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Yuldashev Ravshan Muslimovich, Republican Scientific Centre of Neurosurgery of Ministry of Health of Republic of Uzbekistan,
Senior Researcher E-mail: [email protected]
Open Vertebroplasty in surgical treatment of metastatic tumors of the spine
Abstract: The treatment analysis of patients with pathological fractures of metastatic tumors of the spine in the thoracic and lumbar spine was performed. The results of surgical treatment were studied by using the method of internal stabilization and open vertebroplasty. The following benefits were highlighted: increased support ability of the vertebral height and preservation of his body, and improve the reliability of internal stabilization.
Keywords: tumor metastasis, spine, vertebroplasty, transpedicular stabilization, surgery.
The method of percutaneous (closed) vertebroplasty in treatment of patients with aggressive vertebral haemangiomas and spinal metastasis has proved its necessity and is widely used in treatment of the pathology. However, in surgical practice we often come across the situation, when neurological disorders and destruction of posterior wall of vertebral body do not let apply this method. In such situations, we have to make decompression of spinal canal and its content with removal of a part of metastatic tumor. But, while making posterior wall decompression and transpedicular stabilization, we do not always manage to fix damaged vertebral motion segment, to improve support ability ofvertebral column.
Purpose of the research — to conduct analysis of treatment of patients with pathological ruptures in haemangiomas and metastatic tumors in thoracic and lumbar spine, as well as to learn results of surgical treatment with use of intrinsic stabilization and open vertebroplasty method.
Materials and methods. Results of research and treatment of 12 patients with metastatic tumors and haemangiomas of thoracic and lumbar spine (4 patients with haemangiomas and 8 patients with metastasis) conducted within the period from 2009 to 2015 years at RUz MH RRCN. Age of the patients is between 36 to 55; 4 men and 8 women. Average age of the patients is 40. Clinical and neurological examination of all patients were made, the diagnosis is confirmed on the basis of instrumental examination (MRT, MSCT, Ultrasound investigation of abdominal cavity
and pelvic organs, pneumonography and others) of oncologist's decision. Careful selection of patients have been made — decom-pressive-stabilizing surgery and open vertebroplasty were made only in situations, when it was impossible to confine to percutaneous vertebroplasty, due to availability of long tract disorders as a result of partial compression of spinal cord, but hard destruction ofvertebral body was not reported at that (K. Tomita's classification, type 2,3, 2001y.). Results of the treatment were assessed based on the scale, assessing the dynamics of neurological disorders (ASIA) and dynamics of spinal axis recovery according to radiographic data.
Results. Localization of blastomas in region of vertebral column was as following: In thoracic spine — 4 (67%); in lumbar spine — 8 (33%).
Neurological signs, measured according to ASIA grading scale, are presented as follows. Patients of group B — 7 (58%), group C — 2 (17%), group D — 3 (25%). There are no patients of group A and E.
According to pain syndrome intensity (VAS scale) patients are divided as follows. 3 (25%) patients complained of inconsiderable pains (3-4 scores). 8 (67%) patients complained of moderate pain (5-7 scores). 1 (8%) patient with tumors of lumbar spine complained of severe pains (score 8 and over).
Table 1 presents assessment of spinal injury based on radiology examination.
Section 7. Medical science
Table 1. - Assessment of spinal injury on the basis of radiographic surveys
Parameters Value
VWSDP (n=12) interval from 0% to 55% 19,07%±16,79%
SCP (n=12) interval from 0% to 80% 26,87%±17,06%
Stricture of spinal canal (n=12) interval from 12% to 80% 30,22%±15,73%
Angle of local anterior curvature (n=12) interval from 14° to 39° 13,38°±12,14°
Number of injured axis (level) (n=12)
I 3 (25%)
II 9 (75%)
Spinal deformity scale (level) (n=12)
1 — compression fracture 5 (42%)
2 — fracture with compression prevalence 5 (42%)
3 — fracture with sphenic deformity prevalence 2 (16%)
Tomita classification (level) Number of cases (n=12)
T1 3 (4%)
T2 5 (7%)
T3 2 (4%)
T4 2 (4%)
Average value is equal to: VWSDP (Vertebra wedge-shaped deformation parameter)) — 19,07%±16,79%, SCP (Sp ine compression parameter) — 26,87%±17,06%, stricture of spinal canal — 30,22%±15,73%. Average value of angle of local anterior curvature is equal to — 13,38°±12,14°. While assessment of dorsal spine injury, grade II prevailed (75% of patients). 25% patients had lesions, referring to grade II. While scale assessment of spinal deformity, lesions of grade 1 and grade 2 were revealed in equal frequency. There were 5 (42%) patients in each group. 2 (16%) patients referred to grade 3. In grades T^ T2, T3, T4, of Tomita's classification, all 12 (100%) patients had blastomas limited to bony structure and spinal canal.
Type ofposterolateral surgical approach is presented in table 2.
Table 2. - Type of surgical approach
Type of surgical approach Number of cases (n=12)
1. Arch resection, removal of vertebral arch root and upper intervertebralis 2 (14%)
2. Arch resection, removal of vertebral arch root, upper and lower intervertebralis 3 (19%)
3. Hemilaminectomy, laminectomy, removal of vertebral arch root, articular process, and neural spine — in lumbar spine 4 (48%)
4. Item 3 + removal of costotransverse joint, head of rib and a part of rib — in thoracic spine 3 (19%)
1st and 2nd economic approaches were applied in 5 (42%) cases. 3rd and 4th extensible surgical approaches were made in 7 (58%) cases. Surgical intervention of bilateral decompression of spinal canal elements was made for 8 (67%) patients, and unilateral decompression for 4 (33%) patients.
Table 3 represents spinal stabilization from position ofvertebral body injury level. Transpedicular stabilization was made to all 12 (100%) patients. Acrylic cement, which was used for filling vertebral body defects, was applied for spondylosyndesis.
Table 3. - Spinal stabilization
Stabilization Number of cases, n=12 Spinal injury level
L-L,
Type
Transpedicular 11 (92%) 3 8
Lamina hooks 1 (8%) 1
Spondylosyndesis
Acrylic cement 12 (100%) 4 8
Perfect early result of treatment (group A) was reported with 3 (25%) patients. Good (group B) and satisfactory (group C) results were reported, correspondingly, with 6 (50%) and 3 (25%) patients.
Analysis of neurological disorders in group B on lower limbs function revealed improvement (in average) in levels 1,04±0,56 according to ASIA/IMSOP scale. All 7 patients with blastoma had regression of neurological disorders. Reduction of pain syndrome is reported (in average) in levels 3,17±1,07 according to VAS scale. Reduction of angle of local anterior curvature in group C was equal to (in average) 10,91°±6,44°. Better results were reported with SCP (9,45%±8,50%), rather than with VWSDP (6,55% ±9,86%).
Table 4. - Early results of treatment
Results Number of cases (n=12)
A — perfect 3 (25%)
B — good 6 (50%)
C — satisfactory 3 (25%)
D — bad -
Improvement
According to ASIA/IMSOP scale (level)* 1,04±0,56
According to VAS scale (score)* 3,17±1,07
Angle of local anterior curvature** 10,91°±6,44°
VWSDP ** 6,55% ±9,86%
SCP ** 9,45%±8,50%
* concerning results in groups А and В ** concerning results in groups А and С *** death
Control investigations were made with 8 (67%) patients (table 5). 4 patients did not agree to get control investigation. Long-term good result of treatment was reported in 6 (50%) cases, bad result — in 2 (16%) cases. Improvement according to ASIA/IMSOP scale, in average, was equal to 0,21±0,43 level, and according to VAS scale — 34±0,52 level. Deterioration of neurological condition according to ASIA/IMSOP scale, in average, was equal to 0,25±1,71 level and according to VAS scale — 0,43±0,57 level. Besides, deterioration of average value of local anterior curvature angle in this group began for 2,45°±1,89°. Complications in the form of acrylic cement epidural insertion with spinal cord compression are not revealed.
Discussion. In availability of blastoma, injuring anterior and posterior columns of spinal bone, it is recommended to make two-stage surgical treatment (posterior approach and then anterior approach) [6, 1243-1266; 7, 145-154; 8,438-446]. But we can reduce period of treatment in some cases, by using bilateral posterolateral approach, which enables full vertebrectomy and decompression of spinal cord [9, 211-220; 10, 2240-2250; 11,236-264; 12,36-46]. After tumor removal and spinal cord decompression, it is required to make spine stability, which can be done by using posterior and
anterior approach. Metal implants and bone transplants, which enable to make reconstruction ofvertebral body, are used for stabilization of vertebra.
Table 5. - Results of control investigation
Results Number of cases (n=8)
Good 6 (50%)
Bad 2 (16%)
No data 4 (34%)
Change in group of patients with good result n=6
According to ASIA/IMSOP scale 0,21±0,43
According to VAS scale 0,34±0,52
Change in group of patients with bad result n=2
According to ASIA/IMSOP scale 0,25±1,71
According to VAS scale 0,43±0,57
Angle of local anterior curvature 2,45°±1,89°
In malignant tumor, it is not recommended to replace bone flap, as it will be destructed. Bilski et al. [10, 2240-2250] states that reconstruction of vertebral body is not required, when posterior stabilization is made with saved major part of vertebral body. Bridwell et al. [13, 1383-1394] made posterior stabilization for 25 patients, without reconstruction of vertebral body. Only 1 patient had complications after this way stabilization. Besides, in opinion of Bauer
[14, 514-522], posterior stabilization is sufficient consolidation of unstable vertebra, in availability of blastoma, injuring vertebral body.
29 (73%) patients of 40 with metastatic tumors and tumors coming from hematopoietic system made filling of body with bone cement after decompression of neuroblastomas, partial removal of vertebral body tumor. Tumor removal method was limited only with transformed cells, unaffected bone and hyaline plate were not removed. After tumor removal, the cavern was filled with acryl cement. In all these cases, stabilization of vertebra was made by systems of transpedicular implants. Scoville et al. [15, 274-279] presented results of surgical treatment of vertebral tumors with using of acryl cement. Necessity of strengthening of support ability of normal skeletal elements ofvertebra by means of acrylic cement prostheses was proved. Akeyson et McCutheon [9, 211-220] learned complications after using of acrylic cement in 16% cases. In our material, use of acrylic prostheses did not provide additional strengthening and there was no complication. Bilsky et al. [10, 2240-2250] noted that failure in using of bone cement is connected with the method ofvertebral body removal and type of posterior stabilization. Saving of those parts ofvertebral body, which are not affected by tumor, influence over spine stability and prevents shifting of acrylic prostheses.
So, the method of open vertebroplasty has many advantages. They are: improvement ofvertebra support ability, saving the height ofits body, improvement ofreliability of internal stabilization. Also, several authors report about chemotherapeutic and thermal influence of methylmethacrylate on residual tumor.
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