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Primary tumors of the spine are rare especially of the cervical spine. However it is quite consideralbe the incidence of metastasis
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Malignant Cervical Spine Tumors
Operative treatment
G. SAPKASProfessor in Orthopedics
Orthopaedic Departmentfor
Spinal and Musculoskeletal Disorders“Metropolitan” Hospital
Epidemiology Epidemiology
Lung metastasisLung metastasis
Primary tumors Primary tumors of the spine are rare of the spine are rare especially of the especially of the cervical spine.cervical spine.However it is quite However it is quite consideralbeconsideralbethe incidence the incidence of metastasisof metastasis
A.B.C A.B.C
Benign tumors of the spineBenign tumors of the spine
The most common benign tumors The most common benign tumors are:are:– HemangiomaHemangioma– OsteoblastomaOsteoblastoma– Giant cell tumorGiant cell tumor– ChondroblastomaChondroblastoma– Osteoid osteomaOsteoid osteoma
Their incidence is estimated to be Their incidence is estimated to be 11% – 14%11% – 14%
A lot of them remain asymptomatic A lot of them remain asymptomatic and are diagnosed accidentally and are diagnosed accidentally
Osteochondroma
Malignant tumors of the spineMalignant tumors of the spine(primary and metastatic)(primary and metastatic)
The primary malignant tumors are The primary malignant tumors are rare in the spinerare in the spineThe most common are:The most common are:– OsteosarcomaOsteosarcoma– ChondroblastomaChondroblastoma– Ewing’s sarcomaEwing’s sarcoma– ChordomaChordoma– Lymphoma Lymphoma
Ewing’s sarcoma
Are the most common Are the most common in the spine in the spine The life expectancy The life expectancy contributes contributes to the increased to the increased incidence incidence of spinal metastasesof spinal metastases
Breast metatstasis
Metastatic spinal tumorsMetastatic spinal tumors
Incidence
Skeletal Skeletal MetastasesMetastases
Breast 45-85%
Pneumon 35-60%
Kidney 35-40%
Prostate 35-85%
Thyroid 30-60%
Skull 35%Cervical spine 22%
Humerus 10%Ribs 57%Thoracic spine 37%
Lumbar spine 53%
Sacrum 6%Pelvis 19%Femur 22%
The most common location The most common location for skeletal metastasis: for skeletal metastasis:
• Thoracolumbar Thoracolumbar region region ~ ~ 70%70%
• Lumbar and sacral Lumbar and sacral spine spine ~ ~ 20%20%
• Cervical spine Cervical spine ~ ~ 10%10%
Gilbert R.W. et al. Ann. Neural. 1998 Stomach metastasisStomach metastasis
Clinical symptoms Clinical symptoms of spinal of spinal
metastasismetastasis
PainNeurologic deficit
Stomach metastasisStomach metastasis
PAIN
Is the most common
symptom related to the existence of a primary or
metastatic spinal tumor
Breast metastasisBreast metastasis
The spinal pain may be due:The spinal pain may be due:In destruction of the anatomic In destruction of the anatomic vertebral elements as a result vertebral elements as a result of metastases of metastases
Resulting spinal instabilityResulting spinal instability
The pain is possible to occur The pain is possible to occur as a result of compression or as a result of compression or infiltration of the spinal infiltration of the spinal cord – nerves from cord – nerves from neoplasmatic masses.neoplasmatic masses.
Stomach metastasisStomach metastasis
Pathologic spinal Pathologic spinal fracturefracture
Spinal painSpinal pain
InstabilityInstability Compression Compression of the neural of the neural
tissuestissues
Neurologic Neurologic deficitdeficit
Thyroid metastasis
Neurologic deficitNeurologic deficit
Diagnosis Diagnosis of of
spinal tumorsspinal tumors
Plain x-rays
CT - scan
3D
M.R.I.
SCANNINGTc 99 MDP
P.E.T.P.E.T.
C.T. – guided percutaneous needle - biopsy
Biopsy of the spine
Angiography
Management Management
ChemotherapyChemotherapy
Radiation therapy Radiation therapy
Surgery Surgery
Pre - radiation Post - radiation
Chordoma
Radiotherapy 60g(proton therapy)
Courtesy Ath. Dimopoulos (Metropolitan)
RadiotherapyRadiotherapy
Stereotactic radio intervention following kyphoplasty
Courtesy Ath. Dimopoulos (Metropolitan)
Malignant primary tumors Malignant primary tumors of the of the
cervical spinecervical spine
Factors for evaluationFactors for evaluation::– The biology of the tumorThe biology of the tumor– The locationThe location– The painThe pain
– The neurologic deficitThe neurologic deficit
– The spinal instabilityThe spinal instability
– Life expectancy Life expectancy – Overall condition of the patientOverall condition of the patient
Aboulafia A. Levine A., OKU Spine 2, 2004
1. Spinal instability2. Pain resistible to
conservative treatment (radiotherapy – chemotherapy)
3. Incomplete neurologic deficit resistible to any type of conservative treatment
4. Rapid deterioration of the neurologic deficit
Indications for operative treatmentIndications for operative treatment
Enneking’s surgical Enneking’s surgical staging classification systemstaging classification system
Enneking, WF et al, Clin Orth, 1980
Weinstein-Boriani-Biagnini Weinstein-Boriani-Biagnini Surgical classification systemSurgical classification system
Weinstein et al, 21st ISSSL annual meeting 1994
Tomita’s staging classification system Tomita’s staging classification system for the primary tumors of the spinefor the primary tumors of the spine
Intra-compartmental Extra-compartmental Multiple skip lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site (1 or 2 or 3)
Anterior or posteriorLesion in situ
Site (1 +2 or 3 + 2)
Extension to pedicle
Site (1 +2 +r 3)
Anterio-posterior development
(any site + 4)Epidural extension
(any site + 5)Paravertebral development
Involvement toadjacent vertbra
Tomita T, et al, Spine 2001
Chondrosarcoma Chondrosarcoma
The most common The most common malignant tumor of malignant tumor of the bone in the the bone in the spinespine
7% - 12% of all 7% - 12% of all spine tumors spine tumors
M. Riz.
F 41
15-6-1997
Metastatic tumors Metastatic tumors of the of the
cervical spinecervical spine
Lung metastasisLung metastasis
Tokuhashi scoring system
Tomita surgical staging
Karnofsky performance status scale definitions rating (%) criteria
Methods of evaluation
E. Kar.
F 52
4-6-1991
Tokuhashi’sTokuhashi’s Evaluation System for Evaluation System for prognosis of metastatic spinal tumorsprognosis of metastatic spinal tumors
Symptoms Symptoms 00 11 22
General condition General condition performance statusperformance status
Poor Poor (PS 10% to 40%)(PS 10% to 40%)
ModerateModerate(50% to 70%)(50% to 70%)
GoodGood(80% to 100%)(80% to 100%)
No of extraspinal No of extraspinal skeletal metastasesskeletal metastases
>3>3 1 to 21 to 2 00
Metastases to Metastases to internal organsinternal organs
UnremovableUnremovable RemovableRemovable No metastasesNo metastases
Primary site of tumorPrimary site of tumor Lung stomachLung stomach Kidney liver uterus Kidney liver uterus unknownunknown
Thyroid prostate Thyroid prostate breast rectumbreast rectum
Number of Number of metastases metastases
>3>3 22 11
Spinal cord palsySpinal cord palsy CompleteComplete IncompleteIncomplete None None
Tokuhashi, Y. et al, Spine 1990
Total score versus survival period:
9 to 12 points > 12 months survival
0 to 5 points < 3 months survival
These criteria allow the definition of a pre-operative strategy and therefore considerable variability in the choice of treatment ranging:
• excisional operation should be performed on those who scored above 9 points
• a palliative operation should be performed on those who scored under 5 points
Tokuhashi Y. et al. Spine 1990
Simpler system of preoperative evaluation based on only three parameters:
• the degree of malignacy
• the presence of visceral metastases
• the presence of bony metastases.
Tomita K. et al. Spine 2001
Bauer H. et al. Spine 2002
Tomita’s classification systemTomita’s classification systemIntra-compartmental Extra-compartmental Multiple skip
lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site (1 or 2 or 3)
Anterior or posteriorLesion in situ
Site (1 +2 or 3 + 2)
Extension to pedicle
Site (1 +2 +r 3)
Anterio-posterior development
(any site + 4)Epidural extension
(any site + 5)Paravertebral development
Involvement toadjacent vertbra
Tomita T, et al, Spine 2001
Palliative treatment, generally produces modest results, but contributes greatly to the quality of life.
Moreover, it is reasonable to use palliative means when life expectancy is only:
4 to 15 months.
Wise J.F. et al Spine 1999.
Bouer H. et al. Spine 2002.
Palliative treatmentPalliative treatment
Pneumon’ s metastasis
Posterior decompression & stabilization
Surgical procedures
Vast majority can be managed Vast majority can be managed with dorsal fixationwith dorsal fixationRarely is ventral decompression Rarely is ventral decompression indicated or necessary indicated or necessary Preoperative spinal fracture Preoperative spinal fracture reduction may be attempted reduction may be attempted with awake tractionwith awake tractionVentral decompression may be Ventral decompression may be indicated to decompress indicated to decompress significant ventral tumor causing significant ventral tumor causing persistent spinal cord persistent spinal cord compression compression
Moulopoulos et al, Clin Imaging 1997Poynton Asley et al, Cancer in the spine, 2006
Atlanto-axial metastatic Atlanto-axial metastatic spinal tumorsspinal tumors
Breast’s cancer
A. St.F: 81N(+)
Mastectomies 35 yrs ago
a. Posterior decompression and Occipitocervical stabilization
b. Post-operative adjuvant chemotherapy - radiotherapy
N(-)N(-)
3 yrs pop
A. StF-84 yrs
14-7-2011
Metastastic disease of the Metastastic disease of the subaxial cervical spine is subaxial cervical spine is more common than the more common than the atlanto-axial spineatlanto-axial spine
As with atlanto-axial tumors As with atlanto-axial tumors the majority of the patients the majority of the patients can be managed with can be managed with radiation therapyradiation therapy
Sub-axial cervical spine Sub-axial cervical spine metastatic tumorsmetastatic tumors
El. ZaM 5614-10-2009
N(+)vePneumon’s metastasis
Anterior procedureAnterior procedure– Corpectomy Corpectomy – Vertebral body Vertebral body
replacement by replacement by expandable cage - expandable cage - Peek E.C.S. (Zimmer)Peek E.C.S. (Zimmer)
– Stabilization with plate Stabilization with plate and screws and screws Zephyr (Medtronic)Zephyr (Medtronic)
1st op.
Posterior Posterior procedureprocedure– Cervico thoracic Cervico thoracic
level level
– StabilizationStabilization
Complications Complications
Intra-operative Postoperative
Intra-operative Intra-operative complicationscomplications
Wound dehiscenceNeurologic deteriorationImplants dislodgement or brokeninfections
Post-operative complications
Post-operative complementary
treatment
Radiation therapy
of spinal metastases
Tombolini Y. et al 1994
Ortho - Athens
Best to start > 3wks post - op
Conclusions:Conclusions:
is treated successfully only by operative
procedure
Spinal instability due to bone destruction
Breast’s metastasisBreast’s metastasis
C3
Prosthetic replacement Prosthetic replacement is indicated in case of is indicated in case of vertebral destructionvertebral destruction
at one or two at one or two consecutive vertebraeconsecutive vertebrae
Benign spinal tumorsBenign spinal tumorsMalignant primary spinal Malignant primary spinal tumorstumorsSelected cases of Selected cases of metastatic spinal tumorsmetastatic spinal tumors
Posterior stabilization is recommended:
• For multiple metastases
• Poor general condition
• Short life expectancy
Thyroid metastasis
Anterior vertebral replacement and Anterior vertebral replacement and anterior – posterior stabilizationanterior – posterior stabilization
1. Is indicated in excessively unstable spineand
2. It gives the best overall results
University Hospital “ATTIKON”