Claudio E. Tatsui, Ganesh Rao and Laurence D. Rhines
Ganesh Rao, Robert Bohinski, Iman Feiz-Erfan and Laurence D. Rhines
✓The retroperitoneal surgical approach has gained acceptance as a way to access the ventral aspect of the lumbar spine. Visualization is often limited, however, by the psoas muscle, which lies along the posterolateral aspect of the spine. Improved visualization is often attempted by retracting the muscle from the wound, which generally pulls the muscle laterally from the spine but not posteriorly, which is desirable for a better exposure of the spine, particularly the neural elements. In this paper, the authors describe a simple, atraumatic technique for retraction of the psoas muscle that allows excellent visualization of the spine.
Brian J. Williams, Patrick J. Karas, Ganesh Rao, Laurence D. Rhines and Claudio E. Tatsui
The authors present the first report of laser interstitial thermal therapy (LITT) ablation of a recurrent chordoma metastasis to the cervical spine. This patient was a 75-year-old woman who was diagnosed and treated for a sacral chordoma, and then developed metastases to the lung and upper thoracic spine. Unfortunately she experienced symptomatic recurrence at the C-7 spinous process. She underwent an uncomplicated LITT to the lesion. The patient convalesced without incident and was discharged on postoperative Day 1. She received stereotactic spinal radiosurgery to the lesion at a dose of 24 Gy in 1 fraction. At the 3-month follow-up evaluation she had radiographic response and improvement in her symptoms.
Michele R. Aizenberg, Benjamin D. Fox, Dima Suki, Ian E. McCutcheon, Ganesh Rao and Laurence D. Rhines
Patients presenting with spinal metastases from unknown primary tumors (UPTs) are rare. The authors reviewed their surgical experience to evaluate outcomes and identify predictors of survival in these patients.
This study is a retrospective analysis of patients undergoing surgery for metastatic spine disease from UPTs between June 1993 and February 2007 at The University of Texas M. D. Anderson Cancer Center.
Fifty-one patients undergoing 52 surgical procedures were identified. The median age at spine surgery was 60 years. The median survival from time of diagnosis was 15.8 months (95% CI 8.1–23.6) and it was 8.1 months (95% CI 1.6–14.7) from time of spine surgery. Postoperative neurological function (Frankel score) was the same or improved in 94% of patients. At presentation, 77% had extraspinal disease, which was associated with poorer survival (6.4 vs 18.1 months; p = 0.041). Multiple sites (vs a single site) of spine disease did not impact survival (12.7 vs 8.7 months; p = 0.50). Patients with noncervical spinal disease survived longer than those with cervical disease (11.8 vs 6.4 months, respectively; p = 0.029). Complete versus incomplete resection at index surgery had no impact on survival duration (p > 0.5) or local recurrence (p = 1.0). Identification of a primary cancer was achieved in 31% of patients.
This is the first reported surgical series of patients with an unknown source of spinal metastases. The authors found that multiple sites of spinal disease did not influence survival; however, the presence of extraspinal disease had a negative impact. The extent of resection had no effect on survival duration or local recurrence. With an overall median survival of 8.1 months following surgery, aggressive evaluation and treatment of patients with metastatic disease of the spine from an unknown primary source is warranted.
Ganesh Rao, Chul S. Ha, Indro Chakrabarti, Iman Feiz-Erfan, Ehud Mendel and Laurence D. Rhines
Metastases of multiple myeloma often occur in the cervical spine. These metastases may cause pain and associated spinal instability. The authors report the results of radiotherapy and surgical treatment for myeloma involving the cervical spine. The results of radiation therapy for multiple myeloma metastases to the cervical spine that cause clinical or radiographically documented instability have not been reported previously.
A retrospective chart review of patients with multiple myeloma metastases to the cervical spine was undertaken. Between 1993 and 2005, 35 patients were treated with external-beam radiation and/or surgical stabilization at the University of Texas M. D. Anderson Cancer Center in Houston, Texas. Nineteen of 20 patients with sufficient follow-up data experienced resolution of their pain when treated with radiation without surgical intervention. Twenty-three patients had evidence of spinal instability on radiographic images; 15 of these were treated with radiation alone. Of these, 10 had sufficient follow-up data, and none showed any clinical progression of instability. Radiographic follow-up images demonstrated an arrest of further progression of instability and, in some cases, healing of pathological fractures by means of radiation alone.
The results of this series suggest that, in selected cases, external-beam radiation for multiple myeloma metastases to the cervical spine is an effective palliative treatment, even in cases involving clinical or radiographically documented instability.
Scott L. Zuckerman, Ganesh Rao, Laurence D. Rhines, Ian E. McCutcheon, Richard G. Everson and Claudio E. Tatsui
Treatment of epidural spinal cord compression (ESCC) caused by tumor includes surgical decompression and stabilization followed by postoperative radiation. In the case of severe axial loading impairment, anterior column reconstruction is indicated. The authors describe the use of interbody distraction to restore vertebral body height and correct kyphotic angulation prior to reconstruction with polymethylmethacrylate (PMMA), and report the long-term durability of such reconstruction.
A single institution, prospective series of patients with ESCC undergoing single-stage decompression, anterior column reconstruction, and posterior instrumentation from 2013 to 2016 was retrospectively analyzed. Several demographic, perioperative, and radiographic measurements were collected. Descriptive statistics were compiled, in addition to postoperative changes in anterior height, posterior height, and kyphosis. Paired Student t-tests were performed for each variable. Overall survival was calculated using the techniques described by Kaplan and Meier.
Twenty-one patients underwent single-stage posterior decompression with interbody distraction and anterior column reconstruction using PMMA. The median age and Karnofsky Performance Scale score were 61 years and 70, respectively. Primary tumors included renal cell (n = 8), lung (n = 4), multiple myeloma (n = 2), prostate (n = 2), and other (n = 5). Eighteen patients underwent a single-level vertebral body reconstruction and 3 underwent multilevel transpedicular corpectomies. The median survival duration was 13.3 months. In the immediate postoperative setting, statistically significant improvement was noted in anterior body height (p = 0.0017, 95% confidence interval [CI] −4.15 to −1.11) and posterior body height (p = 0.0116, 95% CI −3.14 to −0.45) in all patients, and improved kyphosis was observed in those with oblique endplates (p = 0.0002, 95% CI 11.16–20.27). In the median follow-up duration of 13.9 months, the authors observed 3 cases of asymptomatic PMMA subsidence. One patient required reoperation in the form of extension of fusion.
In situ interbody distraction allows safe and durable reconstruction with PMMA, restores vertebral height, and corrects kyphotic deformities associated with severe pathological fractures caused by tumor. This is accomplished with minimal manipulation of the thecal sac and avoiding an extensive 360° surgical approach in patients who cannot tolerate extensive surgery.
Iman Feiz-Erfan, Benjamin D. Fox, Remi Nader, Dima Suki, Indro Chakrabarti, Ehud Mendel, Ziya L. Gokaslan, Ganesh Rao and Laurence D. Rhines
Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases.
The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005.
Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25–71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma.
Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4–16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0–29.3 months). The numerical pain scores (scale 0–10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053).
Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.
Indro Chakrabarti, Allen W. Burton, Ganesh Rao, Iman Feiz-Erfan, Roman Hlatky, Laurence D. Rhines and Ehud Mendel
✓ The authors report the use of percutaneous transpedicular vertebroplasty performed using polymethylmethacrylate (PMMA) in two patients. These men (53 and 57 years old) had previously undergone open surgery and posterior instrumentation to treat myelomatous compression fractures. Both patients presented with acute back pain that manifested after minor activities. Kyphotic wedge fractures were diagnosed at T-11 in one case and at L-1 in the other. Both patients were treated at other hospitals with laminectomy and instrumented fusion; multiple myeloma was diagnosed after surgery. The patients experienced severe, recalcitrant, and progressive pain; on referral, they were found to have persistent kyphosis. Multiple myelomatous lesions of the spine were seen in one case and in the other the L-1 fracture represented the only site of disease. Percutaneous vertebroplasty was performed by injecting PMMA into the anterior third of the compressed vertebral body. Both patients experienced a 50% reduction in pain immediately after treatment; 3 months later both were walking and reported minimal back pain while undergoing treatment for multiple myeloma. Three years after surgery one patient reported no back pain and no progressive instability of the spine. Four years after surgery the other patient remains pain free, ambulatory, and with overall disease remission.
Percutaneous vertebroplasty provided effective analgesia in these two patients with progressive back pain despite posterior stabilization. In both cases, the anterior column was effectively stabilized. A much larger operative intervention with its attendant risks of morbidity was avoided. In addition, subsequent aggressive medical treatment was well tolerated.
Brian J. Williams, Benjamin D. Fox, Daniel M. Sciubba, Dima Suki, Shi Ming Tu, Deborah Kuban, Ziya L. Gokaslan, Laurence D. Rhines and Ganesh Rao
Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome.
The authors retrospectively reviewed the records of all patients who were treated with surgery for prostate cancer metastases to the spine between 1993 and 2005 at a single institution. Particular attention was given to initial presentation, operative management, clinical and neurological outcomes, and factors associated with complications and overall survival.
Forty-four patients underwent a total of 47 procedures. The median age at spinal metastasis was 66 years (range 50–84 years). Twenty-four patients had received previous external-beam radiation to the site of spinal involvement, with a median dose of 70 Gy (range 30–74 Gy). Frankel scores on discharge were significantly improved when compared with preoperative scores (p = 0.001). Preoperatively, 32 patients (73%) were walking and 33 (75%) were continent. On discharge, 36 (86%) of 42 patients were walking, and 37 (88%) of 42 were continent. Preoperatively, 40 patients (91%) were taking narcotics, with a median morphine equivalent dose of 21.5 mg/day, and 28 patients (64%) were taking steroids, with a median dose of 16 mg/day. At discharge, the median postoperative morphine equivalent dose was 12 mg/day, and the median steroid dose was 0 mg/day (p < 0.001). Complications occurred in 15 (32%) of 47 procedures, with 9 (19%) considered major, and there were 4 deaths within 30 days of surgery. The median overall survival was 5.4 months. Gleason score (p = 0.002), total number of metastases (p = 0.001), and the degree of spinal canal compression (p = 0.001) were independent predictors of survival. Age ≥ 65 years at the time of surgery was an independent predictor of a postoperative complication (p = 0.005).
In selected patients with prostate cancer metastases to the spine, aggressive surgical decompression and spinal reconstruction is a useful treatment option. The results show that on average, neurological outcome is improved and use of analgesics is reduced. Gleason score, metastatic burden, and degree of spinal canal compression may be associated with survival following surgery, and thus should be considered carefully prior to opting for surgical management.
Claudio E. Tatsui, Dima Suki, Ganesh Rao, Stefan S. Kim, Abhijit Salaskar, Mustafa Aziz Hatiboglu, Ziya L. Gokaslan, Ian E. McCutcheon and Laurence D. Rhines
Renal cell carcinoma (RCC) frequently metastasizes to the spine, and the prognosis can be quite variable. Surgical removal of the tumor with spinal reconstruction has been a mainstay of palliative treatment. The ability to predict prognosis is valuable when determining the role and magnitude of surgical intervention in cancer patients. To better identify factors affecting survival in patients undergoing surgery for spinal metastasis from RCC, the authors undertook a retrospective analysis of a large patient cohort at a tertiary care cancer center.
Relevant clinical data on a consecutive series of patients who had undergone surgery for spinal metastasis of RCC between 1993 and 2007 at The University of Texas MD Anderson Cancer Center were retrospectively reviewed. Demographic data, histopathological grade of primary tumor, timing of spinal surgery relative to diagnosis, treatment history prior to surgery, neurological status, and systemic disease burden were analyzed to determine the impact of these factors on survival outcome.
The authors identified 267 patients who met the study criteria. Five-year overall survival (OS) after spine tumor resection was 7.8%, with a median OS of 11.3 months (95% CI 9.5–13.0 months). Patients with Fuhrman Grade 4 RCC had a median OS of 6.1 months (95% CI 3.5–8.7 months), which was significantly lower than the 14.3 months (95% CI 9.1–19.4 months) observed in patients with Fuhrman Grade 3 or less RCC (p < 0.001). Patients with preoperative neurological deficits had a median survival of 5.9 months (95% CI 4.1–7.7 months), which was significantly lower than the 13.5 months (95% CI 10.4–16.6 months) observed in patients with a normal neurological examination (p < 0.001). Patients whose spine was the only site of metastasis had a median OS of 19 months (95% CI 9.8–28.2 months) after surgery, significantly longer than the 9.7 months (95% CI 8.1–11.3 months) observed in patients with additional extraspinal metastasis sites (p < 0.001). Patients with nonprogressing extraspinal metastasis (no metastasis, stable, or concurrent) had a median survival of 20.6 months (95% CI 15.1–26.1 months), compared with 5.6 months (95% CI 4.4–6.8 months) in patients with progressing metastasis (p < 0.001).
The authors identified several factors influencing survival after spine surgery for metastatic spinal RCC, including grade of the original nephrectomy specimen, activity of the systemic disease, and neurological status at the time of surgery. These clinical features may help to identify patients who may benefit from aggressive surgical intervention.