The surgical treatment of metastatic disease of the spine

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1 The surgical treatment of metastatic disease of the spine Péter Banczerowski National Institute of Neurosurgery, Budapest

2 Spine tumours 15% of the primary tumours of the CNS affect the spine The spine manifestation appear around 10% of cancer patient (growing ) Location: Extradural (55%) Intradural-extramedullary (40%) Intramedullary (5%)

3 Incidence 5-30% of cancer patient suffer from metastatic bone disease 60-70% affect the spinal coloumn The spine manifestation appear around 10% of cancer patient up to 80 cases per million people every year. Frequent in elderly (average 62 year) Frequent in male (60%)

4 Incidence 80% of spine metastatic tumour disease primarily originate from - Lung - Breast - Prostate - Gastro-intestinal - Melanoma - Lymphoma 20-40% of metastatic spine tumour cause neurological demage

5 Localisation Dorsal spine (40-60%) Lumbar spine (30-50%) Cervical spine (25%) Most frequent the epidural localisation (mainly bony structures) Intradural 2-4% Intramedullar 1-2%

6 Symptoms Pain also in rest (95%!) localised,spinal pain or neurogenic, radicular pain Weakness of the limbs (only 18% of patients were able to walk without help at the time of diagnosis 15% paraplegic) Sensory symptoms (50%) Autonomic dysfunction The median times from the onset of symptoms to time of diagnosis were 3 months

7 Pathomechanism Epidural or intradural metastatic tumour - direct tumour growth causing compression of the spinal cord or cauda equina Pathological vertebral body collapse causing spinal canal narrowing, instability and compression of the spinal cord More severe the developed neurological impairment at the time of intervention, more less the chance the recovery of the lost function

8 Guideline:

9 Diagnostic procedures X-ray (positivity 67-85%) MRI CT (bony structures) Bonescan (multiplicity) DSA (embolization) PET

10 The aim of the surgical intervention Elimination of neural compression pain attenuation, improvement of neurological function, prevent the progression Terminate the instability, statical restoration of spinal coloumn, prevent the fracture of vertebra Improve the quality of life Histology (unknown primary tu.) Palliation (surgical treatment do not increase the survival)

11 Contraindications Complet paraplaegia present more than 24h Expected survival time< 3-6 month Oncologically unmanageable widespread metastatic disease Relative kontraindications: Multiplicity of spine metastatic tumours Very sensitive tumor for radiotherapy (small cell (microcellular) pulmonary cancer) Poor performance status

12 Possibility of surgical interventions

13 C II metastatic disease

14 C II metastatic disease

15 HALO external fixation

16 Transoral approach

17 Tumour transoral removal & fixation

18 Occipito-cervical fixation

19 Occipito-cervical fixation

20 CII multiple myeloma

21 CII vertebroplasty, fixation

22 CII vertebroplasty, fixation

23 CII vertebroplasty, fixation

24 Metastatic breast cancer (CIII)

25 Corpectomy

26 360 o tumour removal & fixation

27 Cage, Lift spacer

28 Metastatic disease of cervicothoracic junction

29 Combined 360 o ventro-dorsal surgical removal

30 Thoracic epidural metastasis

31 Thoracic (ThXI) metastasis

32 Thoracic metastasis removal & fixation

33 Thoracic metastasis removal & fixation

34 Thoracic metastasis removal & fixation

35 Polysegmental fixation

36 Surgical removal of the body & fill with methylmetacrilát

37 L II metastasis

38 L II metastasis

39 Kidney cancer with multiple metastasis

40 Kidney cancer with multiple metastasis

41 What does it mean: inoperability?

42 Plasmocytoma, multiple body collapse

43 Non-Hodgkin lymphoma-radiotherapy

44 Pulmonary microcellular carcinoma - radiotherapy

45 Vertebroplasty Indication: Severe, focal pain Lytic lesions, with no neurology

46 Vertebroplasty

47 Spinal navigation

48 Thank you for attention!

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