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P40. Total En Bloc Spondylectomy for Lung Cancer Metastasis to the Spine: A Varied Prognosis
Proceedings of the NASS 23rd Annual Meeting / The Spine Journal 8 (2008) 1S–191S
121S
T10 ESCC. He underwent a T3-T10 laminectomy and FloSeal noted in the canal and was evacuated. He was ambulatory at two weeks and by six months he had complete recovery. The second patient was a 15 y.o. female who underwent T4-L1 PSF. Following screw insertion, deterioration in NMEPs and SSEPs was noted. Screws were removed and SCM data returned to baseline. Except for 3 screws that had an inferior breach (Left T7 and Bil. T8), screws were reinserted and remainder of the surgery was uneventful. Postoperative examination was normal initially but two days later, she developed left LE numbness/weakness. Implants were removed and MRI showed T4-T9 ESCC. She underwent a left (concave) T4-T9 hemilaminectomy. FloSeal was noted and was evacuated. Six weeks following surgery, she had a complete neurologic recovery. CONCLUSIONS: The use of FloSeal to decrease bleeding from cannulated pedicles during pedicle screw insertion can result in inadvertent extravasation into the spinal canal resulting in ESCC even in the absence of an apparent medial pedicle breach. Given the dangers associated with the technique, we recommend that gelatin matrix products be used judiciously in small aliquots or not at all during pedicle screw insertion.
METHODS: 6 patients (3 males and 3 females) without visceral or other bony metastases underwent TES. Mean age at surgery was 59 years. The histological type of the 6 patients was adenocarcinoma. Of the 6 patients, 4 patients had a surgical strategy prognostic score of 5 points. The other 2 patients had 6 points, since they had skip metastases to adjacent vertebra. In the 2 cases with skip metastases, the adjacent vertebra was excised en bloc. The level of spinal metastasis was thoracic in 4 cases and lumbar in 2 cases. Preoperative embolization of bilateral segmental arteries at three levels was performed in 5 cases except for a case which had metastases to T2 and T3. RESULTS: The average amount of bleeding was 1076 ml (430-1730 ml) and operation time was 7 hours 20 minutes on average. Perioperative complications were found in 2 cases. One was deep infection after cerebrospinal fluid leakage, and the other was paralysis due to postoperative hematoma. Revision surgery was required for these 2 cases. At the end of follow-up, 5 of 6 patients are still living after a mean of 28.4 months (range 15–47 months), while 1 patient had died of pneumonia and mediastinitis 16 months after TES due to surgical site infection by MRSA. She had received chemotherapy and radiation just before TES, and was a compromised host. In this series, local recurrence was not found. CONCLUSIONS: Radical surgery such as TES for spinal metastasis from the lung is controversial due to the dismal prognosis. According to recent reports, the mean survival time of lung cancer with bone metastasis is approximately 10 months. From the results of this study, however, each case, except for one death due to a postoperative complication, was still living at 15–47 months without local recurrence. Moreover, TES lacks the excessive morbidity, blood loss and operative time associated with alternate tumor resection strategies. Based on these findings, we conclude that an attempt at curative surgery using TES is appropriate for the unique cases with a controllable primary lung cancer, localized spinal metastasis and no visceral metastasis. For those patients, improvement in the prognosis is expected with TES. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
FDA DEVICE/DRUG STATUS: FloSeal: Not approved for this indication.
doi:10.1016/j.spinee.2008.06.283
doi:10.1016/j.spinee.2008.06.282
P40. Total En Bloc Spondylectomy for Lung Cancer Metastasis to the Spine: A Varied Prognosis Hideki Murakami, MD, Katsuro Tomita, MD, Norio Kawahara, MD, Satoru Demura, MD; Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Japan BACKGROUND CONTEXT: The prognosis of spinal metastasis from the lung is dismal. Historically, the rationale for radical surgery in such cases has been questioned due to high surgical morbidity and limited life expectancy. PURPOSE: The purpose of the current study is to evaluate the surgical results and the prognosis of total en bloc spondylectomy (TES) as a treatment for lung cancer metastasis to the spine and to clarify whether there is indication of radical surgery such as TES for lung cancer metastasis. STUDY DESIGN/ SETTING: We performed a retrospective review of the patients with lung cancer spinal metastasis treated by TES during a recent 10-year period. PATIENT SAMPLE: TES for lung cancer metastasis was performed in 6 patients. OUTCOME MEASURES: Outcome measures were: prognostic score, mean survival time and perioperative complications. Prognostic score was determined according to Tomita’s surgical strategy for spinal metastases. This strategy assigns points according to three prognostic factors: 1) grade of malignancy (lung cancer is 4 points), 2) visceral metastases (no metastasis; 0 points, controllable; 2 points, uncontrollable; 4 points), and 3) bone metastases (solitary; 1 point, multiple; 2 points). These three factors were added together to give a prognostic score between 2 and 10.
P41. Two Year Clinical Results of X-Stop Interspinous Decompression Device in the Management of Symptomatic Lumbar Canal Stenosis Anjali Nandakumar, MBBS1, Natasha Annette Clark, BSc, MBChB, MRCS2, Naval Bilolikar, MBBS, MS, MRCS3, Agata Pawulska, MBBS equivalent1, Alexandru Mertic, Medic, MSc1, Douglas Wardlaw, FRCS, ChM1, Francis W. Smith, FRCS, FRCR, MD1; 1Centre for Spinal Research, Woodend Hospital, Aberdeen, Scotland, United Kingdom; 2Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom; 3Craigavon Area Hospital, Belfast, Northern Ireland, United Kingdom BACKGROUND CONTEXT: The X stop interspinous distraction device has been used effectively for several years in patients with neurogenic claudication secondary to lumbar spinal canal stenosis. The device maintains the affected level in the flexed position increasing the space for exiting nerve roots and spinal canal. This study evaluates the clinical outcome at two years using ZCQ, VAS, ODI and SF36. PURPOSE: To assess the clinical effectiveness of X stop interspinous decompression device in patients with neurogenic claudication due to lumbar canal stenosis at 24 months post surgery. STUDY DESIGN/ SETTING: Prospective observational study. PATIENT SAMPLE: Symptomatic patients, seen by a single spine specialist surgeon were recruited from spine clinic. Inclusion criteria included age of 50 years or older with leg or buttock pain, with or without back pain while standing or walking, at least partly relieved on sitting. Patients had to have failed a trial of conservative treatment. MRI confirmed diagnosis of stenosis at one or two levels was required. The exclusion criteria were unremitting spinal pain; cauda equina syndrome; pathological fractures of the vertebrae; severe osteoporosis of the spine; body mass index greater than 40; presence of active infection; Paget’s disease; spinal metastases; ankylosing spondylitis or fusion at affected level.
121S
T10 ESCC. He underwent a T3-T10 laminectomy and FloSeal noted in the canal and was evacuated. He was ambulatory at two weeks and by six months he had complete recovery. The second patient was a 15 y.o. female who underwent T4-L1 PSF. Following screw insertion, deterioration in NMEPs and SSEPs was noted. Screws were removed and SCM data returned to baseline. Except for 3 screws that had an inferior breach (Left T7 and Bil. T8), screws were reinserted and remainder of the surgery was uneventful. Postoperative examination was normal initially but two days later, she developed left LE numbness/weakness. Implants were removed and MRI showed T4-T9 ESCC. She underwent a left (concave) T4-T9 hemilaminectomy. FloSeal was noted and was evacuated. Six weeks following surgery, she had a complete neurologic recovery. CONCLUSIONS: The use of FloSeal to decrease bleeding from cannulated pedicles during pedicle screw insertion can result in inadvertent extravasation into the spinal canal resulting in ESCC even in the absence of an apparent medial pedicle breach. Given the dangers associated with the technique, we recommend that gelatin matrix products be used judiciously in small aliquots or not at all during pedicle screw insertion.
METHODS: 6 patients (3 males and 3 females) without visceral or other bony metastases underwent TES. Mean age at surgery was 59 years. The histological type of the 6 patients was adenocarcinoma. Of the 6 patients, 4 patients had a surgical strategy prognostic score of 5 points. The other 2 patients had 6 points, since they had skip metastases to adjacent vertebra. In the 2 cases with skip metastases, the adjacent vertebra was excised en bloc. The level of spinal metastasis was thoracic in 4 cases and lumbar in 2 cases. Preoperative embolization of bilateral segmental arteries at three levels was performed in 5 cases except for a case which had metastases to T2 and T3. RESULTS: The average amount of bleeding was 1076 ml (430-1730 ml) and operation time was 7 hours 20 minutes on average. Perioperative complications were found in 2 cases. One was deep infection after cerebrospinal fluid leakage, and the other was paralysis due to postoperative hematoma. Revision surgery was required for these 2 cases. At the end of follow-up, 5 of 6 patients are still living after a mean of 28.4 months (range 15–47 months), while 1 patient had died of pneumonia and mediastinitis 16 months after TES due to surgical site infection by MRSA. She had received chemotherapy and radiation just before TES, and was a compromised host. In this series, local recurrence was not found. CONCLUSIONS: Radical surgery such as TES for spinal metastasis from the lung is controversial due to the dismal prognosis. According to recent reports, the mean survival time of lung cancer with bone metastasis is approximately 10 months. From the results of this study, however, each case, except for one death due to a postoperative complication, was still living at 15–47 months without local recurrence. Moreover, TES lacks the excessive morbidity, blood loss and operative time associated with alternate tumor resection strategies. Based on these findings, we conclude that an attempt at curative surgery using TES is appropriate for the unique cases with a controllable primary lung cancer, localized spinal metastasis and no visceral metastasis. For those patients, improvement in the prognosis is expected with TES. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
FDA DEVICE/DRUG STATUS: FloSeal: Not approved for this indication.
doi:10.1016/j.spinee.2008.06.283
doi:10.1016/j.spinee.2008.06.282
P40. Total En Bloc Spondylectomy for Lung Cancer Metastasis to the Spine: A Varied Prognosis Hideki Murakami, MD, Katsuro Tomita, MD, Norio Kawahara, MD, Satoru Demura, MD; Department of Orthopaedic Surgery, Kanazawa University, Kanazawa, Japan BACKGROUND CONTEXT: The prognosis of spinal metastasis from the lung is dismal. Historically, the rationale for radical surgery in such cases has been questioned due to high surgical morbidity and limited life expectancy. PURPOSE: The purpose of the current study is to evaluate the surgical results and the prognosis of total en bloc spondylectomy (TES) as a treatment for lung cancer metastasis to the spine and to clarify whether there is indication of radical surgery such as TES for lung cancer metastasis. STUDY DESIGN/ SETTING: We performed a retrospective review of the patients with lung cancer spinal metastasis treated by TES during a recent 10-year period. PATIENT SAMPLE: TES for lung cancer metastasis was performed in 6 patients. OUTCOME MEASURES: Outcome measures were: prognostic score, mean survival time and perioperative complications. Prognostic score was determined according to Tomita’s surgical strategy for spinal metastases. This strategy assigns points according to three prognostic factors: 1) grade of malignancy (lung cancer is 4 points), 2) visceral metastases (no metastasis; 0 points, controllable; 2 points, uncontrollable; 4 points), and 3) bone metastases (solitary; 1 point, multiple; 2 points). These three factors were added together to give a prognostic score between 2 and 10.
P41. Two Year Clinical Results of X-Stop Interspinous Decompression Device in the Management of Symptomatic Lumbar Canal Stenosis Anjali Nandakumar, MBBS1, Natasha Annette Clark, BSc, MBChB, MRCS2, Naval Bilolikar, MBBS, MS, MRCS3, Agata Pawulska, MBBS equivalent1, Alexandru Mertic, Medic, MSc1, Douglas Wardlaw, FRCS, ChM1, Francis W. Smith, FRCS, FRCR, MD1; 1Centre for Spinal Research, Woodend Hospital, Aberdeen, Scotland, United Kingdom; 2Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom; 3Craigavon Area Hospital, Belfast, Northern Ireland, United Kingdom BACKGROUND CONTEXT: The X stop interspinous distraction device has been used effectively for several years in patients with neurogenic claudication secondary to lumbar spinal canal stenosis. The device maintains the affected level in the flexed position increasing the space for exiting nerve roots and spinal canal. This study evaluates the clinical outcome at two years using ZCQ, VAS, ODI and SF36. PURPOSE: To assess the clinical effectiveness of X stop interspinous decompression device in patients with neurogenic claudication due to lumbar canal stenosis at 24 months post surgery. STUDY DESIGN/ SETTING: Prospective observational study. PATIENT SAMPLE: Symptomatic patients, seen by a single spine specialist surgeon were recruited from spine clinic. Inclusion criteria included age of 50 years or older with leg or buttock pain, with or without back pain while standing or walking, at least partly relieved on sitting. Patients had to have failed a trial of conservative treatment. MRI confirmed diagnosis of stenosis at one or two levels was required. The exclusion criteria were unremitting spinal pain; cauda equina syndrome; pathological fractures of the vertebrae; severe osteoporosis of the spine; body mass index greater than 40; presence of active infection; Paget’s disease; spinal metastases; ankylosing spondylitis or fusion at affected level.