Spinal Tumors Surgery

Spinal Tumors

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal cord and/or spinal column. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Primary tumors originate in the spine(bone) or spinal cord, and metastatic or secondary tumors result from cancer spreading from another site to the spine.

Based on location within the spine, tumors referred as

Intramedullary – These tumors grow inside the spinal cord which is typically derived from glial or ependymal cells. Astrocytomas and ependymomas are the two most common types.
Intradural-extramedullary – The tumor is located inside the thin covering of the spinal cord (the dura), but outside the actual spinal cord. It is the second most common type of spinal tumor (20-30% )and is usually benign in nature. The most common of these types of tumors are meningiomas, schwannomas, and neurofibromas
Extradural – The tumor is located outside the dura. It is the most common type of spinal tumor and comprises more than 60%. These lesions are typically attributed to metastatic cancer(a.k.a secondary spine tumor). The bony spinal column is the most common site for bone metastasis. Common primary cancers that spread to the spine are lung, breast, and prostate. Estimates indicate as high as 70% of patients with cancer will experience the spread of cancer to their spine.

Primary spinal bone tumors such as hemangioma, osteoblastoma, aneurysmal bone cyst, etc. are benign lesions and rarely cause symptoms such as pain. In fact, hemangioma is the most common spine tumor and in most cases, it is incidental findings on MRI scans. Primary malignant tumors of the spine are the rarest tumor type in the spine. In all bone and soft tissue sarcomas, only 10% of them are related to the spine.

Treatment

Treatment decision-making is often multidisciplinary, incorporating the expertise of spinal surgeons, medical oncologists, radiation oncologists, and other medical specialists.

Non-Surgical Treatments

Nonsurgical treatment options include observation, chemotherapy, and radiation therapy. Tumors that are asymptomatic or mildly symptomatic and do not appear to be changing or progressing may be observed and monitored with regular MRIs. Some tumors respond well to chemotherapy and others to radiation therapy. However, there are specific types of metastatic tumors that are inherently radioresistant (i.e. gastrointestinal tract and kidney): in those cases, surgery may be the only viable treatment option.

Surgery

Indications for surgery vary depending on the type of tumor. Primary (non-metastatic) spinal tumors may be removed through complete en bloc resection for a possible cure. In patients with metastatic tumors, treatment is primarily palliative, with the goal of restoring or preserving neurological function, stabilizing the spine, and alleviating pain.

Indications of surgery:

Primary spinal tumor- needs complete resection(En-bloc resection)
Metastatic spine tumor: causes intractable pain, or spinal cord compression, and the need for stabilization of pathological fractures.

Generally, surgery is only considered as an option for patients with metastases when they are expected to live 3 – 4 months or longer.

Treatment of metastatic spinal tumors must take into consideration the following:

Type of cancer
Number of tumors in the spine
Location of tumor(s)
Current cancer treatment
Life expectancy
Quality of life
Comorbidities such as anemia, diabetes, and high blood pressure
Family support
Financial limitations

Surgical Options

Decompression of neural structure by debulking of the tumor tissue.

Decompression and multisegmental spine fixation.

Minimal invasive surgery(MIS)- for a pathological fracture

Percutaneous vertebroplasty/kyphoplasty
MIS fixation
Arterial Embolization

Advantages of Surgical decompression + Fixation over radiotherapy.

Patients treated with surgical decompression and fixation or vertebroplasty followed by adjuvant radiotherapy allows them to retain or regain the ability to walk and for a longer period.
Increases survival time with a better quality of life as they remain ambulatory
Surgical treatment also reduces the need for corticosteroids and opioids.

A brief guide to surgical procedure

Anesthesia - Surgery is performed in general anesthesia, or with sedation only (in case of MIS surgery) the patient will be fully asleep.

Patient position - Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table with special padding and supports.

Procedure: refer
Balloon kyphoplasty/Vertebroplasty
Decompression and fixation

Post-Operative Care After 1-2 hours of monitoring in the recovery room, patients are shifted toward. Oral fluid intake started after 4 hours and gradually switched to a full diet. Most of the patients with normal pre-surgery neurological status can stand and walk by the next morning with good pain tolerance and can be sent home accordingly in 2-3 days. However, patients who have neurological deficit requires physical neuro-rehabilitation.

Wound Care and follow up: Before leaving the hospital, dressing is changed and surgical drain is removed and a waterproof dressing is applied to the surgical wound. the patient can take shower and will be called on the 5th post-op day for a dressing checkup and change of medication if needed.

Further treatment of malignancy: Following surgery, a medical oncologist will decide on targeted Chemotherapy or radiotherapy based on the report of biopsy, immunohistochemistry, and staging of the tumor.

Complications
Surgery is generally considered a very safe procedure, however, like any other surgery, there are several risks and complications associated with the procedure are:

Operative wound infection
Dural tear and CSF leakage
Bleeding
Pain that persists after the surgery
Implant related complication- loose screw, broken implant

Adjacent segment disease

Pseudoarthrosis or non-union

Nerve root damage

Bowel/bladder incontinence

Deep vein thrombosis, which occurs when blood clots form in the leg

Result of surgery
Vertebroplasty/kyphoplasty or MIS fixation in most patients produces drastic improvement in the quality of life because of pain relief, marked reduction of the number of analgesics and steroids intake, and improvement in physical mobility. Open decompression and fixation enable patients to participate better in rehabilitation exercises and speed up the possible neurological recovery.

Treatment

Role of Steroid

There is continued controversy around the role of high dosage Methylprednisolone (MPSS) in reducing the impact of spinal cord injury. Each hospital, region, or country can have its protocol. We follow to offer a 24-hour infusion of high-dose MPSS to adult patients who present within 8 hours with acute spinal cord injury.

Surgical management vs Non-surgical management

Whether to perform surgery or treat without operation depends upon the nature of the spine injury and the status of neurology of the patient. We make this rational decision using Thoracolumbar Injury Classification and Severity Score (TLICSS) and sub axial cervical spine injury classification (SLIC) based on clinical examination and MRI scan findings. This scoring systems aid treatment decision-making of surgery vs non-surgical method of treatment for patients.

The principles of Surgical treatment are as follows:

To preserve neurological function
To decompress the damaged neurological structures
To stabilizes the spine
To facilitate rehabilitation

Post-Operative Care

After 1-2 hours of monitoring in the recovery room, patients are shifted toward. Oral fluid intake started after 4 hours and gradually switched to a full diet. Most of the patients with normal neurology before surgery can stand and walk by the next morning and can be sent home accordingly in 1-2 days. However, patients with neurological deficits will require intensive physical rehabilitation which may require to continue for many months. Rehabilitation strategies focus on the prevention of secondary complications, promoting neuro recovery, addressing underlying impairments, and maximizing function with aim of making the patient as independent as possible.

Wound Care and follow up

Before leaving the hospital, a waterproof dressing is applied to the surgical wound, and the patient can take shower and will be called on the 5th post-op day for a dressing checkup and change of medication if needed.

Complications

Surgery for Spinal trauma is generally considered a very safe procedure, however, like any other surgery, there are several risks and complications associated with are:

Operative wound infection
Dural tear and CSF leakage
Bleeding
Implant related complication- loose screw, broken implant
Adjacent segment disease
Pseudoarthrosis or non-union
Nerve root damage
Bowel/bladder incontinence
Deep vein thrombosis, which occurs when blood clots form in the leg