Saint-Petersburg, Russia 2014 Vreden Russian Research Institute of Traumatology and Orthopedics PREOPERATIVE EMBOLIZATION VS. LOCAL HEMOSTATIC AGENTS IN SPINAL SURGERY OF HYPERVASCULAR METASTASES Hello! My name is Nikita! I’d like to thank for inviting me. I’m here on behalf of Russian Medicine, Vreden Research Institute of Traumatology and Orthopedics in Saint-Petersburg. Вefore starting, I would like ask you. Have you ever treated a patients with hypervascular spinal metastasis? Did you see intensive bleeding? D. Ptashnikov, V. Usikov, D. Mikhaylov, S. Masevnin, N. Zaborovskii Saint-Petersburg, Russia 2014

INTRO  Berkefeld J.et al. Hypervascular Spinal Tumors: Influence of the Embolization Technique on Perioperative Hemorrhage.// AJNR Am. J. Neuroradiol. – 1999. – №20. pp 757–763. Clarençon F. et al. Onyx injection by direct puncture for the treatment of hypervascular spinal metastases close to the anterior spinal artery: initial experience.// J. Neurosurg. Spine. – 2013. – №18(6). pp 606-610. Clarke A. et al. Total en bloc spondylectomy for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma.// J. Bone Joint Surg. – 2012. – №94. p 26. Gellad F.E. et al. Vascular metastatic lesions of the spine: preoperative embolization.// Radiology. – 1990. – №176(3). pp 683-686. Kato S.et al. Preoperative embolization significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis.// Orthopedics. – 2012. – №35(9). pp 1389-1395. Kobayashi K. et al. Preoperative embolization of spinal tumors: variables affecting intraoperative blood loss after embolization.// Acta Radiol. – 2012 – №53(8). pp 935-942. Olerud C.et al. Embolization of spinal metastases reduces peroperative blood loss. 21 patients operated on for renal cell carcinoma.// Acta Orthop Scand. – 1993. – №64(1). pp 9-12. Renkens K.L. Jr. et al. A multicenter, prospective, randomized trial evaluating a new hemostatic agent for spinal surgery.// Spine (Phila Pa 1976). – 2001. – № 26(15). pp 1645-50. Robial N. et al. Is preoperative embolization a prerequisite for spinal metastases surgical management?// Orthop. Traumatol. Surg. Res. – 2012. – №98(5). pp 536-542 Rossi G. et al. Embolisation of bone metastases from renal cancer.// La radiologia medica. – 2013. – №118. pp 291-302. Sabel M. et al. Haemostasis in spine surgery. The use of local agents: Surgicel and Surgifoam.// European Spine Journal. – 2004. – №13. pp 97-101. Schmidt R. et al. Surgical therapy of vertebral metastases. Are there predictive parameters for intraoperative excessive blood loss despite preoperative embolization?// Tumori. – 2011. – №97(1). pp 66-73.   Currently there is no consensus about how to reduce the intraoperative risk of hemorrhage in spinal decompression surgery of hypervascular metastases such as renal cell carcinoma, multiple mieloma.  

PURPOSE Compare the effectiveness of using different methods to reduce blood loss Currently there is no consensus about how to reduce the intraoperative risk of hemorrhage in spinal decompression surgery of hypervascular metastases such as renal cell carcinoma, multiple mieloma.   Therefore, The Purpose of our research was to Compare the effectiveness of using different methods in reducing blood loss.

♂37 ♀21 MATERIAL AND METHODS 58 patients A retrospective study of 58 patients, operated in our institute, was held in the period between 2001 and 2013. There were 37 male and 21 female patients with extradural hypervascular metastases

MATERIAL AND METHODS There were 39 patients with renal cell carcinoma and 19 patients with multiple mieloma in the study

MATERIAL AND METHODS thoracic spine (n = 45; 77.6%) lumbar spine (n = 13; 22.4%) The metastatic lesions were mainly located in the thoracic spine and less percentage in lumbar spine

MATERIAL AND METHODS I group (n=30) II group (n=28) Age (years) 53.8 55.79 Methods Angiography +embolization Gelatin-thrombin matrix Operation Palliative decompression and MIS stabilization Time (min) 175.67 193.57 We evaluated parameters in a surgically homogeneous group of patients with spinal cord compression. The first group included 30 patients who underwent preoperative spinal angiography and tumor embolization. The second group consisted of 28 patients, which were treated surgically using intraoperative local hemostatic agents (gelatin-thrombin matrix). Each patient underwent a palliative decompression and percutaneus stabilization using a posterior approach as the primary surgery for spinal metastasis.

Parameters: Blood loss volume Hemoglobin level Complications MATERIAL AND METHODS Parameters: Blood loss volume Hemoglobin level Complications neurologic deficit postoperative hematoma infection The parameters under evaluation were the blood loss volume, hemoglobin level and possible complications. The effectiveness of methods to reduce blood loss was analyzed with the help of nonparametric statistical tests.

RESULTS Blood loss (p>0.05) As we can see, the blood loss in the first group was slightly less than in the second one. We did not get significant difference between groups. (p>0.05)

RESULTS HGB level (g/dL) (p>0.05) This graph shows that postoperative hemoglobin level reduce is almost equal in both groups of patients. (p>0.05)

RESULTS Complications I group II group Neurologic deficit postEmb Frankel D -> B - PostOp hematoma 1 2 Infection Postoperative complications were also nearly equal in the groups. However in the first one, a patient developed irreversible neurologic deficits after embolization. Although preoperative embolization is a relatively safe procedure, there still remains risk of cord ischemia.

CONCLUSIONS Preoperative embolization is a good method, but not very safe Local hemostatic agents are an effective tool to reduce blood loss There is no evidence that embolization is better than using local hemostatic agents Even though we found the study very useful and informative. We did not get evidence that embolization is better than using local hemostatic agents for patients with hypervascular metastases who underwent palliative decompression and MIS stabilization.

Thank you for your attention! Vreden Russian Research Institute of Traumatology and Orthopedics Thank you for your attention! Nikita Zaborovskii - n.zaborovskii@yandex.ru