Spinal cord compression in spine tumours and injuries Chaloupka, R., Grosman, R., Repko, M., Tichý, V. Ortopedická klinika, FN Brno, Jihlavská 20, 625 00 Ortopedická klinika FN Brno-Bohunice Pain is caused predominantly by • growing of tumour tissue • nerve structures compression • neural symptoms Spine instability • in extensive involvement of one or more vertebrae • small force results in pathological fracture and neural deficit Neural deficit • growing of tumour and neural compression • worsening of blood supply of spinal cord • pathological fracture with neural compression • combination of these mechanisms Spine involvement in tumours Goals of surgeries • prevention / improvement of neural deficit • pain relief • restoring spine stability • improving quality of life • present / imminent vertebral collaps • present / imminent neural deficit • to 24 hours after plegia onset (severe paresis) • life expectancy – 3 months minimum Indications • X-rays of C, Th, L spine – AP and lateral • CT of affected part, • MRI (optimum MRI of the whole spine, CT of brain, lung, abdomen) • neurological, • internal exam. (laboratory, lung X-ray, ultrasonography of abdomen) Diagnostics Tomita scoring system (Spine, 2001) Spine metastases: Necessary: bone scane - Tc MRI of the whole spine CT of brain, thorax and abdomen 1. low (mamma, prostata, thyroid gland) 1 point 2. middle (kidney, uterus) 2 points 3. high (pulmo, intestinum, stomach, liver, unknown) 4 points Grading of metastasis (according to origo): 1. none 0 point 2. Resectable 2 body 3. untreatable 4 body Organ metastases: Bone metastases: 1. Solitary 1 point 2. Multiple 2 points According to the score value we indicate the extent of surgery: 2-3 wide – marginal resection (en bloc) 4-5 marginal – intralesional resection 6-7 paliative surgery 8-10 conservative – no surgery Extent of surgery depends on • tumour localisation and extent • patient´s age and condition Treatment Quick progression of neural deficit - quick decompression w / wo stabilization • X-rays of the whole spine • CT – MRI • Internal, neurological examination Examination • Bone scan - Tc • MRI of the whole spine • CT of brain, thorax, abdomen Unknown tumour aetiology • Wide / marginal resection • Marginal / intralesional resection • Paliative surgery Surgery types • Anterior – posterior • Combined (1 stage – 2 stages) Surgery • decompression – anterior / posterior • posterior fusion and instrumentation Occiput – C2 • Bone cement with K - wires • autograft • spacer C 3-7 Pelvic autograft and Caspar plate Bone cement with K-wires Posterior surgery - decompression + - instrumentation + - fusion T and L spine Th and L spine Anterior surgery - decompression - vertebral body replacement - bone cement + K-wires - bone graft - spacer Anterior – vertebral body replacement Posterior - fusion and instrumentation Combined surgeries Harms cage and transpedicular fixator Biopsy - thoracoscopic - lumboscopic - transpedicular Unclear cases • spine surgery departments • specialized orthopaedic, neurosurgery, traumatology departments • Surgery in Czech Republic Orthoses – soft collars, Philadelphia collar, three-point body orthoses – Jewett orthosis, belts. Orthotics operated patients: 727 metastases 386 benign 98 malign 175 tumour-like affections 68 1984 – 2005 mammar cancer 75 Grawitz. tumour 54 The most frequent metastases: Malignant tumours: myeloma 72 chordoma 17 chondrosarcoma 12 anterior 168 posterior 350 combined – 1 team 164 - 2 teams 45 Surgeries Frankel scale (now ASIA scale): A plegia, anesthesia B plegia, some sensory function C usefulles motor function D useful motor (gait) E normal During surgery – heart failure, extensive blood loss Chylothorax Infection Exitus Complications Quick progression of paresis Surgery to 24 hours after plegia onset Conclusion SPINE INJURIES AO classification of T+L injuries A anterior column injury (wedge, split, burst) B both columns – flexion distraction C both columns with rotation Neural deficit in Th + L spine  A type – mainly burst fractures  B type - seldom  C type – majority of patients A3.2.1 A3.3.3 A1.3 A3.1.1 A3 burst Injuries with neural deficit  Transport to spine surgery department  X-rays, CT, (MRI), int., neurol.  Surgery to 6 hours after injury in case of severe neural deficit Surgery types  Posterior – decompression, fusion, instrumentation  Anterior – decompression, fusion, instrumentation – spacers, grafts  Combined – posterior and anterior, anterior – vertebral body replacement in anterior column comminution - destruction Multiple Th fractures – post surg, Hartshill – sublaminar – seldom Posterior TL surgery – transpedicular fixation, fusion and decompression - majority A.Injury of anterior column B. posterior C. both columns C 3-7 INJURIES AO classification 1.Bone injury 2.Bone-ligamentous 3.Ligamentous A1 type fracture bone injury wedge Neural deficit: burst fractures majority of cases Combined C5-6 surgery C type - dislocation Neural deficit in C spine A type – burst (C5-7) – majority of cases B type – posterior column – seldom C type – both columns – majority of cases Surgery Anterior – decompression, anterior fusion and plates – majority of cases Combined surgery – C type injuries