Transcript Cervical Multi-level Spondylosis

Metastatic Spine Disease
Moderator
Jack Rock, MD
Department of Neurosurgery
Henry Ford Health System
Case Presentation
• 61 year old female
• History of breast Cancer, HTN
• Back pain for 1 week
Case Presentation
• No detectable weakness
• Hypereflexia in lower extremities
• Babinski
Case Presentation
( Please Choose appropriate case)
Case Presentation
What would you do?
1- Medical treatment (Steroids, Pain Rx, Brace)
2- Radiation therapy
3- Surgical treatment (laminectomy ,Fusion)
4- Bone augmentation for non-surgical mets
Electronic Voting
Treatment options for Spine Metastasis
and Spinal Cord Compression
Samuel Ryu, MD
Professor, Director of Radiosurgery
Radiation Oncology and Neurosurgery
Henry Ford Health System
Treatment of spine metastasis  cord compression
Treatment
Pros
Cons
Steroid
Immediate neurologic relief
Short duration
External beam
radiotherapy
Main-stay treatment
Pain relief
Neurologic improvement
Non-invasive
Protracted course
Pain recurrence
Neurologic progression
Knocks down bone marrow
Surgery
(Circumferential
decompression,
Laminectomy)
Rapid neurologic
improvement
Tissue diagnosis
Invasive
Reconstruction is needed
Long recovery time
Needs radiotherapy
Vertebroplasty
Pain relief
Improve spinal stability?
No tumor control
Chemical leakage
Radiosurgery
Rapid pain & neurologic relief
Spinal cord decompression
Cannot correct
Non-invasive
compression fracture or
Spine instability
Convenience
Bone marrow sparing
Radiotherapy
30 Gy in 10 fractions
Radiosurgery
Phase II - Radiosurgery of Vertebral mets
Durable Pain relief
Median time to pain
relief 14 days
1-yr pain control 84%
% Pain relief
Rapid Pain Relief
Months after RS
(Ryu et al. Pain Symp Manag, 2008)
RTOG 0631
Randomized Phase II/III Study of
Radiosurgery vs. EBRT for Localized Spine Metastasis
Solitary (1-3) spine metastasis
Single arm lead-in (49 pts)
Radiosurgery (16 Gy)
2:1 Randomized (240 pts)
Radiosurgery (16, 18 Gy)
EBRT
8 Gy single dose
Follow-up
1. Pain score & QOL q month
2. Clinical and neuro exams q month
3. Imaging (MRI) q 2 months
(1)
(2)
(3)
Control of Spinal Cord Compression
50%
90%
12/4/04
Breast cancer 16 Gy
1/29/05
65  14%
Epidural
volume
reduction
Epidural
tumor size
0.840.07 mm2
0.410.06 mm2
Thecal sac
area
1.060.06 mm2
1.390.10 mm2
Decompressive Radiosurgery
553 %
Thecal sac
patency
773 %
Comparison of Neurological Outcome
Patchel’s Phase III Trial
S+RT
RT Alone
Overall
Ambulatory rate
84%
(42/50)
57%
(29/51)
Duration ambul
122 d
13 d
Ambulatory rate
in ambulat pts
94%
(32/34)
Ambulatory rate
from nonambulat
62%
(10/16)
Ryu’s Phase II Trial
Radiosurgery
Overall
Intact rate
81%
(50/62)
74%
(26/35)
Intact rate
in intact pts
88%
(31/35)
19%
(3/16)
Intact rate
from deficit
59%
(19/27)
Neurological Outcome
by Radiosurgical Decompression
Neuro before radiosurgery
Neuro
after RS
No deficit
Deficit
Normal
31 pts
16 pts
Improved
-
3 pts
Stable
-
Progressed
4 pts
3 pts 19% (12/62)
5 pts Progress
Total
35 pts
27 pts
81% of
total pts
improve
(Ryu, Cancer 2010)
Dual grading system of metastatic epidural compression
Neurological Grade
Radiographic Grade
0
I
a
No abnormality
b
Minor symptoms (eg, pain,
radiculopathy, sensory change)
c
Functional paresis
Muscle power ≥ 4/5.
II
IV, V
-nerve root sign or spinal cord sign
-functional in the upper extremity
-ambulatory in the lower extremity
III
0
Spine bone involved only
I
Thecal sac impinged
II
Thecal sac compressed
III
Spinal cord impinged
IV
Cord displaced/compressed, CSF
visible between cord and tumor,
Partial block
V
CSF not visible, Complete block
d
Non-Functional paresis
Muscle power ≤3/5.
-non-functional in the upper extrem
-non-ambulatory in the lower extrem
e
Paralysis, Incontinence
Treatment for Canal Compromise at Henry Ford
For surgery
For radiosurgery
Significant neurological
deficit (≤ 3/5 motor power)
Spinal cord compression in
ambulatory patients (≥ 4/5 power)
Compression fracture with
bony retropulsion
Imaging : No upper limit to the
extent of spinal cord compression
at this time
Spinal instability
3 mon
7/08
Renal cell ca, T12,
Grade 4b, 18 Gy
10/08
Grade 2a, Neuro intact
Surgical Options for Spine
Metastases
Ian Lee, MD
Staff Neurosurgeon
Hermelin Brain Tumor Center
Henry Ford Health System
September 21, 2012
Comprehensive Spine Symposium
Disclosures
None
Surgery for Spine Metastases
Up to 35% of cancer patients will develop
spine metastases
>20,000 new cases each year
Multiple levels of involvement in 40-70%
12-20% of patients will present with spine
symptoms as first manifestation of cancer
Spine Metastases
Because most mets originate in the vertebral body, the
site of compression is usually ventral
Tumor infiltration can also cause mechanical instability
due to weakening of the bone
Surgery for Spine Metastases
In the past, treatment was primarily
radiation
Surgery sometimes offered, but without
significant benefit
Retrospective studies demonstrated
laminectomy resulted in neurologic
improvement in a minority of patients and
unsustained (Sorensen et al 1990,
Constans et al 1983)
Surgery for Spine Metastases
In addition, outcomes compared to EBRT
were equivalent with or without
laminectomy (Byrne 1992, Young et al
1980)
Thus, nihilistic attitude regarding role of
surgery in metastatic spine disease
Surgery for Spine Metastases
In 1980’s, newer techniques of surgery
allowed for more aggressive extirpation of
disease and reconstruction
Surgery for Spine Metastases
RCT recently demonstrated superiority of sugical decompression +
EBRT vs. EBRT alone (Patchell, Lancet 2005)
Surgery + EBRT both preserved and regained ambulation better than
EBRT
First Class I study demonstrating advantage of surgery in treatment
of metastatic disease
Surgery for Spine Metastases
However, surgery is not without
drawbacks
– Morbidity as high as 20% in some series
– Prolonged hospital time, rehabilitation time
Many patients cannot or are unwilling to
tolerate surgery
Surgery for Spine metastases
Recommendations
Indications for surgery:
–
–
–
–
–
–
–
Rapid neurologic deterioration
Mechanical instability
Intractable radicular pain/myelopathy
Compression due to bony retropulsion
Relatively limited extant of bony disease/compression
Relatively limited extraspinal disease/good performance status
Prognosis > 3 months
Surgery for Spine Metastases
Surgical Approaches now available:
– Posterior
Laminectomy
– Posterolateral
Transpedicular
Costotransversectomy
Lateral Extracavitary
– Lateral/Anterior
Retroperitoneal
Transthoracic
Posterior approach
Advantages: Familiar approach, less invasive/morbid
Disadvantages: Does not directly address pathology, can cause instability
Has fallen out of favor in the surgical treatment of metastatic disease
from “Review: complications of surgery for thoracic disc disease”.Fessler RG, Sturgill M.Surg Neurol. 1998 Jun;49(6):609-18
Anterior/Lateral Approach
Advantages: Directly address pathology
Disadvantages: Requires two-stage operation
Posterolateral Approaches
Surgical Approach
Posterolateral approaches (transpedicular,
costotransversectomy) have become
increasing popular
Allows for circumferential decompression
and stabilization
Posterolateral approach
Requires working around the spinal cord
and sacrifice of nerve roots
– Less common surgical approach, technically
demanding
– Small risk of cord infarct with nerve root
sacrifice (esp. mid-lower thoracic)
Surgical technique –
Transpedicular/Costotransversectomy
From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.
Surgical technique –
Transpedicular decompression
From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.
Surgical technique - Stabilization
From Wang et al. March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.
Surgery for Spine Metastases
Conclusions
For patients with good performance status
and relatively limited disease, surgery
should be strongly considered
Order of surgery vs RT should be
considered as well
– Preop RT increases complication rate of
surgery
Surgery for Spine Metastases
Current/Future Investigations
More aggressive surgical extirpation – e.g.
en bloc spondylectomy
– Does histology matter?
Less aggressive surgical decompression
followed by SRS
Intraoperative radiotherapy
Phase III trials comparing SRS and
surgery
Spine Metastases - References
Constans JP, de Divitiis E, Donzelli R, et al: Spinal metastases with neurological manifestations. Review of 600 cases.
J Neurosurg 59:111–118, 1983
Sorensen S, Borgesen SE, Rhode K, et al: Metastatic epidural spinal cord compression. Results of treatment and
survival. Cancer 65:1502–1508, 1990
Byrne TN: Spinal cord compression from epidural metastases. N Engl J Med 327:614–619, 1992
Young RF, Post EM, King GA: Treatment of spinal epidural metastases. Randomized prospective comparison of
laminectomy and radiotherapy. J Neurosurg 53:741–748, 1980
Patchell RA, Tibbs PA, Regine WF, et al: Direct decompressive surgical resection in the treatment of spinal cord
compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26;366(9486):643-8
Ghogawala Z, Mansfield FL, Borges LF: Spinal radiation before surgical decompression adversely affects outcomes of
surgery for symptomatic metastatic spinal cord compression. Spine (Phila. Pa 1976) 26(7), 818–824, 2001
Shiue K, Sahgal A, Chow E, Lutz ST, Chang EL, Mayr NA, Wang JZ, Cavaliere R, Mendel E, Lo SS: Management of
metastatic spinal cord compression . Expert Rev Anticancer Ther. 10(5):697-708, 2010
Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 15;11(6):e10,
2001
Fessler RG, Sturgill. Review: complications of surgery for thoracic disc disease. M.Surg Neurol. 1998 Jun;49(6):609-18
Wang JC, Boland P, Mitra N, Yamada Y, Lis E, Stubblefield M, Bilsky MH. Single-stage posterolateral transpedicular
approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential
reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the
Spine and Peripheral Nerves, March 2004.J Neurosurg Spine. 2004 Oct;1(3):287-98.
Bone Augmentation For
Non-surgical Mets
Yahya Albeer, MD
Department of Radiology
Henry Ford Health System
Metastatic Bone Disease
Treatment Goals
• Reduce pain
• Eradicate or reduce tumor when primary
tumors are involved
• Prevent neurologic complications
• Treat pathologic fractures and prevent
recurrent fracture
Primary and Metastatic Bone Disease
Available Treatments - Other1
• Radiation Therapy
– Therapeutic: Reduce tumor in primary bone
cancer
– Palliative: Relieve pain related to bone metastasis
• Surgery
– To provide stability to compromised bone
– To prevent neurologic deterioration after fracture
1. American Cancer Society, 2006.
Results for Tumor Treatment
• Kyphoplasty and Vertebroplasty similar
• Pain relief in 75-85% of malignant lesions
treated with vertebroplasty
• The presence of epidural tissue does NOT
preclude treatment*
•
•
•
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Shimony et al Radiology 2004;232:846-853
Fourney et al J Neurosurg (Spine 1) 2003; 98:21-30
J Clin Neurosci 2011 Jun;18(6):763-7. Epub 2011 Apr 19.
J Surg Oncol 2010 Jul 1;102(1):43-7.
Radiology 2010;254(3):882-890
AJNR 2007;28: 570-574
Q&A
Jack Rock, M.D.
Department of Neurosurgery
Metastatic Spine Disease:
Conclusions
Most patients with metastatic disease involving the spine will be managed
effectively either with observation or radiation
For patients with spinal cord compression and rapidly progressing neurological
deterioration or significant neurological compromise (i.e., non-ambulatory),
tailored surgical decompression +/- fusion remains the gold standard
For ambulatory patients with spinal cord compression, radiosurgery is proving
to be effective in most cases
As a treatment for painful spinal metastases vertebro- and kyphoplasty
are effective augmentation procedures
Thank you