waleed awwad, md, frcsc. red flags: red flags: history of cancer history of cancer unexplained...
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Spine TumorsWaleed Awwad, MD, FRCSC
HistoryRed Flags:
HistoryRed Flags:
History of cancer
Unexplained weight loss >10 kg within 6 months
Age over 50 years or under 17 years old
Failure to improve with therapy
Pain persists for more than 4 to 6 weeks
Night pain or pain at rest
Fever
Physical examFull Spine exam
General exam if unknown primary.
What are the primary tumor that most likely to metastasize to spine?
InvestigationLocal.
Systemic.
Blood and Urine.
Tissue diagnosis.
Investigation
.Enneking classification
.Tomita classification
Investigation Weinstein
Boriani Biagini (WBB) Staging system
The more extensive the less likely a surgical cure
Most useful staging system for spineEasy to
rememberCentred on
what's important
InvestigationSign of instability:
1.Loss of Hight.
2.Focal angular deformity.
3. Kostuik Stability Classification6 columns (2 anterior,2 middle and 2
posterior)Unstable if 3 or more columns involved.
Spine TumorsPrimary benign.
Primary malignant.
Metastatic lesion.
What is the mode of spread?
Spine TumorsPrimary benign.
Spine TumorsPrimary benign.
Aneurysmal Bone Cyst
Giant Cell Tumor
Hemangioma
Osteoblastoma
Osteoid Osteoma
Spine TumorsPrimary malignant
Spine TumorsPrimary malignant
Chondrosarcoma
Chordoma
Ewing’s Sarcoma
Multiple Myeloma
Osteosarcoma
Spine TumorBody Neural element
MM.
Chordoma
GCT
Hemangioma
EG
Osteosarcoma
Spine TumorBody Neural element
ABC
Osteoid osteoma
Osteoblastoma
Osteochondroma
What is this sign?
What is the diagnosis?
What is this radiologic feature called?
What is your diagnosis?
What this radiologic feature called?What is your
DDx?
What is this radiologic feature?
What is your DDx?
MELT.
What is the most
cause?
What is this radiologic sign?
What is your diagnosis?
Treatment of spinal tumors
Non-Surgical Treatment
Surgical Treatment
Treatment of spinal tumorsPre-operative evaluation?
Solitary or multiple
Diagnosis (tissue) if solitary or unknown.
Life expectancy.
Medical fitness.
Patent wishes.
Treatment of spinal tumorsWhat are the indication to operate for
spine tumor?
A. For disease cure or control.
B. Other causes are: Intractable painNeurologic changes (unless long-standing) Instability – impending fractureNeed of open biopsy
Treatment of spinal tumors
Pre-operative embolization.
Radiosensitive tumors.
Chemo sensitive tumors.
Hormone sensitive.
Chemo and radio resisitant.
Post operative?
What is your management?
Cases41 Y/O M
Immigrant from China
No significant PMHx
4 yr Hx of LBP
2 yr Hx of LBP with Rt Leg pain
Neuro exam was N 4 yrs agoNumbness X 1.5 yrsMild weaknes in EHL X .5 yrs
What is your Diagnosis?
How Would you manage this patient?
Bone and Gallium Test hot bone scan, neg gallium, not infection.
Biopsy, fibrous tissue with occ giant cells.
Serology for parasites (echinococcus) neg.
Patient now disabled by pain and cannot work.
Surgery: percutaneous, transpedicular, with currettes, cement, L3&4 followed by L5 w Rt L5 decomp 2 weeks later
2nd Case
45 yo Male6 mo History of LBP with radiation left
leg
2 mo Hx of paraesthesias
1 mo mild Lt Quad weakness requiring a cane
Past History of enbloc resection of Lt buttock Liposarcoma 3 years earlier
Bone Scan
X-Ray
MRI
Other TestsCBC, ESR, CRP all Normal
CT chest Normal
Whole body MRI normal except for L3
Needle Biopsy L3, Liposarcoma same as in hip (myxomatous)
What Would You Do?
Two Stage En Bloc ResectionStage 1 Posterior
Stage 2 Anterior
Surgical Plan, Stage 1-Posterior
Surgical Plan, Stage 1-Posterior
Surgical Plan, Stage 1-Posterior
Head
Screws
Surgical Plan, Stage 1-Posterior
Posterior Surgery:Laminectomy L2,3,4
Facetectomy L2-3-4
Pedicle instrumentation L2-4
Transverse process resection L3 bilat.
Surgical Plan, Stage 2 - Anterior
Surgical Plan, Stage 2 - Anterior
Surgical Plan, Stage 2 - Anterior
Vertebral Body L3
AnteriorEpiduralLiposarcoma
Intra-operative Imaging
Post-operative Imaging
Thank you