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Modern Treatment of Spinal metastases

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Presentation on theme: "Modern Treatment of Spinal metastases"— Presentation transcript:

1 Modern Treatment of Spinal metastases
Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville

2 My Background Neurosurgeon Residency 2002 Fellowships-complex spine-Emory and Spine Oncology-Sloan Kettering-2003 Stanford worked with cyberknife Special interest in spine tumors and spine radiosurgery

3 Goals Epidemiology Presentation Imaging Role of Surgery Emerging Treatment paradigms Decision making and Frameworks Memorial Sloan Kettering NOMS criteria Cases

4 Epidemiology 20000 new cases of metastatic epidural cord compression each year 10% of cancer patients will develop spinal metastatic About 70% of all cancer deaths occur in elderly patients aged over 65 Postmortem studies metastases present in 90% of patients with systemic cancer

5 Epidemiology Number of elderly patients dying from cancer will double by 2030 By age 2050, the number of newly diagnosed patients aged 85 will quadruple

6 Myelopathy-Motor, Sensory, Bowel/Bladder Pain
Signs and symptoms Myelopathy-Motor, Sensory, Bowel/Bladder Usually from epidural cord compression Pain Biologic nocturnal/early morning-resolves during day-usually from tumor infiltration, Steroid responsive Mechanical-movement related Radicular-usually epidural disease in foramen Other Symptoms e.g LOC or AMS from brain

7 Imaging X-rays CT MRI PET

8 Imaging findings Imaging Epidural disease only Vertebral disease only
Vertebral disease with epidural Cord compression Mechanical instability Pathological fractures Single level, Multiple level, Distant metastases

9 Treatment options Surgery Radiation therapy Radiosurgery Chemotherapy

10 Main surgical approaches
Anterior Transthoracic, Retroperitoneal Posterior Laminectomy Posterior transpedicular, costotransversectomy approach


12 Epidural Compression: Surgery is superior to radiation
Patchell et. al, Lancet Vol 366: , 2005

13 Patchell study

14 Surgery vs. radiation-Patchell

15 Surgery improves quality of life outcomes
Quan et. Al., Eur Spine Journal 2011 Jun 26

16 Surgical complications

17 Price of surgery: High Morbidity and mortality
Complication rates-20-40%


19 Emerging Treatment Patterns
Vertebral augmentation Vertebroplasty Kyphoplasty Radiosurgery Combined kyphoplasty and radiosurgery




23 CAFÉ trial

24 Berenson et. Al., Lancet Oncology 2011 Mar;12(3):225-35.

The CyberKnife® a robotic manipulator to move a compact linear accelerator with six degrees of freedom Real-Time Image Guidance Throughout the Treatment Dynamic Motion Tracking Allows for accuracy and conformality Louisville is getting one!!



28 Other radiosurgery systems



31 Concept of Separation surgery

32 Separation surgery



35 DECISION MAKING Who should be operated on? Frameworks for prognosis Algorithms and Decision aids

36 Tokuhashi score 􀂃≥9:•Excision•Survival > 12 months
􀂃≤5:•Palliative•Survival < 3 months

37 Decision Making-NOMS criteria
Neurologic Oncologic Mechanical Systemic

38 NOMS criteria Neurologic-myelopathy, degree of epidural cord compression Oncologic- radiosensitivity of tumor Mechanical instability-movement related pain Systemic disease and medical comorbidities

39 Neurologic-Classification of Epidural compression

40 Neurologic-Classification of epidural compression
Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317

41 Oncologic-Radiosensitivity
–Myeloma & Lymphoma: most radiosensitive –Prostate, Breast, Lung and Colon: moderately –Thyroid, Kidney, Melanoma: not radiosensitive

42 Mechanical Instability


44 Systemic factors

45 SINS score Ranges 0-18 0-6, Stable 7-12, indeterminate, possibly impending instability 13-18-Instability Surgical consultation is recommended for SINS score > 7. Fisher CG, Spine Vol 35(22): , 2010

46 Oncologic factors-Impact of Comorbidities

47 Oncologic and Systemic factors-survival



50 Predictors of Survival
VAriable Hazard ratio 95% CI P-value Age 1.001 0.90 Ambulatory status 2.355 0.0001 Cervical mets 1.07 0.76 Comorbidity 2.96 0.007 Epidural compression 1.20 0.52 Pathologic fracture 1.41 0.08 Radiosensitivity 2.56 <0.0001 Radiotherapy 0.98 0.91 Urinary incontinence 1.16 0.47 Visceral mets 1.09 0.65

51 NOMS decision framework.
Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317









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