-Said D, Rhines LD, et al. Simultane-
3. Black P. Spinal metastasis: current status and recom- ous anterior-posterior approach to the thoracic and
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1979;5:726746 PubMed lowed by reconstruction and stabilization. J Neuro-
4. Cybulski GR. Methods of surgical stabilization for surg 2001;94(2, Suppl):232244 PubMed
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25:240252 PubMed chanical comparison of expandable cages for verte-
5. Patchell RA, Tibbs PA, Regine WF, et al. Direct decom- bral body replacement in the thoracolumbar spine.
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randomised trial. Lancet 2005;366:643648 PubMed extracavitary, costotransversectomy, and transtho-
6. Witham TF, Khavkin YA, Gallia GL, Wolinsky JP, Go- racic thoracotomy approaches to the thoracic spine:
kaslan ZL. Surgery insight: current management of review of techniques and complications. J Spinal Dis-
epidural spinal cord compression from metastatic ord Tech 2013;26:222232 PubMed
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quiz 11 PubMed for lumbar vertebral column resection and expand-
7. Bilsky MH, Boland P, Lis E, Raizer JJ, Healey JH. able cage reconstruction for spinal metastases. JNeu-
Single-stage posterolateral transpedicle approach rosurg Spine 2013;19:2733 PubMed
for spondylectomy, epidural decompression, and cir- 20. Lu DC, Lau D, Lee JG, Chou D. The transpedicular
cumferential fusion of spinal metastases. Spine 2000; approach compared with the anterior approach: an
25:22402249, discussion 250 PubMed analysis of 80 thoracolumbar corpectomies. J Neuro-
8. Gokaslan ZL, York JE, Walsh GL, et al. Transthoracic surg Spine 2010;12:583591 PubMed
vertebrectomy for metastatic spinal tumors. J Neu- 21. Akeyson EW, McCutcheon IE. Single-stage posterior
rosurg 1998;89:599609 PubMed vertebrectomy and replacement combined with pos-
9. Viswanathan A, Abd-El-Barr MM, Doppenberg E, et terior instrumentation for spinal metastasis. J Neu-
al. Initial experience with the use of an expandable rosurg 1996;85:211220 PubMed
titanium cage as a vertebral body replacement in pa- 22. Lu DC, Chou D, Mummaneni PV. A comparison of
tients with tumors of the spinal column: a report of mini-open and open approaches for resection of
95 patients. Eur Spine J 2012;21:8492 PubMed thoracolumbar intradural spinal tumors. J Neurosurg
10. De Giacomo T, Francioni F, Diso D, et al. Anterior ap- Spine 2011;14:758764 PubMed
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Thorac Surg 2011;12:692695 PubMed posterior placement of expandable cages after trans-
11. Shufflebarger HL, Grimm JO, Bui V, Thomson JD. pedicular corpectomy: an alternative to lateral ex-
Anterior and posterior spinal fusion. Staged versus tracavitary and costotransversectomy approaches.
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12. Passias PG, Ma Y, Chiu YL, Mazumdar M, Girardi FP, 24. Knop C, Lange U, Bastian L, Blauth M. Three-dimen-
Memtsoudis SG. Comparative safety of simultaneous sional motion analysis with Synex. Comparative bio-
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Spine 2012;37:247255 PubMed replacement for the thoracolumbar spine. Eur Spine J
13. Wright N. Single-surgeon simultaneous versus staged 2000;9:472485 PubMed
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7
Minimally Invasive Surgery for
Metastatic Spine Disease
Meic H. Schmidt

Introduction bidity such as postoperative wound infection,


reduce the need for blood transfusion, and
Minimally invasive treatment (MIT) of spinal enable faster recovery by allowing for earlier
tumors is becoming increasingly complex, and postoperative adjuvant treatment (e.g., radia-
multiple specialties are contributing to bring tion, chemotherapy).
their techniques to the fore.1 These modalities Minimally invasive surgery can also entail
include percutaneous techniques (e.g., image- doing less surgery at the target site under the
guided biopsy, embolization, cement augmen- principle that less is more. If a better out-
tation, radiofrequency ablation) and minimally come would be expected from adjuvant treat-
invasive surgery (MIS) techniques. Current MIS ment after an initial surgery, that option should
techniques are key components of MIT for the be considered. For example, decompressing the
treatment of metastatic spine disease. spinal cord without removing all the tumor tis-
This chapter defines MIS, discusses the MIS sue might be sufficient if the patient is a suit-
techniques that can be used in addition to tra- able candidate for radiation after surgery.3 In
ditional open techniques, examines potential that sense, MIS can entail doing less surgery to
criteria for the use and evaluation of MIS tech- achieve the equivalent or better outcome com-
niques, and provides an overview of posterior pared with more extensive surgical resection.
and anterior surgical MIS techniques, focusing For example, Laufer et al3 recently published a
on the thoracoscopic approach for tumor re- series of 186 patients treated with separation
section via corpectomy, followed by recon- surgery followed by adjuvant hypofractionated
struction and stabilization. or high-dose single-fraction radiosurgery. Al-
though minimal access techniques were not used
in this series, separation surgery conceptu-
ally shows that less surgery can achieve equal
What Is Minimally Invasive? or better results for palliative care of metastatic
spine disease. It involves decompression of the
Although a precise definition of the term mini- thecal sac by a limited posterior lateral tumor
mally invasive is elusive, most authors agree resection and posterior segmental instrumen-
that MIS involves surgical techniques that re- tation, followed by postoperative cytotoxic
duce collateral tissue damage most commonly radiosurgery doses that spare the spinal cord.
associated with surgical access (approach).2 MIS The results show that local tumor control was
can potentially decrease access-associated mor- achieved in the majority of patients, with a cu-
74 Chapter 7

mulative incidence of local progression 1 year


4. Favorable socioeconomic effect
after radiosurgery of 16.4%. Only four patients
a. MIS must improve quality
required reoperation. i. Increase in quality measures listed above
Thus, it is difficult to reach a consensus on (criteria 13)
a definition of MIS, which can have different b. MIS must be cost effective
meanings for different authors. It is similarly i. Upfront cost must be balanced with
downstream cost savings
difficult to define the added value of MIS based
ii. Imaging cost associated with MIS
on quality and cost measures. The Text Box lists c. MIS must be valuable
some of the criteria I use to evaluate and justify i. Value = quality/cost
MIS procedures including those undertaken for
metastatic spine disease. Although by no means
a complete list, these criteria can be used to an-
alyze and compare various surgical approaches
including open, mini-open, endoscopic, and
percutaneous techniques. Posterior and
Posterolateral Approaches
Criteria for minimally invasive spine surgery Posterior surgical approaches are used for lam-
to be meaningful and valuable inectomies and transpedicular decompression.
More extensive posterolateral approaches like
1. Minimizing surgically induced tissue damage the lateral extracavitary approach allow for ex-
a. Smaller, cosmetically appealing skin incision tensive posterior and anterior decompression
b. Minimal muscle dissection
c. Less bone removal
including more complete corpectomy and en
2. Measurable clinical benefit bloc resection.4 Because of the extensive soft
a. Decrease in surgical morbidity and mortality tissue trauma associated with these traditional
i. Cerebrospinal fluid leak, neurologic approaches, MIS techniques were developed to
worsening, less instability take advantage of the access trajectory of the
b. Lower intraoperative blood loss
i. Less need for blood transfusion
approaches by minimizing the incision.57
ii. Less need for cell saver Deutsch et al6 applied the MIS technique
c. Shorter stay in the hospital using a tubular retractor to access spinal me-
i. Fewer days in intensive care unit tastasis to the thoracic spine in eight patients
ii. Shorter overall stay (Fig. 7.1). Through unilateral or bilateral 3-cm
iii. Lower readmission rate
d. Resumption of activities
incisions they performed intralesional, trans-
i. Less need for rehabilitation pedicular vertebrectomies for spinal cord de-
ii. Less need for physical therapy compression with limited reconstruction using
iii. Faster return to work methylmethacrylate. None of the patients un-
e. Lower infection rates derwent spinal stabilization using instrumenta-
f. Lower reoperation rates
g. Earlier initiation of postoperative therapies
tion. The mean operative time and mean blood
i. Physical therapy, radiation, chemotherapy loss were 2.2 hours and 270 mL, respectively.
3. Clinical effectiveness The mean length of stay was 4 days. Postopera-
a. MIS must achieve the intended surgical goal tively, 62.5% of patients had improved neurologic
i. Decompression, reconstruction function and pain control. All patients under-
b. MIS must have equivalent or better clinical
outcomes
went postoperative radiation therapy. No com-
i. Neurologic improvement and pain plications related to surgery were noted.
outcome Zairi et al7 described 10 patients with me-
c. MIS must have equivalent or better imaging tastasis to the thoracic spine who were treated
outcomes with decompressive corpectomy using a tubu-
i. Fusion rate
ii. Spinal canal decompression
lar retractor. No anterior column reconstruction
was performed after transpedicular corpectomy;
Minimally Invasive Surgery for Metastatic Spine Disease 75

Fig. 7.1 Illustration of exposure for minimally anterior portion of the spine can be visualized.
invasive transpedicular vertebrectomy. The tubular (Courtesy of the Department of Neurosurgery,
retractor facilitates the lateral exposure so that the University of Utah.)

however, the authors used percutaneous ped- which is particularly high in cancer patients,
icle screw fixation to stabilize the spine (Fig. who are frequently immunocompromised and
7.2). They reported a mean operative time of have often had prior radiation therapy. Infec-
170 minutes and mean estimated blood loss tion can be a life-threatening event in oncology
of400 mL. No patient required a blood transfu- because of the limited capacity of patients to
sion. The mean length of stay was 6 days. The fight it despite antibiotic therapy. In addition,
only complication reported was a postoperative infections frequently disqualify patients from
urinary tract infection. Eighty percent of pa- adjuvant radiation, chemotherapy, and experi-
tients improved by at least one Frankel grade. mental protocols. Prior studies indicate that the
Both series demonstrated excellent radio- risk of a posterior wound infection in a cancer
graphic and clinical results but involved only patient is approximately 12 to 32%, depending
asmall number of patients. It is important to on the timing of radiation.8 These initial studies
note that in both series patients with overt neo- on posterior MIS techniques in cancer patients
plastic spinal instability (i.e., kyphosis) were ex- have not yet clearly demonstrated a lower in-
cluded. A major disadvantage of any approach fection risk compared with standard open pos-
with a posterior incision is the risk of infection, terior and anterior approaches.
76 Chapter 7

a b

c d
Fig. 7.2adAxial (a) and sagittal (b) T2-weighted introduction of the rods. (From Zairi F, Arikat A,
magnetic resonance imaging (MRI) depicting spinal Allaoui M, Marinho P, Assaker R. Minimally invasive
cord compression due to a metastasis at T7. (c) The decompression and stabilization for the manage-
operative photograph shows insertion of the wires ment of thoracolumbar spine metastasis. J Neuro-
on the right side. (d) Lateral fluoroscopy shows the surg Spine 2012;17(1):21. Reproduced with
spine after bilateral pedicle screw insertion and the permission.)

Anterior and ity that can be worsened by an indirect de-


AnterolateralApproaches compression with a simple laminectomy. At
the same time, anterior open thoracotomy and
thoracoabdominal approaches were demon-
Traditional Thoracotomy strating improved outcomes by more effectively
Although resection of metastatic spine tumors addressing the goals of tumor resection, neu-
was historically performed via a posterior lam- ral decompression, and anterior reconstruction.
inectomy approach, it frequently resulted in Transpleural thoracotomy allows for direct ac-
unsatisfactory outcome and neurologic wors- cess to the spinal canal for decompression, an-
ening. The most common reason for thera- terior column reconstruction, and stabilization.
peutic failure is related to the fact that most Thoracotomy can be extended to include the
metastases originate in the vertebral body and upper lumbar spine by incising the diaphragm
are associated with a degree of spinal instabil- (thoracolumbar approach).
Minimally Invasive Surgery for Metastatic Spine Disease 77
Several published case series document the opted for spine pathologies such as thoracic disk
excellent outcomes of thoracotomy for pain herniation, spine fracture, and tumors. The goal
control, neurologic improvement, and spinal of both anterior MIS techniques is to decrease
stability for metastatic disease. Gokaslan et al9 the access morbidity without compromising
reported one of the largest series of patients the safety and efficacy of the spinal procedure
who underwent traditional thoracotomy for to be performed. At the target disease site, the
metastatic disease at M.D. Anderson. Seventy- MIS technique needs to enable a corpectomy
two patients with metastatic spine tumors to decompress the spinal canal, followed by in-
underwent thoracotomy for transthoracic ver- terbody reconstruction and stabilization.
tebrectomy, decompression, reconstruction with
polymethyl methacrylate, and anterior plate fix-
ation; supplemental posterior fixation was used
Mini-Open Thoracotomy
in seven patients. The study found that 76% Current anterior mini-open MIS approaches use
ofpatients had improved neurologic function either a retropleural or transpleural approach.
and 77% of nonambulatory patients regained Most patient series are small and retrospective
the ability to walk. Spinal pain decreased in evaluations, but they demonstrate the feasibil-
92.3% (60/65) of patients who initially pre- ity of the mini-open approach. Huang et al10
sented with pain. It is important to note that reported a retrospective series of 46 patients
pain was assessed at 1-month follow-up to with spine metastases: 29 underwent mini-
allow incisional pain to resolve. Although the thoracotomy and 17 underwent standard tho-
risk of wound infection in this series was < 1% racotomy for anterior corpectomy and recon-
(a fraction of the infection risk compared with struction. Clinical and surgical outcomes were
any posterior incision surgery), the morbidity similar with the two techniques; however, only
related to thoracotomy access, including post- 6.9% of mini-thoracotomy patients required a
thoracotomy pain, was approximately 17%. In stay as long as 2 days in the intensive care unit
many patients, the postthoracotomy pain was compared with 88% of the standard thoracot-
severe enough to require narcotics for pain omy group. Uribe et al11 reported their experi-
control. ence of a mini-open retropleural approach for
Because these thoracotomy techniques still thoracic tumor removal in 21 patients, although
involved access morbidity, several MIS tech- the majority of tumors were not metastatic but
niques for anterior access have been developed rather other primary intra- and extradural le-
for spine surgery (see Text Box). sions. Operating time, estimated blood loss, and
length of stay were 117 minutes, 291 mL, and
2.9 days, respectively.
Minimally Invasive Surgery Approaches and I prefer to use a table-mounted retractor
Techniques for Metastatic Spine Disease system for mini-open thoracotomy (SynFrame,
DePuy Synthes, West Chester, PA). Payer and
Posterior/posterolateral
Percutaneous/mini-open pedicle screw Sottas12 reported a case series of 37 patients in
fixation whom the SynFrame was used. Eleven patients
Tubular access for decompression had metastatic spine lesions. The mean operat-
Anterior/anterolateral ing time and mean blood loss were 188 min-
Mini-open thoracotomy (transpleural,
utes and 711 mL, respectively. Two patients had
retropleural)
Video-assisted thoracoscopic surgery complications. Neurologic and pain improve-
ment were excellent.
The major advantage of the mini-open thora-
cotomy is that it enables the surgeon to use the
Mini-thoracotomy and thoracoscopic ap- microscope or loupes for a three-dimensional
proaches have been used in cardiothoracic view of the spine. In addition, the lung does not
surgery to minimize the access morbidity, and need to be deflated or at least can be partially
over the years both techniques have been ad- ventilated during surgery. Disadvantages of the
78 Chapter 7

Table 7.1 Thoracoscopic Vertebrectomy

Total Number of Mean


Procedures/ Mean Mean Duration Mean
Number of Types of Operating Estimated of Chest Length of
Procedures Fixation Room Blood Tube Use Hospital
Study forTumor Used Time Loss (mL) (Days) Stay (Days)

McAfee et al 15 VBR, 8 tumors NA 211 min 890 (150 1.22 6.5 (212)
(1995)13 2,800) (13)
Rosenthal et al 28 VBR, 4 tumors PMMA, 6.8 h 1,450 NA NA
(1996)15 Z plate
Dickman et al 17 VBR, 7 tumors PMMA, 347 min 1,117 2.8 8.7
(1996)14 Z plate

Abbreviations: VBR, thoracoscopic vertebrectomy; NA, not available; PMMA, polymethylmethacrylate.

mini-open approach are the relatively longer at the Huntsman Cancer Institute and the Uni-
incision and the partial removal of the rib that versity of Utah (Salt Lake City, Utah) has slightly
is necessary. This rib resection can cause pain modified the MIS thoracoscopic technique for
in the postoperative period and can affect the metastatic spine tumors.1723
patients ability to breathe. Another disadvan-
tage of the mini-open technique is the difficulty
with using appropriate surgical tools. Because Minimally Invasive
of the long working distance from the chest
wall to the spine, many traditional micro-tools SurgeryUsing the
are too short. In addition, many tools used for Thoracoscopic Approach
thoracoscopic surgery are too long to fit under
the microscope easily and they interfere with As with other endoscopic procedures, access to
direct visualization of the target site. This prob- the thoracic cavity is achieved using small chest
lem can be circumvented by either using sur- incisions for access portals, and the surgery is
gical loupes or a microscope with long focal performed with specially designed instruments.
length. Alternatively, a hybrid technique using By using small thoracoscopic incisions, which
both loupes and the endoscope, which gives minimize chest wall dissection and retraction,
more room to use longer tools, can be employed. postoperative morbidity has been significantly
Thoracoscopic techniques have been used reduced by decreasing blood loss, postopera-
by thoracic surgeons for many years to avoid tive pain, pulmonary and shoulder dysfunc-
thoracotomy-related access morbidity of tradi- tion, days in the intensive care unit, and overall
tional open and mini-open thoracotomy. Tho- hospital stay. Since its inception, minimally
racoscopy has been adapted for use in spinal invasive thoracoscopic surgery has improved
surgery for the treatment of thoracic disk her- significantly with the advancement of endo-
niations and traumatic fractures. Three series scopic video technology and the development
illustrated that thoracoscopy can be applied of surgical tools and anterior plating systems.
to spine surgery including corpectomy (Table Many procedures that had previously been
7.1).1315 The major shortcoming described by performed via open thoracotomy can now be
all of the authors was the limited ability to per- performed safely and effectively with the min-
form without difficulty an instrumented stabi- imally invasive thoracoscopic approach.
lization after thoracoscopic corpectomy and an Thoracoscopic spinal surgery is an alterna-
interbody reconstruction. To address this diffi- tive MIS technique to traditional thoracotomy
culty, Beisse16 pioneered an endoscopic antero- for tumor and vertebral body resection, tho-
lateral plating system that could be placed via racic corpectomy, anterior neural decompres-
small thoracoscopic port incisions. My group sion, and anterolateral spinal reconstruction.
Minimally Invasive Surgery for Metastatic Spine Disease 79
The goals of surgery are to resect tumor and nal implant (Aesculap, Tuttlingen, Germany) is
diseased vertebral body, decompress the an- a rigid fixation plate specifically designed for
terior spinal canal, and restore biomechanical endoscopic use, differing from most other tho-
stability with interbody reconstruction aug- racolumbar plating systems, which have been
mented with anterolateral plating. developed for open surgery.
Thoracoscopic spine surgery is performed
with the patient under general anesthesia and
Preoperative Planning single-lung ventilation, which provides maxi-
A good understanding of the general regional mum surgical exposure. Whereas mini-open MIS
and individual patient anatomy of the thora- approaches can be performed without single
columbar spine, spinal cord, chest wall and lung ventilation, it is nearly impossible to do
thorax, and mediastinal structures is import- this with thoracoscopy.
ant when planning for thoracoscopic surgery. The patient is placed in a lateral decubitus
The side of surgery is chosen based on the lo- position with the spine parallel to a radiolu-
cation and lateralization of disease in relation cent operating table, with the side of surgery
to the surrounding anatomy (e.g., the aorta). In chosen preoperatively based on the patients
general, a left-sided approach is used for the anatomy (Fig. 7.3a,b). After the patient is posi-
thoracolumbar junction (T11-L2) and for dis- tioned optimally, a lateral spine view is obtained
ease on the left side. A right-sided approach using the C-arm fluoroscope to determine the
ispreferred for the middle to upper thoracic relation of the spine and access portals. The
spine (T3-10). Because of the potential vascu- involved vertebral bodies, intervertebral disks,
lar complication from thoracic anterior lateral anterior and posterior spinal lines, and four
instrumentation, my group chooses the side portal access sites are then marked on the skin.
away from the aorta. Proper positioning of these portals enables the
The bony anatomy is studied preoperatively optimal use of the camera retractors and tools
to plan the reconstruction. The vertebral body (Fig. 7.3c).
widths are measured to determine the length The entire area of the lateral chest wall is
of the posterolateral vertebral body screws. The sterilized and draped to prepare for possible
extent of resection, or the distance between conversion to open thoracotomy. The portal
the inferior end plate of the cranial level and located in the most cranial direction is opened
the superior end plate of the caudal level, is first to minimize the risk of injury to the dia-
also measured to determine the size of the in- phragm and underlying organs. After the skin
terbody implant. In addition, we note the po- incision is made, the opening is carried down
tential bone quality, including factors such as to the rib using a mini-thoracotomy technique.
osteoporosis and other metastatic lytic lesions The subcutaneous tissues and intercostal mus-
in the adjacent vertebral bodies. cle layers are freed from the rib using a blunt
dissection technique without removing any rib
to minimize injury to the underlying lung. In
Technique comparison to traditional and most mini-open
Thoracoscopic surgery requires a high-quality approaches, the removal of the rib is not neces-
endoscopic camera, which is essential for opti- sary, which eliminates a source of postopera-
mal illumination and visualization. Endoscopic tive pain. The first trocar is then inserted, and
instruments are designed with nonreflective the 30-degree endoscope is used to inspect the
surfaces for decreased glare, are of adequate thoracic cavity. The remaining three ports are
length for safe intrathoracic maneuvering, and inserted directly under thoracoscopic vision.
have large handles for ease of use. Specialized When operating at or below the insertion,
instrumentation for thoracoscopic spinal recon- the diaphragm is incised to expose the spine.
struction has also been developed. The MACS-TL The prevertebral soft tissue dissection is per-
(Modular Anterior Construct System for the formed next for exposure of the thoracic verte-
Thoracic and Lumbar Spine) anterolateral spi- bral bodies and intervertebral disks. The correct
80 Chapter 7

a b c

d e f

g h i

Fig. 7.3ai (ac) Intraoperative photographs spine (solid lines). The diaphragm is swept inferiorly
depicting positioning. (d,e,g,h) Key endoscopic with a fan retractor and a diaphragmatic incision is
views. (f) Hardware. (i) Closure. (a) The patient is planned (dotted lines). (e) A Kirschner wire is placed
positioned on a radiolucent table in the right lateral above the planned corpectomy and a polyaxial screw-
decubitus position for a left-sided thoracoscopic clamp combination is placed below it. (f) Lateral
approach to L1. The independent arm is in a Krause view of a fully expanded gear-driven cage. (g) The
frame. Adjustable pads at the pubis, sternum, and cage is placed and expanded within the central
lower and upper spine hold the patient in position. corpectomy. (h) Final anterolateral plate construct.
(b) The independent leg is slightly flexed at the hip (i) Closure with chest tube exiting the retraction
to facilitate iliopsoas relaxation, making it easier to port. (From Ragel BT, Amini A, Schmidt MH.
dissect this muscle off the lateral aspect of the Thoracoscopic vertebral body replacement with
vertebral bodies at the thoracolumbar junction. anexpandable cage after ventral spinal canal
(c)The level of interest is marked, identifying the decompression. Neurosurgery 2007;61(5 Suppl
vertebral body above and below, and the four chest 2):ONS319. Reproduced with permission.)
portals are planned. (d) Endoscopic view of the

level is identified visually. After completion of tion. One of the disadvantages of thoracoscopy
the exposure, the surgeon proceeds with place- is the lack of three-dimensional vision, and the
ment of the vertebral body screws, which is screws can be used to maintain proper orien
followed by tumor resection, decompression, tation in a two-dimensional surgical field. The
and reconstruction (Fig. 7.3d,e). clamps of the screws are attached to the screw
In the thoracoscopic approach, it is advanta- heads so that they are oriented parallel to the
geous to place the vertebral body screws above end plates with the holes for the stabilizing
and below the corpectomy prior to the resec- screws situated anteriorly. These screws define
Minimally Invasive Surgery for Metastatic Spine Disease 81
(Fig. 7.3h). The final construct position is veri-
fied with anteroposterior and lateral fluoro-
scopic imaging.
Closure of the operative site begins with
reapproximation of the diaphragm if it was
opened. The thoracic cavity is inspected for he-
mostasis and irrigated, removing visible blood
clots. A 24-French chest tube is inserted under
endoscopic visualization through the more ven-
trally located lung/diaphragm retractor portal
or the suction/irrigation portal. The lung is
reinflated and inspected with endoscopy to
Fig. 7.4 The borders of the clamps define a safety
zone and the extent of corpectomy. The resection ensure that all lobes are properly inflated. The
isperformed within these safe boundaries. (From trocars are removed and the incisions are closed
Bishop FS, Schmidt MH. Thoracoscopic resection in multiple layers (Fig. 7.3i).
and reconstruction. In: Ames C, Boriani, Jandial R, Postoperative computed tomography (CT)
eds. Spine and Spinal Cord Tumors: Advanced scans and plain radiographs centered on the con-
Management and Operative Techniques. St. Louis: struct are obtained, and patient mobilization
Quality Medical Publishing, 2013. Reproduced with and incentive spirometry training also begin on
permission.) postoperative day 1. The chest tube is removed
once the output decreases below 100 mL/day
and the chest radiograph continues to demon-
the anteromedial and posterolateral borders of strate lung inflation without pneumothorax,
an area that includes both the extent of corpec- typically on postoperative day 2. After removal
tomy and a safety zone that protects critical of the chest tube, a final chest radiograph is
structures. The resection is performed by keep- used to verify stable lung inflation.
ing instruments within these safe boundaries
(Fig. 7.4).
The diskectomies are performed endoscopi-
Results
cally at the disk spaces above and below the Operative results for the minimally invasive
lesion, similarly to an open procedure. Decom- thoracoscopic approach have demonstrated
pression of the spinal canal is necessary for its efficacy and safety and are generally better
tumors extending past the posterior vertebral than those associated with open surgery.17,2123
body wall. Tumor and bone fragments in the Operative times initially increase to an aver-
epidural space are carefully brought into the age of 6 hours or longer while the surgeon and
corpectomy cavity and removed. The resection operating room staff learn the new technique;
is complete when gross tumor is removed, the however, the learning curve associated with
anterior spinal canal is decompressed, and the thoracoscopic surgery can be overcome with-
corpectomy adequately accommodates the in- out additional morbidity to the patient.23 The
terbody device. duration of surgery for tumor resection and
After tumor resection, spinal cord decom- reconstruction is decreased to 4 hours for the
pression, and corpectomy, my group prefers entire procedure after the technique has been
to use an expandable titanium cage for an an- mastered. The estimated blood loss has been
terolateral vertebral body reconstruction (Fig. reported to be 600 mL in thoracoscopic tumor
7.3f,g). Once it has been inserted, the cage is cases, compared with 1 L during an open
expanded with endoscopic and fluoroscopic thoracotomy.9,17,21 With care, intraoperative
visualization, noting its position in the coronal complications such as uncontrollable bleeding,
and sagittal planes. Fitting and securing the an- cerebrospinal fluid or chyle leak, or injuries to
terolateral plate completes the reconstruction the vessels or viscera can largely be avoided.
82 Chapter 7

The rate of conversion to an open procedure, in that make an alternate approach better. In that
skilled hands and with meticulous adherence sense, not every open conversion is a complica-
to surgical technique, is 1%.23 tion, but instead represents good judgment.
The principal advantages of thoracoscopic
surgery are the favorable clinical outcomes.17,22
The overall morbidity is low, primarily because
of the limited surgical exposure and approach. Chapter Summary
Although the morbidity rate for all open thora-
cotomy procedures is 14 to 29.5%, with tumor The role of MIS approaches for metastatic spine
cases having a higher incidence than other open disease continues to evolve. The learning pro-
procedures, the complication rate of the thora- cess for most MIS techniques can be mastered
coscopic procedure is 0 to 5.4%. Reported com- without exposing the patient to additional risk.
plications include persistent pleural effusion, Many MIS procedures are a smaller version of
pneumonia, intercostal neuralgia, shoulder dys- open techniques that a surgeon can incorpo-
function, and transient L1 root deficit. Fur- rate with progressive experience. This is par-
thermore, open thoracotomy for tumor has a ticularly true for posterior and posterolateral
reported mortality of 8.2%, whereas no mor- approaches. The use of endoscopy in MIS is
tality has been reported for the thoracoscopic somewhat more challenging because of the loss
approach. Infection rates are low for both tho- of three-dimensional vision. Clinical results for
racotomy and thoracoscopic surgery, around MIS in metastatic spine disease are comparable
0.5%. or better than traditional approaches. MIS
Patients experience a significant reduction in approaches have become an important part in
pain postoperatively with minimally invasive the management of metastatic spine disease,
thoracoscopic surgery.17 Duration and dosages but their meaningful use and value have not
of postoperative analgesic therapy have been been conclusively proven. Future studies will
reported to decrease by 31% and 42%, respec- need to demonstrate in more detail the clinical
tively.16 Rates of chronic postoperative pain and socioeconomic benefit.
after thoracoscopic surgery are between 4%
and 35%, which compares favorably with re-
ported rates of 7 to 55% for open thoracotomy.
Pearls
The median length of stay in the hospital was
7days (range, 410 days) in a series of patients Minimally Invasive Surgery
who underwent thoracoscopic tumor surgery, ThoracoscopicTechnique
compared with a median of 9 days (range, 457 If single-lung ventilation cannot be obtained, it is
days) for patients who underwent open thora- better to convert to a mini-open MIS approach.
If a port is not in the optimal position, it is better
cotomy for tumor resection.9,17
to place a new port to optimize use of the camera
The learning curve for MIS procedures can and the endoscopic tools.
be less difficult to overcome than is frequently Placement of the screws establishes visual refer-
reported.23 Acquiring the techniques should ence points in a two-dimensional environment
be done progressively from open techniques to and helps to maintain orientation during thora-
coscopic surgery.
mini-open and closed techniques such as en-
doscopy and percutaneous procedures. In addi- Pitfall
tion, the surgeon should not hesitate to convert
to a mini-open or open procedure from a Preoperative Planning of a
closed technique if the conditions warrant it. In ThoracoscopicApproach
my experience, it is much better to convert to a Operating on the side with the aorta overlying
the spine is possible, but contact between the
mini-open from a thoracoscopy approach than
hardware and the large vessel can cause cata-
to spend hours to force a thoracoscopic proce- strophic injury in the long term and should be
dure that is not going well. Unexpected find- avoided.
ings and technical difficulties can be encountered
Minimally Invasive Surgery for Metastatic Spine Disease 83
Acknowledgments for Aesculap, Germany. Portions of this chap-
The author thanks Kristin Kraus, MSc, for edi- ter were based on the chapter by Bishop and
torial assistance. The author is a consultant Schmidt.18

References
Five Must-Read References
1. Niazi TN, Sauri-Barraza JC, Schmidt MH. Minimally pression performed endoscopically. Surg Laparosc
invasive treatment of spinal tumors. Semin Spine Endosc 1995;5:339348 PubMed
Surg 2011;23:5159 14. Dickman CA, Rosenthal D, Karahalios DG, et al. Tho-
2. McAfee PC, Phillips FM, Andersson G, et al. Minimally racic vertebrectomy and reconstruction using a mi-
invasive spine surgery. Spine 2010;35(26, Suppl): crosurgical thoracoscopic approach. Neurosurgery
S271S273 PubMed 1996;38:279293 PubMed
3. Laufer I, Iorgulescu JB, Chapman T, et al. Local disease 15. Rosenthal D, Marquardt G, Lorenz R, Nichtweiss M.
control for spinal metastases following separation Anterior decompression and stabilization using a
surgery and adjuvant hypofractionated or high-dose microsurgical endoscopic technique for metastatic
single-fraction stereotactic radiosurgery: outcome tumors of the thoracic spine. J Neurosurg 1996;84:
analysis in 186 patients. J Neurosurg Spine 2013; 565572 PubMed
18:207214 PubMed 16. Beisse R. Endoscopic surgery on the thoracolumbar
4. Schmidt MH, Larson SJ, Maiman DJ. The lateral extra- junction of the spine. Eur Spine J 2010;19(Suppl 1):
cavitary approach to the thoracic and lumbar spine. S52S65 PubMed
Neurosurg Clin N Am 2004;15:437441 PubMed 17. Kan P, Schmidt MH. Minimally invasive thoracosco-
5. Lidar Z, Lifshutz J, Bhattacharjee S, Kurpad SN, Maiman pic approach for anterior decompression and stabili-
DJ. Minimally invasive, extracavitary approach for zation of metastatic spine disease. Neurosurg Focus
thoracic disc herniation: technical report and pre- 2008;25:E8 PubMed
liminary results. Spine J 2006;6:157163 PubMed 18. Bishop FS, Schmidt MH. Thoracoscopic resection and
6. Deutsch H, Boco T, Lobel J. Minimally invasive tran- reconstruction. In: Ames C, Boriani, Jandial R, eds.
spedicular vertebrectomy for metastatic disease to Spine and Spinal Cord Tumors: Advanced Manage-
the thoracic spine. J Spinal Disord Tech 2008;21:101 ment and Operative Techniques. St. Louis: Quality
105 PubMed Medical Publishing, 2013:607628
7. Zairi F, Arikat A, Allaoui M, Marinho P, Assaker R. 19. Bishop FS, Schmidt MH. Thoracoscopic corpectomy,
Minimally invasive decompression and stabilization interbody reconstruction and stabilization. In: Ben-
for the management of thoracolumbar spine metas- zel E, ed. Spine Surgery: Techniques, Complication
tasis. J Neurosurg Spine 2012;17:1923 PubMed Avoidance, 3rd ed. Philadelphia: Elsevier Churchill
8. Ghogawala Z, Mansfield FL, Borges LF. Spinal radia- Livingstone, 2012:583592
tion before surgical decompression adversely affects 20. Ragel BT, Amini A, Schmidt MH. Thoracoscopic verte-
outcomes of surgery for symptomatic metastatic spi- bral body replacement with an expandable cage after
nal cord compression. Spine 2001;26:818824 PubMed ventral spinal canal decompression. Neurosurgery
9. Gokaslan ZL, York JE, Walsh GL, et al. Transthoracic 2007;61(5, Suppl 2):317322, discussion 322323
vertebrectomy for metastatic spinal tumors. J Neuro- PubMed
surg 1998;89:599609 PubMed 21. Ragel BT, Kan P, Schmidt MH. Blood transfusions after
10. Huang TJ, Hsu RW, Li YY, Cheng CC. Minimal access thoracoscopic anterior thoracolumbar vertebrectomy.
spinal surgery (MASS) in treating thoracic spine me- Acta Neurochir (Wien) 2010;152:597603 PubMed
tastasis. Spine 2006;31:18601863 PubMed 22. Ray WZ, Krisht KM, Dailey AT, Schmidt MH. Clinical
11. Uribe JS, Dakwar E, Le TV, Christian G, Serrano S, outcomes of unstable thoracolumbar junction burst
Smith WD. Minimally invasive surgery treatment for fractures: combined posterior short-segment cor-
thoracic spine tumor removal: a mini-open, lateral ap- rection followed by thoracoscopic corpectomy and
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2008;69:2531, discussion 3132 PubMed for thoracolumbar junction fractures and tumors:
13. McAfee PC, Regan JR, Fedder IL, Mack MJ, Geis WP. Surgical technique and evaluation of the learning
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8
Vertebral Augmentation for
Metastatic Disease
Ehud Mendel, Eric C. Bourekas, and Paul Porensky

Introduction cer sites (including breast, prostate, and lung


cancer). The vertebral and epidural hematoge-
Percutaneous vertebroplasty (PVP) is an effec- nous plexuses directly drain both breast and
tive and relatively facile intervention that can prostate tissue, and likely form a direct conduit
achieve both vertebral stabilization and aug- with the pulmonary and genitourinary systems.
mentation. This technique, first described for Additionally, the axial skeleton contains the ma-
the treatment of painful hemangiomas, has ex- jority of red marrow in the human adult, and
panded its indications to include painful osteo- thus maintains a distinct cellular and extracel-
porotic and traumatic compression fractures, lular milieu that may favor secondary tumor
palliation of pathological fractures in combina- deposition and growth.2
tion with radiosurgery, and as an adjunct to Vertebral metastases occur throughout the
neuraxis instrumentation. This chapter discusses neoplastic disease course, with events cluster-
PVP and percutaneous kyphoplasty (PVK) in the ing around periods of primary tumor progres-
setting of vertebral metastatic disease. sion and with accelerating frequency during
Pathological osteolytic vertebral fractures re- more advanced disease.2 Both oncological dis-
sulting from tumor metastasis or myeloma are ease burden and tumor histology play a signif-
both relatively common as well as a significant icant prognostic role in patients with similar
source of painful morbidity. The skeletal system rates of axial skeleton disease burden. As
bears the brunt of neoplastic dissemination, would be expected from tumor-specific survival
occurring in 30 to 95% of the most common curves, primary lung tumors portend a sig-
cancers including breast, prostate, lung, kidney, nificantly shorter survival than those of breast
and thyroid. Among osseous structures, verte- or prostate, a fact that must be taken into ac-
brae are the most common site of spread and count when planning surgical interventions for
are the third most common site of metastases vertebral pathological fractures. Furthermore,
overall after the liver and lung.1 Indeed, spinal prognosis is typically improved with disease
metastases occur in approximately 40% of pa- recurrence within the axial skeleton compared
tients who die of cancer, and a staggering 5 to to visceral sites. For example, median survival
10% of all cancer patients will have symptom- is 24 months in women with metastatic breast
atic spinal metastases at some point during cancer confined to the skeleton, whereas sur-
their disease course.13 The propensity for such vival shrinks to 5 months with dual bone and
high rates of vertebral involvement is likely liver disease.2
due to the unique biology of the neuraxis and Although two thirds of all vertebral metas-
its relation to the most common primary can- tases are asymptomatic, the development of a
Vertebral Augmentation for Metastatic Disease 85
pathological vertebral fracture significantly al- and focal kyphotic deformity. Polymer is then
ters a patients disease course and yields both similarly injected into the cavity to harden and
increased morbidity and mortality. Saad et al3 stabilize the fracture.
demonstrated this in an examination of a large
group of patients with known malignant bone
disease from multiple myeloma or other solid
tissue tumors. Not only did they show a high Patient Selection
rate of fracture for each tumor type in a 2-year
period of observation (39% rate of fracture As with any surgical procedure, proper patient
with breast cancer and 22% with other solid evaluation and selection is critical to ensure a
tumors), but also demonstrated that vertebral successful outcome. The assessment must in-
fracture was associated with a marked increase clude both medical and oncological status, and
in mortality (up to 32% in patients with breast due diligence within both of these realms will
cancer compared with the nonfracture group). guide the practitioner toward optimal diagnos-
It is therefore critical to have a thorough un- tic and treatment selection. Vertebral augmen-
derstanding of the oncological disease burden tation is an excellent option for patients who
when evaluating and informing patients on ver- have severe systemic morbidity that precludes
tebral augmentation interventions. open surgical intervention, and it is likewise
The reasons for increased mortality after favored for healthy patients with osteolytic frac-
vertebral pathological fracture are likely multi- tures that do not cause neurologic sequelae.
variate, though the root causes are likely simi- Both of these groups, however, carry increased
lar to those leading to elevated mortality after surgical risk from their concomitant cancer than
osteoporotic compression fractures. Tumor- and that for the patient undergoing PVP or PVK for
fracture-related pain is a key symptom leading solely osteoporotic fracture.
to a cascade of morbid events, including im- Patients suitable for this procedure describe
paired mobility, concomitant increased throm- a typical axial or mechanical pain pattern that
boembolic risk, progressive deformity with is aggravated with standing or twisting and re-
decreased pulmonary capacity and increased lieved with lying flat. The location of the pain
risk of cardiopulmonary collapse, decondition- should correspond to the level of the fracture,
ing, loss of functional independence, social an obvious but critically important point, as
withdrawal, depression, increased narcotic patients may have other vertebral levels with
analgesia intake, and associated mental status tumor involvement but no fracture. The bio-
decline. Therapies designed to disrupt this cycle logical pain of a tumor is differentiated from
of decline can therefore have a profound im- mechanical fracture pain by both constancy of
pact on patient survival and quality of life even pain throughout the day and night as well as its
in the setting of metastatic disease. Vertebral dull or throbbing qualities. This type of pain
augmentation with PVP and PVK in this patient may be related to tumor release of local factors
population has increasingly demonstrated effi- and cytokines, periosteal stretch, and local tis-
cacy, technical feasibility, and low procedure sue production of endothelins and nerve growth
morbidity. These minimally invasive procedures factors.1 Alternatively, neurologic pain should
both involve percutaneous cannulation of the also be considered, as the compression or infil-
fractured vertebral body followed by injection tration of a nerve root yields shooting pain in a
of a liquid that polymerizes to a durable resin dermatomal pattern and requires a decompres-
within the fractured body, thereby stabilizing sive procedure. An exception to this dictum
the fracture. PVK entails the added step of in- ismechanical instability that causes activity-
sertion of a balloon tamp through the cannula related impingement of the nerve root, where
followed by inflation, out-fracturing, and com- fracture stabilization prevents the intermittent
paction of cancellous bone toward the cortical nerve injury.
vertebral margin. The end plates are pushed Eliciting a neurologic history and performing
apart, partially restoring vertebral body height a thorough examination are important steps in
86 Chapter 8

the patient evaluation. Any neurologic symp- togenous seeding and infection of injected
toms, including paresis, sensory changes, bowel/ c ement often requires a technically difficult
bladder dysfunction, or changes in balance and corpectomy and attendant fusion, and can be
ambulation, can indicate radicular or thecal easily avoided by maintaining a high index of
sac compression by fracture or tumor. Changes suspicion. Antiplatelet agents should be tem-
in affect, cognition, speech, or cranial nerve dys- porarily discontinued.
function should be actively investigated due to Many patients with metastatic and myelo-
the propensity for additional tumorcentral ner- matous osseous disease suffer from hypercal-
vous system (CNS) lesions. Patients should be cemia, most commonly seen in tumors of the
counseled on the likely need for additional ther- lung, breast, and kidney and in myeloma and
apies for tumor control such as radiotherapy, lymphoma. Tumor production of humoral and
as well as the need for optimization of systemic paracrine factors, including parathyroid hor-
bone metabolism through pharmacological monerelated peptide, nurtures an osteolytic
interventions to decrease future fractures. All environment and deranged bone metabolism.2
the traditional risks of osteoporosis are present Early symptoms include fatigue, anorexia, and
in this patient population, as well as the addi- constipation, and can progress to renal and
tional factors of cancer-related immobility, al- cardiovascular collapse. Patients therefore may
tered nutritional intake, and deranged osseous suffer from the dual hit of metastatic vertebral
metabolism from tumor and treatment pro- fracture as well as a deranged metabolism lead-
cesses (chemotherapy or radiation). A detailed ing to osteoporotic fracture.
discussion of these pharmaceuticals is beyond Multimodal neuraxis imaging is a required
the scope of this chapter. But it is important to step for preoperative planning to ensure a suc-
note that bisphosphonates can reduce the inci- cessful augmentation outcome. Complete mag-
dence of additional-level fracture in both mul- netic resonance imaging (MRI) evaluation of
tiple myeloma and metastatic disease.2,3 More the brain and spine should be a standard prac-
recently, receptor activator of nuclear factor B tice for patients with known CNS metastatic
(RANK) ligand inhibitors of osteoclast resorp- disease due to the propensity of multiple me-
tion have been approved for the prevention of tastases. T2-weighted, fat-suppression, or short
skeleton-related events in patients with bone tau inversion recovery (STIR) sequences delin-
metastases from solid tumors such as breast eate the acuity of fracture, edema, and repara-
and lung cancer and appear highly effective.4 tive activity. Bone scintigraphy can provide a
Practitioners should attempt a reasonable further index of fracture-site metabolism, with
trial of medical management for the mechani- increased activity correlating with a greater
cal fracture-related pain, and patients must un- response to augmentation.5 Both modalities
derstand that vertebral augmentation carries can assist with symptomatic fracture localiza-
all the attendant risks of anesthesia and sur- tion when multiple fractures are present. Com-
gery. Active participation of other specialists puted tomography (CT) scan provides valuable
adept at pain management should be sought, characterization of fracture morphology, ver-
including anesthesia and palliative medicine, tebral height, pedicle width, trabecular disrup-
and conservative therapy should be considered, tion (characterized by intravertebral gas), and
including local injections, systemic analgesia, violation/retropulsion of the posterior cortical
and external orthosis. Preoperative laboratory wall. We routinely obtain anteroposterior (AP)
investigations should confirm normal clotting and lateral X-rays to facilitate accurate count-
(platelet level) and coagulation (international ing and to provide a corresponding view of the
normalized ratio [INR]/prothrombin time [PT]/ intraoperative fluoroscopic guidance images.
partial thromboplastin time [PTT]), as well as Dynamic radiography with supine and upright
ensure where appropriate that there is no ac- films delivers valuable information on both the
tive or occult infection (e.g., urinalysis with degree of kyphotic deformity as well as fracture
reflex culture). Bacteremia leading to hema- mobility. Up to 44% of patients have a radio-
Vertebral Augmentation for Metastatic Disease 87
graphically relevant change in vertebral height; tive augmentation can be used as an adjunct
patients whose vertebral height does not change toopen surgical decompression. Asymptomatic
are considered fixed.6 cortical margin disruption or epidural tumor
Relative and absolute contraindications to resulting in severe stenosis should not be con-
vertebral augmentation for metastatic disease sidered an absolute contraindication as long as
are listed in the Text Box. meticulous injection technique is used.

Contraindications to Vertebral Augmentation


for Metastatic Disease Procedure
Absolute Contraindications
Methylmethacrylate (MMA) is a clear, resistant,
Ongoing local or systemic infection
Asymptomatic fractures or those improving on
durable, and relatively inert compound that
medical therapy polymerizes to a resin through an exothermic
Spinal canal compromise resulting in myelopathy reaction. The synthetic polymer of MMA (poly-
from methylmethacrylate [PMMA]) is typically in
Retropulsed bone fragment
powder form and is mixed with a radiopacifier
Epidural tumor
Uncorrectable coagulopathy or ongoing local or
(e.g., barium sulfate) and benzoyl peroxide ini-
systemic infection tiator.8 The foremost mechanism of action of
PMMA vertebral augmentation is mechanical
Relative Contraindications
Severe vertebral body collapse (> 75% loss of fracture stabilization, with unknown contribu-
height) tions of thermal and cytotoxic effects. Labora-
Radiculopathy in excess of vertebral body axial tory studies have investigated the contribution
mechanical pain. of thermal necrosis and sensory nerve ther-
Vertebroplasty can be considered in the set-
moablation. Sensory nerves require sustained
ting of radicular pain that is due to fracture-
related mechanical instability or as an adjunct temperature elevation to > 45C for injury to
prior to open surgical decompression. occur, though one must consider the convec-
Asymptomatic cortical margin disruption or epi- tive heat transfer properties of adjacent vascu-
dural tumor resulting in severe stenosis lature and cerebrospinal fluid (CSF) as cooling
(Adapted from McGraw JK, Cardella J, Barr JD, et al; So- mechanisms to the polymerizing resin. Tem-
ciety of Interventional Radiology Standards of Practice perature measurements of the injection cavity
Committee. Society of Interventional Radiology quality
after vertebral injection do not show sustained
improvement guidelines for percutaneous vertebro-
plasty. J Vasc Interv Radiol 2003;14(9 Pt 2):S311S315. temperature elevation to support a contribu-
Reproduced with permission.) tion of elevated temperature as a means to-
ward pain control.
Vertebral augmentation may be performed
with local anesthesia, monitored anesthesia
Absolute contraindications include patients with care (MAC), or general anesthesia depending
disease characteristics previously discussed, in- on preoperative surgical risk stratification.
cluding local or systemic infection, spinal canal Patients are placed prone with chest and pelvic
compromise from retropulsed bone fragment bolsters to augment pulmonary dynamics, de-
or epidural tumor with associated myelopathy, crease intra-abdominal pressure, and optimize
and uncorrectable coagulopathy. Relative con- kyphotic deformity correction. Biplanar fluo-
traindications are more fluid and some practi- roscopy is an important aid for accurate pedi-
tioners have demonstrated procedural safety cle localization and PMMA monitoring during
and good outcomes in these patients.7 As de- injection. We orient the AP view to a slight
scribed before, intermittent radiculopathy as- oblique angle so that a down the barrel view
sociated with mechanical instability responds of the pedicle is obtained. Local anesthetic in-
to cement stabilization, and pre- or periopera- jection, skin puncture incision, and additional
88 Chapter 8

local injection on the periosteum are performed. England Journal of Medicine have questioned
Pedicle cannulation by trocar is started in the the value of vertebroplasty in osteoporotic pa-
upper-outer corner of the pedicle to facilitate a tients, available evidence suggests that vertebro-
slightly caudal and medial trajectory that will plasty is very useful in the setting of tumor.9,10
enable PMMA injection in the center and con- The predominant literature for vertebral aug-
tralateral vertebral body. A lateral, extrapedic- mentation efficacy in vertebral body metastasis
ular approach can also be used, particularly consists of retrospective cohort or case series,
inthe lumbar spine, enabling the needle to and is subject to the bias that accompanies these
cross the midline. These maneuvers may help types of studies. One prospective trial has re-
avoid the need for a contralateral approach. cently been published with encouraging out-
The more recent advent of curved needles has comes supporting PVP and PVK in this patient
also decreased the need for two needles and a population.11 Typical outcome criteria include
contralateral approach. After trocar insertion to pain control, functional recovery measured by
a depth of approximately 20 mm the pedicle/ performance of activities of daily living (ADLs)
body junction will be reached; crossing this and out-of-bed days, deformity correction,
border with lateral X-ray guidance confirms and procedure-related morbidity. There has not
safe passage lateral to the canal and enables an been a prospective trial directly comparing PVP
exaggerated medial trajectory. We direct the with PVK for metastatic fracture, although sub-
trocar tip just shy of the ventral cortical border. group analyses have pointed to equivalency for
A vertebral biopsy can be performed at this these outcome criteria.
stage if there is any question regarding fracture The available retrospective series of verte-
etiology. bral augmentation in metastatic and myeloma
If a kyphoplasty is performed, the stylet is fractures show robust efficacy for pain control
withdrawn, balloon tamps inserted, and bal- and functional status up to 1 year after inter-
loon inflation performed under fluoroscopic and vention.12,13 Other symptoms that are associ-
manometric guidance. The balloon compacts ated with neoplastic disease, including anxiety,
cancellous bone and pushes the end plates drowsiness, fatigue, and depression, may also
apart. Inflation end points include restoration improve after intervention.14 Rates of symp-
of vertebral body height, balloon-tamp contact tomatic procedural complications were low.
with a cortical vertebral wall, and tamp pres- A meta-analysis of available trials concluded
sure 300 psi or maximum balloon volume. that there is level II evidence supporting PVK
Weprefer PMMA curing to a toothpaste viscos- in osteolytic metastatic and myeloma lesions.15
ity before injection to avoid cement migration Intervention was described as safe and effec-
during injection. The injection is performed tive for alleviation of pain and improvement in
under continuous fluoroscopic guidance with functional status and quality of life, and results
gentle and controlled pressure, and is contin- were maintained for 2 years. Initial corrections
ued until the posterior one-third vertebral line in sagittal deformity were not maintained on
is reached. Continued injection beyond this long-term follow-up. This review was followed
threshold risks cement escape and deposition by the Cancer Patient Fracture Evaluation (CAFE)
around neural elements. The total volume of trial,11 a prospective, randomized, unblinded,
injected cement is less important than obtain- multicenter trial comparing PVK with medical
ing an equivalent injection volume across the management for patients who had cancer
midline to avoid a toggling effect. andconcurrent osteolytic vertebral fractures.
Primary and secondary outcome measures
(back-specific functional status, Karnofsky Per-
formance Scale (KPS), analgesia use, activity
Outcome Studies levels, and radiographic deformity correction)
at 1 month were significantly improved with
Although two recent and somewhat contro- PVK over medical management. Many of the
versial studies of vertebroplasty in the New improved outcome measures were maintained
Vertebral Augmentation for Metastatic Disease 89
at 1 year, and adverse events were equivalent pear to have as robust improvement as func-
between the two groups. tional outcomes.16
Vertebral augmentation through PMMA po- Percutaneous kyphoplasty does have an ad-
lymerization throughout the trabecular network vantage over PVP in postprocedural deformity
of the fractured vertebral body likely achieves correction in mobile fractures due to inflation
much of its therapeutic effect by mechanical of the bone tamps and spreading of the end
stabilization of the deformed neuraxis. Not plates, though patient positioning on the oper-
only does it provide rigidity to an unstable spi- ating table achieves the majority of procedural
nal segment, but it also may prevent further correction. Proper chest and pelvic bolstering
kyphotic deformity and progressive sagittal can achieve an average of 10-degree correction,
imbalance (Fig. 8.1). Many of the above trials whereas bone tamp inflation adds an addi-
incorporated longitudinal analysis of standing tional 3 degrees; approximately 3 degrees are
plain radiographs postprocedure, and though lost immediately on standing.17 Therefore, PVK
many noted early (1 month) improvements may be indicated over PVP if a greater kyphosis
invertebral body height, sagittal alignment, correction is warranted.
and focal kyphosis after PVP or PVK, these im- Despite the benefit afforded these minimally
provements gradually returned to baseline or invasive interventions in the avoidance of open
were equivalent to controls 1 to 2 years later. surgical fixation, they still have associated mor-
Therefore, deformity correction does not ap- bidity that must be considered before inter-

a b
Fig. 8.1a,b Fracture height restored before (a) and after (b) vertebroplasty.
90 Chapter 8

vention. Although the majority of adverse events tematic review of PVP morbidity supports med-
are minor and asymptomatic, there is always ical and neurologic complications up to 7% and
the danger of a catastrophic outcome that re- 8%, respectively, whereas PVK has lower rates
quires that PVK/PVP be performed by experi- at 0.5% and 0%.16
enced practitioners with access to facilities and Postprocedural fracture at a new level oc-
expertise that can manage these rare events. curs in 7 to 20% of cases, though it is difficult
The major complication rate, requiring correc- to determine whether the fracture is related to
tive therapy or an unplanned increase in the local disruption of spinal dynamics or rather
level of care, or entailing permanent sequelae, to new metastatic vertebral deposits and pro-
rises from 1% (osteoporotic fracture) to 5% when gression of osteoporosis. Retrospective analy-
there is neoplastic vertebral disease.18 ses of fracture patterns show that the adjacent
Procedural complications include pedicle level constitutes approximately 40% of new frac-
fracture and cement extravasation into adja- ture lesions, and that these adjacent fractures
cent soft tissue, disk, the venous system, neuro occur more often with pathological fractures
foramina, or spinal canal. Most extraosseous and much sooner after vertebral augmentation
cement deposition is noted only by radio- (median 55 days compared with 127 days for
graphs and is asymptomatic. Nevertheless, any distant fracture).12,20 One can surmise that a
extension of cement outside of the vertebral treated segment acts as a pillar on adjacent
body into the spinal canal, neuroforamina, and levels, increasing stiffness of the segment and
anteriorly into vessels is an indication for pro- intervertebral joints, as well as increasing loads
cedure termination. Neuroforaminal impinge- on adjacent segments.
ment with radiculopathy can often be managed
expectantly with adjuvant nonsteroidal anti-
inflammatory drugs (NSAIDs) or steroids; con-
tinued radicular motor or sensory derangement Novel Uses and
should be surgically decompressed. Of course, FutureApplications
any new evidence of postprocedural spinal cord
injury requires emergent surgical exploration. The minimally invasive character of PVP/PVK
Cardiovascular complications from PMMA permits its use in combination with a number
extravasation can range from minor hypoten- of treatment modalities for vertebral metastatic
sion to cardiopulmonary collapse after PMMA disease. Fracture stabilization with PMMA in-
pulmonary embolism. Proposed mechanisms jected intraoperatively is an option in com
include direct injection into paravertebral veins bination with open posterior decompression/
causing local or distant vascular block, or fusion or with minimally invasive pedicle screw
through PMMA disruption of extracellular cal- fixation, and may avoid the morbidity of open
cium mobilization and activation of coagulation vertebrectomy and cage placement that may
pathways.8 Careful technique including liberal otherwise be required (Fig. 8.2). PVP can also
use of fluoroscopy, termination of injection be performed after multilevel reconstructive
atthe one-third posterior vertebral line, and surgery to augment the anterior column, with
cement injection only after polymerization to vertebroplasty of the fractured vertebral body,
aviscous consistency all decrease the propen- adjacent vertebrae, or vertebrae with pedicle
sity for extravasation. PVK also has a lower ex- screws (Fig. 8.3).
travasation risk than PVP, probably due to the Advancements in stereotactic spinal radio-
balloon tamponade creating a bone capsule surgery enable the delivery of a tumoricidal
that can better contain cement as well as afford dose without injury to adjacent neural struc-
the use of a more viscous consistency.19 How- tures. Radiotherapy, however, likely increases
ever, PMMA interdigitation throughout the can- fracture risk up to 40%, particularly with scle-
cellous bone after PVP injection suggests a more rotic lesions.21 Vertebral augmentation should
robust stabilization than achieved with cavity be considered as a neoadjuvant therapy for
injection after balloon tamponade. Overall, sys- pathological fracture to prevent the relative
Vertebral Augmentation for Metastatic Disease 91

Fig. 8.2a,b A combination approach of open posterior fixation


with vertebral body polymethylmethacrylate (PMMA) augmen
tation. (a) Intraoperative photograph demonstrating pedicle
cannulation for cement injection. (b) Postoperative anteroposte-
a rior (AP) radiograph.

a b
Fig. 8.3a,b Vertebroplasty after open posterior views demonstrate the needle introduced using a
fixation in a patient with melanoma to prevent lateral approach, coursing under the pedicle screw,
further collapse of the superior vertebral body of and with the use of a curved needle to fill the
the construct. Anteroposterior (a) and lateral (b) anterior vertebral body.
92 Chapter 8

likelihood of fracture progression after radio- lization. The two procedures are relatively easy
therapy. A retrospective review did not find any to execute and are typically performed on an
negative interaction between radiation efficacy outpatient basis. Available evidence suggests
before and after vertebral augmentation.22 strong efficacy in the relief of fracture pain,
increased patient function, decreased use of
narcotics, and stabilization if not correction of
focal kyphotic deformity.
Chapter Summary Careful patient selection, including those with
axial mechanical back pain without neurologic
Vertebral compression fractures that are a re- sequelae, as well as preoperative planning with
sult of metastatic disease and multiple my- appropriate imaging sequences, increases treat-
eloma are a source of significant suffering for ment success and reduces potential morbidity.
patients, and fracture progression poses a risk Vertebral augmentation is a relatively safe pro-
for debilitating mechanical and neurologic cedure, though there is the potential for rare
spinal instability. Concurrently, many patients catastrophic neurologic or cardiopulmonary
are high-risk candidates for open surgical sta- events, and thus careful and diligent technique
bilization due to neoplastic disease and its sys- is vital. PVP and PVK are excellent minimally
temic treatment toxicity. PVP and PVK offer an invasive treatment options for fracture stabili-
effective minimally invasive option for fracture zation, and can be used in combination with
stabilization and symptom relief. Treatment ef- tumoricidal therapies for local disease control.
ficacy has been demonstrated in retrospective
case series and a limited number of prospective
trials, and further investigation will help define Pearls
patient selection and expected outcomes.
The spine is a common location for neoplas- Forty percent of cancer patients will have ver
tic dissemination, and up to 10% of cancer pa- tebral metastatic disease, of which 10% will be
tients will suffer from symptomatic pathological symptomatic.
Vertebral augmentation is a minimally invasive
vertebral fractures from metastases during the
technique that decreases vertebral fracture pain
course of disease. Such fractures carry a sig- and increases functional outcomes, likely through
nificant morbidity, including debilitating pain, mechanical stabilization of the spine.
progressive deformity, and the risk of neuro- Perioperative patient positioning can correct focal
logic decline. Conservative treatment options, kyphotic deformity by 10 degrees.
PVP/PVK can be used in conjunction with tu-
excluding external orthosis and narcotic pain
moricidal therapy (i.e., radiation) for local disease
control, are often ineffective and can be difficult control.
to manage, whereas open surgical stabilization
is a high-risk venture for patients suffering from Pitfalls
systemic disease and toxic treatments.
Percutaneous vertebroplasty and kyphop- Preoperative evidence of focal spinal cord dys-
function from fracture or tumor is an absolute
lasty are minimally invasive vertebral stabili-
contraindication to vertebral augmentation.
zation options that have shown efficacy in this Terminate PMMA injection if there is any evidence
vulnerable patient population. The procedure of cement extravasation posteriorly into the spi-
involves cannulation into the fractured verte- nal canal or neuroforamen or anteriorly into a
bral body followed by injection of PMMA, which vascular structure or after reaching the posterior
one-third vertebral line.
will exothermically polymerize to a rigid resin.
PMMA injection volume does not correlate with
Kyphoplasty entails the added step of balloon symptom relief; therefore, avoid overinjection of
tamp inflation within the vertebral body to polymer.
increase vertebral height before cement stabi-
Vertebral Augmentation for Metastatic Disease 93
References
Five Must-Read References
1. Mercadante S. Malignant bone pain: pathophysiol- and kyphoplasty: experience in 407 patients with
ogy and treatment. Pain 1997;69:118 PubMed 1,156 fractures in a tertiary cancer center. Pain Med
2. Coleman RE. Clinical features of metastatic bone di- 2011;12:17501757 PubMed
sease and risk of skeletal morbidity. Clin Cancer Res 13. Jha RM, Hirsch AE, Yoo AJ, Ozonoff A, Growney M,
2006;12(20 Pt 2):6243s6249s PubMed Hirsch JA. Palliation of compression fractures in
3. Saad F, Lipton A, Cook R, Chen YM, Smith M, Coleman cancer patients by vertebral augmentation: a retro-
R. Pathologic fractures correlate with reduced survi- spective analysis. J Neurointerv Surg 2010;2:221
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2007;110:18601867 PubMed 14. Mendoza TR, Koyyalagunta D, Burton AW, et al.
4. Henry DH, Costa L, Goldwasser F, et al. Randomized, Changes in pain and other symptoms in patients with
double-blind study of denosumab versus zoledronic painful multiple myeloma-related vertebral fracture
acid in the treatment of bone metastases in patients treated with kyphoplasty or vertebroplasty. J Pain
with advanced cancer (excluding breast and prostate 2012;13:564570 PubMed
cancer) or multiple myeloma. J Clin Oncol 2011;29: 15. Bouza C, Lpez-Cuadrado T, Cediel P, Saz-Parkinson Z,
11251132 PubMed Amate JM. Balloon kyphoplasty in malignant spinal
5. Maynard AS, Jensen ME, Schweickert PA, Marx WF, fractures: a systematic review and meta-analysis. BMC
Short JG, Kallmes DF. Value of bone scan imaging in Palliat Care 2009;8:12 PubMed
predicting pain relief from percutaneous vertebro- 16. Mendel E, Bourekas E, Gerszten P, Golan JD. Percuta-
plasty in osteoporotic vertebral fractures. AJNR Am J neous techniques in the treatment of spine tumors:
Neuroradiol 2000;21:18071812 PubMed what are the diagnostic and therapeutic indications
6. Faciszewski T, McKiernan F. Calling all vertebral frac- and outcomes? Spine 2009;34(22, Suppl):S93S100
tures classification of vertebral compression fractures: PubMed
a consensus for comparison of treatment and out- 17. Voggenreiter G. Balloon kyphoplasty is effective in
come. J Bone Miner Res 2002;17:185191 PubMed deformity correction of osteoporotic vertebral com-
7. Hentschel SJ, Burton AW, Fourney DR, Rhines LD, pression fractures. Spine 2005;30:28062812 PubMed
Mendel E. Percutaneous vertebroplasty and kypho 18. McGraw JK, Cardella J, Barr JD, et al; Society of In-
plasty performed at a cancer center: refuting pro- terventional Radiology Standards of Practice Com-
posed contraindications. J Neurosurg Spine 2005;2: mittee. Society of Interventional Radiology quality
436440 PubMed improvement guidelines for percutaneous vertebro-
8. Leggat PA, Smith DR, Kedjarune U. Surgical applica- plasty. J Vasc Interv Radiol 2003;14(9 Pt 2):S311
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Arch Environ Occup Health 2009;64:207212 PubMed 19. Barragn-Campos HM, Valle JN, Lo D, et al. Percuta-
9. Kallmes DF, Comstock BA, Heagerty PJ, et al. A Ran- neous vertebroplasty for spinal metastases: compli-
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10. Buchbinder R, Osborne RH, Ebeling PR, et al. A Ran- after vertebroplasty: adjacent fractures occur sig-
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Patient Fracture Evaluation (CAFE) Investigators. radiation therapy to spinal metastases. J Clin Oncol
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9
Surgical Complications
and Their Avoidance
Michelle J. Clarke

Introduction most cases, surgery is considered semi-urgent


and a thorough but expedited workup is ap-
Operative treatment of metastatic spine disease propriate. Even in emergent cases of cata-
is palliative and targeted to improve health- strophic neurologic deterioration, medical and
related quality of life (HRQOL). Surgical treat- oncological consultation should be obtained.
ment is usually reserved for patients with Surgical intervention in metastatic spine
metastatic spinal cord compression or spinal disease is intended to protect or restore neuro-
instability. The primary goals of surgery are logic function; thus, a surgical candidate must
todecompress neurologic elements to prevent, meet functional criteria to be considered for
stabilize, or improve neurologic deficit, provide surgery. Poor performance status may be a
a safe margin for radiotherapy, stabilize the contraindication for surgery. Exceptions to
spinal column, and achieve local disease con- this include patients with pathological frac-
trol. Despite these relatively clear indications, tures that have apoor performance status due
surgeons must not lose sight of the bigger pic- to pain-related immobility, or patients with
ture: although palliative spine surgery can im- rapid neurologic deterioration in the previous
prove HRQOL,1 complications will lengthen the 24 to 48 hours.
hospitalization2 and negatively impact the qual- Although they have been refined, the origi-
ity of life. Additionally, surgical complications nal Patchell criteria are an appropriate starting
may delay or prevent adjuvant radiation and point. Patients should have a life expectancy of
chemotherapy for the patients primary dis- at least 3 months but preferably 6 months to
ease. This chapter discusses specific complica- achieve a measurably enhanced quality of life
tions and their avoidance. following the procedure,1 although this may
beshortening with the advent of percutaneous
and other minimally invasive procedures. Widely
metastatic disease may be a contraindication
Patient Selection for surgery. Thus, oncological workup may in-
clude needle biopsy of the spine or other acces-
For surgical treatment of metastatic spine dis- sible lesion to obtain pathological diagnosis of
ease to be successful, a patient must be able the primary tumor. Metastatic workup in-
tomake a meaningful recovery. Accurately as- cluding chest, abdomen, and pelvis computed
sessing the extent of disease and the medical tomography (CT); bone scan; pan-spine mag-
risks of the procedure are important for prog- netic resonance imaging (MRI) and brain MRI;
nostication and surgical decision making. In and positron emission tomography can be con-
Surgical Complications and Their Avoidance 95
sidered to determine the extent of disease. the surgical target itself may warrant preoper-
Radiation-responsive tumors require particu- ative intervention to decrease the surgical risk
lar thoughtfulness related to stability and the as discussed in the embolization section below.
cause of neurology. A patient may be better Additionally, the overall disease burden and the
served without a surgical procedure; however, effect of previous radiation or chemotherapy
cord compression involving bone fragments that the patient may have already have under-
due to a pathological burst fracture may still gone can greatly affect surgical outcome. Thus,
require operative intervention, even in a radio- this section discusses the hematologic and neu-
sensitive tumor. rotoxic considerations that should be carefully
The surgical procedure must be well planned. addressed in the preoperative period.
In some cases, the burden of disease in the spi-
nal column makes surgical resection or recon-
struction technically impossible. The surgeon
Hemorrhage
must be able to achieve a worthwhile decom- Although sudden catastrophic hemorrhage is
pression and restore biomechanical stability rare in metastatic spine tumor surgery, a number
to the spinal column. If either of these goals of factors lead to high blood loss. Thus, surgical
cannot be met, the patient may not be a surgi- planning should include strategies to correct
cal candidate. hematologic abnormalities, minimize blood loss,
If a patient is deemed an oncological and and manage intraoperative hemorrhage.3
functional candidate for surgery, a patient must
be able to tolerate the anticipated procedure.
Coagulation Abnormalities
For a standard extracavitary approach, verte-
brectomy, and stabilization, it is reasonable to The oncology patients natural hemostatic re-
estimate a 2-L blood loss and a 6-hour opera- sponse may be disrupted by the primary disease,
tive time, with the patient in the prone posi- especially in cases of hematologic malignancies,
tion. These estimates may enable the medical those involving the liver, or following certain
and anesthesia physicians to determine the sur- nonsurgical therapies resulting in bone mar-
gical risk. Patients without a high probability row suppression. Preoperatively, a complete
of surviving the procedure should not undergo coagulation panel is imperative, with factor cor-
it, even in the face of imminent paralysis. rection as necessary. Additionally, large-bore
Appropriate patient selection and antici- intravenous access or central lines should be
pation of adverse events based on comorbid considered preoperatively. Fluid and blood can
medical conditions is the most important com- be infused through warmers, which in con-
ponent of complication avoidance. Detailed junction with body warmers may reduce in-
discussion of appropriate patient surgical se- traoperative coagulopathies. Unfortunately, due
lection is discussed in Chapter 1. to the risk of metastasizing tumor from the
surgical site, blood salvage equipment should
not be used.
Intraoperatively, attention should be paid to
Preoperative Evaluation nontumoral blood loss and tumoral bleeding.
and Preparation In addition to standard soft tissue and bony
bleeding, epidural venous bleeding can be ex-
Once it has been determined that a patient is tensive. Patient positioning can minimize in-
acandidate for surgery, a thoughtful approach traabdominal pressure, and the use of multiple
should be employed, even in urgent or emer- hemostatic agents is helpful. Postoperatively,
gent cases, to minimize oncology-specific risk hematologic parameters should be monitored,
factors. In most cases, the surgical target has as fluid shifts and blood loss via drains may be
been chosen because of potential or actual neu- significant.
rologic decline due to compression of instabil- Conversely, cancer patients are often hyper-
ity or pain related to instability. The tumor at coagulable, leading to disseminated intravascu-
96 Chapter 9

lar coagulation, deep venous thromboses (DVTs), spine tumor patients. Most patients are selected
and pulmonary emboli (PEs). Intraoperatively, for surgical intervention due to spinal cord com-
sequential compression devices (SCDs) are used pression or instability resulting in neurologic
during these often long procedures with the compromise. Thus, care must be taken not to
patient in the prone position. Postoperatively, worsen spinal cord compression during posi-
consideration should be given to early mobili- tioning. Documenting a preoperative examina-
zation, the continued use of SCDs, and the use tion, obtaining preoperative electrophysiological
of anticoagulants such as subcutaneous hepa- monitoring baselines, and performing awake or
rin. This is especially important in patients who fiberoptic intubation in cervical cases should
have suffered neurologic deterioration and re- be considered. Careful positioning, including
cent loss of mobility. A low threshold for lower log-roll or Jackson table sandwich techniques
extremity Doppler ultrasound to investigate and pinions are especially important to protect
possible DVTs and aggressive treatment with the spinal cord. Postposition electrophysiolog-
intravascular filter placement and anticoagula- ical monitoring and wake-up tests to assess neu-
tion are indicated. Similarly, surgeons should rologic status and pre-draping imaging studies
have a low threshold for investigation of sus- to assess preopeative alignment are helpful.
pected PEs and should aggressively treat them Should any study demonstrate decreased neu-
upon diagnosis. rologic function, the surgeon must consider
reversing the positioning, waking the patient,
and employing a set spinal cord injury protocol
Preoperative Embolization
as discussed below (see Neurologic Injury).
Tumors, especially vascular lesions, are often Oncology patients also require special atten-
difficult to cauterize and do not stop bleeding tion to their peripheral nervous system. Many
until they are completely resected. Certain le- patients have been exposed to neurotoxic che-
sions may benefit from preoperative emboli- motherapeutic agents prior to undergoing sur-
zation to decrease intraoperative hemorrhage, gical intervention. These agents may increase
not only to reduce the physiological stress on their risk of position-dependent injuries such
the patient by decreasing blood loss,4 but also as ulnar neuropathies; thus, special attention
to make it easier for the surgeon to visualize should be paid to table padding and straps. Fi-
and complete the procedure efficiently and nally, the operating room staff should note and
safely. Specifically, renal cell carcinoma, follic- protect any chemotherapeutic ports the patient
ular thyroid carcinoma, neuroendocrine tumors, may have in place for systemic treatment.
and tumors of unknown histology with sugges-
tions of hypervascularity on imaging studies
should be considered for embolization.3 In other Intraoperative
cases, if a vascular lesion is suspected and em-
bolization is not possible, en bloc resection can Complications: Prevention
be attempted to avoid violating the tumor (dis- and Minimization
cussed in Chapter 4). An additional advantage
to embolization is the ability to localize major The basic tenets of spine surgery are the key to
spinal segmental feeding arteries such as the a successful procedure in the oncology patient.
artery of Adamkiewicz. Rhizotomy or nerve root Even in emergent situations, the surgeon must
sacrifice at this level can lead to anterior spinal thoroughly understand the regional anatomy,
artery ischemia and spinal cord infarction and obtain adequate exposure, and employ gentle
should be avoided if possible. tissue handling techniques. Most importantly,
pathological changes in anatomy must be un-
derstood and regional structures of vital im-
Operative Positioning portance must be identified before proceeding.
Protection of both the central and peripheral It is wise to work from normal to pathological
nervous systems is imperative in metastatic anatomy to maintain orientation. Tumors are
Surgical Complications and Their Avoidance 97
notoriously unpredictable in their behavior: signals are poor, consideration can be given to
ensuring that all structures are well visualized a postpositioning wake-up test. The surgical,
and protected in a systematic fashion allows a anesthesia, and neuromonitoring teams should
surgeon to react confidently in the face of un- be well versed in their response to a decreased
expected complications such as sudden hemor- monitoring response.6 The surgical team should
rhage. Finally, respecting natural tissue planes, consider whether new or increased mechani-
maintaining reasonable hemostasis, and ensur- cal cord compression has occurred, such as
ing that soft tissue remains vital and perfused hematoma, instrumentation malposition, or de-
will lessen the physiological stress of surgery formity correction, and consider decompress-
and improve healing in patients who may be ing or reversing it if possible. The anesthesia
weakened by their primary disease and treat- team should ensure that the patient is nor-
ments. A thoughtful and deliberate approach mothermic and hemodynamically resuscitated,
to these technically challenging surgeries and and that there were no changes to anesthetic/
complex patients will improve the chance of medication delivery, and should consider rais-
success. ing mean arterial pressure to 90 mm Hg. The
monitoring team should check its equipment
and leads to ensure there is no technical prob-
Neurologic Injury lem with the device. Steroid bolus can be con-
One of the major goals of spine surgery for me- sidered if not already given.
tastasis is the prevention or potential reversal of Postoperatively, at the discretion of the sur-
neurologic deficit due to spinal cord compres- gical team, blood pressure may be artificially
sion. However, one of the most feared surgical elevated and steroids continued in an effort to
complications is spinal cord injury. Preopera- increase cord perfusion and decrease edema.
tive, intraoperative, and postoperative practices This is especially helpful in patients with new
may reduce the risk of neurologic deteriora- deficits, or in instances where it is suspected
tion. Additionally, appropriate intraoperative that the vascular perfusion pattern of the spi-
and postoperative response to suspected spinal nal cord is altered, such as multiple nerve root
cord injury may minimize or reverse potential and radicular artery sacrifices.
deficits.
Preoperatively, unless medically contrain-
dicated, patients with new neurologic deficit
Adjacent Organ Injury
who are undergoing preoperative medical and Epidural tumor surgery may be complicated by
oncological workup should receive high-dose injury to an adjacent structure. Surgical plan-
steroids to decrease spinal cord edema.5 Com- ning to minimize such transgressions includes
monly, this takes the form of a loading dose understanding anatomy distortion through
and subsequent maintenance doses. The stan- pathological processes, protecting adjacent
dard is now 10 mg of dexamethasone bolus and structures (for example, placing ureteral stents
4 to 6 mg every 6 hours is a reasonable start- or employing preoperative endovascular vessel
ing point, although this standard remains con- sacrifice), and minimizing multiple-compart-
troversial. Ultimately, following surgery, the ment surgeries (for instance, using an extra-
drug is tapered down to oncologically useful cavitary approach to thoracic spinal lesions
doses. while avoiding the chest cavity). A plan for in-
Intraoperatively, for cases involving spinal traoperative iatrogenic adjacent organ injury
cord decompression, we commonly use somato- should be considered preoperatively.
sensory evoked potential (SSEP) and motor
evoked potential (MEP) monitoring, and free-
Spinal Fluid Leak
running electromyogram (EMG) can be used
in cases of root compression. Prepositioning Cerebrospinal fluid (CSF) extravagation may
neurophysiological baselines should be obtained complicate wound healing and result in intra-
and maintained throughout the procedure. If dural tumor seeding (Fig. 9.1). Although best
98 Chapter 9

low threshold for involving their plastic surgery


colleagues to provide healthy tissue coverage
in the setting of a CSF leak.
The CSF leaks become very difficult to treat
when the operative cavity is open to the pleu-
ral space such as a transthoracic approach or
acostotransversectomy with pleural violation.
In these cases, exquisite attention must be paid
to closing the dura and potentially separating
the area of leak from the negative pressure chest
cavity and chest tube. Patients with mental
status decline and suspected CSF leak, especially
those with nearby negative pressure suction
devices, should have an urgent CT to rule out
remote hemorrhages. In both of these cases,
suction should be immediately stopped, the CSF
leak located and repaired, and life-threatening
hemorrhages treated to avoid potentially fatal
brain herniation. Of note, in multispecialty cases
Fig. 9.1 Patient with inadequately repaired primary involving CSF leak, attention should be paid
dural tear and improperly closed fascia who has todrains to gravity and chest tubes left by
developed a pseudomeningocele immediately prior other surgical services; chest tubes to water-seal
to his first wound dehiscence. The patient required and drains to gravity, which must be clearly
three surgical revisions including vascularized
communicated if a nonspine service is closing
rotational flap, resulting in 4-month hospitaliza-
the incision.
tion. Two years later he has a palpable but stable
Although a stable subfascial pseudomenin-
pseudomeningocele and continued low-pressure
headaches. gocele is an acceptable result, any transcutane-
ous CSF fistula must be promptly addressed to
promote wound healing and prevent infection
avoided, if dural tears occur in oncological cases, and meningitis. Unfortunately, as with other
they should be aggressively treated in a similar wound issues, CSF leaks, especially transcuta-
fashion to those occurring in other spine sur- neous fistulas, will delay adjuvant therapy. Pa-
geries.7 Dural rents should be repaired primar- tients should not be treated with local radiation
ily or using a patch graft if the rent is too large or systemic chemotherapy until the wound is
for primary closure. Similarly, if rhizotomy is completely healed. Aggressive treatment in-
performed, the root should be tied or clipped cluding early reoperation, detailed attempts at
securely to prevent CSF egress. Oversewing a primary repair, and adequate soft tissue cover-
muscle pledget or using a dural sealant can be age are indicated. In cases of transcutaneous
considered. When a durotomy is irreparable, CSF leak, a subfascial wound drain can be placed
the use of a lumbar drain for several days will as a last resort to provide CSF with a distant
decrease the hydrostatic pressure on the repair. egress to promote wound healing, but avoiding
Additionally, CSF absorption may be compro- suction to prevent a negative pressure scenario
mised in irradiated tissue, thus even low-volume will decrease the risk of the leaks worsening,
leaks are prone to wound healing problems.3 overdrainage, and other adverse events such
Probably the most important principle in as subdural hematoma or pneumocephalus
treating a CSF leak is adequate soft tissue cov- creation. Other CSF diversion tactics including
erage around the dura. CSF leaks are unlikely lumbar drainage, lumbo- or ventriculoperito-
to heal if there is dead space around the dura, neal shunts, and plastic surgery closure may be
asituation not uncommon after surgery for required to heal the primary wound in chal-
spine metastases. Surgeons should have a very lenging cases.
Surgical Complications and Their Avoidance 99
Vascular Injury tients, stabilization alone to reduce the pain of
pathological fracture may be the indicated
Anatomic distortion due to pathological anatomy
treatment. In other patients, a 360-degree
makes vascular transgression a risk. Preopera-
spinal canal decompression will result in the
tive angiography, temporary balloon occlusion,
elimination of a large portion of the stabilizing
and permanent vessel sacrifice may be useful
components of the spinal column, thus requir-
preoperative adjuncts, especially in lesions
ing extensive reconstruction. Typically, subaxial
encasing the vertebral arteries of the cervical
decompression involves resection of a vertebral
spine. Promptly alerting the anesthesia team
body and anterior canal tumor requiring stabi-
to potential high-volume blood loss and obtain-
lization; however, the occipitocervical junction
ing immediate assistance from the vascular
is often best approached via posterior decom-
surgery or interventional department may be
pression and fusion alone. See Chapter 6 for
required.
a thorough discussion of fixation/fusion and
Chapter 8 for vertebroplasty/kyphoplasty in-
Esophageal/Bowel Injury dications and techniques.
In general, instrumentation designed for
Proximity to the spine, pathological distortion degenerative, deformity, and trauma surgery
by tumoral processes, and radiation-related is employed, although specific guidelines for
scarring may result in violation of the gastro instrumentation choice and construct design
intestinal tract. Prompt attention from a gen- in tumor patients should be considered. In all
eral surgeon or otolaryngologist may be needed cases, the initiation of cytotoxic adjuvant ther-
for primary repair or diversion procedures. apies, high metabolic demands of the cancer
Additionally, alterations in the antibiotic reg and cancer treatments, and the common use of
imen and nutritional parameters should be steroids make fusion difficult to achieve. Thus,
addressed. Unfortunately, spillage of gastro surgeons should consider this a stabilization
intestinal contents greatly increases the risk procedure as opposed to a true arthrodesis and
of infection, especially complicating cases in- fusion. Ongoing tumor surveillance and radio-
volving instrumentation. therapy planning using MRI means that sur-
geons should attempt to reduce the amount of
metal artifact by judicious use of crosslinks or
Chyle Leak alternating screws. Polyetheretherketone (PEEK),
Chyle leaks may occur during transthoracic pro- polymethylmethacrylate (PMMA), and allograft
cedures and are often difficult to detect. Milky or autograft bone struts may be preferable to
fluid in the operative cavity may be noted, but titanium cages due to their large amount of
the problem may not become apparent until the metal artifact, although expandable metal cages
postoperative period. In this case, assistance offer safety and simplicity. Newer cobalt Chro-
from the thoracic surgery service may be re- malloy rods and screw heads may lead to in-
quired, and diet alterations have proved to be creased imaging artifact, and should be avoided
the best therapy. if possible.
Bone quality can affect the surgical plan,
and therefore contingency plans must be in
place before the operation has started. Bone
Postoperative weakened by osteoporosis or previous radio-
Complications therapy may be difficult to instrument. It may
be wise to increase load-sharing by increasing
the number of levels fixated, or increase pull-
Instability and Pseudarthrosis out strength by augmenting vertebral bodies
Attention should be paid to stabilizing and re- with the addition of PMMA or large-diameter
constructing the spinal column to promote pain screws. Generally in these patients it is recom-
control and early mobilization. In some pa- mended to err on the side of overfixation.
100 Chapter 9

Late instrumentation complications are par- Perioperative antibiotics should be admin-


ticularly challenging (Fig. 9.2). Following treat- istered prior to surgical incision and continued
ment, loose instrumentation or pathological postoperatively. Routinely, antibiotics such as
fracture may require attention. Unfortunately, cefazolin, vancomycin, or both, are used to
reoperation often reveals porcelain-white bone cover skin flora. Ampicillin/gentamycin my
and gray surrounding tissue. Upsizing the in- beadded of operating through the abdominal
strumentation to obtain a mechanical fixation cavity, or ciprofloxacin/flagyl if an oropharyn-
is important, but the surgeon may want to geal approach is required. Antibiotics should
consider extending the construct to an area of be redosed appropriately throughout the pro-
greater viability, outside of the radiation field, cedure and continued for 24 hours postopera-
for example. Often the best solution is to forgo tively or while drains are in place. Although
further surgery; only symptomatic patients itis not standard, topical vancomycin powder
should be operated on, and with the awareness may be applied in the wound as an additional
that wound and bone healing may become a precaution.
major problem. Prior to final closure, the wound is thor-
oughly irrigated with saline. The wound is ap-
proximated in tight layers and prophylactic
Infection and Wound soft tissue closure can be considered at the
Surgical-site infection or wound dehiscence is index procedure.8 A suture that has a longer
a very serious complication. Not only will addi- absorption time course or even a permanent
tional interventions and suffering occur, but suture may be useful due to the slow wound
patients will be unable to undergo local radia- healing in oncological patients. Subfascial drains
tion or systemic chemotherapies until wound are used to minimize dead space, prevent the
healing is complete, which can directly affect accumulation of fluid that can act as an infec-
survival. Wound complications have been re- tive nidus, and eliminate transdermal wound
ported in up to a third of patients undergoing drainage. The wound is kept covered for 24
surgical treatment of spinal neoplasms.8 Cancer hours until the epithelium is sealed. In patients
patients are particularly susceptible to infec- with prior radiation, sutures are left in place
tion due to the primary disease, malnutrition, for a longer period than standard.
tissue damage due to recent radiation, immu- Adjustment in adjuvant therapy scheduling
nosuppression due to chemotherapeutic agents, is usually required to promote wound heal-
and immunosuppression related to adminis- ing.Conformal treatment such as intensity-
tration of steroids that often occurs in the set- modulated radiation therapy (IMRT) has less-
ting of metastatic spinal cord compression.9,10 ened the risk of wound breakdown associated
It is ideal to delay surgical treatment until an with external beam radiotherapy; however, op-
oncological treatment window is beneficial. timal radiationsurgery/surgeryradiation tim-
However, most cases are treated emergently ing guidelines remain elusive.11 Normally, a
due to neurologic compromise. Despite the 3-week postoperative healing period prior to
increased risk of infection, high-dose cortico- resumption of chemotherapy or local radiation
steroids should still be administered as a neuro- therapy is preferred.
protectant in patients suffering from symp- Patients and their families are given strict
tomatic high-grade spinal cord compression. instructions to watch the wound for signs of
Although many of these risk factors are un- infection or wound breakdown and to bring the
modifiable, filgrastim (Neupogen) may be used patient for examination as soon as possible if
to recover the absolute neutrophil count in itoccurs. Of note, immunosuppressed patients
severely neutropenic patients.3 Additionally, a may not mount a strong immune response; thus,
dietary consult may be beneficial, as many pa- late infections or serious infections, despite an
tients are malnourished due to their primary absence of purulence and laboratory markers,
disease process, which will impair healing. should be considered a possibility. Baseline
Surgical Complications and Their Avoidance 101

a b

c d
Fig. 9.2ad A patient with a renal cell carcinoma when he developed a painful adjacent segment
metastasis to L5 (a) underwent resection and compression fracture (c). This was biopsy negative
stabilization from a posterior approach (b) followed and the patient was treated with T10 to pelvis
by radiation. Although the patient demonstrated stabilization (d), with evidence of bony fusion in
instrumentation loosening and lack of bony fusion, thenonradiated bed 2 years postoperatively.
he was asymptomatic until 3 years postoperatively,
102 Chapter 9

infectious lab tests, cultures, and imaging of surgically treated spine metastases of mixed
should be obtained. Early washout, wound re- pathology, recurrence rates were as high as 60%
vision, and intravenous antibiotics must be at 6 months and 70% at 1 year.13 Although MRI
considered and can be tailored based on sus- usually provides adequate information, instru-
ceptibilities. To resume adjuvant therapy as ex- mentation artifact may necessitate a CT myelo-
peditiously as possible, it is preferable to close gram to definitively diagnose cord compression.
the wound primarily or use flaps during initial If a surgical lesion is noted, once again, based
washout as opposed to multiple washouts or on overall patient health, functional status, and
leaving the wound packed open.12 disease burden, further surgeries may be war-
Wound dehiscence and poor healing are ranted and may prolong survival.14
common in metastatic tumor patients even
without a primary surgical site infection. In
patients who have undergone preoperative ra-
diation at the surgical site, the surgeon should Chapter Summary
take pains to debride unhealthy tissue prior to
closure. Should regional tissue be unviable at Surgical treatment of metastatic spine disease
the index procedure, or if this becomes appar- is important to improve patient quality of life.
ent by a postoperative wound dehiscence, vas- However, surgical complications may have dire
cularized flaps may be required for closure. A consequences for overall survival as they may
plastic surgeon should be consulted for consid- preclude further life-prolonging adjuvant ther-
eration of rotational or free flaps. It is import- apies. A methodical approach and meticulous
ant to culture superficial and deep tissue in the attention to detail are required for optimal re-
setting of wound dehiscence, as patients may sults. Appropriate patient selection is essential
harbor an infection without mounting an obvi- to achieve a good outcome; patients must be
ous response. able to tolerate the anticipated surgery with the
hope of regaining or maintaining a good qual-
ity of life for a reasonable period of time to
make the intervention worthwhile. Patients
Follow-Up should be medically optimized and coagulation
factors normalized prior to surgery. A thought-
Following surgical treatment, multidisciplinary ful approach, including preoperative emboli-
coordination is required to ensure appropriate zation, attention to positioning, and the use of
follow-up and adjuvant treatment. Normally, intraoperative electrophysiological monitoring,
patients return for a wound examination or should be considered. Surgeons should take
send a digital picture of their incision 2 to 3 care to optimize wound healing, as this is the
weeks postoperatively, prior to embarking on most common and often most difficult compli-
further local or systemic treatment, to ensure cation and delays adjuvant therapy. This in-
that the wound has fully epithelialized and is cludes definitive repair of CSF leaks and the use
without signs of breakdown. It is important to of lumbar drains, copious wound irrigation, and
follow instrumented patients at regular inter- amultilayered closure to eliminate dead space.
vals to ensure that there are no new pathologi- Patients should have close follow-up in the
cal fractures or instrumentation issues. perioperative period by a multidisciplinary team.
Oncologically, the patient should be moni-
tored and treated in conjunction with medical Pearls
and radiation oncology. Although monitoring
intervals usually range from 3 to 6 months, they Expected survival from primary disease, medical
vary based on tumor histology and treatment clearance for surgery, and functional status are
vital for appropriate prognostication and suit-
planning. Any recurrence of pain or neurologic ability for surgery (see Chapter 1).
decline prompts swift reimaging. In one series
Surgical Complications and Their Avoidance 103

Medically optimize the patient prior to surgery, Multidisciplinary follow-up and adjuvant treat-
including normalization of coagulation factors. ment planning are essential.
Completely understand the local anatomy, and
work from normal to pathological to maintain Pitfalls
orientation.
Embolize suspected vascular tumors pre- Inadequate recognition of the pathological distor-
operatively. tion of normal anatomy can result in catastrophic
Protect the neural elements throughout the pro- complications.
cedure, acting promptly and with forethought if Inattention to closure and the creation of dead
there is a decline in neurophysiological monitoring. space will increase wound complications.
Perioperative antibiotics and impeccable closure Inadequate treatment of even minor CSF leaks
are required. may cause wound breakdown.
Intervene early and aggressively in any suspected Avoid inadequate stabilization; ensure there is
wound infection or dehiscence. enough structure to biomechanically fixate the
Local radiation and systemic chemotherapy should spine in the face of poor bone quality and low
be withheld until the wound is healed. likelihood of obtaining a true fusion.

References
Five Must-Read References
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Index

Page numbers followed by f or t indicate figures or tables, respectively.

A anteriorly-placed, with posterior


Adjacent organ injury, intraoperative, 97 supplementation, 67, 69
Algorithm for Spinal Metastases, 9, 10f expandable titanium, 37, 61, 64, 80f, 81, 99
Angiography, preoperative, 62, 99 in thoracoabdominal approach, 55, 55f
Anterior column reconstruction, 3738, 6364 in transpedicular approach, 53f, 54
Anterior longitudinal ligament (ALL), 34, 37 Cancer. See specific types of cancer
Anterior surgical approach, 36, 58, 62, 6364 Cancer Patient Fracture Evaluation (CAFE) trial, 88
Anticoagulant therapy, 96 Carcinoid tumors, metastatic, 5
Artery of Adamkiewicz, 36, 62, 96 Cardiac tamponade, 58
Atlantoaxial ligamentous complex, 46 Cement augmentation, 16, 73. See also
Atlantoaxial subluxation, anterior, 46 Polyetheretherketone (PEEK);
Polymethylmethacrylate (PMMA)
B Cerebrospinal fluid diversion techniques, 98
Beth Israel Deaconess Hospital, 27 Cerebrospinal fluid fistulas, 98
Biologically effective dose (BED), in stereotactic Cerebrospinal fluid leaks, 48t, 49, 54, 9798
ablative radiotherapy, 24, 25, 29 Cervical spine metastases, 1
Biopsy, indications for, 6 as pain cause, 46
Bisphosphonates, 6 as spinal instability cause, 16, 19f, 46
Bladder cancer, metastatic, 5 surgical approaches to, 4649, 47t, 48t, 4951, 50f
Bone allografts, 16, 20, 63, 99 surgical treatment planning for, 46
Bone autografts, 20, 38, 63, 99 Chemotherapy, 56, 27, 3031
Bone metastases, extraspinal, 67 Chest tubes, in spinal reconstruction, 61
Bone mineral density (BMD), as vertebral fracture Children, spinal tumors in, 1
predictive factor, 15 Chyle leaks, 99
Bone quality, implication for surgical planning, 99 Clinical target volume (CTV), in stereotactic ablative
Bone scintigraphy, preoperative, 86, 9495 radiotherapy, 25, 30
Borianis Algorithm for Spinal Metastases, 9, 10f Coagulation abnormalities, 9596
Bowel, intraoperative injury to, 99 Cobalt Chromalloy rods and screw heads, 99
Brachial plexopathy, stereotactic ablative Colorectal cancer, 1, 6
radiotherapy-related, 2728, 29 Colostomy, 57
Brachial plexus, contouring atlas of, 29 Complications, of metastatic spinal tumors. See also
Breast cancer, 1, 5, 6, 17f, 39, 8485, 86 specific complications
Brief Pain Inventory (BPI), 26 intraoperative, 1, 8, 95102
Computed tomography (CT), 45
C intraoperative, 62
Cages, for spinal reconstruction, 16, 19 preoperative, 61, 62, 86, 9495
for anterior column reconstruction, 37, 63 Computed tomography angiography, 62
106 Index
Computed tomography myelography, 31, 62 after posterior-only spinal reconstruction, 64
Corpectomy after transpedicular corpectomy, 65, 67f
as subaxial cervical instability treatment, 16 biomechanics of, 67, 69
thorascopic, 78, 80f, 81f combined anterior and posterior approach in, 67,
transpedicular, 64, 65, 67, 71 6971
Corticosteroids, 45 implant loosening in, 8
Costotransversectomy, 16, 64, 98 obstacles to, 99
Craniovertebral junction instability, treatment of, 16 occipitocervical, 16, 48, 99
CyberKnife radiosurgery, 28, 31 open posterior, 90, 91f
posterior pedicle, in en bloc resection, 37
D Flap reconstruction, 9, 11, 102
Decompression, 53f, 5556, 99 Foraminotomy, 46, 56
Deep venous thrombosis, 9596 Fractures, vertebral compression
Dexamethasone, 27, 45, 97 after vertebral augmentation, 90
Disk disease, lumbar, 55 as immobility cause, 94
Diskectomy, endoscopic, 81 as mortality risk factor, 85
Disseminated intravascular coagulation (DIC), multiple, 86
9596 open posterior fixation of, 90, 91f
Doxorubicin, implication for stereotactic ablative osteoporotic, 86, 90
radiotherapy, 27, 3031 as pain cause, 99
Dura, metastases invasion of, 1 percutaneous kyphoplasty/percutaneous
Dural tears, 9798, 98f vertebroplasty of, 8493
postoperative, 90, 92, 100, 101f
E prevention of, 86
Edema, spinal cord, 97 stereotactic ablative radiotherapy-related, 21,
Electromyography, 97 2526, 29, 30
Embolism, pulmonary, 9596 stereotactic radiosurgery-related, 90, 92
Embolization, preoperative, 36, 43 vertebral augmentation of, 8493
Embolization, preoperative, of hypervascular Functional status, of surgical candidates, 94
tumors, 8, 36, 43, 45, 62, 96
En bloc resection, of metastatic spinal tumors, G
3444 Gemcitabane, implication for stereotactic ablative
complications of, 39t, 40, 41, 46 radiotherapy, 27, 3031
goal of, 34 Giant cell tumors, metastatic, 6
indications for, 8, 4042
local tumor control with, 3840, 39t, 4142 H
surgical technique, 3538 Hemangiopericytomas, preoperative embolization
survival time after, 46 of, 62
tumor recurrence after, 42 Hematologic malignancies, 1, 6, 95
of vascular tumors, 96 Hemilaminectomy, for cervical spinal metastases,
vertebrectomy with, 35, 3637, 43 46
End-of-life care, prognostic indicators in, 67 Hemipericardium, 58
Endoscopic procedures, 7882 Hemorrhage, 6, 95, 98
Enneking, William, 34 Hemostasis, 95
Enneking staging system, 3435 Hemothorax, thoracotomy-related, 48t, 54, 58
Epidural spinal cord compression. See Metastatic Hepatocellular carcinoma, 6, 62
epidural spinal cord compression (MESCC) Histology, of tumors, as treatment decision making
Esophageal cancer, metastatic, 5 factor, 56, 11, 12
Esophagus, 27, 29, 3031, 32, 58, 99 Hoffmans ligaments, in en bloc resection, 37, 43
Evaluation, of metastatic spinal tumor patients. Huntsman Cancer Institute, 78
SeeTreatment decision making Hypercalcemia, 86
Ewings sarcoma, chemotherapy for, 6 Hypervascular tumors, 6, 8, 36, 43, 45, 62, 96
Extracavitary approach, in posterior-only spinal Hypoglossal nerve, surgery-related injury to, 49
reconstruction, 64
I
F Imaging, 6162. See also Computed tomography
Fixation/fusion, spinal, 6172 (CT); Magnetic resonance imaging (MRI);
after anterior column reconstruction, 64 Positron emission tomography (PET)
after instrumentation complications, 101 Implants, spinal, 8, 62
107
Index

Infections, of surgical sites, 75, 77, 86, 100, 102. Memorial Sloan-Kettering Cancer Center, 2526, 27
Seealso Wound healing, postoperative Metastases, 1, 67
Instrumentation, complications of, 99, 101f Metastatic epidural spinal cord compression
Instrumentation artifacts, 99, 102 (MESCC)
Intensity-modulated radiation therapy, 1 assessment of, 3
Intraoperative complications, prevention of, 9699 decompressive laminectomy of, 2
grading system for, 3, 3f
K incidence of, 61
Karnofsky Performance Scale, 7, 27 medical treatment of, 45
Kidney cancer. See Renal cell carcinoma, metastatic preoperative imaging of, 6162
Kyphoplasty prevalence of, 2
Percutaneous, 8590, 92 radiation therapy for, 3f, 45
prophylactic, 29 surgical treatment of, 23, 8
as spinal instability treatment, 14, 16 treatment decision making regarding, 23, 3f
Kyphoscoliosis, spinal metastases-related, 20 Metastatic spinal tumors. See Cervical spine
Kyphosis, spinal metastases-related, 20 metastases; Lumbar spine metastases
Methylmethacrylate (MMA), 87
L Methylprednisolone, as pain flare prophylaxis, 29
Laminectomy Minimally invasive surgery, 12, 7383
with adjuvant radiation therapy, 4546 advantages of, 5758
advantages of, 48t anterior and anterolateral approaches in, 67,
complications of, 15, 48t, 76 7678, 78t
decompression via, 2, 46, 47f, 48, 53f, 56, 61 criteria for, 74
Lateral approach, 62, 67 definition of, 7374
Lateral extracavitary approach, 6465 disadvantages of, 58
Lateral mass screws, misplacement in vertebral posterior approach in, 7475, 75f, 76f, 77
artery, 49, 58 posterolateral approach in, 77
Life expectancy, after spinal metastases treatment, thorascopic, 7882
94 Morphine, 2627, 45
Linear accelerators (LINACs), 28 Motor evoked potential (MEP) monitoring, 97
Linear-quadratic model, of spinal cord reirradiation, Motor evoked potentials (MEPs), 63
25, 29 Multiple myeloma, 1, 3, 6, 18f, 45, 8485, 86
Lingual nerve, surgery-related injury to, 49 Myelopathy, 21, 46
Liposarcoma, myxoid, 40
Liver cancer, metastatic, 5, 45 N
Load sharing, spinal, 15 National Cancer Institute Common Toxicity Criteria
Locking plates and screws, 63, 64 for Adverse Events, 27
Lumbar spine metastases, 1, 15 Neck dissection, anterior, with sternotomy, 48t, 50f,
Spinal Instability Neoplastic Score (SINS) of, 51, 52f
1718f Neck pain, stereotactic ablative radiotherapy-
surgical approaches to, 48t, 5556, 64 related, 29
Lumbosacral junction, spinal instability treatment Nerve plexuses, stereotactic ablative radiotherapy-
in, 20 related toxicity in, 29, 31
Lumbosacral spine, retroperitoneal access to, 62, 63 Nerve root compression, 2
Lung cancer, 1, 3, 5, 6, 40, 45, 84, 86 Nerve roots, stereotactic ablative radiotherapy-
Lymphoma, 3, 6, 45, 86 related toxicity in, 29, 31
Neuroblastomas, 1
M Neuroendocrine tumors, 6, 96
Magnetic resonance angiography (MRA), Neurologic, oncological, mechanical, and systemic
preoperative, 62 (NOMS) treatment decision framework, 9, 11,
Magnetic resonance imaging (MRI), 3, 3f, 6162, 86, 11f, 41
9495, 99 Neurologic deficits
Margins, surgical. See also En bloc resection assessment during operative positioning, 96
Enneking system of, 3435 en bloc resection-related, 38
M.D. Anderson Cancer Center, 26, 27 spinal metastases-related, 45
Medical fitness, of metastatic spinal tumor surgery-related, 96, 97
patients,2 vertebral compression fracture-related, 8586
Medrol Pak Oral, 29 Neurologic evaluation, of metastatic spinal tumor
Melanoma, metastatic, 1, 6 patients, 23
108 Index
Neurologic monitoring to the lumbar spine, 56
intraoperative, 62, 96 in minimally invasive surgery, 7475, 75f, 76f, 77
preoperative, 96 to the sacral spine, 57
Neurologic pain, vertebral compression fracture- Posterior arch resection, 35, 36, 43
related, 85 Posterior column reconstruction, in en bloc
New England Journal of Medicine, 88 reconstruction, 38
Posterior longitudinal ligament (PLL)
O in en bloc resection, 37
Occipitocervical fixation/fusion, 16, 48, 99 in retroperitoneal surgical approach, 56
Oncological status, of metastatic spinal tumor in transpedicular approach, 54
patients, 57 tumor invasion of, 3435, 43
Osteopenia, 8 Posterolateral approach, 16, 77
Osteoporosis, 8, 86 Primary tumors, 56, 3435, 35f, 36f, 94
Osteotomy, 35, 43, 57 Prognosis, 57, 35, 35f, 4041, 43, 45
Ovarian cancer, radiosensitivity of, 6 Prostate cancer, 1, 5, 6, 84
Pseudoarthrosis, 99
P Pseudomeningoceles, 98
Pain, metastatic spinal tumor-related, 45, 46
local, 4 Q
mechanical, 4, 45, 20021 Quality of life, health-related, 94
minimally invasive surgery-related reduction in,
82 R
palliative therapy for, 4546 Radiation necrosis, as vertebral compression
radicular, 4 fracture risk factor, 26
treatment decision making about, 34 Radiation therapy, 56, 4546
vertebral compression fracture-related, 85, 86 Radiation Therapy Oncology Group (RTOG),
Pain flare, stereotactic ablative radiotherapy-related, stereotactic ablative radiotherapy trial, 23, 31
2627, 29 Radiculopathy, 27, 46, 85, 87
Palliation, as spinal metastases treatment goal, 8 Radioresistant tumors, definition of, 6
Palliative therapy, 67, 4041, 4546, 55, 7374 Radiosensitive tumors, 6, 4041, 45, 95
Pancreatic cancer, metastatic, 5 Reconstruction, after metastatic spinal tumor
Paragangliomas, metastatic, 40 resection, 6172
Patchell Criteria, 94 anterior, 6364
Patient positioning, 96 combined anterior and posterior, 67, 6971
Patient selection criteria, 9495 preoperative planning for, 89, 11, 6163
Pedicle screws, 64, 65, 6769, 67f, 69f, 70f purpose of, 99
Percutaneous kyphoplasty. See Kyphoplasty, selection of techniques for, 89, 11
percutaneous staged, 62
Percutaneous vertebroplasty. See Vertebroplasty, surgical approaches in, 62, 6371
percutaneous Renal cell carcinoma, metastatic, 1, 84
Periosteum, tumor invasion of, 34 en bloc resection of, 39
Pheochromocytomas, metastatic, 40 hypercalcemia associated with, 86
Planning organ-at-risk volume (PRV), 2829 preoperative embolization of, 45, 62, 96
Plastic surgeons, collaboration with, 9, 11, 102 radioresistance of, 6
Pneumothorax, thoracotomy-related, 48t, 54, 58 surgical and radiation treatment for, 101f
Polyetheretherketone (PEEK), 63, 99 tumor resection-related hemorrhage from, 6
Polymethylmethacrylate (PMMA), 16, 19 Retroperitoneal approach, 38, 48t, 56, 62, 63
as alternative to titanium cages, 99 Rhizotomy, cerebrospinal fluid leak prevention
for anterior column reconstruction, 6364 in,98
cardiovascular complications of, 90
Steinmann pin-augmented, 19, 63 S
for vertebral augmentation, 90, 91f, 92 Sacral spine, 1, 20, 5657
as vertebrectomy defect filler, 6364 Sacrectomy, 5657
Positron emission tomography (PET), preoperative, Sarcoma, 1, 5, 6
61, 9495 Satellite tumors cells, 34, 35
Posterior approach Scoliosis, lumbar, 55
to the cervical spine, 46, 4849 Segmental arteries, 37, 38, 43. See also Artery of
in en bloc resection, 36, 37 Adamkiewicz
as infection risk factor, 75 Seminomas, radiosensitivity of, 6
109
Index

Separation surgery, 73 Stomach cancer, metastatic, 5


Sequential compression devices (SCDs), 96 Surgical approaches, 4560, See also specific surgical
Skip lesions, 34 approaches
Smith Robinson/anterolateral approach, 48t, 4951, region-specific
50f cervical spine, 47, 48t, 4951
Somatosensory evoked potentials (SSEPs), 63, 97 complications of, 4849, 48t
Spinal cord compression, 1, 97. See also Metastatic lumbar spine, 48t, 5556
epidural spinal root compression (MESCC) sacral, 5657
Spinal cord injury, 63, 96, 97 thoracic spine, 48t, 5155, 52f, 53f, 54f
Spinal deformity, spinal instability-related, 1920 relationship to patients life expectancy, 4546
Spinal instability, tumor-related, 4, 1422 selection of, 8
assessment of, 45, 5t transoral, 48t, 49
biomechanical factors in, 1415 Surgical candidates, evaluation of, 9495
in the cervical spine, 46 Surgical Classification of the Vertebral Tumors, 35,
definition of, 4, 1415 35f, 43
diagnosis of, 14 Surgical planning, 89, 95
as mechanical pain cause, 4, 2021
postoperative, 99 T
predictive factors for, 15 Tension bands, vertebral, 15
as spinal deformity cause, 1920 Thomas Jefferson University, 25
treatment of, 4, 8, 14, 16, 1920 Thoracic region, trapdoor approach to, 48t, 50f, 52,
Spinal Instability Neoplastic Score (SINS), 45, 5t, 53f, 63
14, 1516, 1719f, 21, 45 Thoracic spine metastases, 1
Spinal metastases, 1, 34, 45, 8485. See also Cervical as instability cause
spine metastases; Lumbar spine metastases; Spinal Instability Neoplastic Score (SINS) of, 16,
Metastatic spinal tumors; Thoracic spine 1920
metastases treatment for, 16, 1920
Spine Oncology Study Group (SOSG), metastatic surgical approaches to, 48t
epidural spinal cord compression grading anterior column reconstruction, 6364
system of, 3, 3f anterior neck dissection with sternotomy, 51,
Spinopelvis, reconstruction of, 57 52f
Spondylectomy, total, in en bloc resection, 36, lateral extracavitary approach, 6465
3840, 39t, 43 minimally invasive surgery, 7475, 75f, 76f
Spondylolisthesis, decompression-related posterior approaches, 7475, 75f, 76f
worsening of, 5556 posterior-only approach, 64
Staging, of metastatic spinal tumors, 67 posterolateral approaches, 7475, 75f, 76f
Stanford University, 27 thoracoabdominal approach, 5455, 55f, 76
Steinmann pins, 19, 63 thoracolumbar approach, 76
Stereotactic ablative radiotherapy (SABR) transpedicular approach, 53f, 54
complications of, 2333 trapdoor approach, 48t, 50f, 52, 53f, 63
avoidance of, 2831 as vertebral collapse cause, 15
esophageal toxicity, 27, 3031, 32 Thoracoabdominal approach, 5455, 55f, 76
pain flare, 2627 Thoracolumbar approach, 76
radiation myelopathy, 2324, 24t, 29 Thoracolumbar spine, vertebral collapse in, 15
radiation plexopathy/radiculopathy, 2728 Thoracoscopy, 28, 7782
vertebral compression fractures, 21, 2526, Thoracotomy, 48t, 5254, 53f, 58, 63, 64. 7678, 82
30,32 Thyroid cancer/carcinoma, metastatic, 1, 84
dose constraints in, 24t, 25t, 2829, 30t en bloc resection in, 3940
immobilization systems for, 28 histology of, 5
linear-accelerator (LINAC)-based systems, 28 preoperative embolization of, 62, 96
organs at risk (OAR) in, 2830, 31 radioresistance of, 6
planning organ-at-risk volume (PRV) for, 2829 tumor resection-related hemorrhage from, 6
reirradiation dosage recommendations for, 24, Tokuhashi scoring system, for metastatic spinal
25t, 29 tumor prognosis, 7, 40, 41, 45
Stereotactic body radiotherapy (SBR). See Tomita scoring system, for metastatic spinal tumor
Stereotactic ablative radiotherapy (SABR) prognosis, 67, 35, 35f, 4041, 43, 45
Stereotactic spinal radiosurgery, 1, 6, 41, 42, 43, Transoral surgical approach, to the cervical spine,
90,92 48t, 49
Steroids, 97, 99, 100 Transpedicular approach, 48t, 53f, 54, 64
110 Index
Transpedicular corpectomy, 64, 65, 67, 71 Vertebral augmentation, 4. See also Vertebroplasty
Transpedicular decompression, posterior surgical as adjunctive treatment, 89
approach in, 74 contraindications to, 87
Transpedicular vertebrectomy, 74, 75f for increased pull-out strength, 99
Transperitoneal approach, in en bloc reconstruction, indications for, 16
38 as infection cause, 86
Transthoracic approach, 48t, 5254, 53f, 98, 99 prophylactic, 21
Trapdoor approach, to the thoracic region, 48t, Vertebral body collapse, 15. See also Spinal
50f, 52, 53f, 63 instability
Traumatic injury, differentiated from spinal Spinal Instability Neoplastic Score (SINS) of,
instability, 15 1516, 1719f
Treatment algorithms, 9, 10f, 41 Vertebral metastases. See Spinal metastases
Treatment decision making, in metastatic spinal Vertebrectomy
tumor surgery, 113 anterior, 1920, 63
factors affecting, 27, 11, 12, 35, 35f, 4042, 43, in en bloc resection, 35, 3637, 43
45, 9495 lateral, 67
Treatment goals, 40, 95 lateral extracavitary, 64
Treatment modalities, for spinal metastatic tumors, posterior, 53t
12 transpedicular, 74, 75f
Tumor of unknown origin, 5, 96 Vertebroplasty
Tumor seeding, intradural, 97 percutaneous (PVP), 8492, 89f, 91f,
prophylactic, 29
U as spinal instability treatment, 14, 16
University of Toronto, 23, 26, 28, 29 Volumetric modulated arc therapy (VMAT), 28
University of Utah, 78
Unstable spinal lesions, preoperative neuro- W
monitoring of, 63 Wake-up tests, 96, 97
Wound dehiscence, 100, 102
V Wound healing, postoperative, 9, 12, 46, 5758, 97,
Vascular injuries, intraoperative, 99 100, 101
Venous thrombosis, postoperative, 62
Vertebrae, as surgical compartment, 34 X
Vertebral artery, 4849, 58 X-rays, preoperative, 61, 62, 8687