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Surgical Management of
Metastatic Spine Disease
FANOR M. SAAVEDRA-POZO, MD NEUROSURGERY - SPINE SURGERY
ASSISTANT PROFESSOR OF NEUROSURGERY
UNIVERSITY OF PUERTO RICO
SAN JUAN, PUERTO RICO
EPIDEMIOLOGY
Spinal Metastasis
• 20% all Ptes. CANCER
• 5-10% Spinal Cord
Compression
• 70% Thoracic - (T/L)
• 40- 60 y/o
• Hematogenous >> Direct
Extension
• 80% Prostate, Breast, Lung
Presentation
Clinical
• Pain 84%
• Axial 60%
• Radicular 24%
• Neurologic Deficit
Imaging
• “X” Ray
• CT
• Sclerotic (slow growing)
• Lytic (fast growing)
• MRI
• Bone Scan (99m-Teg)
• PET Scan
Surgery: What is the Role?
• Neurologic Function
• Stability of the Spine
• Local Tumor Control
• Pain control
Surgical Goals
Palliative
Multidisciplinary Approach
• Systemic therapy:
• Chemo - Inmuno - Hormonal therapy
• Radiation therapy:
• Conventional EBRT
• Image guided Intensity Modulated RT
(IMRT)
• Spine Surgery:
• Cement Augmentation
• Anterior, Posterior, Combined
The NOMS framework: approach to the treatment of spinal metastatic tumors.
Laufer I1, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, Bilsky MH.Oncologist. 2013 Jun;18(6):744-51. doi: 10.1634/theoncologist.2012-0293. Epub 2013 May 24
Neurologic
Epidural Extension
High Grade
Low Grade
0 Intraosseous
1a,
1b,
1c
Epidural and thecal sac
2 Spinal Cord
Compression
with some CSF
3 Spinal cord compression
and No CSF
Oncologic:
Tumor Histology and Radiosensitivity
EBRT SRS
EBRT Surgery and SRS
Radiosensitive Radioresistant
Low Grade
epidural cord compression
High Grade
epidural cord compression
Oncologic:
Tumor Histology and Radiosensitivity
67 y/o M
Back Pain
Percutaneous
Biopsy
MM
The NOMS framework: approach to the treatment of spinal metastatic tumors.
Laufer I1, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, Bilsky MH.Oncologist. 2013 Jun;18(6):744-51. doi: 10.1634/theoncologist.2012-0293. Epub 2013 May 24
Post Radiation
The Spinal Instability
Neoplastic Score
(SINS)
MECHANICAL INSTABILITY
0-6 STABLE
7-12 UNDETERMINATE
13-18 UNSTABLE
SYSTEMIC DISEASE
Tokuhashi, Score
◼0-8 = <6 months
◼9-11 = >6 months
◼12-15 = >1 year
◼Intervention
◼0-8 = Conservative (RT)
◼9-11 = Palliativ Decompression
◼12-15 = Decompression Circunferential stabilizacion
Tokuhashi, et al, 1990 with revision in 1998
SYSTEMIC DISEASE
Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global
Spine Tumour Study Group. Eur Spine J. 2010 Feb; 19(2): 215–222. Published online 2009 Dec 29.
doi: 10.1007/s00586-009-1252-x PMCID: PMC2899817
Tomita Score
Lancet 2005; 366: 643–48
Published online July 21, 2005
DOI:10.1016/S0140-6736(05) 66954-1
Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nat Clin Pract Neurol. 2006 Feb;2(2):87-94; quiz 116.
Witham TF1, Khavkin YA, Gallia GL, Wolinsky JP, Gokaslan ZL
OCT 2013
OCT 2013
Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases
Moulding HD1, Elder JB, Lis E, Lovelock DM, Zhang Z, Yamada Y, Bilsky MH.
J Neurosurg Spine. 2010 Jul;13(1):87-93. doi: 10.3171/2010.3.SPINE09639.
11/2013
11/27/2013
8/19/2014
9/2/2014
Gracias!