Management of Malignant

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Management of Malignant Lesions of the
Spine Treatment algorithm and challenges
Bassem A. Georgy, M.D.,Valley Radiology
ConsultantsAssistant Clinical Professor,Universi
ty of California, San Diego
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Financial Disclosure

• Consultant DePuy Spine
• Consultant Arthrocare
• Consultant Boston Scientific

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Overview

• Epidemiology
• Patient Evaluation
• Technical difficulties
• Treatment algorithm
• Challenging situations

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Epidemiology

• Metastasis are the most common spinal tumors
• Vertebral body is the most common site
• 40 of cancer patients develops vertebral
  metastasis
• Breast 75
• Lung 35
• Renal 25

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Technical Difficulties

• Complication rate is 3-4 times more in malignant
  compression fractures compared to benign ones
  (Mathis AJNR 2001).
• Why!
• Epidural extension
• Cortical disruption (specially posterior)
• Para spinal extension
• Distal metastasis
• General condition

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Patient Evaluation

• MRI
• Degree of compression
• Epidural extension
• Paraspinal extension
• Other lesions
• Vascularity
• CT
• Location of the lesion
• Cortical disruption
• Extension into pedicles
• Bone Scan
• Coagulopathy
• Other treatments (Radiation therapy or
  chemotherapy)

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Biomechanics of Pathologic Spine Fractures

• Center of gravity (CG) moves forward
• Large bending moment created
• Posterior muscles and ligaments must
  counterbalance increased bending
• Anterior spine must resist larger compressive
  stresses

CG
White III and Panjabi 1990
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Surgical Techniques

• Anterior Approach
• Corpectomy
• Direct access to the tumor
• Effective reconstruction of the weight
• bearing anterior column

Zone III
Zone IV
Most difficult to treat May require both
approaches
Zone II
Zone I

• Posterior approach
• Decompresive Laminectomy with or without
• Instrumentation
• Does not treat actual tumor
• Does not address instability if lesion anteriorly

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Background

• In Malignant lesions every effort should be done
  to deposit cement anteriorly
• Add to stabilization
• Influence surgical treatment
• Epidural extension
• Posterior cortical defect

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No Cortical disruption No Epidural extension No
Pedicle extension
Consider Routine VP or KP

• No place for height restoration
• Tumor displacement (use a small balloon)
• Thick cement to avoid leakage
• Does thick cement can displace tumor!

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5 min 8 min 11 min
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86 years old women with breast cancer and treated
with chemotherapy
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L2
L4
L5
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KP
VP
VP
Biopsy Low grade lymphoma Confidence system
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80 years old with lymphoma solid bone
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Consider Coblation Followed by cementation
Cortical disruption Epidural extension Pedicle
extension
Consider RF/ Cryo/ embolization Followed
by cementation
Para-spinal soft tissue extension
Notes Consider myelogram if no posterior
cortex Consider arterial embolozation before
cementation if vascular lesion Cosider
neuromountering if tumor extend into pedicle
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Advanced casesDefective posterior cortex and
epidural extension
Create a cavity
Controlled delivery of cement inside
the vertebral body can be achieved by creating a
cavity inside the vertebral body
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cancer 71 years old women with Undefrentiated
cancer and sacral lesion
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Coblation and cement distribution

• 34 levels
• CT before and after procedure
• 75 or more of the cement in the anterior 2/3 of
  the vertebral body in 28 levels
• 9 levels, 100 of cement in anterior column
• Leakage rate 52, Cotten et al 1996 72)

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Consider Coblation Followed by cementation
Cortical disruption Epidural extension Pedicle
extension
Consider RF/ Cryo/ embolization Followed
by cementation
Para-spinal soft tissue extension
Notes Consider myelogram if no posterior
cortex Consider arterial embolozation before
cementation if vascular lesion Cosider
neuromountering if tumor extend into pedicle
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MM
Renal cell cancer
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Dehydrated Alcohol injection Recurrent Renal cell
metastasis After Radiation
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Lung Cancer Patient refused Radiofrequency
treatment
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77 years old women History of Melanoma
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Neuro Monitoring
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Final diagnosis Plasmacytoma
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Metastatic Lung cancer
JR
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SummaryCement Augmentation in Malignant
Compression Fractures

• CT examination
• Posterior cortex
• Epidural extension
• Pedicles
• Thick Cement
• Anterior deposition of cement

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Sacral lesions

• CT or fluoroscopy guidance
• One or more than one needle can be used.

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66 years old male with Multiple Myeloma
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83 years old man with lymphoma
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Benign Lesions
Aneurysmal Bone Cyst in 25 y old female, TW2
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Benign Lesions
CT guided Injection Of Calcitonin Steroids
Spine 200025527-30
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Benign Lesions
3 month
6 month
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Osteosarcoma in a 12 years old dog
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