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.

Postoperative Symptomatic Anterior Spinal Epidural Hematoma: Complete Drainage Using Corpectomy and a Bladder Catheter.

STUDY DESIGN: A case report. OBJECTIVE: We describe a technique to drain a thoracic and cervical postoperative epidural hematoma causing paraplegia after anterior cervical discectomy and fusion. SUMMARY OF BACKGROUND DATA: Postoperative compressive spinal epidural hematoma (SEH) is a devastating complication and early diagnosis and treatment is essential. The most commonly accepted treatment is decompression and drainage of hematoma. METHODS: A 65-year-old male with a degenerative disc disease located at C4-C5, C5-C6, and C6-C7 levels with disc herniation underwent a standard anterior cervical decompression and fusion at C4-C5-C6-C7. Three hours after the procedure, the patient started complaining of progressive paraplegia and affectation of upper extremity. A magnetic resonance imaging (MRI) revealed a postoperative SEH extending from C3 to T6, causing compression.To resolve this unusual complication, a new surgery was performed. An anterior approach through the previous one was performed, and a C6 corpectomy was done. The anterior epidural hematoma was drained with an elastic urinary catheter. At the end of the surgery, a tricortical iliac crest autograft was placed between C5-C7 and the plate was placed as previously. RESULTS: The patient recovered tactile and vibratory senses, as well as motor function in both hands 12 hours after the second procedure. The complete drainage of the hematoma was MRI-verified the first postoperative day.The patient was discharged from the hospital presenting a complete sensitive recovery and a 3/5 of muscle recovery. At one year, the patient made a full recovery and was able to walk unassisted. CONCLUSION: The treatment of choice in SEH is the early decompression as complete as possible, usually with the same approach or at the level of major compression. In rare cases like this, we recommend the use of an elastic catheter to complete hematoma drainage, distant from the surgical wound. LEVEL OF EVIDENCE: N/A.