1. Waleed Awwad, MD, FRCSC

2. Red Flags: Red Flags:

3. History of cancer History of cancer Unexplained weight loss >10 kg within 6 months Unexplained weight loss >10 kg within 6 months Age over 50 years or under 17 years old Age over 50 years or under 17 years old Failure to improve with therapy Failure to improve with therapy Pain persists for more than 4 to 6 weeks Pain persists for more than 4 to 6 weeks Night pain or pain at rest Night pain or pain at rest Fever Fever

4. Full Spine exam Full Spine exam General exam if unknown primary. General exam if unknown primary. What are the primary tumor that most likely to metastasize to spine? What are the primary tumor that most likely to metastasize to spine?

5. Local. Local. Systemic. Systemic. Blood and Urine. Blood and Urine. Tissue diagnosis. Tissue diagnosis.

6.  Enneking classification  Tomita classification

7. Weinstein Boriani Biagini (WBB) Staging system Weinstein Boriani Biagini (WBB) Staging system The more extensive the less likely a surgical cure The more extensive the less likely a surgical cure Most useful staging system for spine Most useful staging system for spine Easy to remember Easy to remember Centred on what's important Centred on what's important

8. Sign of instability: Sign of instability: 1.Loss of Hight. 1.Loss of Hight. 2.Focal angular deformity. 2.Focal angular deformity. 3. Kostuik Stability Classification 3. Kostuik Stability Classification 6 columns (2 anterior,2 middle and 2 posterior) 6 columns (2 anterior,2 middle and 2 posterior) Unstable if 3 or more columns involved. Unstable if 3 or more columns involved.

9. Primary benign. Primary benign. Primary malignant. Primary malignant. Metastatic lesion. Metastatic lesion. What is the mode of spread? What is the mode of spread?

10. Primary benign. Primary benign.

11. Aneurysmal Bone Cyst Aneurysmal Bone Cyst Giant Cell Tumor Giant Cell Tumor Hemangioma Hemangioma Osteoblastoma Osteoblastoma Osteoid Osteoma Osteoid Osteoma

12. Primary malignant Primary malignant

13. Chondrosarcoma Chondrosarcoma Chordoma Chordoma Ewing’s Sarcoma Ewing’s Sarcoma Multiple Myeloma Multiple Myeloma Osteosarcoma Osteosarcoma

14. Body

15. MM. MM. Chordoma Chordoma GCT GCT Hemangioma Hemangioma EG EG Osteosarcoma Osteosarcoma Body ABC ABC Osteoid osteoma Osteoid osteoma Osteoblastoma Osteoblastoma Osteochondroma Osteochondroma

17. What is this radiologic feature called? What is this radiologic feature called?

19. What is your What is your DDx? DDx?

20. What is your DDx? What is your DDx? MELT. MELT. What is the most What is the most cause? cause?

23. Non-Surgical Treatment Non-Surgical Treatment Surgical Treatment Surgical Treatment

24. Pre-operative evaluation? Pre-operative evaluation? Solitary or multiple Solitary or multiple Diagnosis (tissue) if solitary or unknown. Diagnosis (tissue) if solitary or unknown. Life expectancy. Life expectancy. Medical fitness. Medical fitness. Patent wishes. Patent wishes.

25. What are the indication to operate for spine tumor? What are the indication to operate for spine tumor? A. For disease cure or control. A. For disease cure or control. B. Other causes are: B. Other causes are: Intractable pain Intractable pain Neurologic changes (unless long-standing) Neurologic changes (unless long-standing) Instability – impending fracture Instability – impending fracture Need of open biopsy Need of open biopsy

26. Pre-operative embolization. Pre-operative embolization. Radiosensitive tumors. Radiosensitive tumors. Chemo sensitive tumors. Chemo sensitive tumors. Hormone sensitive. Hormone sensitive. Chemo and radio resisitant. Chemo and radio resisitant.

27. What is your management? What is your management?

28. 41 Y/O M 41 Y/O M Immigrant from China Immigrant from China No significant PMHx No significant PMHx 4 yr Hx of LBP 4 yr Hx of LBP 2 yr Hx of LBP with Rt Leg pain 2 yr Hx of LBP with Rt Leg pain Neuro exam was N 4 yrs ago Neuro exam was N 4 yrs ago Numbness X 1.5 yrs Numbness X 1.5 yrs Mild weaknes in EHL X.5 yrs Mild weaknes in EHL X.5 yrs

32. What is your Diagnosis? What is your Diagnosis? How Would you manage this patient? How Would you manage this patient?

33. Bone and Gallium Test hot bone scan, neg gallium, not infection. Bone and Gallium Test hot bone scan, neg gallium, not infection. Biopsy, fibrous tissue with occ giant cells. Biopsy, fibrous tissue with occ giant cells. Serology for parasites (echinococcus) neg. Serology for parasites (echinococcus) neg. Patient now disabled by pain and cannot work. Patient now disabled by pain and cannot work.

36. 6 mo History of LBP with radiation left leg 6 mo History of LBP with radiation left leg 2 mo Hx of paraesthesias 2 mo Hx of paraesthesias 1 mo mild Lt Quad weakness requiring a cane 1 mo mild Lt Quad weakness requiring a cane Past History of enbloc resection of Lt buttock Liposarcoma 3 years earlier Past History of enbloc resection of Lt buttock Liposarcoma 3 years earlier

40. CBC, ESR, CRP all Normal CBC, ESR, CRP all Normal CT chest Normal CT chest Normal Whole body MRI normal except for L3 Whole body MRI normal except for L3 Needle Biopsy L3, Liposarcoma same as in hip (myxomatous) Needle Biopsy L3, Liposarcoma same as in hip (myxomatous)

41. What Would You Do? What Would You Do?

42. Stage 1 Posterior Stage 1 Posterior Stage 2 Anterior Stage 2 Anterior

45. Head Screws

47. Laminectomy L2,3,4 Laminectomy L2,3,4 Facetectomy L2-3-4 Facetectomy L2-3-4 Pedicle instrumentation L2-4 Pedicle instrumentation L2-4 Transverse process resection L3 bilat. Transverse process resection L3 bilat.

50. Vertebral Body L3 Anterior Epidural Liposarcoma

54. Thank you Thank you