General Session: MIS - Hall F
Presented by: T. Li
(1) Zibo Central Hospital Affiliated to Shandong University, Spine Surgery, zibo, China
Background: MIS and radiotherapy has been widely acknowledged in the treatment of metastatic epidural spinal cord compression (MESCC), since it brings more satisfied clinical outcomes including better functional recovery, quality of life and even longer survivals. In practice, many MESCC patients were poor surgical candidates who were not able to tolerate traditional surgery like direct decompressive surgical resection (DDSR) or radiotherapy. We need to find a way satisfied these patients with relatively mild treatment strategies besides palliative treatment/conservative management. Patients and
Methods: Retrospectively, we reviewed medical records and our follow-up files until Jan 1st, 2017. The therapeutic schedules included 125I brachytherapy followed by PVP with basic palliative management (MIS group, 11 cases) and palliative treatment alone (palliative group, 18 patients). The average age of MIS patients and palliative cases were 59.36±6.31 and 62.50±5.17 years respectively, without significant difference between groups (p =0.156). Magnetic resonance imaging (MRI) results suggested metastatic neoplastic tissues and vertebral fractures with spinal cord compression at thoracic vertebral levels. All candidates complained intense back pain, with the average visual analogue scale (VAS) score and muscle strength tested, and the pain could not be alleviated by Fentanyl patch (Table 1). For patients in MIS group, we performed 125I seed interstitial implantation brachytherapy in the metastatic vertebrae (with spinal cord compression) and PVP in fractured vertebrae without obvious metastatic tissues (if any) via bilateral transpedicular approaches under local anesthesia. Patients in palliative group received routine palliative management including pain relief.
Results: Instantly, the back pain was significantly alleviated for both groups, and better outcomes were observed among patients in MIS group (Table 1). But we hadn't observed instant improvement of neurological functions. Two months after first procedure, partial neural functional recoveries were observed of MIS patients, with significant recovery of sphincter function and/or cutaneous sense, and improved muscle strength in the lower extremities. MRI scan suggested the impaired anterior walls of canal were restored to normal or partly normal. The metastatic tumors shrunk significantly and no neoplastic tissue was visible around the cord. Then we gave secondary procedures by using PVP in previous metastatic vertebrae. After that, candidates were able to sit in wheel chair and walk with or without support from others. Six of these patients (54.55%) survived over six months after treatment, with satisfied living quality until passed away. For palliative patients, no improvement of muscle strength in the lower extremities was observed as shown in Table 1, consistent with imaging data.
Conclusions: We acknowledged that palliative treatment is very useful as it could effectively reduce pain, for poor surgical candidates with MESCC. But palliative management might not be the only choice since some patients could tolerate mild MIS if surgeons gave proper pretreatment. Our therapeutic strategy aims to diminish the volume of the spinal metastases and decompress the injured spinal cord first, then to augment the vertebrae later. It also allows effective reconstruction of the anterior portion of the vertebral body without using allograft, autograft, cages, or plates, avoiding extensive anterior surgical approaches. Further surgical attempt using large-scale cohort is urgently warranted to confirm or modified the findings from this exploration.