29 Treatment of Neoplastic Vertebral Compression Fractures
Summary
The spine is the most frequently involved bony structure in cancer metastasis, the order of frequency being the thoracic (70%), lumbosacral (20%), and cervical (10%) spine. The spine metastasis usually originates from a cancer of the adjacent organs: the thoracic spine from the lung and breast; the lumbosacral spine from the colon, prostate, urinary bladder, and uterine cervix; the cervical spine from the thyroid or lung.
Diagnosis is rendered by a history of weight-bearing pain, tenderness in the supraspinous area with or without adjacent facet area tenderness on physical examination, loss of a pedicle on a plain film x-ray with or without vertebral height loss on the lateral view, active bone lesions on bone scans, and posterior wall destruction of the compressed vertebral body on computed tomography (CT) or magnetic resonance imaging (MRI).
Treatment for painful osteolytic and osteoblastic metastatic fractures, such as percutaneous vertebroplasty (PVP) or kyphoplasty, may start with performing facet-joint injections to determine the exact painful level in patients with multilevel spine metastases. This is done with the patient in the prone position with care taken to minimize facet-mediated pain. The levels are localized so as to minimize obscuration of the underlying anatomy by the potentially overlying radio-opaque bone cement.
A vertebral needle should be placed at the anterior one-third to one-fourth of the vertebral body to prevent leakage of bone cement into the anterior epidural space through the damaged posterior wall of the vertebral body. Injecting bone cement equal to 20 to 25% of the volume of the vertebral body is sufficient.
The mechanism of pain relief is not only augmentation by bone cement that provides pain relief by stabilizing the vertebral body but also denervation (by both thermal and chemical means) of basivertebral nerve branches that carry pain from the end plates through the vertebral. If leakage of bone cement is avoided, the result of PVP is similar to that of percutaneous kyphoplasty.
PVP for the treatment of painful metastatic osteolytic or osteoblastic compression fractures provides immediate pain relief and allows for early ambulation.
29.1 Introduction
Percutaneous vertebroplasty (PVP) was first reported for the treatment of painful benign vertebral angioma in 1987. 1 The procedure has been widely used to treat painful osteoporotic compression fractures, commonly in the thoracolumbar junction.
Increased life expectancy after cancer diagnoses and a higher prevalence of bony metastases has increased the number of cases of painful metastatic vertebral compression fractures (VCFs). As with osteoporosis, metastatic vertebral fractures mainly occur in the thoracic spine, followed in frequency by the lumbosacral and cervical spines. 2
Spinal metastases usually develop from cancers of the adjacent organs, and most common types of spinal metastases (60%) originate from breast, lung, or prostate, and far less frequently from the kidney, urinary bladder, and thyroid. 2 The segment of the spine involved with metastatic disease is usually the portion of the spine nearest to the affected organ. For example, the thoracic spine is usually affected by cancers of the lung and breast; the lumbosacral spine by cancers from the colon, prostate, urinary bladder, and uterine cervix; the cervical spine by cancers from the thyroid or lung.
Spinal metastases from breast cancer are common in women in their forties and fifties but spinal metastases from lung cancer are more common in men in their sixties and seventies. About 10% of all cancers eventually metastasize to the spine. 2
29.2 Diagnosis
29.2.1 History
Patients who have painful metastatic osteolytic or osteoblastic fractures are more frequently referred from the oncology department, rather than from a pain or spine clinic. In patients with spine metastases, it is easier to find the metastasis to the spine if there are red flags, such as recent sudden weight loss, combined motor deficits, or if the patient is less than 40 years old and has severe unremitting back pain.
On the contrary, in cases referred by way of findings on cross-sectional imaging usually come to the physician’s attention after an emergency room visit or following a scan obtained after surgery, chemotherapy, or radiotherapy. The typical complaints are of sudden and severe back pain that is exacerbated with the patient changing position or in transition. Many times the patient is debilitated to the point where they are unable to sit and stand by themselves and are relegated to lying on their back.
29.2.2 Physical Examination
It is important to check combined motor deficits in a supine position and it is especially important for both doctors and patients to recognize existing motor deficits that may be present prior to the procedure. After discovery of any motor deficits, the doctor should inform the patient as to their presence. The motor deficits may eventually progress, whether or not the PVP is performed and it is optimal to document this prior to performing any intervention. The initial examination must include palpation of the paraspinal region and overlying the posterior superior iliac spine keeping in mind that it may not be easy to put the patient in the prone in order to be able to examine them. 3
If the metastatic vertebral fractures are combined with diskogenic back pain or facet-joint pain, it may be very difficult to determine the exact region that is producing the pain. In this case it may be better to perform intradiskal or facet-joint injections prior to the PVP to be able to further localize the pain generator. The merits of performing injections prior to the PVP are (1) after relieving pain from the painful disk or facet joint, the residual presence of supraspinous tenderness has a value in choosing the correct level for the PVP among the multiple metastatic levels, (2) after relieving the patients’ degenerative back pain, they can lie in a prone position and better cooperate with the augmentation procedure, and (3) if the PVP is performed prior to the injections, the cement may obscure the injection targets, making it difficult to perform the appropriate injections. 3
29.2.3 Imaging Diagnosis
Plain film X-rays: It is difficult to diagnose neoplastic VCFs until they are prominent or even severe. However, if there is a loss of the pedicle on the anteroposterior view, this provides strong evidence of spinal metastasis. This is in contradistinction to a vertebra with intact pedicles but a compressed vertebral body. This type of compression fracture can be difficult to determine whether the fracture is a result of osteoporosis or tumor (▶Fig. 29.1).
Bone scans: Nuclear medicine bone scanning tends to be an optimal diagnostic tool if the lesions detected are in the posterior wall of the vertebral body or pedicle. In the sacrum and pelvis, a signature sign of a benign sacral insufficient fracture is classically seen as a ‘Honda sign’ on bone scan, composed of vertically oriented fractures primarily through S1 and S2 vertebral bodies and a horizontally oriented fracture through S2 (▶Fig. 29.2a).
Computed tomography (CT): It is helpful to reveal whether the posterior wall of the vertebral body is intact or not and where the exact fracture lines in the vertebrae are located.
Positron emission computed tomography (PET/CT): Is effective in evaluating the status of both the primary focus of the cancer and spinal metastasis and when combined with CT or MRI scanning can be highly accurate at localizing the exact anatomic location of the neoplastic involvement.
Magnetic resonance imaging (MRI): The soft tissues such as the intervertebral disks, spinal cord, cauda equina, and dorsal nerve root ganglion are seen clearly, as well as other areas of interest such as the anterior epidural space and the cerebral spinal fluid. The extent of the tumor or metastasis involvement is typically well characterized by MRI.
29.2.4 Valuable Scoring Systems for Evaluation of the Patients with Metastatic Bone Lesions
Karnofsky performance status (KPS) scale (▶Table 29.1): It is very helpful to evaluate patients’ physical performance status before and after PVP. If the score is 50% or higher, patients can be discharged from the hospital. 4
Tokuhashi revised scoring system for preoperative evaluation of metastatic spine tumor prognosis (▶Table 29.2): It is important to predict the prognosis of a metastatic spine tumor before the PVP. 5
Characteristic | Score |
1. General condition (performance scale) | |
Poor (10–40%) | 0 |
Moderate (50–70%) | 1 |
Good (80–100%) | 2 |
2. Number of extraspinal bone metastases foci | |
≥3 | 0 |
1–2 | 1 |
0 | 2 |
3. Number of metastases in the vertebral body | |
≥3 | 0 |
1–2 | 1 |
0 | 2 |
4. Metastases to the major internal organs | |
Lung, osteosarcoma, stomach, bladder, esophagus, pancreas | 0 |
Liver, gall bladder, unidentified | 1 |
Others | 2 |
Kidney, uterus | 3 |
Rectum | 4 |
Thyroid, breast, prostate, carcinoid tumor | 5 |
5. Palsy | |
Complete (Frankel A, B) | 0 |
Incomplete (Frankel C, D) | 1 |
None (Frankel E) | 2 |
Criteria of predicted prognosis | |
Total score 0–8 < 6 months | |
Total score 9–11 ≥ 6 months | |
Total score 12–15 ≥ 1 year | |
Related posts:
4 Physical Examination Findings in Patients with Vertebral Compression Fractures
13 Radiation Exposure and Protection: A Conversation Beyond the Inverse Square Law, Thermoluminescent Dosimeters, and Lead Aprons
16 Cost-Effectiveness of Vertebral Augmentation
14 Appropriateness Criteria for Vertebral Augmentation
25 Postural Fatigue Syndrome
30 Vertebral Augmentation in Instrumented Spinal Fusions
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