Mark Bilsky and Ilya Laufer
Gene H. Barnett, Andrew E. Sloan and Claudio E. Tatsui
Laser ablation (also known as laser interstitial thermal therapy [LITT]) has emerged as an important new technology for treating various disorders of the brain and spine. As with any new or emerging technology, there is a learning curve for its optimal use, and video tutorials can be important learning tools to help bridge gaps in knowledge for those who wish to become more familiar with laser ablation. In this special supplement to Neurosurgical Focus, videos illustrate laser ablation’s use in the treatment of epilepsy and failed radiosurgery, as well as technical aspects of performing these procedures in eloquent brain and in the spine. We hope that these videos will enable you to enhance your understanding of the evolving use of laser ablation for disorders of the brain or spine. It is the editors’ sincere hope that this will be helpful either in your own practice or in determining whether to refer to a neurosurgical colleague experienced in this field.
Claudio E. Tatsui, Ganesh Rao and Laurence D. Rhines
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.
Claudio E. Tatsui, Frederick F. Lang, Joy Gumin, Dima Suki, Naoki Shinojima and Laurence D. Rhines
There is currently no reproducible animal model of human spinal metastasis that allows for laboratory study of the human disease. Consequently, the authors sought to develop an orthotopic model of spinal metastasis by using a human lung cancer cell line, and to correlate neurological decline with tumor growth.
To establish a model of spinal metastasis, the authors used a transperitoneal surgical approach to implant PC-14 lung tumors into the L-3 vertebral body of nude mice via a drill hole. In 24 animals, motor function was scored daily by using the validated semiquantitative Basso-Beattie-Bresnahan (BBB) scale. A second group of 26 animals (6 or 7 per time point) were sacrificed at specific times, and the spines were removed, sectioned, and stained. Canal compromise was analyzed quantitatively by determining the ratio of the area of the neural elements to the area of the spinal canal on histological sections (neural/canal ratio). Correlations between BBB score and histological evaluation of tumor growth were assessed.
Lung cancer xenografts grew in all animals undergoing functional evaluation (24 mice) according to a reliable and reproducible time course, with paraplegia occurring at a median interval of 30 days following tumor implantation (95% CI 28.1–31.9 days). Importantly, the analysis defined 4 key milestones based on components of the BBB score; these were observed in all animals, were consistent, and correlated with histological progression of tumor. From Days 1 to 14, the mean BBB score declined from 21 to 19. The animals progressed from normal walking with the tail up to walking with the tail constantly touching the ground (milestone 1). The median time to tail dragging was 12 days (95% CI 10.8–13.2). Histological studies on Day 14 demonstrated that tumor had progressed from partial to complete VB infiltration, with initial compression of the neural elements and epidural tumor extension to adjacent levels (mean neural/canal ratio 0.32 ± 0.05, 7 mice). From Days 15 to 20/21 (left/right leg), the mean BBB score declined from 19 to 14. Animals showed gait deterioration, with the development of dorsal stepping (milestone 2). The median time to dorsal stepping was 21 days (95% CI 19.4–22.6) in the left hindlimb and 23 days (95% CI 20.6–25.4) in the right hindlimb. Histological studies on Day 21 demonstrated an increase in the severity of the neural element compression, with tumor extending to adjacent epidural and osseous levels (mean neural/canal ratio 0.19 ± 0.05, 6 mice). From Days 22 to 26/27 (left/right leg), the mean BBB score declined from 14 to 8. Animals had progressive difficulty ambulating, to the point where they showed only sweeping movements of the hindlimb (milestone 3). The median time to hindlimb sweeping was 26 days (95% CI 23.6–28.4) and 28 days (95% CI 27.1–28.9) in the left and right hindlimbs, respectively. Histological studies on Day 28 revealed progressive obliteration of the spinal canal (mean neural/canal ratio 0.09 ± 0.01, 7 mice). From Days 29 to 36, the animals progressed to paralysis (milestone 4). The median time to paralysis was 29 days (95% CI 27.6–30.4) and 30 days (95% CI 28.1–31.9) in the left and right hindlimbs, respectively.
The authors have developed an orthotopic murine model of human spinal metastasis in which neurological decline reproducibly correlates with severity of tumor progression. Although developed for lung cancer, this model can be expanded to study other types of metastatic or primary spinal tumors. Ultimately, this will allow testing of targeted therapies against specific tumor types.
Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2005
Claudio E. Tatsui, Gonzalo Martinez, Xiuming Li, Pradip Pattany and Allan D. Levi
Peridural fibrosis is the scar tissue formed over the dura mater after a laminectomy. It has been implicated as a cause of persistence of pain after spinal surgery and associated with increased risk of complications during revision surgery. The application of a mechanical barrier to cover the peridural space to block the migration of inflammatory cells from superficial layers to the epidural space can potentially prevent or decrease scar formation. The authors evaluated the use of DuraGen for this purpose.
Seventeen New Zealand White rabbits underwent bilateral L-4 and L-7 laminectomies. Each space was randomly assigned to either receive DuraGen, fat graft, or no (sham) treatment. At a mean 18 ± 4 weeks after surgery, the animals underwent magnetic resonance (MR) imaging with and without Gd enhancement, and the area of the scar tissue overlying the middle of the laminectomy was measured. The rabbits were killed and the spinal cords with an intact dural covering were harvested. The midsection of each treated level was evaluated histologically and the scar area was measured.
In rabbits in which a fat graft was placed, MR imaging of the epidural space demonstrated a significant (p < 0.05) increase in the mean area (0.9713 mm2) of scar tissue compared with those in which DuraGen was used (0.687 mm2) or those receiving sham treatment (0.6661 mm2). The same correlation was observed when the histological sections were measured at the middle of the laminectomy site where the mean areas of both DuraGen (1008 mm2) and control (2249 mm2) groups were significantly lower than that in the fat graft group (6007 mm2) (p < 0.01 and 0.05, respectively). No significant differences between the DuraGen and control groups were observed.
The authors demonstrated that peridural scarring formed in all groups. The mean area of scar deposition was significantly higher in the fat graft group than in the DuraGen or control group both on MR imaging and histological analysis. DuraGen was more effective than a fat graft in preventing epidural fibrosis but not significantly different from that occurring in control animals.
Nelson Moussazadeh, Linton T. Evans, Roxana Grasu, Laurence D. Rhines and Claudio E. Tatsui
Spinal laser interstitial thermal therapy has been developed as a minimally invasive modality to treat epidural spinal tumors percutaneously. The safe and effective use of this technology requires meticulous preoperative trajectory planning and an intraoperative workflow incorporating navigation and MR thermography. Instrumented stabilization can be performed during the same operation if needed. Operative considerations and technical aspects are reviewed.
The video can be found here: https://youtu.be/P--frsag6gU.
Daniel K. Fahim, Claudio E. Tatsui, Dima Suki, Joy Gumin, Frederick F. Lang and Laurence D. Rhines
There is currently no reproducible animal model of human primary malignant bone tumors in the spine to permit laboratory investigation of the human disease. Therefore, the authors sought to adapt their previously developed orthotopic model of spinal metastasis to a model for primary malignant bone tumors of the spine.
A transperitoneal surgical approach was used to implant osteosarcoma (Krib-1) into the L-3 vertebral body of nude mice via a drill hole. Motor function was evaluated daily using the previously validated qualitative key milestones of tail dragging, dorsal stepping, hindlimb sweeping, and paralysis. A subset of these animals was euthanized upon reaching the various milestones, and the spines were removed, sectioned, and stained. The degree of spinal cord compression was correlated with the occurrence of milestones and assessed by a ratio between the neural elements divided by the area of the spinal canal. Another subset of animals received stably transfected Krib-1 cells with the luciferase gene, and bioluminescence was measured at 10, 20, and 30 days postimplantation.
Osteosarcoma xenografts grew in all animals according to a reliable and reproducible time course; the mean time for development of behavioral milestones was noted in relation to the day of implantation (Day 1). Tail dragging (Milestone 1) occurred on Day 19.06 (95% CI 16.11–22.01), dorsal stepping (Milestone 2) occurred on Day 28.78 (95% CI 26.79–30.77), hindlimb sweeping (Milestone 3) occurred on Day 35.61 (95% CI 32.9–38.32), and paralysis of the hindlimb (Milestone 4) occurred on Day 41.78 (95% CI 39.31–44.25). These clinically observed milestones correlated with increasing compression of the spinal cord on histological sections. The authors observed a progressive increase in the local bioluminescence (in photons/cm2/sec) of the implanted level over time with a mean of 2.17 (range 0.0–8.61) at Day 10, mean 4.68 (range 1.17–8.52) at Day 20, and mean 5.54 (range 1.22–9.99) at Day 30.
The authors have developed the first orthotopic murine model of a primary malignant bone tumor in the spine, in which neurological decline reproducibly correlates with tumor progression as evidenced by pathological confirmation and noninvasive bioluminescence measurements. Although developed for osteosarcoma, this model can be expanded to study other types of primary malignant bone tumors in the spine. This model will potentially allow animal testing of targeted therapies against specific primary malignant tumor types.
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.
Claudio E. Tatsui, R. Jason Stafford, Jing Li, Jonathan N. Sellin, Behrang Amini, Ganesh Rao, Dima Suki, Amol J. Ghia, Paul Brown, Sun-Ho Lee, Charles E. Cowles, Jeffrey S. Weinberg and Laurence D. Rhines
High-grade malignant spinal cord compression is commonly managed with a combination of surgery aimed at removing the epidural tumor, followed by spinal stereotactic radiosurgery (SSRS) aimed at local tumor control. The authors here introduce the use of spinal laser interstitial thermotherapy (SLITT) as an alternative to surgery prior to SSRS.
Patients with a high degree of epidural malignant compression due to radioresistant tumors were selected for study. Visual analog scale (VAS) scores for pain and quality of life were obtained before and within 30 and 60 days after treatment. A laser probe was percutaneously placed in the epidural space. Real-time thermal MRI was used to monitor tissue damage in the region of interest. All patients received postoperative SSRS. The maximum thickness of the epidural tumor was measured, and the degree of epidural spinal cord compression (ESCC) was scored in pre- and postprocedure MRI.
In the 11 patients eligible for study, the mean VAS score for pain decreased from 6.18 in the preoperative period to 4.27 within 30 days and 2.8 within 60 days after the procedure. A similar VAS interrogating the percentage of quality of life demonstrated improvement from 60% preoperatively to 70% within both 30 and 60 days after treatment. Imaging follow-up 2 months after the procedure demonstrated a significant reduction in the mean thickness of the epidural tumor from 8.82 mm (95% CI 7.38–10.25) before treatment to 6.36 mm (95% CI 4.65–8.07) after SLITT and SSRS (p = 0.0001). The median preoperative ESCC Grade 2 was scored as 4, which was significantly higher than the score of 2 for Grade 1b (p = 0.04) on imaging follow-up 2 months after the procedure.
The authors present the first report on an innovative minimally invasive alternative to surgery in the management of spinal metastasis. In their early experience, SLITT has provided local control with low morbidity and improvement in both pain and the quality of life of patients.