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Cho ST, Cho JH, Kim JH, Um SH, Lee DH, Hwang CJ, Park S. Measuring the paraspinal muscles as an important tool for predicting the overall survival period after spine surgery in lung cancer patients with spine metastasis. BMC Musculoskelet Disord 2025; 26:414. [PMID: 40275240 PMCID: PMC12023636 DOI: 10.1186/s12891-025-08483-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/01/2025] [Indexed: 04/26/2025] Open
Abstract
STUDY DESIGN Retrospective cohort study BACKGROUND: Metastatic lung cancer in the spine is difficult to determine whether to perform an additional surgical intervention, as patients at the end stage of lung cancer often have low performance status with significant muscle atrophy. This study aimed to demonstrate whether sarcopenia affects the prognosis after spine surgery in lung cancer patients by measuring the paraspinal muscles. METHODS A total of 65 lung cancer patients who underwent spine surgery were reviewed. Patients were divided into two groups based on the survival period after surgery (≤ 6 months; n = 33 and > 6 months; n = 32). Based on magnetic resonance imaging, the quantity and quality of the paraspinal muscles (psoas major, quadratus lumborum, erector spinae, and multifidus) were analyzed by an Image J program. Patient- and surgery-related factors were compared between the two groups. RESULTS The quantity of the erector spinae muscle was higher in the > 6 months group (11.5 ± 2.8 cm2/m2) than in the ≤ 6 months group (10.0 ± 2.3 cm2/m2, p = 0.013). The logistic regression analysis showed that the muscle quantity of the erector spinae (p = 0.026, odds ratio 1.343) and the number of vertebrae involved in metastasis (p = 0.016, odds ratio 0.199) were the main prognostic factors for the survival period after spine surgery. CONCLUSIONS Lung cancer patients with a low quantity of the erector spinae muscles are at a high risk of poor prognosis after spine surgery. Therefore, measuring the erector spinae muscle could be an important tool for distinguishing patients appropriate for palliative treatments and surgical interventions.
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Affiliation(s)
- Sung Tan Cho
- Department of Orthopedic Surgery, Seoul Seonam Hospital, Seoul, Republic of Korea
| | - Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43, Olymipic-Ro, Songpa-Gu, Seoul, Republic of Korea.
| | - Jin Hwan Kim
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170, Juhwa-Ro, Ilsangeo-Gu, Goyang-Si, Gyeonggi-Do, Republic of Korea
| | - Se Hwan Um
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University, 170, Juhwa-Ro, Ilsangeo-Gu, Goyang-Si, Gyeonggi-Do, Republic of Korea
| | - Dong-Ho Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43, Olymipic-Ro, Songpa-Gu, Seoul, Republic of Korea
| | - Chang Ju Hwang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43, Olymipic-Ro, Songpa-Gu, Seoul, Republic of Korea
| | - Sehan Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 43, Olymipic-Ro, Songpa-Gu, Seoul, Republic of Korea
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Pierik RJB, Amelink JJGJ, Groot OQ, Som A, van Munster BT, de Reus DC, Chua TL, Zijlstra H, Verlaan JJ, Shin JH, Rabinov JD, Tobert DG. Surgical Outcomes After Preoperative Embolization in Hypervascular Spinal Metastases: A Propensity Scored Study of 191 Patients. Spine (Phila Pa 1976) 2025; 50:437-446. [PMID: 39451152 DOI: 10.1097/brs.0000000000005182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Accepted: 09/06/2024] [Indexed: 10/26/2024]
Abstract
STUDY DESIGN Retrospective propensity-score matched, case-control study at 2 academic tertiary care centers. OBJECTIVE To assess the effect of preoperative embolization (PE) on (1) intraoperative blood loss, defined as conventional estimates of blood loss (EBL) and hemoglobin mass loss; and (2) secondary outcomes in patients with spinal metastases from hypervascular histologies. BACKGROUND CONTEXT PE intends to reduce blood loss during surgery for spinal metastases of hypervascular tumors such as renal cell carcinoma. However, studies investigating the effect of PE in hypervascular tumors often consist of small cohorts, do not correct for confounding factors, and have conflicting results. MATERIALS AND METHODS After propensity score matching, 46 PE patients were matched to 46 non-PE patients without baseline differences. The constraints of propensity score matching did not allow analysis of patients with tumor volumes >9 cm 3 . Multiple linear regression models were fitted for EBL and hemoglobin mass loss. Poisson regression models were fitted for both intraoperative and postoperative transfusions. RESULTS There was no difference in EBL [948 mL (IQR: 500-1750) vs. 1100 mL (IQR: 388-1925), P =0.68] and hemoglobin mass loss [201 g (IQR: 119-307) vs. 232 g (IQR: 173-373), P =0.18] between PE and non-PE patients. Other than higher 1-year survival rates (65% vs. 43%, P =0.05) in PE patients, there were no differences in secondary outcomes. In multiple regression analyses, PE was not associated with decreased intraoperative blood loss, hemoglobin mass loss, or perioperative blood transfusions. CONCLUSIONS Our study demonstrated that, for tumors <9 cm 3 , PE did not reduce EBL, hemoglobin mass loss, or perioperative blood transfusions in patients undergoing spine surgery for metastases from hypervascular histologies. These findings suggest that urgent spine surgeries indicated for hypervascular histologies should not be delayed based on the availability of PE and accurate detection of preoperative hypervascularity, beyond histology, will likely be an important determination of future PE utilization for spinal metastases. LEVEL OF EVIDENCE Level III-treatment benefits.
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Affiliation(s)
- Robertus J B Pierik
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Jantijn J G J Amelink
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Olivier Q Groot
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Avik Som
- Department of Radiology, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Bram T van Munster
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Daniël C de Reus
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Theresa L Chua
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Hester Zijlstra
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, The Netherlands
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - James D Rabinov
- Department of Radiology, Massachusetts General Hospital-Harvard Medical School, Boston, MA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital-Harvard Medical School, Boston, MA
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Papalexis N, Peta G, Carta M, Quarchioni S, Di Carlo M, Miceli M, Facchini G. How Arterial Embolization Is Transforming Treatment of Oncologic and Degenerative Musculoskeletal Disease. Curr Oncol 2024; 31:7523-7554. [PMID: 39727678 DOI: 10.3390/curroncol31120555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 11/18/2024] [Accepted: 11/20/2024] [Indexed: 12/28/2024] Open
Abstract
BACKGROUND Arterial embolization is a minimally invasive treatment that occludes blood vessels supplying pathological tissue. Developed to control bleeding without surgery, it has evolved over decades and is now applied in musculoskeletal oncology as a preoperative treatment, palliative care, or standalone therapy for select tumors. Recently, its use has expanded globally in treating chronic pain syndromes and osteoarthritis. MATERIALS AND METHODS We reviewed the literature on arterial embolization in various musculoskeletal conditions. The focus was on established oncologic indications for primary and metastatic bone or soft tissue tumors, and emerging evidence on degenerative diseases like osteoarthritis, inflammatory musculoskeletal pathology, and intractable pain. Emphasis was placed on leading studies regarding efficacy, complications, and recurrence rates. DISCUSSION Arterial embolization has progressed from bleeding control to a versatile therapeutic option in musculoskeletal medicine. It offers symptom relief, reduces tumor size, and improves quality of life. Applications include oncologic interventions and management of degenerative and inflammatory conditions. Despite its benefits, variations in complications and recurrence rates highlight the need for standardized protocols and further research. CONCLUSIONS Arterial embolization is a safe and effective minimally invasive tool in the multidisciplinary management of a wide range of musculoskeletal pathologies. Ongoing research is crucial to understand long-term efficacy, optimize protocols, and broaden its applications.
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Affiliation(s)
- Nicolas Papalexis
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Giuliano Peta
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Michela Carta
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Simone Quarchioni
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Maddalena Di Carlo
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Miceli
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Giancarlo Facchini
- Department of Diagnostic and Interventional Radiology, IRCCS-Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Zulkharnain EM, Muhamad Ariffin MH, Tan JA, Zakaria MAA. Giant Cell Tumour of the Spine. Cureus 2024; 16:e71166. [PMID: 39525210 PMCID: PMC11549031 DOI: 10.7759/cureus.71166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2024] [Indexed: 11/16/2024] Open
Abstract
Giant cell tumour (GCT) is a benign bone tumour characterised by osteoclastic-like multinucleated cells. This tumour predominantly occurs in adults during the third decade of life, commonly in the distal femur, proximal tibia, distal radius, and sacrum. Treatment options include wide local excision with possible adjuvant therapy depending on tumour size and site. We present a case of an 18-year-old lady with no prior medical history complaining of worsening insidious onset localised back pain and preceding numbness of the bilateral lower limbs, diagnosed with a giant cell tumour of the spine (T11).
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Affiliation(s)
- Emir M Zulkharnain
- Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, MYS
| | | | - Jin Aun Tan
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala Lumpur, MYS
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Batista S, Fim Andreão F, Sousa MP, Oliveira LDB, Palavani LB, Melo Silva G, de Abreu LV, Bertani R, Gomes Quadros D. Spinal tumor embolization with Onyx: A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241227990. [PMID: 38646670 PMCID: PMC11571165 DOI: 10.1177/15910199241227990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION Onyx embolization has emerged as a promising technique for spinal tumor embolization due to its high devascularization rate and low incidence of complications. OBJECTIVE Evaluate the safety and efficacy of Onyx embolization in spinal tumor procedures. METHODS Following the PRISMA guidelines, we conducted a systematic review and meta-analysis. To be included, the articles had to report specific outcomes of Onyx embolization for spinal tumors (complications, mortality, blood loss, tumor devascularization, or reduction in tumor blush). RESULTS We selected 11 out of 2941 articles, encompassing 127 patients. Among them, no major complications or persistent neurological deficits were reported, and no deaths occurred as a result of the embolization procedure. Of the 63 patients with available data, two complications were observed: one infarct leading to transient neurological deficit and one clinically silent vessel perforation related to the microcatheter. Thus, the complication rate was 1% (95% confidence interval (CI): 0% to 6%). Blood loss during surgery ranged from 100 to 1500 mL (four studies). Complete tumor blush reduction was achieved in 52% of the cases (95% CI: 16% to 88%) across 32 patients. Three studies reported a median percentage of tumor devascularization of 91% (86.1% to 97.5%). CONCLUSION Onyx embolization for spinal tumor procedures appears to be a safe technique, as evidenced by the absence of major complications or deaths. However, the determination of its efficacy remains challenging due to limited data availability and substantial heterogeneity across studies. These findings highlight the need for future research to address this knowledge gap and further validate our results.
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Affiliation(s)
- Savio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Marcelo Porto Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | | | | | - Guilherme Melo Silva
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Livia V de Abreu
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of Sao Paulo, Sao Paulo, Brazil
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McGuire LS, Nico E, Hossa J, Tshibangu M, Mehta A, Alaraj A. Refinement of nBCA embolization technique in treatment of metastatic spinal tumors: Case series and technical report. Interv Neuroradiol 2024:15910199241235975. [PMID: 38470406 DOI: 10.1177/15910199241235975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Preoperative embolization of metastatic spinal tumors (MSTs) has proven advantageous in limiting intraoperative blood loss (IBL) during resection. N-butyl cyanoacrylate (nBCA) is a liquid embolic agent known for its rapid hemostatic effects. However, nBCA is associated with a higher risk of distal nontarget embolization. This study highlights the refinement of the embolization technique and assesses its efficacy in performing an initial distal segmental artery plug with concentrated nBCA followed by proximal diluted nBCA for MSTs. METHODS A retrospective review of patients with MST (2018-2023) was performed. Patients who underwent preoperative nBCA endovascular embolization prior to tumor resection and spinal instrumentation were included. Baseline standard spinal angiography was performed. RESULTS Sixteen patients (13 men, 3 women; 56.0 ± 12.4 years) met inclusion criteria. And 43.75% (7 of 16) had thoracic levels, 37.5% (6 of 16) lumbar, and 18.75% (3 of 16) sacral. The most common primary tumor was renal cell carcinoma (43.75%, 7 of 16). A total of 43 pedicles were embolized (median 3), resulting in complete/near complete obliteration of the tumor blush. Most pedicles (83.7%, 36 of 43) received a single dilute concentration of nBCA; however, 16.3% (7 of 43) received two separate concentrations of nBCA, a denser concentration distally into the segmental artery and a diluted concentration proximally into the tumor bed. Mean IBL was 1150 ± 1201 mL in 3 distal plug patients distal plug patients versus 1625 ± 681 mL in 12 other patients. There were no complications related to embolization. CONCLUSION Performing a distal, concentrated nBCA plug during preoperative nBCA embolization of MSTs may increase tumor penetration and reduce IBL.
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Affiliation(s)
- Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Elsa Nico
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jessica Hossa
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mpuekela Tshibangu
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ankit Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Qiao R, Ma R, Zhang X, Lun D, Li R, Hu Y. Comparison of intraoperative blood loss and perioperative complications between preoperative embolization and nonembolization combined with spinal tumor surgeries: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:4272-4296. [PMID: 37661228 DOI: 10.1007/s00586-023-07898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The present study aimed to comparatively evaluate intraoperative blood loss (IBL) and perioperative complications between preoperative embolization (PE) and nonembolization (NE) combined with spinal tumor surgeries as well as to determine the subgroup of spinal tumor surgeries suitable for PE. METHODS A systematic search in PubMed and EMBASE and an additional search by reference lists of the retrieved studies were undertaken by two reviewers. The mean IBL and perioperative complication rate were employed as the effect size in the general quantitative synthesis through direct calculation. Meta-analysis was performed using standardized mean difference (SMD) and weighted mean difference (WMD) of IBL and the odds ratio (OR) of complications. Heterogeneity was assessed using the I2 statistic. RESULTS The reviewers selected 17 published studies for the general quantitative synthesis and meta-analyses. The mean IBL of spinal tumor surgeries was 1786.3 mL in the NE group and 1716.4 mL in the PE group. The mean IBL between the two groups was similar. The pooled WMD and SMD of IBL in spinal tumor surgeries was 324.15 mL (95% CI 89.50-1640.9, p = 0.007) and 0.398 (95% CI 0.114-0.682, p = 0.006), respectively. The reduction of the PE group compared with the NE group for the rates of major complications and major hemorrhagic complications were 7.80% and 5.71%, respectively. The risk of PE-related complications in the PE group was only 1.53% more than in the PE group. The pooled OR of major complications in spinal tumor surgeries was 1.426 (95% CI 0.760-2.674; p = 0.269). CONCLUSIONS PE may be suitable for spinal tumor surgeries and some subgroups. From the perspective of complications, PE may also be a feasible option for spinal tumor surgeries.
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Affiliation(s)
- Ruiqi Qiao
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China
| | - Rongxing Ma
- Graduate School, Tianjin Medical University, Tianjin, China
| | | | - Dengxing Lun
- Department of Bone Oncology, Weifang People's Hospital, Weifang, China
| | - Ruifeng Li
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Yongcheng Hu
- Department of Bone and Soft Tissue Oncology, Tianjin Hospital, 406 Jiefang Southern Road, Tianjin, 300000, MD, China.
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Motov S, Stengel F, Ringel F, Bozinov O, Stienen MN. Current state of preoperative embolization for spinal metastasis - A survey by the EANS spine section. BRAIN & SPINE 2023; 3:102712. [PMID: 38021014 PMCID: PMC10668085 DOI: 10.1016/j.bas.2023.102712] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023]
Abstract
Introduction Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers. Research question The aim was to understand the current decision-making process in European spine centers. Material and methods The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023. Results We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13). Discussion and conclusions PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications.
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Affiliation(s)
- Stefan Motov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Felix Stengel
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Florian Ringel
- University Hospital Mainz & Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
- Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St. Gallen, St.Gallen, Switzerland
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Key BM, Callstrom MR, Filippiadis D. Musculoskeletal Interventional Oncology: A Contemporary Review. AJR Am J Roentgenol 2023; 221:503-516. [PMID: 37222277 DOI: 10.2214/ajr.23.29110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Musculoskeletal interventional oncology is an emerging field that addresses the limitations of conventional therapies for bone and soft-tissue tumors. The field's growth has been driven by evolving treatment paradigms, expanding society guidelines, mounting supportive literature, technologic advances, and cross-specialty collaboration with medical, surgical, and radiation oncology. Safe, effective, and durable pain palliation, local control, and stabilization of musculoskeletal tumors are increasingly achieved through an expanding array of contemporary minimally invasive percutaneous image-guided treatments, including ablation, osteoplasty, vertebral augmentation (with or without mechanical reinforcement via implants), osseous consolidation via percutaneous screw fixation (with or without osteoplasty), tumor embolization, and neurolysis. These interventions may be used for curative or palliative indications and can be readily combined with systemic therapies. Therapeutic approaches include the combination of different interventional oncology techniques as well as the sequential application of such techniques with other local treatments, including surgery or radiation. This article reviews the current practice of interventional oncology treatments for the management of patients with bone and soft-tissue tumors with a focus on emerging technologies and techniques.
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Affiliation(s)
- Brandon M Key
- Department of Radiology, Division of Vascular & Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Rm 2803, Milwaukee, WI 53226
| | - Matthew R Callstrom
- Department of Radiology, Division of Vascular & Interventional Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Rm 2803, Milwaukee, WI 53226
| | - Dimitrios Filippiadis
- Department of Diagnostic and Interventional Radiology, University General Hospital "Attikon" Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Damante MA, Gibbs D, Dibs K, Palmer JD, Raval R, Scharschmidt T, Chakravarti A, Bourekas E, Boulter D, Thomas E, Grecula J, Beyer S, Xu D, Nimjee S, Youssef P, Lonser R, Blakaj DM, Elder JB. Neoadjuvant Arterial Embolization of Spine Metastases Associated With Improved Local Control in Patients Receiving Surgical Decompression and Stereotactic Body Radiotherapy. Neurosurgery 2023; 93:320-329. [PMID: 36861971 DOI: 10.1227/neu.0000000000002411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/16/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Spine metastases often cause significant pain, instability, and/or neurological morbidity. Local control (LC) of spine metastases has been augmented with advances in systemic therapies, radiation, and surgical technique. Prior reports suggest an association between preoperative arterial embolization and improved LC and palliative pain control. OBJECTIVE To further elucidate the role of neoadjuvant embolization on LC of spine metastases and the potential for improved pain control in patients receiving surgery and stereotactic body radiotherapy (SBRT). METHOD A retrospective single-center review between 2012 and 2020 identified 117 patients with spinal metastases from various solid tumor malignancies managed with surgery and adjuvant SBRT with or without preoperative spinal arterial embolization. Demographic information, radiographic studies, treatment characteristics, Karnofsky Performance Score, Defensive Veterans Pain Rating Scale, and mean daily doses of analgesic medications were reviewed. LC was assessed using magnetic resonance imaging obtained at a median 3-month interval and defined as progression at the surgically treated vertebral level. RESULTS Of 117 patients, 47 (40.2%) underwent preoperative embolization, followed by surgery and SBRT and 70 (59.8%) underwent surgery and SBRT alone. Within the embolization cohort, the median LC was 14.2 months compared with 6.3 months among the nonembolization cohort ( P = .0434). Receiver operating characteristic analysis suggests ≥82.5% embolization predicted significantly improved LC (area under the curve = 0.808; P < .0001). Defensive Veterans Pain Rating Scale mean and maximum scores significantly decreased immediately after embolization ( P < .001). CONCLUSION Preoperative embolization was associated with improved LC and pain control suggesting a novel role for its use. Additional prospective study is warranted.
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Affiliation(s)
- Mark A Damante
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Gibbs
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju Raval
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Scharschmidt
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Bourekas
- Division of Neuroradiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Boulter
- Division of Neuroradiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Evan Thomas
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Grecula
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Xu
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shahid Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick Youssef
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Russell Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Dukagjin M Blakaj
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - J Bradley Elder
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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11
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Papalexis N, Peta G, Errani C, Miceli M, Facchini G. Preoperative Arterial Embolization for Heterotopic Ossification of the Hip. J Vasc Interv Radiol 2022; 34:608-612. [PMID: 36481323 DOI: 10.1016/j.jvir.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/11/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate the efficacy and safety of preoperative arterial embolization for neurogenic heterotopic ossification (NHO) of the hip. MATERIALS AND METHODS This single-center retrospective study reviewed outcomes in 16 consecutive patients who had surgical resection of NHO of the hip: 8 of whom underwent preoperative arterial embolization and 8 of whom did not. Both patient cohorts had similar baseline characteristics. A mean of 2.62 ± 1.9 arteries per patient, including the gluteal, lateral circumflex femoral, and deep circumflex iliac branches, were embolized using an n-butyl cyanoacrylate (NBCA)-ethiodized oil mixture. Data from both cohorts regarding intraoperative blood loss, volume of blood transfused, complications, and duration of hospitalization were compared. RESULTS A mean of 2.6 ± 1.9 arteries were embolized with NBCA-ethiodized oil, mainly the gluteal arteries, lateral circumflex femoral artery, and deep circumflex iliac artery. In the embolization group, mean intraoperative blood loss was 875 mL ± 320, mean number of units of blood used was 0.5 ± 0.7, and average number of days of hospitalization was 6.4 days ± 1.6. In the control group, mean intraoperative blood loss was 1,350 mL ± 120, mean number of units of blood used was 2 ± 1.1, and average number of days of hospitalization was 11.5 days ± 1.4. The embolization group had an average reduction in blood loss of 40.7% (P = 0.035), reduction in units of blood administered of 75% (P = 0.021), and reduction in days of hospitalization of 44.7% (P = 0.014). No procedural complications were recorded. CONCLUSIONS Preoperative arterial embolization is effective and safe in reducing intraoperative blood loss, number of hospitalization days, and need for blood transfusions in surgical resection of NHO of the hip.
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Affiliation(s)
- Nicolas Papalexis
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Giuliano Peta
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giancarlo Facchini
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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12
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Spinal Tumors: Diagnosis and Treatment. J Am Acad Orthop Surg 2022; 30:e1106-e1121. [PMID: 35984082 DOI: 10.5435/jaaos-d-21-00710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/10/2022] [Indexed: 02/01/2023] Open
Abstract
Tumors that present in or around the spine can be challenging to diagnose and treat. A proper workup involves a complete history and physical examination, appropriate staging studies, appropriate imaging of the entire spine, and a tissue biopsy. The biopsy defines the lesion and guides treatment, but in some rare instances, rapid neurological decline may lead to urgent or emergent surgery before it can be analyzed. "Enneking-appropriate" margins should remain the goal for primary tumors while adequate debulking/separation/stabilization are often the goals in metastatic disease. Primary tumors of the spine are rare and often complex tumors to operate on-achieving Enneking-appropriate margins provides the greatest chance of survival while decreasing the chance of local recurrence. Metastatic tumors of the spine are increasingly more common, and timing of surgery must be considered within the greater framework of the patient and the patient's disease, deficits, stability, and other treatments available. The specific tumor type will dictate what other multidisciplinary approaches are available, allowing for chemotherapy and radiation as needed.
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13
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Groot OQ, van Steijn NJ, Ogink PT, Pierik RJ, Bongers MER, Zijlstra H, de Groot TM, An TJ, Rabinov JD, Verlaan JJ, Schwab JH. Preoperative embolization in surgical treatment of spinal metastases originating from non-hypervascular primary tumors: a propensity score matched study using 495 patients. Spine J 2022; 22:1334-1344. [PMID: 35263662 DOI: 10.1016/j.spinee.2022.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative embolization (PE) reduces intraoperative blood loss during surgery for spinal metastases of hypervascular primary tumors such as thyroid and renal cell tumors. However, most spinal metastases originate from primary breast, prostate, and lung tumors and it remains unclear whether these and other spinal metastases benefit from PE. PURPOSE To assess the (1) efficacy of PE on the amount of intraoperative blood loss and safety in patients with spinal metastases originating from non-hypervascular primary tumors, and (2) secondary outcomes including perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. STUDY DESIGN Retrospective propensity-score matched, case-control study at 2 academic tertiary medical centers. PATIENT SAMPLE Patients 18 years of age or older undergoing surgery for spinal metastases originating from primary non-thyroid, non-renal cell, and non-hepatocellular tumors between January 1, 2002 and December 31, 2016 were included. OUTCOME MEASURES The primary outcomes were estimated amount of intraoperative blood loss and complications attributable to PE, such as neurologic injury, wound infection, thrombosis, or dissection. The secondary outcomes included perioperative allogeneic blood transfusion, anesthesia time, hospitalization, postoperative complication within 30 days, reoperation, 90-day mortality, and 1-year mortality. METHODS In total, 495 patients were identified, of which 54 (11%) underwent PE. After propensity score matching on 21 variables, including primary tumor, number of spinal levels, and surgical treatment, 53 non-PE patients were matched to 53 PE patients. Matching was adequate measured by comparing the matched variables, testing the standardized mean differences (<0.25), and inspecting Kernel density plots. The degree of embolization was noted to be complete, until stasis, or successful in 43 (80%) patients. RESULTS Intraoperative blood loss did not differ between both groups with a median blood loss in liters of 0.6 (IQR, 0.4-1.2) for non-PE patients and 0.9 (IQR, 0.6-1.2) for PE patients (p=.32). No complications occurred during embolization or the time between embolization and surgery. No differences were found in terms of the secondary outcomes. CONCLUSIONS Our data suggest that, although no complications occurred and the embolization procedure can be considered safe, patients with non-hypervascular spinal metastases might not benefit from PE. A larger, prospective study could confirm or refute these study findings and aid in elucidating a subset of spinal metastases that might benefit from PE.
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Affiliation(s)
- Olivier Q Groot
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA; Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Nicole J van Steijn
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Paul T Ogink
- Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Robert-Jan Pierik
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Michiel E R Bongers
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Hester Zijlstra
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA; Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Tom M de Groot
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
| | - Thomas J An
- Department of Radiology, Radiology Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St. Boston, MA 02114, USA
| | - James D Rabinov
- Department of Radiology, Radiology Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St. Boston, MA 02114, USA
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht - Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Orthopedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, 55 Fruit St., Boston, MA 02114, USA
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14
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Voelker A, Osterhoff G, Einhorn S, Ebel S, Heyde CE, Pieroh P. Does the anatomical region predict blood loss or neurological deficits in embolized renal cancer spine metastases? A single-center experience with 31 patients. World J Surg Oncol 2022; 20:208. [PMID: 35710422 PMCID: PMC9202195 DOI: 10.1186/s12957-022-02676-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background No comparison of a single hypervascular tumor entity in terms of major complications in different spinal regions has been performed. We aimed to evaluate post-embolic and post-operative outcomes in anatomic regions with renal cell carcinoma (RCC) metastases to the spine. Methods We retrospectively evaluated data from patients with confirmed, embolized, and surgically treated RCC spine metastases at a single-spine center between 2010 and 2020. Patients were divided into thoracic (TSM) and lumbar (LSM) spine metastasis groups. Results Seventeen patients had TSM and 14 had LSM. In all cases, embolization was performed preoperatively. The ΔHb value did not differ between the two groups pre- and postoperatively (p=0.3934). There was no significant difference in intraoperative blood loss between both groups either within 1 day or 2 days after embolization. Neurological deficits occurred in eight patients after embolization or surgery, with no significant difference between TSM (n=5) and LSM (n=3). Conclusions Embolization is the standard procedure for the preoperative treatment of hypervascular spinal metastases, possible up to 48 h before surgery, without the risk of higher intraoperative blood loss. Regardless of intraoperative complications, major complications can occur up to several hours after embolization. We recommend surgery the day after embolization to reliably detect neurologic complications from this procedure.
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Affiliation(s)
- Anna Voelker
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Georg Osterhoff
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Stefanie Einhorn
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Sebastian Ebel
- Department of Radiology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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15
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Sgalambro F, Zugaro L, Bruno F, Palumbo P, Salducca N, Zoccali C, Barile A, Masciocchi C, Arrigoni F. Interventional Radiology in the Management of Metastases and Bone Tumors. J Clin Med 2022; 11:3265. [PMID: 35743336 PMCID: PMC9225477 DOI: 10.3390/jcm11123265] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 01/10/2023] Open
Abstract
Interventional Radiology (IR) has experienced an exponential growth in recent years. Technological advances of the last decades have made it possible to use new treatments on a larger scale, with good results in terms of safety and effectiveness. In musculoskeletal field, painful bone metastases are the most common target of IR palliative treatments; however, in selected cases of bone metastases, IR may play a curative role, also in combination with other techniques (surgery, radiation and oncology therapies, etc.). Primary malignant bone tumors are extremely rare compared with secondary bone lesions: osteosarcoma, Ewing sarcoma, and chondrosarcoma are the most common; however, the role of interventional radiology in this fiels is marginal. In this review, the main techniques used in interventional radiology were examined, and advantages and limitations illustrated. Techniques of ablation (Radiofrequency, Microwaves, Cryoablation as also magnetic resonance imaging-guided high-intensity focused ultrasound), embolization, and Cementoplasty will be described. The techniques of ablation work by destruction of pathological tissue by thermal energy (by an increase of temperature up to 90 °C with the exception of the Cryoablation that works by freezing the tissue up to -40 °C). Embolization creates an ischemic necrosis by the occlusion of the arterial vessels that feed the tumor. Finally, cementoplasty has the aim of strengthening bone segment weakened by the growth of pathological tissue through the injection of cement. The results of the treatments performed so far were also assessed and presented focused the attention on the management of bone metastasis.
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Affiliation(s)
- Ferruccio Sgalambro
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.S.); (A.B.); (C.M.)
| | - Luigi Zugaro
- San Salvatore Hospital, 67100 L’Aquila, Italy; (L.Z.); (F.B.); (P.P.)
| | - Federico Bruno
- San Salvatore Hospital, 67100 L’Aquila, Italy; (L.Z.); (F.B.); (P.P.)
| | - Pierpaolo Palumbo
- San Salvatore Hospital, 67100 L’Aquila, Italy; (L.Z.); (F.B.); (P.P.)
| | - Nicola Salducca
- Oncological Orthopaedics Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (N.S.); (C.Z.)
| | - Carmine Zoccali
- Oncological Orthopaedics Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy; (N.S.); (C.Z.)
| | - Antonio Barile
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.S.); (A.B.); (C.M.)
| | - Carlo Masciocchi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (F.S.); (A.B.); (C.M.)
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16
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Taha MM, Elsharkawy AM, AlBakry A, Ezat M, Alawamry A. Outcome of surgical treatment of hepatocellular carcinoma-derived spinal metastases: Single center experience in Egypt. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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17
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Facchini G, Parmeggiani A, Peta G, Martella C, Gasbarrini A, Evangelisti G, Miceli M, Rossi G. The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2839-2851. [PMID: 34415449 DOI: 10.1007/s00586-021-06963-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications. METHODS We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy. RESULTS Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts. CONCLUSION Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.
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Affiliation(s)
- Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Anna Parmeggiani
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Giuliano Peta
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Claudia Martella
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine (DIMES), S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Gisberto Evangelisti
- Department of Oncological and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Rossi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G.C.Pupilli, 1, 40136, Bologna, Italy
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18
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Gao ZY, Zhang T, Zhang H, Pang CG, Xia Q. Effectiveness of Preoperative Embolization in Patients with Spinal Metastases: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e745-e757. [PMID: 34153484 DOI: 10.1016/j.wneu.2021.06.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/12/2021] [Accepted: 06/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Debate on the effectiveness of preoperative embolization for spinal metastatic lesions, especially for nonhypervascular tumors, has persisted. The present study aimed to identify the effectiveness of preoperative embolization in patients who had undergone surgery for spinal metastasis. METHODS Two of us (Z.T. and Z.H.) independently searched the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases to identify eligible clinical studies that had compared the outcomes of patients treated surgically for spinal metastatic disease with or without preoperative embolization. The primary outcomes included intraoperative blood loss, perioperative blood loss, and transfusion requirements. The secondary outcomes include the operative time, overall survival, and complication rates. Meta-analyses were performed for subgroups of hypervascular, nonhypervascular, and mixed tumors. A fixed effects model was applied when I2 was <50%, and a random effects model was applied when I2 was >50%. RESULTS A total of 12 studies (1 randomized controlled trial and 11 retrospective case-control studies), with 744 patients, were included. Significantly less intraoperative blood loss (mean difference [MD], -1171.49 mL; 95% confidence interval [CI], -2283.10 to -59.88; P = 0.039), fewer blood transfusions (MD, -3.13 U; 95% CI, -4.86 to -1.39; P < 0.001), and shorter operative times (MD, -33.91 minutes; 95% CI, -59.65 to -8.17; P = 0.010) were identified for the embolization group in the hypervascular subgroup. In the nonhypervascular and mixed tumor subgroups, no differences in effectiveness were identified in blood loss, transfusion requirement, or operative time when stratified by the use of embolization. The overall survival and complication rates were similar between the embolization and nonembolization groups in each subgroup. CONCLUSIONS The current data support the use of preoperative embolization for hypervascular metastatic tumors to the spine. However, little evidence is available to support the use of preoperative embolization for nonhypervascular metastatic tumors to the spine.
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Affiliation(s)
- Zhong-Yu Gao
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Tao Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Hui Zhang
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | | | - Qun Xia
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China.
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19
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An Overview of Decision Making in the Management of Metastatic Spinal Tumors. Indian J Orthop 2021; 55:799-814. [PMID: 34194637 PMCID: PMC8192670 DOI: 10.1007/s43465-021-00368-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 01/29/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors. METHODS A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed. DISCUSSION Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment. CONCLUSION The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.
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20
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Gong Y, Wang C, Liu H, Liu X, Jiang L. Only Tumors Angiographically Identified as Hypervascular Exhibit Lower Intraoperative Blood Loss Upon Selective Preoperative Embolization of Spinal Metastases: Systematic Review and Meta-Analysis. Front Oncol 2021; 10:597476. [PMID: 33585214 PMCID: PMC7874195 DOI: 10.3389/fonc.2020.597476] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/02/2020] [Indexed: 01/25/2023] Open
Abstract
Background The role of preoperative embolization (PE) in reducing intraoperative blood loss (IBL) during surgical treatment of spinal metastases remains controversial. Methods A systematic search was conducted for retrospective studies and randomized controlled trials (RCTs) comparing the IBL between an embolization group (EG) and non-embolization group (NEG) for spinal metastases. IBL data of both groups were synthesized and analyzed for all tumor types, hypervascular tumor types, and non-hypervascular tumor types. Results In total, 839 patients in 11 studies (one RCT and 10 retrospective studies) were included in the analysis. For all tumor types, the average IBL did not differ significantly between the EG and NEG in the RCT (P = 0.270), and there was no significant difference between the two groups in the retrospective studies (P = 0.05, standardized mean difference [SMD] = −0.51, 95% confidence interval [CI]: −1.03 to 0.00). For hypervascular tumors determined as such by consensus (n = 542), there was no significant difference between the two groups (P = 0.52, SMD = −0.25, 95% CI: −1.01 to 0.52). For those determined as such using angiographic evidence, the IBL was significantly lower in the EG than in the NEG group, in the RCT (P = 0.041) and in the retrospective studies (P = 0.004, SMD = −0.93, 95% CI: −1.55 to −.30). For IBL of non-hypervascular tumor types, both the retrospective study (P = 0.215) and RCT (P = 0.947) demonstrated no statistically significant differences in IBL between the groups. Conclusions Only tumors angiographically identified as hypervascular exhibited lower IBL upon PE in this study. Further exploration of non-invasive methods to identify the vascularity of tumors is warranted.
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Affiliation(s)
- Yining Gong
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.,Health Science Center, Peking University, Beijing, China
| | - Changming Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hua Liu
- Health Science Center, Peking University, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
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21
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Premat K, Shotar E, Burns R, Shor N, Eloy G, Cormier É, Drir M, Morardet L, Lenck S, Sourour N, Chiras J, Dormont D, Bonaccorsi R, Clarençon F. Reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography in hypervascular spinal metastases prior embolization. Eur Radiol 2021; 31:4690-4699. [PMID: 33449182 DOI: 10.1007/s00330-020-07654-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization. METHODS All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized "yes vs no" scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics. RESULTS Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI [0.09-0.81]) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI [0.37-1.00]). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0). CONCLUSIONS TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool. KEY POINTS • TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases. • TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography. • TR-CE-MRA's spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.
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Affiliation(s)
- Kévin Premat
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France.
| | - Eimad Shotar
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Robert Burns
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Natalia Shor
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Gauthier Eloy
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Orthopaedic Surgery, F75013, Paris, France
| | - Évelyne Cormier
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Mehdi Drir
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Anaesthesiology, F75013, Paris, France
| | - Laetitia Morardet
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Oncology, F75013, Paris, France
| | - Stéphanie Lenck
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Nader Sourour
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Jacques Chiras
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Didier Dormont
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
| | - Raphaël Bonaccorsi
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Orthopaedic Surgery, F75013, Paris, France
| | - Frédéric Clarençon
- Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, Department of Neuroradiology, F75013, Paris, France
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Houten JK, Swiggett SJ, Hadid B, Choueka DM, Kinon MD, Buciuc R, Zumofen DW. Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury. World Neurosurg 2020; 143:374-388. [PMID: 32805465 DOI: 10.1016/j.wneu.2020.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preoperative embolization of spinal metastases may improve outcomes of resection by reducing surgical blood loss and operative time. Neurologic complications are rarely reported and the mechanisms leading to injury are poorly described. METHODS We present 2 illustrative cases of embolization-related neurologic injury from distinct mechanisms and the findings of a systemic literature review of similar complications according to the PRISMA guidelines. RESULTS A 77-year-old man with a history of renal cell carcinoma presented with gait dyscoordination and arm pain/weakness. Magnetic resonance imaging showed a C7/T1 mass causing severe compression of the C7/T1 roots and spinal cord. After embolization and tumor resection/fusion, lethargy prompted imaging showing multiple posterior circulation infarcts believed to be secondary to reflux of embolic particles. A 75-year-old man with renal cell carcinoma presented with L1 level metastasis causing conus compression and experienced paraplegia after superselective particle embolization presumed to be secondary to flow disruption of the artery of Adamkiewicz. Analysis of the literature yielded 6 articles reporting instances of cranial infarction/ischemia occurring in 10 patients, 12 articles reporting spinal cord ischemia/infarction occurring in 17 patients, and 5 articles reporting symptomatic postembolization tumoral swelling in 5 patients. CONCLUSIONS Neurologic injury is a risk of preoperative embolization of spinal metastasis from either compromise of spinal cord vascular supply or cranial stroke from reflux of embolic particles. Postprocedural tumor swelling rarely leads to clinical deficit. Awareness of these complications and the presumed mechanisms of injury may aid clinicians in implementing interventions and in counseling patients before treatment.
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Affiliation(s)
- John K Houten
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA.
| | - Samuel J Swiggett
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Bana Hadid
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - David M Choueka
- Department of Orthopedic Surgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Merritt D Kinon
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Razvan Buciuc
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Daniel W Zumofen
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Radiology, Maimonides Medical Center, Brooklyn, New York, USA
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23
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Westbroek EM, Pennington Z, Ahmed AK, Xia Y, Boone C, Gailloud P, Sciubba DM. Comparison of complete and near-complete endovascular embolization of hypervascular spine tumors with partial embolization. J Neurosurg Spine 2020; 33:245-251. [PMID: 32244203 DOI: 10.3171/2020.1.spine191337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative endovascular embolization of hypervascular spine tumors can reduce intraoperative blood loss. The extent to which subtotal embolization reduces blood loss has not been clearly established. This study aimed to elucidate a relationship between the extent of preoperative embolization and intraoperative blood loss. METHODS Sixty-six patients undergoing preoperative endovascular embolization and subsequent resection of hypervascular spine tumors were retrospectively reviewed. Patients were divided into 3 groups: complete embolization (n = 22), near-complete embolization (≥ 90% but < 100%; n = 22), and partial embolization (< 90%; n = 22). Intraoperative blood loss was compared between groups using one-way ANOVA with post hoc comparisons between groups. RESULTS The average blood loss in the complete embolization group was 1625 mL. The near-complete embolization group had an average blood loss of 2021 mL in surgery. Partial embolization was associated with a mean blood loss of 4009 mL. On one-way ANOVA, significant differences were seen across groups (F-ratio = 6.81, p = 0.002). Significant differences in intraoperative blood loss were also seen between patients undergoing complete and partial embolization (p = 0.001) and those undergoing near-complete and partial embolization (p = 0.006). Pairwise testing showed no significant difference between complete and near-complete embolization (p = 0.57). Analysis of a combined group of complete and near-complete embolization also showed a significantly decreased blood loss compared with partial embolization (p < 0.001). Patient age, tumor size, preoperative coagulation parameters, and preoperative platelet count were not significantly associated with blood loss. CONCLUSIONS Preoperative endovascular embolization is associated with decreased intraoperative blood loss. In this series, blood loss was significantly less in surgeries for tumors in which preoperative complete or near-complete embolization was achieved than in tumors in which preoperative embolization resulted in less than 90% reduction of tumor vascular blush. These findings suggest that there may be a critical threshold of efficacy that should be the goal of preoperative embolization.
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Affiliation(s)
| | | | | | | | - Christine Boone
- 2Department of Interventional Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Philippe Gailloud
- 3Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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24
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Ma J, Tullius T, Van Ha TG. Update on Preoperative Embolization of Bone Metastases. Semin Intervent Radiol 2019; 36:241-248. [PMID: 31435132 DOI: 10.1055/s-0039-1693120] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Management of patients with bone metastasis is complex and should include different specialties. Goals of therapy should be identified for each individual patient prior to the start of treatment. Preoperative embolization has generally been considered a safe and effective means of reducing intraoperative blood loss with recent studies and advances in technique reported. Update on indications, contraindications, technique, and efficacy, as well as prognostic factors and complications of preoperative embolization of bone metastases will be reviewed. New trends such as transradial arterial access and usage of liquid embolic agents will be discussed. Large tumor size, increased preprocedural tumor vascularity, longer embolization-to-surgery interval, and radical surgical procedures are associated with greater intraoperative blood loss and prolonged operative time. An accurate, noninvasive method to evaluate tumor vascularity prior to angiography is needed to identify patients who are most likely to benefit from preoperative embolization. Particular attention will be paid to skeletal metastases and spinal metastases as each has its own set of complexity.
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Affiliation(s)
- Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Shanghai Medical School of Fudan University, Shanghai, People's Republic of China
| | - Thomas Tullius
- Department of Radiology, The University of Chicago Medicine, Chicago, Illinois
| | - Thuong G Van Ha
- Department of Radiology, The University of Chicago Medicine, Chicago, Illinois
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25
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Omid-Fard N, Fisher CG, Heran MKS. The evolution of pre-operative spine tumour embolization. Br J Radiol 2019; 92:20180899. [PMID: 30817177 PMCID: PMC6724624 DOI: 10.1259/bjr.20180899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/22/2019] [Accepted: 02/27/2019] [Indexed: 11/05/2022] Open
Abstract
Pre-operative spine tumour embolization is a useful adjunct to minimize operative complications and blood loss during complex resections. While the efficacy of this procedure has been well studied, relatively little is documented regarding how to optimize technical parameters for tumour characteristics. This pictorial case series seeks to review our centre's experience over the last decade in using a range of embolization techniques. As experience with this procedure has matured, we propose an approach based on the patient's vascular anatomy and tumour angioarchitecture. This includes the use of coils as protective barriers rather than primary embolics; particle embolization to permeate fine capillary networks; consideration for liquid embolic agents in the presence of large caliber tumour vessels with associated arteriovenous shunting; and percutaneous intralesional embolization when endovascular access is insufficient to achieve the desired outcome. In many cases, a combination of these methods is needed, and close communication with the surgeon ensures the best outcome. Despite these advances, continued work is needed to determine how to optimize complete devascularization, and thus surgical benefit, while safely sparing critical neuroanatomical structures.
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Affiliation(s)
- Nima Omid-Fard
- University of British Columbia Medical School, Vancouver, Canada
| | - Charles G Fisher
- Division of Spine Surgery, Vancouver General Hospital, University of British Columbia. Past President, Canadian Spine Society, Vancouver Spine Surgery Institute, Vancouver, Canada
| | - Manraj KS Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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26
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Westbroek EM, Ahmed AK, Pennington Z, Goodwin ML, Xia Y, Boone C, Gailloud P, Sciubba DM. Hypervascular Metastatic Spine Tumor Angiographic Relationships with the Artery of Adamkiewicz and Other Radiculomedullary Arteries. World Neurosurg 2019; 126:e480-e485. [DOI: 10.1016/j.wneu.2019.02.075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 01/05/2023]
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27
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Westbroek EM, Ahmed AK, Pennington Z, Goodwin ML, Xia Y, Boone C, Gailloud P, Sciubba DM. Atypical Vertebral Hemangiomas Are Frequently Associated with Radiculomedullary Arteries. World Neurosurg 2019; 127:e1215-e1220. [PMID: 31004857 DOI: 10.1016/j.wneu.2019.04.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Preoperative endovascular embolization of atypical hemangiomas of the spine can reduce intraoperative blood loss. One frequent concern raised about embolizing these tumors is a possible association with arteries feeding the spinal cord, such as the artery of Adamkiewicz. This study aimed to elucidate a relationship between spinal levels affected by atypical spinal hemangiomas and radiculomedullary arteries. METHODS This was a retrospective review of 8 patients undergoing preoperative embolization of atypical spinal hemangiomas. We evaluated 54 spinal levels by angiography during embolization procedures. Each spinal level was categorized on the basis of the presence or absence of tumor and radiculomedullary artery. RESULTS Six of 15 (40%) affected levels had an associated radiculomedullary artery. Four of 39 (10.2%) unaffected levels had an associated cord feeding artery. The relative risk of affected spinal levels having an associated radiculomedullary artery was 3.9 (95% confidence interval 1.28-11.91). The attributable risk was 0.40 (95% CI 0.12-0.76). The chi-squared statistic was 6.35, with a P value of 0.01. Six of 8 patients (75%) had a radiculomedullary artery at a level of disease and embolization. CONCLUSIONS In this study, spinal levels affected by atypical hemangiomas requiring surgery were associated with radiculomedullary arteries. When performing preoperative embolization, great care must be taken to identify and preserve arteries supplying the spinal cord.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine Boone
- Division of Interventional Radiology, University of California, San Diego School of Medicine, La Jolla, California, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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28
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Yoo SL, Kim YH, Park HY, Kim SI, Ha KY, Min HK, Seo JY, Oh IS, Chang DG, Ahn JH, Kim YW. Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors. J Korean Neurosurg Soc 2018; 62:106-113. [PMID: 30630297 PMCID: PMC6328796 DOI: 10.3340/jkns.2018.0073] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/19/2018] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss. METHODS A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed. RESULTS The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring. CONCLUSION Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.
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Affiliation(s)
- Sung-Lim Yoo
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Youl Park
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee-Yong Ha
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Ki Min
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun-Yeong Seo
- Department of Orthopedic Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea
| | - In-Soo Oh
- Department of Orthopedic Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Dong-Gune Chang
- Department of Orthopedic Surgery, Sanggye Paik Hospital, The Inje University College of Medicine, Seoul, Korea
| | - Joo-Hyun Ahn
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong-Woo Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Zhang J, Kumar NS, Tan BWL, Shen L, Anil G. Pre-operative embolisation of spinal tumours: neither neglect the neighbour nor blindly follow the gold standard. Neurosurg Rev 2018; 42:951-959. [DOI: 10.1007/s10143-018-1003-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/10/2018] [Accepted: 06/25/2018] [Indexed: 01/10/2023]
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30
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Zaborovskii N, Ptashnikov D, Mikaylov D, Masevnin S, Smekalenkov O. RENAL CELL CARCINOMA METASTASIS OF THE SPINE: BLEEDING CONTROL METHODS. COLUNA/COLUMNA 2018. [DOI: 10.1590/s1808-185120181703193262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: This report compares various methods of bleeding control, and their influence on outcome and survival after decompression procedures for spinal metastasis of renal cell carcinoma (MRCC). Methods: A retrospective study. All patients underwent palliative decompression procedures. We compared 3 groups of patients stratified by methods of bleeding control. The first group (EMB) included 22 patients who underwent preoperative embolization of a tumor. The second group (HEM) consisted of 20 patients, treated surgically using intraoperative local hemostatic agents. In the third group (COMBI) 15 patients were treated with a combination of methods. Results: The average intraoperative blood loss for the EMB group was slightly less than the average for the HEM and COMBI groups, but without significant differences. The postoperative drainage loss in the HEM and COMBI groups was significantly less than in EMB group. The complication rate (infections, hematomas, neurological deficit) was practically equal in all groups. No statistically significant differences in local tumor recurrence and overall survival were found between groups. Conclusions: The overall results did not show that usage of different bleeding control methods can affect early or long-term outcomes. Level of Evidence III; retrospective study.
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Affiliation(s)
- Nikita Zaborovskii
- R.R.Vreden Russian Research Institute of Traumatology and Orthopedics, Russia
| | - Dmitrii Ptashnikov
- R.R.Vreden Russian Research Institute of Traumatology and Orthopedics, Russia
| | - Dmitrii Mikaylov
- R.R.Vreden Russian Research Institute of Traumatology and Orthopedics, Russia
| | - Sergei Masevnin
- R.R.Vreden Russian Research Institute of Traumatology and Orthopedics, Russia
| | - Oleg Smekalenkov
- R.R.Vreden Russian Research Institute of Traumatology and Orthopedics, Russia
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Tang B, Ji T, Guo W, Tang X, Jin L, Dong S, Xie L. Which is the better timing between embolization and surgery for hypervascular spinal tumors, the same day or the next day?: A retrospective comparative study. Medicine (Baltimore) 2018; 97:e10912. [PMID: 29879030 PMCID: PMC5999470 DOI: 10.1097/md.0000000000010912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Previous series presented the timing between embolization and surgery in a wide range on the basis of their experience rather than supportive data. And comparative studies were limited to small samples. In addition, there is no study publishing the timing by considering both safety and efficacy of embolization. The aim of this study was to determine the better timing (the same day or the next day) between embolization and surgery for hypervascular spinal tumors by assessing the safety and efficacy of embolization.One hundred twenty-five embolizations with subsequent 120 operations for hypervascular spinal tumors between January 2010 and April 2013 were retrospectively reviewed. The time between embolization and surgery was mainly determined by interventional radiologist schedules and operating room available. Major complications of embolization were documented. The efficacy of embolization was compared between the same day and the next day group.Of the 125 embolizations, there were 4 major complications, all of which occurred on the same day of procedure. Of the 120 operations, 36 cases were operated on the same day of embolization, 74 on the next day, and 10 on the second day. When comparing the efficacy of embolization between the same day and the next day group, intraoperative blood loss (1483 ± 1475 vs 1548 ± 1099 mL, P = .80), intraoperative transfusion requirement (1011 ± 1200 vs 1112 ± 890 mL, P = .62), and postoperative blood loss (1146 ± 933 vs 1031 ± 777 mL, P = .50) were not significantly different.Embolization carries certain risks (4/125, 3.2%) for major complications, which may occur within the time window of 1 day. Two patient groups showed no difference on the efficacy of embolization. Operation should be scheduled on the next day of embolization if possible.
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Affiliation(s)
- Benqiang Tang
- Musculoskeletal Tumor Center, People's Hospital, Peking University
- Department of Spine Surgery, Beijing Luhe Hospital, Capital Medical University
| | - Tao Ji
- Musculoskeletal Tumor Center, People's Hospital, Peking University
| | - Wei Guo
- Musculoskeletal Tumor Center, People's Hospital, Peking University
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, People's Hospital, Peking University
| | - Long Jin
- Department of Radiology, People's Hospital, Peking University, Beijing, China
| | - Sen Dong
- Musculoskeletal Tumor Center, People's Hospital, Peking University
| | - Lu Xie
- Musculoskeletal Tumor Center, People's Hospital, Peking University
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Preoperative embolization and local hemostatic agents in palliative decompression surgery for spinal metastases of renal cell carcinoma. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018. [DOI: 10.1007/s00590-018-2162-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Qiao Z, Jia N, He Q. Does preoperative transarterial embolization decrease blood loss during spine tumor surgery? Interv Neuroradiol 2018; 21:129-35. [PMID: 25934787 DOI: 10.15274/inr-2014-10091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This paper aimed to evaluate the effect of preoperative transarterial embolization (TAE) on estimated blood loss (EBL) during surgical excision of the vertebral tumors. Three hundred and forty-eight patients with spinal tumors were retrospectively analyzed. The preoperative TAE group consisted of 190 patients and the control group consisted of 158 patients. Gelatin sponge particles mixed withy contrast agent were used in the TAE group to embolize the tumor-feeding artery. The factors evaluated included: the time interval between embolism and surgery; the number of vertebrae involved by the tumor; pathological type of tumor; surgical approach; extent of excision and instrumental fixation. The time interval (P = 0.4669)between embolism and surgery had no significant correlation with EBL during surgery. The pathological diagnosis of vertebral tumor such as plasma cell myeloma, giant cell tumor, chondrosarcoma, hemangioma and metastasis had no significant correlation with EBL between the TAE group and control group during surgery, while the EBL of chordoma in the TAE group was significantly higher than that in the control group (p = 0.0254). The number of vertebrae involved (p = 0.4669, 0.6804, 0.6677), posterior approach (p = 0.3015), anterior approach (p = 0.2446), partial excision (p = 0.1911) and instrumental fixation (p = 0.1789) had no significant correlation with EBL during surgery between the TAE group and the control group. This study showed that preoperative TAE of the spinal tumor had no significant effect on intra-operative blood loss during surgical excision of the spinal tumor. In view of the risk of embolism, this method should be carefully considered.
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Affiliation(s)
- Zhihong Qiao
- Department of Imaging, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China Department of Imaging, Shanghai Armed Police Corps Hospital, Shanghai, China
| | - Ningyang Jia
- Department of Imaging, Shanghai Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - Qian He
- Analysis Center, The Second Military Medical University, Shanghai, China
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Schmidt R, Rupp-Heim G, Dammann F, Ulrich C, Nothwang J. Surgical Therapy of Vertebral Metastases. Are there Predictive Parameters for Intraoperative Excessive Blood Loss despite Preoperative Embolization? TUMORI JOURNAL 2018; 97:66-73. [DOI: 10.1177/030089161109700113] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims and background Preoperative embolization of vertebral metastases has been shown to lower intraoperative blood loss. Nevertheless, excessive up to life-threatening blood loss can occur despite embolization. We therefore decided to evaluate possible parameters for predicting significant blood loss in a surgically homogeneous group of patients with vertebral metastases. Methods Patients with vertebral metastases of the thoracic and thoracolumbar spine who underwent preoperative embolization were included. All patients had existing or impending neurological deficit as the main indication for direct metastasis reduction. The parameters evaluated were the technical feasibility of embolization, vascularization grade of metastasis, success of embolization, tumor type in relation to blood loss, and interval between embolization and surgery. Results Twenty-seven patients fullfilled the inclusion criteria. Technically complete embolization was feasible in 14 patients (52%) and fully successful embolization was obtained in 10 patients (37%). Eighty-three percent of the renal cell carcinomas were hypervascularized, but also 67% of the breast carcinoma patients had hypervascularized tumors. No permanent complications occurred during embolization, but two patients had pain and another two experienced a transient burning sensation. A significant difference in intraoperative blood loss was only found between patients achieving partially or fully successful embolization in the subgroup of hypervascularized grade III metastases. Conclusions The success of embolization in the group of hypervascularized grade III metastases was the only predictor for the extent of blood loss in our study. Due to the inaccuracy of predicting high blood loss in general all possible precautions for excessive blood loss should be taken despite preoperative embolization. Further randomized studies to determine the indications and results of embolization seem desirable. Free full text available at www.tumorionline.it
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Affiliation(s)
- René Schmidt
- Department of Orthopedics and Traumatology, University Medical Center Mannheim, Göppingen, Germany
- Department of Orthopedics and Traumatology, Klinik am Eichert, Göppingen, Göppingen, Germany
| | | | - Florian Dammann
- Department of Radiology, Klinik am Eichert, Göppingen, Germany
| | - Christoph Ulrich
- Department of Orthopedics and Traumatology, Klinik am Eichert, Göppingen, Göppingen, Germany
| | - Jürgen Nothwang
- Department of Orthopedics and Traumatology, Klinik am Eichert, Göppingen, Göppingen, Germany
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Unilateral vertebral artery injury in a patient with displaced upper cervical spine fractures: the treatment for one case of vertebral artery embolism. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:409-414. [PMID: 29119335 DOI: 10.1007/s00586-017-5386-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 10/09/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To report a novel treatment method for vertebral artery injury. Vertebral artery injuries may be caused during trauma by fracture and excessive motion with subluxation from C2 to C6 in spite of vertebral artery deeply seated and normally well protected inside the transverse foramen. Optimal medical management of the occluded vertebral artery has yet to be determined. METHODS We report on a severely displaced C2-C3 fracture that was found to have a vertebral artery injury. Medical records and imaging were reviewed. RESULTS A 50-year-old lady was hit by steel tube without loss of consciousness, but complaining of severe cervical and bilateral periscapular pain. Physical examination identified a neurologically intact patient with frontotemporal ecchymosis and posterior cervical tenderness. MRA and DSA showed an occluded left vertebral artery. After 3 days of observation, the patient showed no symptoms of brain ischemia or abnormal sensation and motor at four limbs. To ensure safety, we took the left vertebral artery embolism at the C2 and C5 levels before operation. CONCLUSIONS To our knowledge, this is the first report of a displaced C2-C3 fracture in which transcatheter unilateral VAI embolization was used to prevent VAI bleeding during operation.
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Recurrent primary osseous hemangiopericytoma in the thoracic spine: a case report and literature review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:386-392. [DOI: 10.1007/s00586-017-5322-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/23/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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Tan BWL, Zaw AS, Rajendran PC, Ruiz JN, Kumar N, Anil G. Preoperative embolization in spinal tumour surgery: Enhancing its effectiveness. J Clin Neurosci 2017. [PMID: 28629680 DOI: 10.1016/j.jocn.2017.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We conducted a retrospective review of 221 patients, who underwent spinal oncologic surgery at a tertiary university hospital between 2005 and 2014; in order to identify and validate factors that influence the impact of preoperative embolization of spinal tumours on outcome measures of blood loss and transfusion requirements in spinal oncologic surgery. We also focused on primary tumour type and type of spinal surgery performed. Patients' electronic and physical records were reviewed to provide demographic data, tumour characteristics, embolization techniques and surgical procedure details. These data were analysed against recorded outcome measures of blood loss (absolute volume and haemoglobin reduction) and transfusion requirements. Forty eight patients who received preoperative embolization were compared against 173 patients who did not. There was a tendency towards reduced blood loss and transfusion requirements in embolized spinal metastases from HCC and thyroid; as well as primary spine tumours, though the differences were not significant. Total embolization of arterial supply to spinal tumours resulted in significantly less blood loss as compared to partial or subtotal embolization. In addition, median blood loss was lower in patients receiving a more proximal embolization and in patients who underwent surgery between 13 and 24h post-embolization despite the insignificant difference. To conclude, preoperative spinal tumour embolization is likely to be effective in reducing blood loss if a total embolization is performed 13-24h prior to the surgery. Similarly, the impact of embolization is likely to be more profound in metastases from HCC, thyroid and primary spine tumours.
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Affiliation(s)
- Barry Wei Loong Tan
- Department of Orthopaedic Surgery, National University Hospital, Singapore 119074, Singapore
| | - Aye Sandar Zaw
- Department of Orthopaedic Surgery, National University Hospital, Singapore 119074, Singapore
| | | | - John Nathaniel Ruiz
- Department of Orthopaedic Surgery, National University Hospital, Singapore 119074, Singapore
| | - Naresh Kumar
- Department of Orthopaedic Surgery, National University Hospital, Singapore 119074, Singapore.
| | - Gopinathan Anil
- Department of Diagnostic Imaging, National University Hospital, Singapore 119074, Singapore
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Gao X, Zhao C, Wang J, Cai X, Chen G, Liu W, Zou W, He J, Xiao J, Liu T. Surgical management and outcomes of spinal clear cell sarcoma: A retrospective study of five cases and literature review. J Bone Oncol 2017. [DOI: 10.1016/j.jbo.2016.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance. Clin J Pain 2016; 32:337-50. [PMID: 25988937 DOI: 10.1097/ajp.0000000000000255] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metastatic disease is the most common malignancy of the bone. Prostate, breast, lung, kidney, and thyroid cancer account for 80% of skeletal metastases. Bone metastases are associated with significant skeletal morbidity including severe bone pain, pathologic fractures, spinal cord or nerve roots compression, and malignant hypercalcemia. These events compromise greatly the quality of life of the patients. The treatment of cancer patients with bone metastases is mostly aimed at palliation. OBJECTIVE This article aims to present these palliative treatments for the patients with bone metastases, summarize the clinical applications, and review the techniques and results. METHODS It gives an extensive overview of the possibilities of palliation in patients with metastatic cancer to the bone. RESULTS AND DISCUSSION Currently, modern treatments are available for the palliative management of patients with metastatic bone disease. These include modern radiation therapy, chemotherapy, embolization, electrochemotherapy, radiofrequency ablation, and high-intensity focused ultrasound. As such it is of interest for all physicians with no experience with these developments to make palliative procedures safer and more reliable.
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McDonald K, Murphy LE, Eames N. Is it necessary to embolise all spinal metastases from primary renal tumours? J Orthop 2016; 13:472-474. [PMID: 27857484 PMCID: PMC5103045 DOI: 10.1016/j.jor.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 12/15/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Spinal metastases secondary to renal cell carcinoma are associated with significant intra-operative blood loss. Our aim was to assess if embolisation reduced the intra-operative blood loss and transfusion requirement. METHODS We performed a retrospective cohort study of 25 patients undergoing surgery between 2003 and 2011. RESULTS 14 underwent pre-operative embolisation; 11 did not. There was no significant difference in intra-operative blood loss, 1336 ml vs 1492 ml in the non-embolised (p value = 0.116). 43% of embolised patients required an intra operative blood transfusion vs 27% in the non-embolised. CONCLUSION Our results suggest that not all patients with spinal metastatic renal carcinoma require pre-operative embolisation.
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Affiliation(s)
- Kyle McDonald
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom
| | - Lynn Esther Murphy
- Altnagelvin Area Hospital, Londonderry, Northern Ireland, United Kingdom
| | - Niall Eames
- Department of Trauma and Orthopaedics, Royal Victoria Hospital, Belfast, Northern Ireland, United Kingdom
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Meng XX, Zhang YQ, Liao HQ, Liu HC, Jiang HL, Ke SJ, Dong WH. Dynamic contrast-enhanced MRI for the assessment of spinal tumor vascularity: correlation with angiography. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3952-3961. [DOI: 10.1007/s00586-016-4713-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/26/2016] [Accepted: 07/16/2016] [Indexed: 01/26/2023]
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Jha R, Sharma R, Rastogi S, Khan SA, Jayaswal A, Gamanagatti S. Preoperative embolization of primary bone tumors: A case control study. World J Radiol 2016; 8:378-389. [PMID: 27158424 PMCID: PMC4840195 DOI: 10.4329/wjr.v8.i4.378] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/29/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the safety and effectiveness of preoperative embolization of primary bone tumors in relation to intraoperative blood loss, intraoperative blood transfusion volume and surgical time.
METHODS: Thirty-three patients underwent preoperative embolization of primary tumors of extremities, hip or vertebrae before resection and stabilization. The primary osseous tumors included giant cell tumors, aneurysmal bone cyst, osteoblastoma, chondroblastoma and chondrosarcoma. Twenty-six patients were included for the statistical analysis (embolization group) as they were operated within 0-48 h within preoperative embolization. A control group (non-embolization group, n = 28) with bone tumor having similar histological diagnosis and operated without embolization was retrieved from hospital record for statistical comparison.
RESULTS: The mean intraoperative blood loss was 1300 mL (250-2900 mL), the mean intraoperative blood transfusion was 700 mL (0-1400 mL) and the mean surgical time was 221 ± 76.7 min for embolization group (group I, n = 26). Non-embolization group (group II, n = 28), the mean intraoperative blood loss was 1800 mL (800-6000 mL), the mean intraoperative blood transfusion was 1400 mL (700-8400 mL) and the mean surgical time was 250 ± 69.7 min. On comparison, statistically significant (P < 0.001) difference was found between embolisation group and non-embolisation group for the amount of blood loss and requirement of blood transfusion. There was no statistical difference between the two groups for the surgical time. No patients developed any angiography or embolization related complications.
CONCLUSION: Preoperative embolization of bone tumors is a safe and effective adjunct to the surgical management of primary bone tumors that leads to reduction in intraoperative blood loss and blood transfusion volume.
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Patsalides A, Leng LZ, Kimball D, Marcus J, Knopman J, Laufer I, Bilsky M, Gobin YP. Preoperative catheter spinal angiography and embolization of cervical spinal tumors: Outcomes from a single center. Interv Neuroradiol 2016; 22:457-65. [PMID: 27020696 DOI: 10.1177/1591019916637360] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 02/04/2016] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The existing literature regarding preoperative cervical spinal tumor embolization is sparse, with few discussions on the indications, risks, and best techniques. We present our experience with the preoperative endovascular management of hypervascular cervical spinal tumors. METHODS We performed a retrospective review of all patients who underwent preoperative spinal angiography (regardless of whether tumor embolization was performed) at our institution (from 2002 to 2012) for primary and metastatic cervical spinal tumors. Tumor vascularity was graded from 0 (tumor blush equal to the normal adjacent vertebral body) to 3 (intense tumor blush with arteriovenous shunting). Tumors were considered "hypervascular" if they had a tumor vascular grade from 1 to 3. Embolic materials included particles, liquid embolics, and detachable coils. The main embolization technique was superselective catheterization of an arterial tumor feeder followed by injection of embolic material. This technique could be used alone or supplemented with occlusion of dangerous anastomoses of the vertebral artery as needed to prevent inadvertent embolization of the vertebrobasilar system. In cases when superselective catheterization of the tumoral feeder was not feasible, embolization was performed from a proximal catheter position after occlusion of branches supplying areas other than the tumor ("flow diversion"). RESULTS A total of 47 patients with 49 cervical spinal tumors were included in this study. Of the 49 total tumors, 41 demonstrated increased vascularity (vascularity score > 0). The most common tumor pathology in our series was renal cell carcinoma (RCC) (N = 16; 32.7% of all tumors) followed by thyroid carcinoma (N = 7; 14.3% of all tumors).Tumor embolization was undertaken in 25 hypervascular tumors resulting in complete, near-complete, and partial embolization in 36.0% (N = 9), 44.0% (N = 11), and 20.0% (N = 5) of embolized tumors, respectively. We embolized 42 tumor feeders in 25 tumors. The most commonly embolized tumor feeders were branches of the vertebral artery (19.0%; N = 8), the deep cervical artery (19.0%; N = 8), and the ascending cervical artery (19.0%; N = 8). Sixteen hypervascular tumors were not embolized because of minimal hypervascularity (8/16), unacceptably high risk of spinal cord or vertebrobasilar ischemia (4/16), failed superselective catheterization of tumor feeder (3/16), and cancellation of surgery (1/16). Vertebral artery occlusion was performed in 20% of embolizations. There were no new post-procedure neurological deficits or any serious adverse events. Estimated blood loss data from this cohort show a significant decrease in operative blood loss for embolized tumors of moderate and significant hypervascularity. CONCLUSIONS Preoperative embolization of cervical spinal tumors can be performed safely and effectively in centers with significant experience and a standardized approach.
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Affiliation(s)
- Athos Patsalides
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
| | - Lewis Z Leng
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
| | - David Kimball
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
| | - Joshua Marcus
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
| | - Jared Knopman
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
| | - Ilya Laufer
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, USA
| | - Mark Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, USA
| | - Y Pierre Gobin
- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, USA
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The role of preoperative vascular embolization in surgery for metastatic spinal tumours. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3962-3970. [DOI: 10.1007/s00586-016-4494-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 01/08/2023]
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Preoperative Embolization of Spinal Tumors: A Systematic Review and Meta-Analysis. World Neurosurg 2016; 87:362-71. [DOI: 10.1016/j.wneu.2015.11.064] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/16/2015] [Accepted: 11/19/2015] [Indexed: 11/21/2022]
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Recurrent Spinal Giant Cell Tumors: A Study of Risk Factors and Recurrence Patterns. Asian Spine J 2016; 10:129-35. [PMID: 26949468 PMCID: PMC4764524 DOI: 10.4184/asj.2016.10.1.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 06/13/2015] [Accepted: 06/28/2015] [Indexed: 11/23/2022] Open
Abstract
Study Design Retrospective study. Purpose To highlight risk factors, recurrence patterns and multimodal treatment in management of recurrent giant cell tumors (GCTs). Overview of Literature GCTs of the spine are rare and challenging entities. Recurrences are very common and warrant complex management to prevent multiple recurrences. Gross total resection is preferred over subtotal procedures to prevent recurrences. However, resection is associated with morbidity and mortality. Proper understanding of risk factors and a high index of suspicion helps to spot recurrences early and aids in subsequent management. Methods Ten patients (six females, four males) with recurrent GCTs underwent 17 interventions. There were six lesions in the thoracic spine, two in the cervical spine and two in the lumbar spine. Recurrences were managed with preoperative digital subtraction embolization, intralesional curettage and postoperative radiotherapy. Results The average age at intervention was 31.3 years. The average duration of recurrence in patients following index surgery in a tertiary care hospital and surgery elsewhere was 7.3 years and was 40 months, respectively. The minimum recurrence-free interval after the last recurrent surgery was 10 years. Conclusions Our study reports the largest recurrence-free interval for GCTs. Recurrent GCTs are challenging entities. Understanding of risk factors and meticulous planning is required to prevent recurrences. Intralesional surgery could be a safer and effective modality in managing recurrences.
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Facchini G, Di Tullio P, Battaglia M, Bartalena T, Tetta C, Errani C, Mavrogenis AF, Rossi G. Palliative embolization for metastases of the spine. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 26:247-52. [PMID: 26667933 DOI: 10.1007/s00590-015-1726-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 11/21/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND To present palliative selective and superselective arterial embolization with N-butyl-cyanoacrylate for cancer patients with spinal metastases. MATERIALS AND METHODS We studied the files of 164 cancer patients (94 men and 70 women; mean age 57.6 years; range 35-81 years) treated from March 2003 to March 2013 with 178 selective arterial embolization procedures for metastases of the spine from variable primary cancers. We evaluated the technical success of the embolization procedure with post-procedural angiography, the clinical effect in pain relief, need for analgesics and tumor size reduction, and the embolization-related complications. RESULTS Post-embolization angiography showed complete occlusion of the pathological feeding vessels in all procedures. Pain score and need for analgesics reduced by 50 % in 159 patients (97 %); no response was achieved in five patients with metastases of the sacrum. The mean duration of pain relief was 9.2 months (range 1-12 months). Metastatic tumor size reduced from a mean of 5.5 cm (range 3.5-7.5 cm) pre-embolization to a mean of 4.5 cm (range 3-5 cm) at the 6-month follow-up; the difference was not statistically significant. Ninety-three patients (56.7 %) experienced embolization-related complications the most common being post-embolization syndrome (80 patients, 48.8 %) followed by leg paresthesias (ten patients, 6 %), and rupture of a lumbar artery (one patient, 0.6 %). CONCLUSION Selective arterial embolization with N-butyl-cyanoacrylate should be considered for pain palliation of patients with metastases of the spine. However, pain relief is temporary, and complications, although minor may occur.
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Affiliation(s)
- Giancarlo Facchini
- Department of Diagnostic and Interventional Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Milva Battaglia
- Department of Diagnostic and Interventional Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Cecilia Tetta
- Department of Diagnostic and Interventional Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedics, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Giuseppe Rossi
- Department of Interventional Angiographic Radiology, Istituto Ortopedico Rizzoli, Bologna, Italy
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Awad AW, Almefty KK, Ducruet AF, Turner JD, Theodore N, McDougall CG, Albuquerque FC. The efficacy and risks of preoperative embolization of spinal tumors. J Neurointerv Surg 2015; 8:859-64. [DOI: 10.1136/neurintsurg-2015-011833] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/31/2015] [Indexed: 11/03/2022]
Abstract
BackgroundThe goal of preoperative embolization of spinal tumors is to improve surgical outcomes by diminishing the vascular supply to the tumor to reduce intraoperative blood loss and operative time.ObjectiveTo report our institutional experience with spinal tumor embolization and review the present literature.MethodsClinical records from January 1, 2001 to December 31, 2012 were reviewed and analyzed. Angiograms were used to calculate the percentage reduction in tumor vascularity, and relevant clinical and operative data were collected and analyzed.ResultsThirty-seven patients underwent preoperative spinal tumor embolization (24 metastatic and 13 primary lesions) and were included in the study. One complication resulted in transient lower extremity weakness and was attributed to post-embolization swelling, which fully resolved after surgical resection. The transient neurological complication rate was 1/37 (3%) and the permanent rate was 0/37 (0%). The average surgical estimated blood loss (EBL) was 1946 mL (100–7000 mL) and the average operative time was 330 min (range 164–841 min). After embolization, tumor blush was reduced by 83% on average. Average pre- and postoperative modified Rankin Scale scores were 2.10 and 1.36, respectively (p=0.03). Cases in which tumor blush was decreased by ≥90% (classes 1 or 2) after embolization had significantly less operative blood loss than those cases in which <90% (classes 3 or 4) was achieved (mean EBL 1391 vs 2296 mL, respectively, p=0.05).ConclusionsSpinal tumor embolization is a safe procedure, is associated with few complications, and may improve surgical outcomes by limiting intraoperative blood loss and reducing operative time.
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Alfawareh MD, Shah ID, Orief TI, Halawani MM, Attia WI, Almusrea KN. Pediatric Upper Cervical Spine Giant Cell Tumor: Case Report. Global Spine J 2015; 5. [PMID: 26225290 PMCID: PMC4516742 DOI: 10.1055/s-0034-1396433] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Study Design Case report. Objective The purpose of this work is to report the case of a giant cell tumor involving the second cervical vertebra in a pediatric patient. Surgical management included a combined posterior and anterior cervical approach. There has been no recurrence in 2 years of follow-up. Case Report A 13-year-old girl presented with scoliosis with incidentally lytic lesion involving the second cervical vertebra. The radiologic investigations and biopsy result indicated a giant cell tumor of the bone. A combined posterior and anterior cervical approach was performed to resect the lesion, reconstruct the spine, and restore stability. Two years of follow-up revealed no recurrence of the lesion with stable reconstruction of the spine. Results The lesion was surgically managed for excision and spinal fusion by combining a posterior occipitocervical arthrodesis with an anterior retropharyngeal cervical approach. The final histopathology result confirmed a giant cell tumor of the bone. Conclusions Giant cell tumor involving the second cervical vertebra is uncommon; this tumor can be managed surgically by using a combined posterior and anterior cervical retropharyngeal approach. The presented case was unique in terms of the tumor location, patient age, and surgical management.
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Affiliation(s)
- Mohammad D. Alfawareh
- Department of Spine Surgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia,Address for correspondence Mohammad D. Alfawareh, MD Consultant of Orthopedic Spine Surgery, Department of Spine Surgery, National Neuroscience InstituteKing Fahad Medical City, PO Box 365386, Riyadh 11393Saudi Arabia
| | - Irfanullah D. Shah
- Department of Spine Surgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Tamer I. Orief
- Department of Neurosurgery, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Mohammad M. Halawani
- Department of Spine Surgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Walid I. Attia
- Department of Spine Surgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khaled N. Almusrea
- Department of Spine Surgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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Risk factors for major complications in surgery for hypervascular spinal tumors: an analysis of 120 cases with adjuvant preoperative embolization. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:2201-8. [DOI: 10.1007/s00586-015-4122-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 07/08/2015] [Accepted: 07/08/2015] [Indexed: 11/25/2022]
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