Surgical Management of Metastatic Spine Disease · The NOMS framework: approach to the treatment of...

Surgical Management of

Metastatic Spine Disease

FANOR M. SAAVEDRA-POZO, MD NEUROSURGERY - SPINE SURGERY

ASSISTANT PROFESSOR OF NEUROSURGERY

UNIVERSITY OF PUERTO RICO

SAN JUAN, PUERTO RICO

EPIDEMIOLOGY

Spinal Metastasis

• 20% all Ptes. CANCER

• 5-10% Spinal Cord

Compression

• 70% Thoracic - (T/L)

• 40- 60 y/o

• Hematogenous >> Direct

Extension

• 80% Prostate, Breast, Lung

Presentation

Clinical

• Pain 84%

• Axial 60%

• Radicular 24%

• Neurologic Deficit

Imaging

• “X” Ray

• CT

• Sclerotic (slow growing)

• Lytic (fast growing)

• MRI

• Bone Scan (99m-Teg)

• PET Scan

Surgery: What is the Role?

• Neurologic Function

• Stability of the Spine

• Local Tumor Control

• Pain control

Surgical Goals

Palliative

Multidisciplinary Approach

• Systemic therapy:

• Chemo - Inmuno - Hormonal therapy

• Radiation therapy:

• Conventional EBRT

• Image guided Intensity Modulated RT

(IMRT)

• Spine Surgery:

• Cement Augmentation

• Anterior, Posterior, Combined

The NOMS framework: approach to the treatment of spinal metastatic tumors.

Laufer I1, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, Bilsky MH.Oncologist. 2013 Jun;18(6):744-51. doi: 10.1634/theoncologist.2012-0293. Epub 2013 May 24

Neurologic

Epidural Extension

High Grade

Low Grade

0 Intraosseous

1a,

1b,

1c

Epidural and thecal sac

2 Spinal Cord

Compression

with some CSF

3 Spinal cord compression

and No CSF

Oncologic:

Tumor Histology and Radiosensitivity

EBRT SRS

EBRT Surgery and SRS

Radiosensitive Radioresistant

Low Grade

epidural cord compression

High Grade

epidural cord compression

Oncologic:

Tumor Histology and Radiosensitivity

67 y/o M

Back Pain

Percutaneous

Biopsy

MM

The NOMS framework: approach to the treatment of spinal metastatic tumors.

Laufer I1, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, Bilsky MH.Oncologist. 2013 Jun;18(6):744-51. doi: 10.1634/theoncologist.2012-0293. Epub 2013 May 24

Post Radiation

The Spinal Instability

Neoplastic Score

(SINS)

MECHANICAL INSTABILITY

0-6 STABLE

7-12 UNDETERMINATE

13-18 UNSTABLE

SYSTEMIC DISEASE

Tokuhashi, Score

◼0-8 = <6 months

◼9-11 = >6 months

◼12-15 = >1 year

◼Intervention

◼0-8 = Conservative (RT)

◼9-11 = Palliativ Decompression

◼12-15 = Decompression Circunferential stabilizacion

Tokuhashi, et al, 1990 with revision in 1998

SYSTEMIC DISEASE

Review of metastatic spine tumour classification and indications for surgery: the consensus statement of the Global

Spine Tumour Study Group. Eur Spine J. 2010 Feb; 19(2): 215–222. Published online 2009 Dec 29.

doi: 10.1007/s00586-009-1252-x PMCID: PMC2899817

Tomita Score

Lancet 2005; 366: 643–48

Published online July 21, 2005

DOI:10.1016/S0140-6736(05) 66954-1

Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nat Clin Pract Neurol. 2006 Feb;2(2):87-94; quiz 116.

Witham TF1, Khavkin YA, Gallia GL, Wolinsky JP, Gokaslan ZL

OCT 2013

OCT 2013

Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases

Moulding HD1, Elder JB, Lis E, Lovelock DM, Zhang Z, Yamada Y, Bilsky MH.

J Neurosurg Spine. 2010 Jul;13(1):87-93. doi: 10.3171/2010.3.SPINE09639.

11/2013

11/27/2013

8/19/2014

9/2/2014

Gracias!