Spinal metastases combined with leptomeningeal metastasis: A case report / 北京大学学报(医学版)

Spinal metastases (SM) is the commonest form of solid tumors osseous metastasis, for which surgical dissection is often performed when combined with spinal cord compression. Leptomeningeal metastasis (LM) results from dissemination of cancer cells to both the leptomeninges (pia and arachnoid) and cerebrospinal fluid (CSF) compartment. The spread of LM may occur via multiple routes, such as hematogenous, direct infiltration from metastatic brain lesions, or via iatrogenic seeding of CSF. Signs and symptoms associated with LM are generalized and various while early diagnosis of LM is challenging. Cytological evaluation of the CSF and gadolinium enhanced MRI brain and spine is the gold standard for diagnosing LM and CSF can help assess treatment response. While a number of other potential CSF biomarkers have been investigated both for the diagnosis as well as monitoring of LM, none have been established as a component of the standard evaluation of all LM or suspected LM patients. Management goals of LM include improving patient's neurologic function, quality of life, preventing further neurologic deterioration and prolonging survival. In many cases, it may be reasonable to pursue a palliative and comfort focused course, even from the initial LM diagnosis. Surgery is not recommended considering the risk of seeding with cerebrospinal fluid. A diagnosis of LM carries a poor prognosis with an estimated median survival of only 2-4 months despite therapy. Spinal metastases combined with leptomeningeal metastasis (SM+LM) is not uncommon and its treatment is similar to LM. LM can appear at the same time as SM or directly invaded by SM, which is thought regarding the pathophysiology of LM remains speculative and not systematically studied. The present article reports a 58-year-old woman who was first diagnosed with SM, but worsened after surgery repeated MRI examinations confirmed coexisting LM. Relevant literature was reviewed to summarize the epidemiology, clinical manifestations, imaging characteristics, diagnosis and treatment of SM+LM, so as to improve the understanding of the disease and promote early diagnosis. It should be vigilant to merge LM for the patient with SM when atypical clinical manifestations, rapid disease progression or inconsistent with imaging occurred. Repeated examinations of cerebrospinal fluid cytology and enhanced MRI should be considered when SM+LM is suspected to achieve timely adjustment of diagnosis and treatment strategy for better prognosis.

Percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of spinal metastases / 北京大学学报(医学版)

OBJECTIVE@#To investigate the effectiveness of percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of patients with spinal metastases.@*METHODS@#In the study, 12 patients of spinal metastases treated with percutaneous pedicle screw fixation combined expandable tubular retractor in our hospital were retrospectively reviewed between June 2017 and October 2019. Among the 12 patients, 9 were males and 3 were females; the median age was 62.5 years [(65.1±2.9) years]. The decompression segment of 7 patients was located at the lower thoracic spine (including 1 patient with incomplete paraplegia) and the decompression segment of 5 patients was located at the lumbar spine; Tomita score was 6.0±0.6. Perioperative data of the patients were reviewed. Visual analog scale (VAS score), Karnofsky score, and Eastern Cooperative Oncology Group (ECOG) score were compared before and after surgery. The patient's survival, adjuvant treatment, and internal fixation failure were observed in the follow-up period.@*RESULTS@#All the 12 patients had a successful operation with percuta-neous pedicle screw fixation combined expandable tubular retractor. The average operative time, blood loss, and blood transfused of the patients were (247.0±14.6) min, (804.2±222.3) mL and (500.0±100.0) mL, respectively. The average amount of drainage was (240.8±79.3) mL. Drainage tubes were pulled out early postoperative [(3.2±0.3) d], allowing early mobilization. The patients discharged (7.8±0.8) d postoperative. All the patients were followed up for 6-30 months, and the average overall survival time was (13.6±2.4) months. During the follow-up period, 2 patients experienced screw displacement, the internal fixation was stable after conservative treatment and no revision surgery was performed. The VAS of the patients was 7.1±0.2 before surgery, which decreased to 2.3±0.1 and 2.8±0.4 at 3 and 6 months after surgery (P < 0.05). The Karnofsky score of the patients was 59.2±1.9 before surgery, which increased to 75.0±1.9 and 74.2±3.1 at 3 and 6 months after surgery (P < 0.05). The ECOG of the patients was 2.3±0.2 before surgery, which decreased to 1.7±0.1 and 1.7±0.2 at 3 and 6 months after surgery (P < 0.05).@*CONCLUSION@#For selected patients with spinal metastases, minimally invasive surgical treatment of spinal metastases (percutaneous pedicle screw internal fixation combined with expandable tubular retractor) can effectively relieve the clinical symptoms and improve the quality of life, with satisfactory clinical outcome.

Association Between Constipation and a Reduction in Lower Limb Muscle Strength in Preoperative Patients with Thoracic Spinal Tumors / 中国医学科学杂志(英文版)

Objective To investigate the clinical symptoms experienced by patients with thoracic spinal tumors and verify the associated symptoms that are predictive of a decline in muscle strength in the lower limbs. Methods A single-center, retrospective cross-sectional study was conducted on in-patients diagnosed with epidural thoracic spinal tumors between January 2011 and May 2021. The study involved a review of electronic medical records and radiographs and the collection of clinical data. The differences in clinical manifestations between patients with constipation and those without constipation were analyzed. Binary logistic regression analyses were performed to identify risk factors associated with a decline in muscle strength in the lower limbs.Results A total of 227 patients were enrolled, including 131 patients with constipation and 96 without constipation. The constipation group had a significantly higher proportion of patients who experienced difficulty walking or paralysis compared to those without constipation prior to surgery (83.2% vs. 17.7%, χ2 = 99.035,P < 0.001). Constipation (OR = 9.522, 95%CI: 4.150-21.849, P < 0.001) and urinary retention (OR = 14.490, 95%CI: 4.543-46.213, P < 0.001) were independent risk factors for muscle strength decline in the lower limbs. Conclusions The study observed that patients with thoracic spinal tumors who experienced constipation symptoms had a higher incidence of lower limb weakness. Moreover, the analysis revealed that constipation and urinary retention were independent risk factors associated with a preoperative decline in muscle strength of lower limbs.

Progress of decompression surgery for spinal metastases / 中国骨伤

The spine is the most common site of bone metastases from malignant tumors, with metastatic epidural spinal cord compression occurring in about 10% of patients with spinal metastases. Palliative radiotherapy and simple laminectomy and decompression have been the main treatments for metastatic spinal cord compression. The former is ineffective and delayed for radiation-insensitive tumors, and the latter often impairs spinal stability. With the continuous improvement of surgical techniques and instrumentation in recent years, the treatment model of spinal metastases has changed a lot. Decompression surgery underwent open decompression, separation surgery, minimally invasive surgery and laser interintermal thermal ablation decompression. However, no matter what kind of surgical plan is adopted, it should be assessed precisely according to the specific situation of the patient to minimize the risk of surgery as far as possible to ensure the smooth follow-up radiotherapy. This paper reviews the research progress of decompression for spinal metastases.

Correspondencia entre los diagnósticos clínico, imagenológico e histopatológico en pacientes con tumores y seudotumores raquídeos intramedulares / Correspondence between the clinical, imaging and histopatologic diagnosis in patients with intramedullary spinal canal tumors and seudotumors

Introducción: Los tumores intramedulares son poco usuales y se generan dentro del tejido de la médula espinal, desplazando o invadiendo la materia blanca, los tractos y los cuerpos neuronales. Objetivo: Caracterizar a pacientes con tumores y seudotumores raquídeos intradurales intramedulares según variables clínicas, imagenológicas (resonancia magnética) e histopatológicas. Métodos: Se realizó un estudio observacional, descriptivo, longitudinal y prospectivo de 11 pacientes con diagnóstico clínico provisional de tumor o seudotumor raquídeo intramedular, confirmado por medio de la resonancia magnética, quienes fueron atendidos en el Departamento de Imagenología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba de enero de 2014 a igual mes de 2017, procedentes de los hospitales generales de esta provincia y de Guantánamo. Resultados: En la investigación primaron las féminas (63,6 %), sobre todo en las edades de 40 a 59 años (45,4 %), así como las manifestaciones clínicas de debilidad muscular (100,0 %) y dolor en la columna vertebral (81,8 %). De acuerdo a la intensidad de las señales obtenidas en la resonancia magnética, resultaron más frecuentes las imágenes heterogéneas, predominantemente en la zona dorsal. Asimismo, sobresalió la mielopatía compresiva dorsal (27,3 %) como diagnóstico clínico de sospecha, mientras que 54,5 % de los diagnósticos imagenológicos fueron confirmados histopatológicamente, con un mayor porcentaje en el caso de los astrocitomas (36,4). Conclusiones: La resonancia magnética es el método imagenológico de elección para la identificación de estos tumores, dado que ofrece una aproximación al diagnóstico definitivo, el cual es corroborado mediante el estudio anatomopatológico.

Introduction: The intramedullary tumors are not very usual and they are generated inside the tissue of the spinal cord, displacing or invading the white matter, tracts and neuronal bodies. Objective: To characterize patients with intradural intramedullary spinal canal tumors and seudotumors according to clinical, imaging (magnetic resonance) and histopatologic variables. Methods: An observational, descriptive, longitudinal and prospective study of 11 patients with clinical provisional diagnosis of intramedullary spinal canal tumor or seudotumor was carried out, confirmed by means of magnetic resonance who were assisted in the Imaging Department of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba from January, 2014 to the same month in 2017, coming from the general hospitals of this province and Guantánamo. Results: In the investigation there was a prevalence of females (63.6 %), mainly in the ages of 40 to 59 (45.4 %), as well as the clinical signs of muscular weakness (100.0 %) and pain in the spine (81.8 %). According to the intensity of signs obtained in the magnetic resonance, the heterogeneous images were more frequent, predominantly in the dorsal area. Also, dorsal compressive myelopathy was notable (27.3 %) as clinical diagnosis of suspicion, while 54.5 % of the imaging diagnosis was histopathologically confirmed, with a higher percentage in the case of astrocytomas (36.4). Conclusions: The magnetic resonance is the radiological method of election for the identification of these tumors, since it offers an approach to the definitive diagnosis, which is corroborated by means of the pathologic study.

Síndrome de la mano inútil con astereognosia secundaria a un astrocitoma cervical / Useless hand syndrome with astereognosis secondary to a cervical astrocytoma

Resumen El presente caso es un ejemplo del síndrome de la mano inútil de Oppenheim secundario a un astrocitoma cervical alto. La pérdida sensorial propioceptiva y discriminativa suspendida con conservación de la termoalgesia y el tacto crudo en ambas extremidades superiores es secundaria al daño a la entrada de la raíz dorsal y al núcleo cuneiforme. La torpeza y las dificultades para una prensión precisa con la mano se deben al daño del núcleo proprioespinal en las astas dorsales a nivel C3-C4. Este núcleo integra influencias excitadoras descendentes del tracto corticoespinal e interneuronas inhibitorias controladas por los sistemas descendentes y las aferencias de las extremidades anteriores. Probablemente la pérdida de las aferentes cervicales propioceptivas inhibitorias sea la culpable de las dificultades para agarrar con las manos.

The present case is an example of the useless hand syndrome of Oppenheim secondary to a high cervical astrocytoma. The suspended proprioceptive and discriminative sensory loss with conservation of thermoalgesia and crude touch in both upper extremities is secondary to damage to dorsal root entry and cuneate nucleus. The clumsiness and difficulties in precise grasping with the hand are due to damage of the propriospinal nucleus in the dorsal horns at C3-C4 level. This nucleus integrates descending excitatory influences from corticospinal tract and inhibitory interneurons controlled by descending systems and the forelimb afferents. Probably the loss of the inhibitory proprioceptive cervical afferents is the culprit of the difficulties in grasping by the hands.

Quiste óseo aneurismático vertebral agresivo: presentación de un caso y revisión bibliográfica / Aggressive aneurysmal bone cyst of the spine. Case report and literature review

Introducción: El quiste óseo aneurismático es una lesión seudotumoral lítica, expansiva, compuesta por espacios llenos de sangre separados por tabiques. Representa el 15% de los tumores primarios en la columna, y su presentación de comportamiento agresivo es aún más infrecuente. Se han descrito diferentes opciones terapéuticas en función de su estadio y tasa de recurrencia. Presentamos a un paciente con compromiso neurológico secundario a un quiste óseo aneurismático en la columna torácica, de comportamiento agresivo, que requirió resolución quirúrgica. Conclusión: Las opciones de tratamiento del quiste óseo aneurismático se deben adecuar a cada caso en particular, según sus características. Nivel de Evidencia: IV

Introduction: An aneurysmal bone cyst is an expansive, lytic, pseudotumoral lesion that consists of blood-filled spaces separated by septa. It represents 15% of primary spinal tumors. An aggressive presentation is even rarer. Different therapeutic options are described depending on its stage and recurrence rate. We present the case of a patient with neurological involvement due to the aggressive behavior of an aneurysmal bone cyst in the thoracic spine, which required surgical treatment. Conclusion: Treatment options for aneurysmal bone cysts must adapt to each case, depending on its characteristics. Level of Evidence:IV

Resección de osteoma osteoide vertebral asistida por planificación 3D. Presentación de un caso / Resection of spinal osteoid osteoma assisted by 3D planning. Case report

La localización vertebral de una lesión compatible con un osteoma osteoide requiere, muchas veces, su resección en bloque mar-ginal mediante cirugía. El objetivo de este artículo es informar sobre el uso de la tecnología en impresión 3D para desarrollar guías de corte y así lograr una resección segura y completa de un osteoma osteoide de L1. Presentamos a un varón de 13 años, operado de un osteoma osteoide de L1 y detallamos la planificación preoperatoria con asistencia de la tecnología 3D, la técnica quirúrgica mediante guías de corte impresas y un modelo real de la columna lumbar y el control posoperatorio. Conclusiones: Ante la indicación de cirugía para una lesión compatible con osteoma osteoide en la columna debe decidirse entre la posibilidad de resección intralesional abierta o percutánea y la resección marginal en bloque. Para localizar la lesión durante la cirugía, se utilizan diferentes métodos. En nuestro Servicio, estamos utilizando la tecnología 3D para la planificación preoperatoria de múltiples enfermedades traumatológicas agudas y las secuelas. Esto nos permite una mayor precisión y seguridad en la identificación de los márgenes de resección intraoperatoria, reduciendo, al mínimo, la extracción de tejidos sanos y evitando la inestabilidad posoperatoria. Nivel de Evidencia: IV

The vertebral location of a lesion compatible with an osteoid osteoma often requires a marginal en bloc resection. Our objective is to present the use of 3D printing technology for the development of specific cutting guides that achieve a safe and complete resection of an L1 osteoid osteoma. We present the case of a 13-year-old male who underwent surgery for an L1 osteoid osteoma, de-tailing the preoperative planning assisted by 3D technology, the surgical technique using 3D printed cutting guides, a real model of the lumbar spine, and the postoperative control. Conclusion: Before the surgical indication of a lesion compatible with an osteoid osteoma in the spine, we must decide between the possibility of an open intralesional resection or percutaneous and marginal en bloc resection. Different methods can be used for the intraoperative location of the lesion. In our department, we use 3D technology for preoperative planning of multiple acute and post-traumatic pathologies. This allows us to be precise and safe in the identification of intraoperative resection margins, minimizing the removal of healthy tissues and avoiding postoperative instability. Level of Evidence: IV

Fatores Prognósticos e Funcionalidade na Síndrome de Compressão Medular Metastática: um Estudo de Coorte / Prognostic Factors and Functionality in Metastatic Spinal Cord Compression: Cohort Study / Factores Pronósticos y Funcionalidad a Síndrome de Compresión Espinal Metástasico: un Estudio de Cohorte

Introdução: A síndrome de compressão medular metastática (SCMM) tem grande potencial de perda irreversível da função motora e sensitiva, sendo considerada uma emergência oncológica. Objetivo: Avaliar o prognóstico da SCMM e a funcionalidade dos pacientes com tumores sólidos. Método: Estudo de coorte que incluiu pacientes com câncer que desenvolveram SCMM entre janeiro de 2017 e dezembro de 2018. Os dados clínicos e sociodemográficos foram extraídos dos prontuários físicos e eletrônicos. Análise de sobrevida foi realizada pelo método Kaplan-Meier. Resultados: O estudo abrangeu 90 pacientes que apresentaram SCMM. Ao diagnóstico da SCMM, 55,5% dos pacientes não conseguiam realizar marcha. Os pacientes com SCMM após câncer de pulmão tiveram 4,1 vezes maior risco de morrer (IC 95%, 1,79-9,41; p=0,001), os pacientes com tumores geniturinários tiveram 1,9 vezes maior risco de morrer (IC 95%, 1,06- 3,45; p=0,02) e os pacientes com outros tipos de tumor tiveram 3,1 vezes maior risco de morrer (IC 95%, 1,58-6,24; p=0,001) quando comparados aos pacientes com SCMM após câncer de mama. Conclusão: Destaca-se a relevância clínica deste estudo ao descobrir que o tipo de tumor primário é um fator preditor independente para sobrevida da SCMM. Ao diagnóstico da SCMM, mais da metade dos pacientes não realizam marcha

Introduction: Metastatic Spinal Cord Compression (MSCC) has great potential of irreversible loss of motor and sensory function, and it is considered an oncological emergency. Objective: Evaluate the prognosis of MSCC and the functionality of patients with solid tumors. Method: Cohort study was conducted in patients with cancer who developed MSCC between January 2017 and December 2018. Clinical and socio-demographic data were extracted from physical and electronic charts. Survival analysis was performed by the Kaplan-Meier method. Results: The study included 90 patients who were diagnosed with MSCC. At the time of MSCC diagnosis, 55.5% of patients were unable to walk. Patients with MSCC after lung cancer had 4.1-fold more odds of death (95% CI: 1.79-9.41; p=0.001), those with genitourinary tumors, 1.9-fold higher risk of death (95% CI: 1.06-3.45; p=0,02), and with other types of tumors, 3.1-fold higher risk of death (95% CI: 1.58-6.24; p=0.001) when compared with patients with MSCC after breast cancer. Conclusion: The clinical relevance of this study relies on the findings that the primary type of tumor is a predictive factor for overall survival of MSCC. More than half of the patients were unable to walk at the MSCC diagnosis

Introducción: El síndrome de compresión espinal (SCE) tiene un gran potencial de pérdida irreversible de la función motora y sensorial, siendo considerado una emergencia oncológica. Objetivo: Evaluar el pronóstico de SCE y la funcionalidad de los pacientes. Método: Estudio de cohorte que incluyó pacientes con cáncer que desarrollaron SCE entre enero de 2017 y diciembre de 2018. Se extrajeron datos clínicos y sociodemográficos de historias clínicas físicas y electrónicas. El análisis de supervivencia se realizó mediante el método de Kaplan-Meier. Resultados: El estudio cubrió a 90 pacientes que tenían SCE. En el diagnóstico de SCE, 55,5% de los pacientes no pueden caminar. En comparación con los pacientes con cáncer de mama, los pacientes con cáncer de pulmón tenían 4,1 veces más riesgo de morir (IC 95%, 1,79-9,41; p=0,001), los pacientes con tumores genitourinarios 1,9 veces mayor de morir (IC 95%, 1,06-3,45; p=0,02) y aquellos pacientes con otro tipo de tumor, 3,1 veces mayor riesgo de morir (IC 95%, 1,58- 6,24; p=0,001). Conclusión: Este estudio encontró que el tipo de tumor primario es un factor predictivo para la supervivencia de le SCE. Más de la mitad de los pacientes no caminan en el momento del diagnóstico de SCE. Palabras clave: compresión de la médula espinal; neoplasias de la columna

Microscopic resection of lumbar intraspinal tumor through keyhole approach: A clinical study of 54 cases / 北京大学学报(医学版)

OBJECTIVE@#To explore the feasibility and key technology of microscopic resection of lumbar intraspinal tumor through microchannel keyhole approach.@*METHODS@#The clinical features, imaging characteristics and surgical methods of 54 cases of lumbar intraspinal tumor which were microscopically operated by microchannel from February 2017 to September 2019 were reviewed and analyzed. There were 8 cases of extradural tumor, 3 cases of extra-and intradural tumor and 43 cases of subdural extramedullary tumor (including 3 cases of ventral spinal tumor). The tumors were 0.5-3.0 cm in diameter. The clinical symptoms included 49 cases of pain in the corresponding innervation area, 5 cases of sensory disturbance (numbness) at or below the tumor segment, 7 cases of limb weakness and 2 cases of urination and defecation dysfunction.@*RESULTS@#In the study, 37 tumors were resected through hemilaminectomy, 14 tumors were resected through interlaminar fenestration, 3 tumors were resected through hemilaminectomy or interlaminar fenestration combined with facetectomy of medial 1/4 facet. All of the 54 tumors were totally resected. The operation time was 75-135 min, with an average of 93.3 min. The postoperative hospital stay was 4-7 days, with an average of 5.7 days. Postoperative pathology included 34 cases of schwannoma, 4 cases of meningioma, 9 cases of ependymoma, 1 case of enterogenous cyst, 5 cases of teratoma/epidermoid/dermoid cyst, and 1 case of paraganglioma. No infection or cerebrospinal fluid leakage was found after operation. No neurological dysfunction occurred except 1 case of urination dysfunction and 4 cases of limb numbness. The follow-up period ranged from 3 to 33 months with an average of 14.4 months. Five patients with new onset symptoms returned to normal. The pain symptoms of 49 patients were completely relieved; 4 of 5 patients with hypoesthesia recovered completely, the other 1 patient had residual mild hypoesthesia; 7 patients with limb weakness, and 2 patients with urination and defecation dysfunction recovered to normal. No spinal instability or deformity was found, and no recurrence or residual tumors were found. According to McCormick classification, they were of all grade Ⅰ.@*CONCLUSION@#The lumbar intraspinal extramedullary tumors within two segments (including the ventral spinal tumors) can be totally resected at stage Ⅰ through microchannel keyhole approach with appropriate selection of the cases. Microchannel technique is beneficial to preserve the normal structure and muscle attachment of lumbar spine, and to maintain the integrity and stability of lumbar spine.

Dosimetric effect of patient arm position on Cyberknife radiosurgery for spinal tumors / 北京大学学报(医学版)

OBJECTIVE@#To assess the potential dosimetric effects of arms movement in patients with Cyberknife spine tumors.@*METHODS@#In the study, 12 patients with thoracic and lumbar tumors were retrospectively selected respectively. The contour of the patient's arms was sketched and the CT density was modified to be equivalent to air in order to simulate the extreme case when the arm was completely removed from the radiation fields. The dose of simulated plan was re-calculated with the original beam parameters and compared with the original plan. The changes of V100, D95, and D90, conformity index (CI) and heterogeneity index (HI) in planning target volume (PTV), as well as Dmax, D1cc and D2cc in the spinal cord, stomach, esophagus, and intestines were analyzed by comparing with the original plans.@*RESULTS@#Compared with the original treatment plan, V100, D95, D90 and CI of PTV for the simulated plan was increased by 0.86%, 2.02%, 1.97% and 0.80% respectively, the difference was statistically significant (P < 0.05). Dmax, D1cc and D2cc of spinal cord was increased by 2.35%, 0.59% and 1.49% on average, compared with the original plan, the difference was statistically significant (P < 0.05). The difference was statistically significant only in average D2cc of stomach, which was increased by 1.70%, compared with the original plan (P < 0.05). There was no significant difference in dose change of eso-phagus and intestine between the original and simulated plans.@*CONCLUSION@#This study analyzed the most extreme arm position in spinal tumor of radiation therapy based on Cyberknife. It was found that the change of arm position had little effect on dosimetry. In addition, with the change of arm position, the dose in PTV and organ at risk (OAR) increased, but the increase was relatively small. Therefore, in some special cases where the patient really can't keep the arm position consistent during treatment, reasonable adjustment can be accepted. However, in order to ensure accurate radiotherapy, patient position should be as stable and consistent as possible.

Vertebral metastasis of renal carcinoma at diagnosis: mechanical and clinical evaluation: surgical management / Metástasis vertebral de carcinoma renal en el momento del diagnóstico: evaluación mecánica y clínica: manejo quirúrgico

Renal cell carcinoma accounts for 2-3% of all malignant neoplasms. Metastatic disease of the spine is common and 50% of bone metastases are already present at the time of primary diagnosis. Bone metastases from renal cell carcinoma are difficult to manage, especially vertebral localization.A 48-year-old woman was diagnosed with renal cell carcinoma in the context of low back pain. The patient presented two skeleton metastases at diagnosis (T11 and 5th rib). The patient received neoadjuvant treatment with cabozantinib, followed by removal of the renal tumor. Radiotherapy was administered for the lumbar lesion. In spite of the radiotherapy treatment, increased low back pain limiting mobility and ambulation. MRI showed an occupation of the spinal canal, without neurological lesion. The SINS scale revealed a score of 14 (vertebral instability). The patient's prognosis was greater than 12 months according to the Tokuhashi score. Based on clinical and mechanical criteria, surgical treatment of the vertebral lesion was decided. T11 vertebrectomy was performed, the reconstruction was made with an expandable cage, and T8 a L2 posterior spinal arthrodesis. A partial resection of the fifth rib was performed in order to remove the whole macroscopic tumor. After 3 months, she was diagnosed with a local infection, treated by irrigation, debridement and antibiotherapy, with good evolution. At 1-year follow-up, she has no low back pain or functional limitation. Follow-up chest-abdomen-pelvis computed CT scan showed absence of disease progression, furthermore, the vertebral arthrodesis shows fusion signs. At the time of this report, there are no clinical or radiological data of infection

El carcinoma de células renales representa el 2-3% de todas las neoplasias malignas. La enfermedad metastásica de la columna vertebral es frecuente y el 50% de las metástasis óseas ya están presentes en el momento del diagnóstico. Las metástasis óseas del carcinoma de células renales son difíciles de manejar, especialmente en localización vertebral.Una mujer de 48 años fue diagnosticada de carcinoma de células renales en el contexto de un dolor lumbar. La paciente presentaba dos metástasis óseas en el momento del diagnóstico (T11 y 5ª costilla). Inicialmente recibió tratamiento neoadyuvante con cabozantinib, seguido de la extirpación quirúrgica del tumor renal. Se administró radioterapia para la lesión lumbar. A pesar del tratamiento radioterápico, aumentó el dolor lumbar con limitación para la movilidad y la deambulación. La RM mostró una ocupación del canal espinal, sin lesión neurológica. La escala SINS reveló una puntuación de 14 (inestabilidad vertebral). El pronóstico de la paciente era superior a 12 meses según la puntuación de Tokuhashi. Basándose en criterios clínicos y mecánicos, se decidió el tratamiento quirúrgico de la lesión vertebral. Se realizó una vertebrectomía de T11, para la reconstrucción se usó una caja extensible, junto con una artrodesis vertebral T8-L2. Se realizó una resección parcial de la quinta costilla para eliminar todo el tumor macroscópico. A los 3 meses de la cirugía la paciente fue diagnosticada de infección local, tratada mediante irrigación, desbridamiento y antibioterapia, con buena evolución. Al año de seguimiento, no presenta dolor lumbar ni limitación funcional. La tomografía computarizada de tórax-abdomen-pelvis de seguimiento mostró ausencia de progresión de la enfermedad, además, la artrodesis vertebral muestra signos de fusión. En el momento de este informe, no hay datos clínicos ni radiológicos de infección.

Complications after partial, total or extended sacrectomy: a case series / Complicações depois de sacrectomia parcial, total ou estendida: série de casos / Complicaciones después de sacrectomía parcial, total o extendida: serie de casos

ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.

RESUMO Objetivo O objetivo deste estudo é fazer um levantamento das diferentes complicações da sacrectomia parcial, total ou estendida para tratamento de tumores da coluna vertebral. Métodos O estudo é uma análise descritiva de prontuários de uma série de 18 pacientes submetidos à sacrectomia entre 2010 e 2019 em um centro terciário especializado em cirurgias de neoplasia na coluna. As variáveis analisadas foram sexo, idade, tempo de internação, diagnóstico oncológico, padrão de fixação posterior, taxa de complicações e escalas de Frankel, ASA e ECOG. Resultados Dos 18 pacientes, 10 (55,5%) eram homens e 8 (44,5%) mulheres com média de idade de 48 anos. O tempo médio de internação foi de 23 dias. Dos 18 pacientes, 8 (44,5%) contraíram infecções pós-operatórias com necessidade de cirurgia. As complicações perioperatórias incluíram fistula liquórica (22,25%), instabilidade hemodinâmica com necessidade de medicação vasoativa no pós-operatório imediato (22,25%), deiscência da ferida operatória (11,1%), abdome obstrutivo agudo (11,1%), oclusão da artéria ilíaca externa esquerda (11,1%), óbito pós-operatório imediato por infarto agudo do miocárdio (11,1%) e óbito intraoperatório por instabilidade hemodinâmica (11,1%). Conclusões A sacrectomia parcial, total ou estendida é um procedimento complexo com alta taxa de mortalidade e morbidade, mesmo em centros especializados no tratamento de tumores na coluna. Nível de evidência IV; Série de casos.

RESUMEN Objetivo El objetivo de este estudio es evaluar las diferentes complicaciones de la sacrectomía parcial, total o extendida para el tratamiento de tumores vertebrales. Métodos El estudio es un análisis descriptivo de las historias clínicas de 18 pacientes sometidos a sacrectomía entre 2010 y 2019 en un centro terciario especializado en cirugías de neoplasia de columna. Las variables analizadas fueron sexo, edad, estancia hospitalaria, diagnóstico de cáncer, patrón de fijación posterior, tasa de complicaciones, escalas de Frankel, ASA y ECOG. Resultados De los 18 pacientes, 10 (55,5%) eran hombres y 8 (44,5%) mujeres con una edad promedio de 48 años. La estancia hospitalaria promedio fue de 23 días. De los 18 pacientes, 8 (44,5%) contrajeron infecciones posoperatorias que requirieron cirugía. Las complicaciones perioperatorias incluyeron fístula de líquido cefalorraquídeo (22,25%), inestabilidad hemodinámica que requirió medicación vasoactiva en el posoperatorio inmediato (22,25%), dehiscencia de la herida quirúrgica (11,1%), abdomen obstructivo agudo (11,1%), oclusión de la arteria ilíaca externa izquierda (11,1%), muerte posoperatoria inmediata por infarto agudo de miocardio (11,1%) y muerte intraoperatoria por inestabilidad hemodinámica (11,1%). Conclusiones La sacrectomía parcial, total o extendida es un procedimiento complejo con una alta tasa de mortalidad y morbilidad, incluso en centros especializados en el tratamiento de tumores de la columna. Nivel de evidencia IV; Series de casos

Manejo actual de las metástasis vertebrales: un trabajo en equipo / Current management of vertebral metastases: teamwork

La enfermedad metastásica vertebral es frecuente en los pacientes con cáncer avanzado, y conlleva a complicaciones inherentes a su progresión, como lo son la fractura patológica vertebral y la compresión neural metastásica. Se realizó una revisión de los aspectos terapéuticos actuales del manejo de la progresión y de las complicaciones de la enfermedad metastásica vertebral, enfatizando su enfrentamiento sistémico y personalizado. Nuestro objetivo principal es proporcionar información sobre el tratamiento actual de esta afección y la utilidad del manejo sistémico y multidisciplinario.

Metastatic spinal disease is common in patients with advanced cancer, and leads to complications inherent in its progression, such as pathological vertebral fracture and metastatic neural compression. A review of the current therapeutic aspects regarding the progression and complications of metastatic spinal disease was performed, highlighting its systemic, personalized approach. Our aim is to provide information about the current treatment of this condition and the usefulness of its systemic and multidisciplinary management.

Effectiveness of Fluoroscopy-Guided Percutaneous Vertebral Biopsy / Eficácia da biópsia vertebral percutânea guiada por fluoroscopia

Abstract Objective To define the effectiveness of fluoroscopy-guided percutaneous vertebral biopsy. Methods Prospective study of patients with vertebral destruction syndrome at one institution. Percutaneous transpedicular vertebral biopsies guided by fluoroscopy were performed, and bony tissue and intervertebral disc tissue were extracted; histopathology and microbiology studies were also performed. Age, sex, vertebral segment, neurologic status, and biopsy and culture results were analyzed. Results The average age of the patients was 53.8 years (range: 2 to 83 years), and the main spine segment was the lumbar segment in 62% of the cases. According to the impairment scale of the American Spinal Injury Association (ASIA), preoperatively, 49% of the patients were classified as Asia E, and 100% had pain. Definitive etiology was identified in 83% of the sample. The etiology was grouped into three categories: infectious, neoplasia, and degenerative (osteoporotic). The infectious group was composed of 36% of the patients, in whom Staphylococcus aureus was the most common agent identified; in 34.9% the sample, the etiology was neoplastic, most commonly multiple myeloma and metastatic disease due to prostate cancer; 21.7% of the patients had osteoporosis. The average surgical time was of 47.5 minutes, the average blood loss was of 10 mL. No complications were reported. Conclusion Transpedicular percutaneous biopsy guided by fluoroscopy had an effectiveness of 83% for the etiological diagnosis of vertebral destruction syndrome in the present series. It should be considered a useful minimally-invasive procedure, which is easy, economical, and reproducible, with low risk of short- and long-term complications.

Resumo Objetivo Definir a eficácia da biópsia vertebral percutânea guiada por fluoroscopia. Métodos Este é um estudo prospectivo de pacientes com síndrome de destruição vertebral em uma instituição. Os pacientes foram submetidos a biópsias vertebrais transpediculares percutâneas guiadas por fluoroscopia, com obtenção de tecido ósseo e tecido do disco intervertebral, para estudo histopatológico e microbiológico. Idade, sexo, segmento vertebral, estado neurológico, e resultados de biópsia e de cultura foram analisados. Resultados A idade média dos pacientes foi de 53,8 anos (gama: 2 a 83 anos), e o principal local acometido da coluna foi a segmento lombar, em 62% dos casos. Segundo a escala de disfunção da American Spinal Injury Association (ASIA), no pré-operatório, 49% dos pacientes foram classificados como ASIA E, e 100% apresentavam dor. A etiologia definitiva foi identificada em 83% dos pacientes. A etiologia foi agrupada em três categorias: infecciosa, neoplásica, e degenerativa (osteoporótica). O grupo infeccioso era composto por 36% dos pacientes da amostra, e Staphylococcus aureus foi o agente mais comumente identificado; em 34,9% dos casos, a etiologia era neoplásica, principalmente mieloma múltiplo e doença metastática por câncer de próstata; 21,7% dos pacientes apresentavam osteoporose. O tempo cirúrgico médio foi de 47,5 minutos, e a perda média de sangue foi de 10 mL. Nenhuma complicação foi relatada. Conclusão Nesta série, a biópsia percutânea transpedicular guiada por fluoroscopia teve 83% de eficácia no diagnóstico etiológico da síndrome de destruição vertebral. Este procedimento minimamente invasivo deve ser considerado bom, fácil, barato e reprodutível, com baixo risco de complicações em curto e longo prazos.

Gangliocytic paraganglioma of the spine

Paragangliomas are rare, encapsulated, benign neuroendocrine tumors that can arise from the adrenal medulla or extra-adrenal paraganglia. Extra-adrenal paragangliomas may develop a gangliocytic component with ganglion cells (Gangliocytic paragangliomas). Nearly 25%of cauda equina paragangliomas are gangliocytic paragangliomas. Here, we describe the case of a 35-year-old male who presented with weakness of both lower limbs over the last two months. Radiological findings were suggestive of myxopapillary ependymoma. However, the histopathological examination revealed a tumor with cells arranged in sheets, papillae, lobules, and around vessels forming pseudo rosettes. Ganglion cells were seen in small groups and, also singly. Tumor cells were immunopositive for chromogranin, synaptophysin, and S-100. Ganglion cells were immunopositive for synaptophysin, NSE, and NFP. A final histological diagnosis of Gangliocytic paraganglioma (WHO grade I) was made. To date, only nine gangliocytic paraganglioma cases have been previously reported, and to the best of our knowledge, this is the largest gangliocytic paraganglioma.

Uso de denosumab para el quiste óseo aneurismático de columna. Reporte de un caso y revisión bibliográfica / Use of denosumab in an aneurysmal bone cyst of the spine. Case report and literature review

Los tumores vertebrales de columna tienen una frecuencia muy baja. La incidencia de quiste óseo aneurismático es del 1-4% de todos los tumores. Su ubicación predominante es la columna lumbar, en mayor medida, en el arco posterior. Según estudios publicados, esta enfermedad se comporta de forma agresiva, por la compresión radicular que genera debido a su expansión. Si bien hay bibliografía sobre el tratamiento quirúrgico del tumor y su resección en bloque y embolización, no hay experiencias sobre el tratamiento con anticuerpos monoclonales. Existen muy pocos artículos que corroboren un tratamiento para las recidivas o los quistes óseos aneurismáticos inoperables o intralesionales, los cuales dejan la posibilidad abierta a otras técnicas. Presentamos el caso de una mujer de 38 años con lumbocruralgia. En los estudios, se detecta una tumoración, y la biopsia por punción y las imágenes confirman que se trata de un quiste óseo aneurismático. Se planifica el tratamiento con embolización preoperatoria y exéresis intracompartimental mediante cirugía posterior con liberación del saco dural. A los seis meses, el tumor recidiva. Se indica tratamiento con denosumab por dos años, se realizan controles periódicos y se constata la remisión de los síntomas y la mejoría de las imágenes. Nivel de Evidencia: IV

Vertebral tumors of the spine have a very low frequency. The incidence of aneurysmal bone cyst (ABC) ranges between 1% and 4% of all tumors. Its predominant location is the lumbar spine, to a greater extent, in the posterior arch. According to published studies, this condition behaves aggressively, due to the root compression generated by its expansion. While there is literature on the surgical treatment of the tumor and its en bloc resection and embolization, there is no experience on the treatment with monoclonal antibodies. There are very few published articles that corroborate a treatment for recurrences or for inoperable or intralesional aneurysmal bone cysts, which leave the possibility open to other techniques. We present the case of a 38-year-old woman with lumbar pain radiating to the thigh. In studies, a tumor was detected, and the needle biopsy and imaging confirmed that it was an aneurysmal bone cyst. We planned the treatment with preoperative embolization and intracompartmental excision by subsequent surgery with the release of the dural sac. At six months, tumor recurrence was observed. Treatment with denosumab was indicated for two years, periodic controls were carried out and the remission of symptoms and improvement in the images were verified. Level of Evidence: IV

Paraparesia aguda por hemangioma vertebral agresivo. Reporte de dos casos y revisión bibliográfica / Acute paraparesis due to aggressive vertebral hemangioma. Report of two cases and literature review

Introducción: Los hemangiomas agresivos constituyen el 1% del total de los hemangiomas vertebrales. Pueden producir dolor, fracturas, deformidad y compromiso neurológico, generalmente de larga evolución. Se han descrito diferentes opciones terapéuticas, pero el manejo óptimo sigue sin estar claro. Comunicamos dos casos de paraparesia aguda secundaria a un hemangioma torácico agresivo, describimos su tratamiento y evolución. Realizamos una revisión narrativa de la bibliografía. Conclusión: Mediante la descompresión y la artrodesis tempranas seguidas de radioterapia, se logró la recuperación neurológica completa y el control de la enfermedad en un seguimiento a mediano plazo. Nivel de Evidencia: IV

Introduction: Aggressive hemangiomas make up 1% of all vertebral hemangiomas. They can produce pain, fractures, deformity and slowly progressive neurological compromise. Different treatment approaches have been described, but optimal management remains unclear. We report two cases of acute paraparesis secondary to aggressive thoracic hemangioma, we describe their treatment and evolution. We carry out a narrative review of the literature on vertebral hemangiomas. Conclusion: Through early decompression and arthrodesis followed by local adjuvant radiotherapy, we obtained complete neurological recovery and disease control in a medium-term follow-up. Level of Evidence: IV

Normograma predictivo para evaluar la supervivencia en pacientes con metástasis vertebrales / Predictive nomogram for evaluating survival in patients with spinal metastases

Introducción: La decisión respecto al procedimiento quirúrgico y la estrategia operatoria se basa en las expectativas de vida de los pacientes. Los sistemas difieren mucho en los parámetros evaluados y en el resultado del puntaje total. Por lo tanto, para un mismo paciente, se pueden calcular diferentes períodos de supervivencia y sugerir estrategias de tratamiento contradictorias. Objetivo: Analizar pacientes con metástasis vertebrales que fueron operados y evaluar la supervivencia mediante el normograma del SORG (Skeletal Oncology Research Group). materiales y métodos: Estudio retrospectivo que incluyó a 20 pacientes, de marzo de 2017 a marzo de 2019. Los criterios de inclusión fueron metástasis vertebrales con compresión medular o sin ella. Parámetros de evaluación: el normograma del SORG con probabilidad de supervivencia a los 30, 90 y 365 días, en la fase prequirúrgica, y la evaluación alejada: supervivencia a marzo de 2020. Resultados: 14 mujeres y 6 hombres, edad promedio: 67.9 años. Seguimiento de 6-36 meses. El puntaje promedio final fue de 222,4, lo que equivaldría a una supervivencia del 99% al mes, 78% a los 3 meses y 50% al año. Conclusión: En pacientes oncológicos con metástasis vertebrales, el normograma del SORG sería útil para predecir la supervivencia, sobre todo, al año. Nivel de Evidencia: IV

Introduction: The decision of a surgical procedure and the surgical strategy are based on the life expectancies of the patients. The systems differ greatly in the parameters evaluated and in the result of the total score. Therefore, for the same patient, different survival periods can be calculated and contradictory treatment strategies suggested. Objective: To evaluate patients with spinal metastases who underwent surgery, evaluating survival according to the SORG (Skeletal Oncology Research Group) Nomogram. materials and methods: Retrospective study, March 2017 to March 2019. 20 patients. Inclusion criteria: spinal metastases, with or without spinal compression. Evaluation parameters: the SORG Nomogram with probability of survival, at 30, 90 and 365 days, in the preoperative phase and the remote evaluation: survival to March 2020. Results: 14 women and 6 men, average age: 67.9 years. Follow-up 6 to 36 months. Average final score: 222.4 points, which would be equivalent to a survival of 99% after a month, 78% after 3 months and 50% after a year. Conclusion: In cancer patients with spinal metastases, the SORG nomogram would be useful to predict survival, especially at one year.Key words: Spinal metastases; survival; spine surgery. Level of Evidence: IV