Is minimally-invasive spinal surgery a reliable treatment option in symptomatic spinal metastasis?

OBJECTIVE: Up to 70% of patients with cancer are likely to develop spine metastasis. Radiation therapy is the standard of care for painful spinal metastases in absence of unstable or impending fractures. More frequently these patients require open palliative surgery for pain, vertebral collapse and neurological deficits. Minimally Invasive Spine Surgery (MISS) techniques using percutaneous pedicle screw fixation may be considered as an alternative to open surgery in selected cases. MISS techniques are thought to be associated with fewer tissues damages resulting in early pain relief, they also allow for early mobilization and optimization of function. PATIENTS AND METHODS: From 2011 to 2018, 52 patients affected by spinal metastasis were treated with MISS techniques in Rizzoli Orthopaedic Institute of Bologna and in Cisanello Hospital of Pisa, Italy. All patients underwent percutaneous pedicle screw fixations (PPSF) coupled with mini-decompressions in case it was required by spinal cord compressions. All patients were evaluated pre and post-operatively by Frenkel classification and VAS scores. RESULTS: Mean follow-up time was 19,4 months. Preoperatively, Frankel scores were E in 37 patients, D3 in 6 patients, D2 in 3 cases, D1 in 3 patients, B in one patient and C in two. The Frankel score improved in 10 patients, remained stable in 40 patients and worsened in two patients. Preoperatively, the mean VAS score in 29 patients treated with PPSF procedure with spinal decompression was 7, while postoperatively, it became 5. In 23 patients who underwent only PPSF procedure without spinal decompression mean VAS score was 5, postoperatively it became 3. CONCLUSIONS: In selected cases, MISS surgeries may be considered as a valid alternative to open surgery. Although the efficacy of PPSF has been well documented in trauma or degenerative spine surgery, there is not sufficient literature about MISS techniques in spinal metastasis and further studies are needed to elucidate the most appropriate patient in which this approach could represent the gold standard of treatment

Indications and Limits of Surgery for Spinal Metastases Derived from Lung Cancer: A Single-Center Experience

Lung cancer is the second most frequently diagnosed cancer in the world, and surgery is an integral part of the treatment for spinal metastases. The aims of this retrospective study were to assess the overall survival of surgically treated patients affected by lung cancer spinal metastases and identify any factors related to a better survival rate. We recruited 56 consecutive patients (34 male and 22 female) surgically treated for metastatic lung cancer in the spine from 2009 to 2019. Surgical indications were based on a previously published and validated flow chart following a multidisciplinary evaluation. We assessed the localization of vertebral metastases, the presence of other bone or visceral metastases, neurological status according to the Frankel score, ambulatory autonomy, and general status, measured with the Karnofsky performance scale. The expected prognosis was retrospectively assessed according to the revised Tokuhashi score. The median survival was 8.1 months, with over a third of patients surviving more than 1 year. We observed a global improvement in all clinical parameters after surgical treatment. The Tokuhashi predictive score did not correlate with survival after surgery. The results of this study suggest that the surgical treatment of symptomatic spinal metastases from lung cancer can improve quality of life, even in patients with a shorter life expectancy, by controlling pain and improving autonomy

XXXVI Congresso Nazionale SICV&GIS - "Perchè le scoliosi dell'adolescenza spesso giungono alla prima osservazione ortopedica con curve gravi?"

Trattamento conservativo della scolios

Polymethylmethacrylate-augmented fenestreted pedicle-screw fixation in low bone quality patients: a case series and literature review

The use of pedicle screws in low bone quality patients implicates risks of secondary implant loosening for grip lack. In fact, the result is a reduced mechanical stability at bone-screw interface and consequently an increased chance of pullout and hardware failure. Augmentation techniques have been described for many years and fenestrated screws that allow cement injection is one of them. This is a retrospective observational study of patients treated at our department with polymethylmethacrylate- (PMMA) augmented fenestrated screws. Indications for posterior instrumentation were traumatic fracture in osteoporotic spine, oncological disease, post-traumatic deformity, degenerative disease, revision surgery and sickle cell disease fractures. Implant stability was evaluated with X-Rays and CT scan performed 3 days after surgery and every 3 months during the follow-up. Accuracy of screw placement was evaluated with Heary classification. Fifty-three surgical treatments in 52 patients were performed and 247 PMMA augmented fenestrated screws were placed. According to the Heary classification, 96.21% resulted Grade I, 1.8% Grade II, 2% Grade IV. A total of 17 complications occurred. Fenestrated screw augmentation should be performed in selected patients in whom the bone quality is insufficient to guarantee implant stability. These screws may result useful in complex cases as revision surgeries, osteoporosis and tumour affections where bone quality is highly compromised

Composite peek/carbon fiber pre-shaped rods and sublaminar bands for posterior stabilization of cervico-thoracic junction: A novel technique

The combination of surgery plus radiotherapy is a valid treatment option when en bloc resection with wide margins is not feasible. The aim of this paper is to show a novel technique for fixation of cervico-thoracic junction with carbon fiber reinforced peek pre-shaped rods with sublaminar bands in order to guarantee cervical spine stability and particle therapy efficacy. A 42 years-old man with a Sclerosing Epithelioid Fibrosarcoma (SEF) arising from C7, involving the right latero-cervical region from C5 to the apex of the right lung, underwent an en bloc resection with a double approach (anterior plus posterior). Fixation of cervical spine was achieved with composite PEEK/carbon fiber rods connected to C4 and T2 laminae with sublaminar bands. After surgery, the patient received 9 cycles of chemotherapy (cisplatin, etoposide and adriamycin) and proton therapy. At 2 years follow-up, no local recurrence was detected with implant stability demonstrating no mechanical failure. The main issues related to this case were: planning en bloc resection able to achieve an Enneking appropriate margin; incorporate in the decision making process the functional loss related to the sacrifice of neurological structures infiltrated by the tumor; establish a therapeutic strategy that included, in addition to surgery, adjuvant chemotherapy and radiotherapy for improving local and systemic control; stabilize with implants that do not interfere with accelerated particle radiotherapy

[Artículo traducido] Manejo de metástasis sintomáticas de columna: un enfoque multidisciplinario basado en un diagrama de flujo

Resumen: Describimos un algoritmo para el manejo de las metástasis espinales en el que la importancia de los parámetros individuales varía dependiendo del momento en el que se contemplan.Cada paciente sigue su propio proceso secuencial «personal» que no necesariamente considera todos los parámetros cada vez, ya que algunos pueden ser irrelevantes a la hora de elegir el tipo de tratamiento para ese individuo. Por ejemplo, un paciente en mal estado general con una puntuación ASA alta generalmente no es candidato para la cirugía, independientemente de la naturaleza del tumor primario o del número de metástasis. Para este paciente, el elemento más importante sería la sensibilidad del tumor al tratamiento adyuvante. Del mismo modo, un paciente con lesión aguda y progresiva de la médula espinal se sometería a descompresión quirúrgica y estabilización sin considerar una intervención más agresiva. Abstract: We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated.Each patient follows his own «personal» sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high ASA score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention

Management of symptomatic spine metastases: A multidisciplinary approach based flow-chart

We described an algorithm for the management of spinal metastases in which the importance of single parameters varies depending on when they are contemplated.Each patient follows his own “personal” sequential process which does not necessarily consider all the parameters each time as some may be irrelevant for the purpose of choosing the type of treatment for that single individual. For instance, a patient in general poor condition with a high “ASA” score is usually not a candidate for surgery, regardless of the primary tumor nature or the number of metastases. For this patient, the most important element would be the sensitivity of the tumor to adjuvant treatment. Similarly, a patient with acute and progressive spinal cord injury would undergo surgical decompression and stabilization without considering a more strenuous intervention. Resumen: Describimos un algoritmo para el manejo de las metástasis espinales en el que la importancia de los parámetros individuales varía dependiendo del momento en el que se contemplan.Cada paciente sigue su propio proceso secuencial «personal» que no necesariamente considera todos los parámetros cada vez, ya que algunos pueden ser irrelevantes para el propósito de elegir el tipo de tratamiento para ese individuo. Por ejemplo, un paciente en mal estado general con una puntuación alta de «ASA» generalmente no es candidato para la cirugía, independientemente de la naturaleza del tumor primario o el número de metástasis. Para este paciente, el elemento más importante sería la sensibilidad del tumor al tratamiento adyuvante. Del mismo modo, un paciente con lesión aguda y progresiva de la médula espinal se sometería a descompresión quirúrgica y estabilización sin considerar una intervención más agresiva

Surgical Management of Multiple Myeloma and Plasmocytoma of the Spine

Multiple Myeloma (MM) is caused by the neoplastic proliferation of plasma cells that produce monoclonal immunoglobulins in the bone marrow thereby causing skeletal damage. Other MM-related complications include hypercalcemia, renal insufficiency, anaemia, and infections [1].</p

Image-guided Cryotherapy for Musculoskeletal Tumors

Background: This article represents a review about the use of image-guided cryotherapy in the treatment of musculoskeletal tumor lesions. Cryotherapy is able to induce a lethal effect on cancer cells through direct and indirect mechanisms. In this manuscript, we combined our experience with that of other authors who have published on this topic in order to provide indications on when to use cryotherapy in musculoskeletal oncology. Discussion: Image-Guided percutaneous cryotherapy is a therapeutic method now widely accepted in the treatment of patients with musculoskeletal tumors. It can be used both for palliative treatments of metastatic bone lesions and for the curative treatment of benign bone tumors such as osteoid osteoma or osteoblastoma. In the treatment of bone metastases, cryotherapy plays a major role in alleviating or resolving disease-related pain but it has also been demonstrated that it can have a role in local disease control. In recent years, the use of cryotherapy have also expanded for the treatment of both benign and malignant soft tissue tumors. Conclusion: Percutaneous cryotherapy can be considered a safe and effective technique in the treatment of benign and malignant musculoskeletal tumors. Cryotherapy can be considered the first option in benign tumor lesions such as osteoid osteoma and a valid alternative to radiofrequency ablation. In the treatment of painful bone metastases, it must be considered secondarily to other standard treatments (radiotherapy, bisphosphonate therapy and chemotherapy) where they are no longer effective in controlling the disease or when they cannot be repeated (for example radiotherapy)