Comparison of clinical results of decompression/fusion surgery for paralysis caused by metastatic spinal tumors of unknown versus known origin / Journal of Rural Medicine

Objective: Whether or not emergent decompression/fusion surgery for paralysis caused by metastatic spinal tumors of unknown origin improves patient neurological outcome and survival remains unclear. This study aimed to evaluate the clinical outcomes of emergent decompression/fusion surgery for paralysis caused by spinal tumors of unknown or not previously diagnosed origin.Patients and Methods: Data from the medical records of 11 patients with spinal tumors of unknown origin (study group) were compared with those of 15 patients with metastatic spinal tumors of known origin (control group). The outcome measures were postoperative performance status, motor function evaluated with the Frankel grade, and actual survival after surgery as compared with the estimated survival calculated using the Tokuhashi score. χ2 analyses were performed to evaluate differences between the groups.Results: The mean performance status was 3.6 preoperatively, which improved to 2.9 postoperatively (P<0.05), in the unknown origin group and 3.6 preoperatively, which improved to 2.7 postoperatively (P<0.05), in the control group. Seven patients (64%) in the unknown origin group showed improvement in paralysis by ≥1 Frankel grade. By contrast, only 4 patients (27%) in the control group showed improvement in paralysis. The unknown origin group tended to show better improvement (P=0.05). All the patients in the unknown origin group underwent adjuvant therapy after definitive diagnosis following surgery. The unknown origin group showed a slight tendency toward better survival than toward the estimated survival.Conclusion: Emergent decompression/fusion surgery for patients with paralysis caused by metastatic tumors of unknown origin is potentially useful for diagnosing tumor origin and improving neurological outcomes and performance status, and thus for extending survival.

Acute and Delayed Epidural Hematoma After Total Spondylectomy for a Metastatic Spinal Tumor: A Case Report

STUDY DESIGN: Case report. OBJECTIVES: We report a case of recurrent spinal epidural hematoma after total spondylectomy for a metastatic spinal tumor. SUMMARY OF LITERATURE REVIEW: Postoperative epidural hematoma is rare, and no case of delayed epidural hematoma after hematoma removal has been reported. MATERIALS AND METHODS: A 74-year-old woman experienced a ninth thoracic vertebral (T9) pathologic fracture caused by a metastatic spinal tumor and underwent total spondylectomy. Immediate postoperative epidural hematoma occurred and neurological symptoms appeared. After hematoma removal, the symptom improved. Ten days after surgery, the neurological symptoms worsened again. Spine magnetic resonance imaging showed delayed epidural hematoma. Hematoma removal was done again. RESULTS: The patient's neurological symptoms improved after delayed hematoma removal. CONCLUSIONS: Delayed hematoma that cause neurological symptoms may occur after primary hematoma removal. If neurological symptoms recur after hematoma removal, the surgeon should consider the possibility of hematoma recurrence. Before total spondylectomy surgery, preoperative embolization is recommended.

Surgical Management with Radiation Therapy for Metastatic Spinal Tumors Located on Cervicothoracic Junction : A Single Center Study

OBJECTIVE: The cervicothoracic junction (CTJ) is a biomechanically and anatomically complex region that has traditionally posed problems for surgical access. In this retrospective study, we describe our clinical experiences of the treatment of metastatic spinal tumors at the CTJ and the results. METHODS: From June 2006 to December 2011, 23 patients who underwent surgery for spinal tumors involving the CTJ were enrolled in our study. All of the patients were operated on through the posterior approach, and extent of resection was classified as radical, debulking, and simple neural decompression. Adjuvant radiation therapy (RT) was also considered. Visual analog scale score for pain assessment and Medical Research Council (MRC) grade for motor weakness were used, while pre- and post-operative performance status was evaluated using the Eastern Cooperative Oncology Group (ECOG). RESULTS: Almost all of the patients were operated using palliative surgical methods (91.3%, 21/23). Ten complications following surgery occurred and revision was performed in four patients. Of the 23 patients of this study, 22 showed significant pain relief according to their visual analogue scale scores. Concerning the aspect of neurological and functional recovery, mean MRC grade and ECOG score was significantly improved after surgery (p<0.05). In terms of survival, radiation therapy had a significant role. Median overall survival was 124 days after surgery, and the adjuvant-RT group (median 214 days) had longer survival times than prior-RT (63 days) group. CONCLUSION: Although surgical procedure in CTJ may be difficult, we expect good clinical results by adopting a palliative posterior surgical method with appropriate preoperative preparation and postoperative treatment.

Implantation of Liquid Nitrogen Frozen Tumor Tissue after Posterior Decompression and Stabilization for Metastatic Spinal Tumors

STUDY DESIGN: A retrospective study. PURPOSE: To evaluate the immunity-enhancing effect of implantation of a liquid nitrogen-treated tumor. OVERVIEW OF LITERATURE: We have developed a new technique of implanting a tumor frozen in liquid nitrogen after posterior decompression and stabilization, with the aim of enhancing antitumor immunity in order to prolong the survival period of the patient. In the current study, the immunity-enhancing effect of this new technique has been evaluated. METHODS: The subjects were 19 patients in whom we had earlier performed decompression and stabilization between April 2011 and September 2013. The 19 subjects were divided into two groups, namely a frozen autologous tumor tissue implantation group (n=15; "implantation group"), which consisted of patients, who underwent implantation with autologous tumor tissue frozen in liquid nitrogen, and a control group (n=4), which consisted of patients, who did not undergo autologous cancer transplantation. To evaluate the immunity-enhancing effect of the protocol, plasma cytokines (interferon [IFN]-gamma and interleukin [IL]-12) were analyzed before surgery and a month after surgery. RESULTS: The mean rate of increase in IFN-gamma was significantly higher in the implantation group (p=0.03). Regarding IL-12, no significant difference was observed between the groups, although the implantation group exhibited increased levels of IL-12 (p=0.22). CONCLUSIONS: Decompression and stabilization combined with autologous frozen tumor cell implantation can enhance cancer immunity in metastatic spinal tumor patients. It is hypothesized that this procedure might prevent local recurrence and prolong survival period.

Chest Pain due to Rapidly Developed Metastatic Spinal Tumor : A case report / 한국호스피스완화의료학회지

Chest pain is a symptom observed commonly in outpatients and emergency room patients, and its causes are variable. Because treatment and prognosis of chest pain are different depending on its cause, it is more important than anything else to accurately diagnose the cause of chest pain. Most of patients complaining of chest pain undergo basic tests at a private local clinic or at the Internal medicine or chest surgery department of a general hospital and, they are referred to the pain clinic, with a note stating no particular finding. However, if they have sustained severe neuropathic pain in spite of nerve block, accurate diagnosis for chest pain is essential. We experienced rapidly developing spine breakdown and cord compression caused by metastatic spinal tumor in an inpatient who was being treated for chest pain, and thus, we report here in the case with literature review.

Results of Surgical Treatment for Metastatic Cervical Spine Tumor

OBJECTIVE: The incidence of spinal metastases continues to increase, likely a result of increasing survival times for patients with cancer. This retrospective study was undertaken to analyze the results of surgery and the outcome of patients with extradural metastases in the cervical spine. METHODS: Thirty-three patients with cervical spine metastases who underwent spinal surgery by two surgeon at a single center in a 14-year period(1993-2007) were analyzed. Indications for surgery include intractable pain, neurological deficits, spinal cord compression, and the need for stabilization of impending pathological fractures. Numerous factors affect outcome including the nature of the primary cancer, the presence of fracture or dislocation, approach of surgery, and the severity of spinal cord compression. The change of predominant symptoms and survival time were evaluated after surgery. RESULTS: There were 17 male and 16 female patients aged from 29 to 78 years old(mean age, 59.9 years). Among the metastatic tumors, colon, breast, and liver were the most common primary sites of origin, and lung, kidney, stomach and thyroid were also common. All patients had bony invasion and 24 patients had pathologic vertebral fracture and 6 patients had dislocation. Based on the tumor location, approaches included 12 anterior, 6 posterior and 15 combined. Epidural spinal cord compression on the axial T2-weighted magnetic resonance(MR) image was noted in 31 patients(93.9%). The American Spinal Injury Association(ASIA) impairment scale scores in preoperative state were stable in 29 patients(87.9%) who presented with ASIA Score D and E. The most common predominant symptoms of patients were cervical and/or radiating pain(26 patients) and 23 patients had neurological deficits. At Follow-up, predominant preoperative symptoms improved in 28(84.8%) patients who had pain or neurological deficits. The overall mean survival duration for patients with cervical metastatic tumors after diagnosis was 7.4 months in 28 expired patients and 17.4 months in 5 survived patients. There were four major early and late complications in this study. One patient suffered from the immediate postoperative epidural hematoma and improved after evacuation of hematoma. There were three cases of instrumentation failure. One of them was symptomatic and underwent second-look surgery. CONCLUSION: Surgery for the treatment of cervical spine metastases is effective for improvement of the neurological deficits and relief the local pain in a significant proportion of patients with acceptable complication rates. The tech- nical evolution of cervical implants has improved our ability to achieve long-term rigid fixation, particularly over the cervicothoracic junction.

Pulsed Radiofrequency Lesioning of the Medial Branch in a Patient with Cervical Pain Caused by a Metastatic Tumor: A case report / 대한마취과학회지

Metastatic spinal tumor may cause pain by direct tumor involvement of bone with activation of local nociceptors or compression of adjacent structures. As an adjunct to pharmacologic therapy, many patients benefit from the use of additional nerve blocks to treat cancer pain. However, they require repeated injections as nerve block under local anesthetic sometimes only give the patient temporary relief of pain. Recently, the advent of pulsed radiofrequency application has proved a successful treatment for refractory pain disorders. A 43 year-old man was presented with a constant, dull, aching pain in the posterior neck with radicular pain referred to right shoulder due to metastatic cervical spinal tumor. Right C5 and C6 medial branch nerve blocks, with local anesthetic-steroid injections were effective, but short pain relief for a couple of days. However, the pain relief lasted longer and was effective with pulsed radiofrequency application over 3 months.

Surgical Treatment of Metastatic Spinal Tumor

The authors present a series of 35 patients who underwent operation for metastatic spinal tumor. Patients were operated via anterior, posterior or posterolateral and combined anterior-posterior approach. The anterior approach was used in cases where there was no involvement of the posterior column, tolerable of a thoracotomy and involvement of three or less adjacent vertebral bodies. The posterior or posterolateral approach was used in cases with involvement of the posterior column, disease at two seperated locations, intolerable of a thoracotomy and involvement of three columns. The combined anterior-posterior approach was used when it was not enough to obtain stabilization with anterior or posterior approach alone and expected greater than 1 year life expectancy. Twenty-five(89%) of the 28 patients improved neurologically following surgery. Average neurologic improvement was 1.3 Frankel grade. Pain relief was obtained in twenty-six(93%) of the 28 patients. Recovery of spincter change was obtained twelve(80%) of the 15 patients. Two patients died postoperatively due to DIC and pneumonia. Prior to operation, selective spinal angiography and embolization were performed in nine patients with metastases from renal carcinoma, thyroid cancer and hepatoma to reduce intraoperative bleeding. The authors believe that the choice of surgical approach has to be individualized for each patient depending on extent and location of the tumor, general condition of patient, goal of therapy and life expectancy.

A Case of Metastatic Spinal Tumor in the Upper and Lower Thoracic Region Arising from Follicular Carcinoma of the Thyroid Gland

Among spinal tumors, the metastatic form is the most common form. This report describes a case of metastatic spinal tumor in the upper and lower thoracic region arising from follicular carcinoma of the thyroid gland. A 53-year-old female presented with a history of several months radiating pain in the right shoulder and arm. Magnetic resonance imaging showed bony expansion and a mass lesion of the first thoracic vertebra together with subtle cord compression. Using the anterior approach, the tumor was removed, and a bone graft was performed ; this was followed by radiation therapy. After discharge, the patient was followed up for 18 months, but was then readmitted due to right intercostal and midback pain. Plain X-ray and magnetic resonance imaging showed a destructive lesion of the right tenth rib and thoracic vertebra caused by an invasive tumor. Using the costotransversectomy approach, this was removed, and a bone graft was performed ; radiation and chemotherapy followed. The histological diagnosis was follicular carcinoma of the thyroid gland and the patient was discharged with no neurologic deficits. For neurologic recovery and the maintenance of stability, surgical treatment of a metastatic spinal tumor is thus necessary.

Surgical Treatment for Metastatic Spinal Tumors

The authors analysed 33 cases of metastatic spinal tumors admitted to the department of neurosurgery, Hanyang University Hospital from January 1983 to December 1992. During this period, we operated 12 cases of 33 cases. The results were as follows : 1) The common incidence of age was fifth decade, the most frequent primary site of metastatic tumors was lung, and the thoracic region was the most common site of metastatic tumors. 2) The most common complaints of patients were pain, weakness of extremities and sphincter disturbance in order. 3) The indication to surgical treatments comprises spinal instability, aggravation of neurologic symptom, diagnosis in doubt, known radioresistance of tumor and intractable pain. Anterior approach was used in cervical area for tumor removal and fusion and posterior approach was used in the thoracolumbar area for decompressive laminectomy. The result was better in surgery group. 4) Early identification of spinal metastasis were considered to be important for better prognosis. 5) The survival rate of the primary lesion may imfeuence on the pregnosis of metastatic spinal tumor.