Diagnosis and Management of Metastatic Cervical Spine Tumors

Urothelial carcinoma (UC) is a common urinary tract malignancy that predominantly affect the urinary bladder with a low recurrence rate after surgical removal. It usually metastasizes to the lungs, regional lymph nodes, and liver. However, it rarely spread to the thoracic spine and bones, especially in the Asian populations.

A 50-years-old Asian man, with a one-year history of surgically resected UC, presented to us with a complaint of worsening upper back pain for three months. Magnetic resonance imaging (MRI) showed a destructed second thoracic (T2) vertebra with lytic lesion. A thoracic vertebrectomy was performed and histopathological examination (HPE) showed high-grade infiltrating metastatic malignant UC. Postoperatively, he was well and did not have any back pain. He was followed up under combined spine and oncology clinic regularly and was planned for chemoradiotherapy.

UC commonly metastasizes to the lungs, liver, and lymph nodes. In young Asians, thoracic spinal metastases are rare. Urgent palliative spinal surgery is indicated to prevent further deterioration of function. Intraoperative usage of targeted controlled infusion (TCI) of remifentanil and propofol as maintenance of anaesthesia are gold standard in assisting spine surgeons who are guided by neuromuscular monitoring.

Spinal metastasis to the thoracic vertebra is rare among young Asian men. Patients presented with acute neurological deficits and back pain are indicated for spinal surgery. Multidisciplinary approach is needed for management of patients with spinal metastasis. Targeted controlled infusion (TCI) of remifentanil and propofol are gold standard for maintenance of anaesthesia for spine surgeries which are guided by somatosensory, and motor evoked potential monitoring.

In this article, we investigated the efficiency of surgery in treating symptomatic spinal metastases from neuroendocrine neoplasms and performed univariate analysis for identification of possible prognostic factors.

A retrospective study was performed, enrolling a total of 19 patients who received surgeries in our center for symptomatic spinal metastases from neuroendocrine neoplasms (NEN). The Kaplan-Meier method was adopted to estimate overall survival (OS) and recurrence free survival (RFS). Univariate analysis was performed for identification of possible prognostic factors.

All patients recruited displayed stable recovery after surgical intervention, with a median OS of 27.3 months (95% Confidence Interval: 16.4–38.1 months) and a median RFS of 23.0 months (95% Confidence Interval: 12.1–33.8 months). Postoperatively, 15 patients exhibited improved neurological function based on the Frankel classification, while 16 patients experienced significant pain relief, with mean visual analog scale (VAS) score decreasing from 7.47 ± 2.32–2.47 ± 1.25 (p < 0.05). Univariate analysis revealed that the presence of visceral metastases (p = 0.034) and extraspinal bone metastases (p = 0.016) are both related with poor prognosis. Additionally, well histologic differentiation (p = 0.010) and administration of postoperative octreotide (p = 0.041) or bisphosphonate (p = 0.023) are all indicators for better outcome.

Surgery is an efficient option for treating symptomatic spinal metastases from NEN due to its immediate and assured benefits in pain alleviation, restoration of function and stability reconstruction.

Patients with metastatic disease to the cervical spine have historically had poor outcomes, with an average survival of 15 months. Every effort should be made to avoid complications of surgical intervention for stabilization and decompression.

We identified patients who had undergone anterior cervical corpectomy and fusion (ACCF) or posterior cervical laminectomy and fusion (PCLF) for metastatic disease of the cervical spine using the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2016. Patients meeting the inclusion criteria were subsequently propensity matched 1:1. We compared the overall complications, intensive care unit level complications, mortality, and return to the operating room between the 2 groups.

After identifying the patients who met the inclusion criteria and propensity matching, a cohort of 240 patients was included, with 120 (50%) in the ACCF group and 120 (50%) in the PCLF group. The patients in the ACCF group were more likely to have experienced any complication (odds ratio, 2.1; 95% confidence interval, 1.1–4.1; P = 0.026) but not severe complications or a return to the operating room (P = 0.406 and P = 0.450, respectively).

In the present study, we found that anterior surgical approaches (ACCF) for metastatic cervical spine disease resulted in a significantly greater rate of overall complications (2.1 times more) compared with PCLF in the first 30 days. Although more studies are required to further elucidate this relationship, the general belief that the anterior approach is better tolerated by patients might not apply to patients with metastatic tumors.

Cancer patients quite commonly will report different types of pain associated with the disease substrate. Systemic analgesia and radiotherapy provide only partial pain relief in the majority of these patients. Interventional Oncology techniques for pain management and mobility improvement in cancer patients include percutaneous techniques such as neurolysis, ablation and augmentation (both in the spine and peripheral skeleton) as well as trans-arterial embolization. Percutaneous neurolysis acts indirectly providing regional anesthesia whilst the rest of the aforementioned techniques act directly upon the tumor either by inhibiting local growth or by providing stability and skeletal augmentation. Whenever possible, techniques such as ablation and trans-arterial embolization apart from pure palliation may add to the principle of local tumor control. The aim of this review is to provide details concerning the Interventional Oncology techniques used for cancer pain management and to address the necessity for a tailored-based approach applying different techniques or combinations of them in different cases and locations.