SURGICAL MANAGEMENT OF METASTATIC TUMORS OF THE CERVICAL SPINE

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1 Copyright 2013 Medical University Plovdiv doi: /folmed SURGICAL MANAGEMENT OF METASTATIC TUMORS OF THE CERVICAL SPINE Atanas N. Davarski*, Borislav D. Kitov, Christo B. Zhelyazkov, Stefan D. Raykov, Ivo I. Kehayov, Ilyan G. Koev, Borislav M. Kalnev Department of Neurosurgery, Medical University, Plovdiv, Bulgaria ABSTRACT OBJECTIVE: To present the results from the clinical presentation, the imaging diagnostics, surgery and postoperative status of 17 patients with cervical spine metastases, to analyse all data and make the respective conclusions and compare them with the available data in the literature. PATIENTS AND METHODS: The study analysed data obtained by patients with metastatic cervical tumours treated in St George University Hospital over a period of seven years. All patients underwent diagnostic imaging tests which included, separately or in combination, cervical x-rays, computed tomography scan and magnetic-resonance imaging. Severity of neurological damage and its pre- and postoperative state was graded according to the Frankel Scale. For staging and operating performance we used the Tomita scale and Harrington classification. RESULTS: Seven patients had only one affected vertebra, 4 patients - two vertebrae, one patient - three vertebrae, 2 patients - four vertebrae, and in the other 3 patients more than one segment was affected. Surgery was performed in 12 patients. One level anterior corpectomy was performed in 6 patients, three patients had two-level surgery, and one patient - three-level corpectomy; in the remaining 2 cases we used posterior approach in surgery. Complete corpectomy was performed in 4 patients, subtotal corpectomy was used in 6 patients and partial - in 2 patients. Anterior stabilization system ADD plus (Ulrich GmbH & Co. KG, Ulm, Germany) was implanted in 2 patients; in 8 patients anterior titanium plate and bone graft were used, and in 1 patient - posterior cervical stabilization system. CONCLUSIONS: Because of the pronounced pain syndrome and frequent neurological lesions as a result of the cervical spine metastases use of surgery is justified. The main purpose is to maximize tumor resection, achieve optimal spinal cord and nerve root decompression and stabilize the affected segment. Key words: surgery, metastasis, spine INTRODUCTION The social importance and incidence of vertebral metastatic tumors causing pain and/or neurologic deficit thus adversely affecting the patients quality of life increase with the aging of the population. This disease poses an interdisciplinary problem that requires the combined efforts of neurosurgeons, oncologists, radiotherapists and physiotherapists. 1-3 Bone metastases are the third most common malignancy involving bone and come after those of the lungs and liver in the frequency list, while the predominant cases of metastasis in bones are spinal. 2,4,5 The spread of metastases occurs mainly via the blood, which explains the much more frequent involvement of well-vascularized vertebral bodies at the expense of less frequent involvement of elements of the back vertebral column - pedicles, arches and processes. 5,6 Spinal metastases have been found in 30-70% of all autopsied cancer patients, but only 14%-20% of these were symptomatic before death. 1 Over 95% of spinal metastases have extradural location while pure intradural lesions are rare. 2 The cervical segment of the spine is affected by metastases only in 10-15% of all cases, but the disease poses a real risk leading to severe disability, while on the other hand offering opportunities for greater radicalism in its surgical treatment. 2,4,7,8 The clinical picture of cervical spine metastases almost always starts with the predominant symptom of pain which is of three types: constant localised pain, radicular pain and axial pain. 1 The pain is characterized most often with considerable intensity *Correspondence and reprint request to: A. Davarski, Department of Neurosurgery, Medical University, Plovdiv atanas.davarski@gmail.com; Mob.: A Vassil Aprilov Blvd., 4002 Plovdiv, Bulgaria Received 1 February 2013; Accepted for publication 11 November

2 A. Davarski et al to which, constituting a significant percentage in all cases, is the added segmental and conductive neurological deficit. 9 Modern methods of imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), make it possible to fine-tune both the degree of the lesions and the relationship of the tumor with the neural elements and paravertebral structures. In proven cases of cancer performing bone scintigraphy must also be considered, allowing early detection of metastatic lesions. 10 The main indications for surgery are therapyrefractory pain, neurological deficit, histologically proven malignant process with obscure primary site, instability of the affected segment, and failure of prior radiotherapy and/or chemotherapy. 2,4 The goals of surgical intervention in metastatic cervical spine tumors are maximal tumor resection and decompression of neural structures as well as a subsequent reconstruction and stabilization of the affected segment. 2,11 The combination of surgery with radiotherapy and chemotherapy is an essential approach to prolonging the patient s life and improving their quality of life on the basis of optimal control of the oncological disease. 6,12 AIM To present the results of preoperative clinical picture in patients with secondary cervical spine malignancies and the impact of surgery - the volume of tumor resection, the medullary decompression and stabilization of the segment on neurological status and quality of life in the early postoperative period. Another goal we had in the study is to analyze the material and draw conclusions based on the literature review. PATIENTS AND METHODS The data presented concern the patients treated in the Clinic of Neurosurgery, St. George University Hospital - Plovdiv for secondary cervical spine malignancies between 2004 and The total number of patients with metastatic spinal tumors for the period were 123, with those in the cervical area Twelve of them were operated, and the other five were treated conservatively. The ratio of men to women was 10:7. The age of the patients in our series ranged between 24 and 75 years, with mean age of 56.9 years; mean age of operated patients years; mean age of unoperated patients years. In 7 of the patients the primary site was found at admission into the Clinic of Neurosurgery, while in 4 it was unknown. As for the remaining 6 patients, the period between detecting the primary site and their hospitalization at the clinic ranged from 6 to 48 months. Local and/or radicular pain was found in all 17 patients, in 14 of them there were neurological symptoms of listlessness of varied severity. No detectable neurological deficit was found only in 1 patient of all who had undergone surgical intervention. Severity of neurological damage, as well as its dynamics before and after surgery, were assessed according to Frankel Scale of degrees of neurological deficit. Imaging diagnostics was administered to all patients, including single or combined use of cervical spondilography, CT and MRI. The treatment plan was determined in view of the clinical and imaging results. For staging and operating performance we used the Tomita scale and Harrington classification. In order to achieve an optimal therapeutic effect in any of the patients in our series, after a comprehensive analysis of the clinical picture and the degree of spinal involvement, we used different surgical techniques. Our surgical strategy was driven primarily by the location of metastasis to the vertebral column, the number of affected levels, the involvement of neural structures, the existing instability of the affected segment or the potential of such induced by surgery. We used posterior approach only in two patients with whom the metastasis was located only in the third column. When performing surgery we strived to achieve maximal resection of tumor process, decompression of neural structures and stabilization of the affected spinal segment without causing aggravation of symptoms. In 11 of the operated patients we had to stabilize the affected segment, which was achieved through the application of different types of implants and stabilizing systems. In two of the patients ADD plus system (Anterior distraction device plus) (Fig. 1) was used, in 8 cases bone graft fixed with titanium plate (Fig. 2), and in 1 patient with implemented 4 level laminectomy, we applied posterior cervical instrumentation. Contraindications for surgery were the multiple metastases and presence of extraspinal metastases - in three patients, poor general condition and pronounced anemia and immunosuppression - in 1 patient, and in one case the patient categorically refused surgery Medical University Plovdiv

3 Surgical Management of Metastatic Tumors of the Cervical Spine Figure 1. Left: Sagittal T2-weighted MRI demonstrating extradural tumor process involving the C4 and C5 vertebrae and exercising medullary compression (non-hodgkin s lymphoma, histologically verified). Right: Postoperative profile spondilography after performed corporectomy C4 and C5 vertebrae with subsequent anterior C3-C6 corporodesis through front distraction device (ADD plus ). Figure 2. Left: Sagittal T2-weighted MRI demonstrating extradural tumor with involvement of the C6 vertebra exercising medullary compression (Metastatic fibrosarcoma -histologically verified). Right: Postoperative profile cervical radiography after corporectomy of C6 vertebra with subsequent anterior C5-C7 corporodesis through bone graft and a titanium plate Medical University Plovdiv 41

4 A. Davarski et al RESULTS There were recorded no complications and deaths in the operated patients with regard to the metastatic cervical spine in our series. In the immediate postoperative period, reduction of local and radicular pain was reported in 10 patients, while the remaining 2 patients showed no dynamics in the intensity of the pain. There was also improvement in symptomatic neurological listlessness, with 9 patients joining the more favorable class by the Frankel scale for degree of neurological deficit, while the other 3 did not change their status. Table 1. Primary site of secondary malignant tumors in our series Histological verification Primary site n = 17 Non-Hodgkin s lymphoma 3 Squamous cell carcinoma Lung 3 Ductal adenocarcinoma Mammary gland 3 Fibrosarcoma Hip 1 Adenocarcinoma Thyroid gland 1 Adenocarcinoma Prostate 1 Adenocarcinoma Stomach 1 Poorly differentiated carcinoma Unclear 2 No histological result Unclear 2 Table 2. Severity of the clinical picture by Frankel scale Class Severity of neurological symptoms n = 17 A Complete loss of motor and sensory function 1 B Complete motor and incomplete sensory damage 1 C Severe, but incomplete motor and partial sensory damage 8 D Partial motor and sensor damage 4 E Normal motor and sensory function 3 Table 3. Classification of spinal tumors according to Tomita Type Degree of involvement of the spine n = 17 1 Involving only the vertebral body 1 2 Involvement of the vertebral body and pedicle 4 3 Involvement of the vertebral body, pedicle, arches and branches 2 4 Involving the epidural space 1 5 Paravertebral sprouting 2 6 Involvement of 2-3 adjacent vertebrae 4 7 Multiple vertebral involvement of different spinal segments Medical University Plovdiv

5 Surgical Management of Metastatic Tumors of the Cervical Spine Table 4. Harrington classification of conduct for spinal tumors Class Severity of neurological and bone damage Conservative treatment n = 5 1 Without focal neurological symptoms or minimal sensory deficit 2 2 Bone lesion without vertebral body collapse or instability of the segment 1 Surgical treatment n = 12 3 Pronounced neurological deficit without significant bone destruction Vertebral body collapse and instability with minor neurological deficit 5 5 Vertebral body collapse, instability and pronounced neurological deficit 6 Table 5. Surgical techniques used in the study Surgical technique n = 12 Corporectomy of 1 vertebra 6 Corporectomy of 2 vertebrae 3 Corporectomy of 3 vertebrae 1 Level 1 laminectomy 1 4 level Laminectomy 1 Table 6. Volume of tumor resection Volume of tumor resection n = 12 Total 4 Subtotal 6 Partial 2 DISCUSSION The data presented in our report on the frequency of metastases in the cervical area in relation to the other parts of the spine and their distribution by age and sex are consistent with the results in most publications on the topic. In our research of Bulgarian medical literature we came across a study by Kalevski and colleagues from the Medical University of Varna, published in the journal Military medicine in 2009, with results and conclusions largely similar to those in our series. With the introduction of modern methods of diagnosis and treatment, the survivability of patients with certain types of neoplastic processes has significantly increased and reached two or more years. 3 Within this period it is not rare that we observe spread of metastases to distant organs and systems including to the spine. In our series a symptomatic metastasis in the cervical spine occurred after detection of the primary site between 6 and 48 months. This requires in the first months after the discovery of the malignancy to perform bone scintigraphy to detect the still nonsymptomatic spinal metastases in order to apply radiotherapy and/or chemotherapy, and possibly, the significantly more minor surgical procedures such as percutaneous vertebroplastics. 2 In the presence of symptomatic spinal cord metastasis, unresponsive to conservative treatment, surgery is the only means to reduce pain in the patients, improve their neurological deficits, take material for histological treatment and eventually improve their quality of life and provide maximum independence. This is achieved by decompression of the neural structures and stabilisation of the affected segment. Complete removal of metastatic tumors is not always possible and should not be a central objective of the intervention. On the other hand, the introduction of modern construction and reconstruction surgical techniques provide significantly greater opportunities for maximal tumor resection. It should be borne in mind that laminectomy performed through posterior operational approach does not allow the maximal removal of the vertebral body of the neoplasm. This is accomplished through anterior approach, which allows elimination of the tumor and the affected vertebral body and achievement of direct decompression of the spinal cord and nerve roots. Certainly the indications for surgical treatment must be specified in the light of the expected survivability and the potential effect of surgery on the patients general condition. The preoperative neurological deficit and its duration, the number of affected vertebrae, the localization of spinal compression, the presence of other visceral metastases and the patient s general state are all factors that determine both the type of surgery and the prognosis of the disease. Cervical 2013 Medical University Plovdiv 43

6 A. Davarski et al localization of secondary malignancies favors the possibility of total or subtotal tumor resection and decompression of neural structures, while modern methods of reconstruction make maximum stabilization possible. CONCLUSIONS In conclusion, we believe that surgical treatment in patients with metastatic lesions localized in the cervical segment of the spine is a treatment of choice in modern behavioral algorithm. The indications for surgical treatment are drug refractory pain, progressive neurological deficit, obscure localization and histology of the primary site and instability of the affected segment. Surgery should be performed after a rigorous selection of patients with a longer period of expected survivability, as the primary drive should be improving the quality of life and facilitating patients maximum independence in meeting their daily needs. REFERENCES 1. Kassamali RH, Ganeshan A, Hoey ETD, et al. Pain management in spinal metastases: the role of percutaneous vertebral augmentation. Ann Oncol 2011;22(4): Bartels RM, van der Linden YM, van der Graaf WT. Spinal extradural metastasis: review of current treatment options. CA Сancer J Clin 2008;58;(4): Georgy BA. Metastatic spinal lesions: state-of-the-art treatment options and future trends. Am J Neuroradiol 2008;29(9): Кalevski S, Peev N, Haritonov S, et al. Surgical treatment of metastatic spinal neoplasms in thoraco-lumbal region. Indications, strategy, early postoperative results. Mil med (Sofia); 2009;4:22-6 (Bulgarian). 5. Acosta F, Aryan H, Chi JH, et al. Modified paramedian transpedicular approach and spinal reconstruction for intradural tumors of the cervical and cervicothoracic spine. Spine 2007;32(6):E Chi JH, Gokazlan ZL. Vertebroplasty for spinal metastases. Curr Opin in Support and Palliat Care. 2008;2(1): Agarawal JP, Swangsilpa T, van der Linden Y, et al. The role of external beam radiotherapy in the management of bone metastases. Clin Oncol (R Coll Radiol) 2006;18: Pilge H, Holzapfel BM, Prodinger PM, et al. Diagnostics and therapy of spinal metastases. Orthopade 2011;40(2): Heidecke V, Rainov NG, Burkert W. Results and outcome of neurosurgical treatment for extradural metastases in the cervical spine. Acta Neurochir 2003;145: Courtois AC, Colliqnon Y, Brugere PY, et al. Single cervical metastasis of breast cancer. Rev Med Liege 2011;66(5-6): Falicov A, Fisher C, Sparkes J, еt al. Impact of surgical intervention on quality of life in patients with spinal metastases. Spine 2006;31;(24): Thomas KC, Nosyk B, Fisher CG, et al. Costeffectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression. Int J Radiat Oncol Biol Phys 2006;66: ХИРУРГИЧЕСКИЕ АСПЕКТЫ ЛЕЧЕНИЯ МЕТАСТАТИЧЕСКИХ ОПУХОЛЕЙ НА ШЕЙНОМ УЧАСТКЕ ПОЗВОНОЧНОГО СТОЛБА А. Даварски, Б. Китов, Х. Желязков, С. Райков, И. Кехайов, И. Коев, Б. Калнев РЕЗЮМЕ ЦЕЛЬ: Представить результаты клинической картины, образной диагностики, проведенного лечения и постоперативных результатов у 17 пациентов с метастатическими опухолями на шейном участке позвоночника, анализировать материал и сделать соответствующие выводы, которые сопоставляются с литературными данными. ПАЦИЕНТЫ И МЕТОДЫ: Анализированы данные лечения в клинике нейрохирургии, УМБАЛ им. «Святого Георгия», пациентов с метастатическими шейными опухолями в течение 7 лет. Во всех случаях проведена образная диагностика, включающая самостоятельно или в сочетании шейные спондилографии, компьютерную томографию и магнитную резонансную томографию. Тяжесть нейрологического повреждения и его динамику до и постоперативно определяли по классификации Frankel. В целях определения стадии заболевания и оперативного поведения использовали шкалу Tomita и классификацию Harrington. РЕЗУЛЬТАТЫ: У 7 пациентов поражен один позвонок, у 4 два соседних, у 1 три, у 2 четыре, а у остальных трех пациентов затронуто более одного сегмента. Оперативная интервенция проведена на 12 пациентах; корпорэктомия на одном уровне - на 6 пациентах; на двух уровнях на трех пациентах; на трех уровнях на одном больном; в остальных двух случаях применен задний оперативный доступ. Тотальное устранение достигнуто у 4 больных; субтотальное у 6; парциальное у 2. Стабилизация затронутых сегментов в двух случаях достигнута посредством системы ADD+ (Ulrich GmbH & Co Medical University Plovdiv

7 Surgical Management of Metastatic Tumors of the Cervical Spine KG, Ulm, Germany); у 8 больных использованы титаниевая пластинка и аутотрансплантат, а у одного пациента задняя шейна стабилизация. ВЫВОДЫ: Выраженный болевой синдром и частое поражение невральных структур метастазами в области шейного участка позвоночного столба оправдывают их оперативное лечение, при чем основной целью является максимальная резекция опухолевой массы, декомпрессия позвоночного мозга и корешков, а также и стабилизация пораженного сегмента Medical University Plovdiv 45