Management Of Spinal Tumors Research Articles

Advances in Instrumentation and Implant Technology for Spine Oncology: A Focus on Carbon Fiber Technologies

The challenges inherent in spinal oncology are multi-dimensional, stemming from the complex anatomy of the spine, the high risk of neurological complications, and the indispensability of personalized treatment plans. These challenges are further compounded by the variability in tumor types and locations, which complicates the achievement of optimal treatment outcomes. To address these complexities, the manuscript highlights the pivotal role of technological advancements in surgical practices. The review focuses on the evolution of spinal oncology instrumentation, with a special emphasis on the adoption of carbon fiber implants in the management of spinal tumors. The advancements in instrumentation and implant technology are underscored as vital contributors to the improvement in patient outcomes in spine surgery. Carbon fiber implants are lauded for their reduced imaging artifacts, biocompatibility, and favorable mechanical properties. When combined with other technological innovations, these implants have substantially elevated the efficacy of surgical interventions. The review articulates how these advancements emphasize precision, customization, and the integration of innovative materials, significantly enhancing the effectiveness of surgical procedures. This collective progress marks a considerable advancement in the treatment of spinal tumors, highlighting a shift towards more effective, patient-focused outcomes in spinal oncology.

Radiation Therapy for Primary and Metastatic Spine Tumors.

Radiation therapy plays an important role in the management of patients with primary and metastatic spine tumors. Technological innovations in the past decade have allowed for improved targeting, dose escalation, and precision of radiation therapy while concomitant improvements in surgical techniques have resulted in improved outcomes with reduced morbidity. Patients with cancer have increasingly complex oncologic needs, and multidisciplinary management is more essential than ever. This review will provide an overview of radiation principles, modern radiation techniques, management algorithms, and expected toxicities of common radiation treatments in the management of spine tumors.

Advances in imaging modalities for spinal tumors.

The spinal cord occupies a narrow region and is tightly surrounded by osseous and ligamentous structures; spinal tumors can damage this structure and deprive patients of their ability to independently perform activities of daily living. Hence, imaging is vital for the prompt detection and accurate diagnosis of spinal tumors, as well as determining the optimal treatment and follow-up plan. However, many clinicians may not be familiar with the imaging characteristics of spinal tumors due to their rarity. In addition, spinal surgeons might not fully utilize imaging for the surgical planning and management of spinal tumors because of the complex heterogeneity of these lesions. In the present review, we focus on conventional and advanced spinal tumor imaging techniques. These imaging modalities include computed tomography, positron emission tomography, digital subtraction angiography, conventional and microstructural magnetic resonance imaging, and high-resolution ultrasound. We discuss the advantages and disadvantages of conventional and emerging imaging modalities, followed by an examination of cutting-edge medical technology to complement current needs in the field of spinal tumors. Moreover, machine learning and artificial intelligence are anticipated to impact the application of spinal imaging techniques. Through this review, we discuss the importance of conventional and advanced spinal tumor imaging, and the opportunity to combine advanced technologies with conventional modalities to better manage patients with these lesions.

Carbon Fiber-Reinforced Polyetheretherketone Spinal Implants for Treatment of Spinal Tumors: Perceived Advantages and Limitations.

Carbon-fiber reinforced polyetheretherketone (CFRP)-based spinal implants are an alternative to titanium, offering less image artifact as their metallic counterparts while maintaining similar biomechanical and biocompatibility properties. Its use in the management of spinal tumors has been reported, however the perceived advantages related to improved imaging quality, radiation treatment planning, and detection of tumor recurrence have not been fully assessed. We performed a retrospective review of medical records amongst oncologic patients treated at MD Anderson Cancer Center with CFRP implants. Histology, tumor location, construct features, time of follow-up, adjuvant radiation, recurrences, overall survival, and hardware-related complications were recorded. Sixty-nine consecutive patients were assessed (22 primary tumors, 47 metastases) and the median time for follow-up was 5.4 months. Amongst the cohort, a total of 491 CFRP pedicle screws were implanted. Hardware complications were observed in 5 cases (7.04%). Adjuvant radiation was completed in 8 patients with primary tumors and 29 patients with spinal metastases. A total of 28 patients (40.5%) from the combined primary and metastatic cohorts experienced systemic disease progression, with 12 patients (17.3%) demonstrating local recurrences. Amongst primary and metastatic tumors, overall survival (p = 0.363) and rate of local recurrence (p = 0.112) were similar. This largest series of CFRP implants demonstrates safe and effective spinal stabilization for patients with both primary and metastatic tumors. Enhanced postoperative imaging led to minimal imaging artifacts which facilitated postoperative radiation planning and the ability to detect local recurrence.

P121. Carbon fiber reinforced PEEK implants for spine tumors: a single center experience

<h3>BACKGROUND CONTEXT</h3> Titanium is the most common material used to manufacture spinal implants; however, its metallic properties are associated with imaging artifacts on CT and MRI scans which impede treatment planning and clinical follow among oncologic patients. Carbon fiber-reinforced Polyether ether ketone (CFR-PEEK) based spinal implants are an alternative to titanium, offering less image artifact as its titanium counterparts while maintaining similar biomechanical and biocompatibility properties. Its use in the management of spinal tumors has been reported, however the perceived advantages related to improved imaging quality, radiation treatment planning, and detection of tumor recurrence have not been fully assessed. <h3>PURPOSE</h3> We report our experience at the MD Anderson Cancer Center with the use of CFR-PEEK implants in the treatment of oncological patients. <h3>STUDY DESIGN/SETTING</h3> Retrospective single-arm single-center study. <h3>PATIENT SAMPLE</h3> All consecutive patients from September 2019 to July 2021 who were operated for spine conditions and had carbon fiber-reinforced implants. <h3>METHODS</h3> We performed a retrospective review of the medical records and imaging studies of patients treated with CFR-PEEK implants from September 2019 to July 2021. Histology type, tumor location, construct features, time of follow up, type of adjuvant radiation, recurrences, overall survival and hardware related complications were recorded. <h3>RESULTS</h3> Seventy-one consecutive patients were assessed (20 primary tumors, 47 metastases, 4 others). The median time for followup was 5.4 months (Q1 1.13, Q3 11.9, IQR 10.77). Of those 6 patients received conventional external beam radiotherapy, 31 received spinal stereotactic radiosurgery with a median time to radiation of 35 days among primary tumors and 30 days among metastatic cases. A total of 4 patients with primary tumors presented recurrence at a median time of 4.7 months (N=4, Q1 2.7, Q3 7, IQR 4.3) and 7 patients with metastatic disease presented recurrence at a median time of 3.4 months (N=6, Q1 2.0, Q3 5.1, IQR 3.1). Hardware complications were observed in a total of 5 cases (7.04%) and included screw loosening, intraoperative screw breakage and loosened set screw. Imaging review demonstrated significant reduction in imaging artifact and enhanced detection of local recurrence when compared to similar cases operated with standard titanium spinal instrumentation. <h3>CONCLUSIONS</h3> Carbon fiber reinforced PEEK implants provided safe and effective spinal stabilization for patients with both primary and metastatic tumors while integrating into postoperative imaging and radiation planning. The associated reduction in imaging artifacts enhanced postoperative radiation planning and the ability to detect local recurrence. <h3>FDA DEVICE/DRUG STATUS</h3> Carbon fiber thoracolumbar screws and rods (Icotec AG, Altstätten, Switzerland) (Approved for this indication)

Complication Avoidance in Surgical Management of Vertebral Column Tumors

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.

Feasibility of local administration of chemotherapeutic drugs as an effective adjuvant therapy in primary, recurrent and metastatic extradural tumours of the spine—review

Present day multimodality treatment with advances in systemic chemotherapy and radiotherapy has increased the survival of patients significantly even in those primary tumours which were once considered to have a poor prognosis. However, local recurrence can severely jeopardise the quality of life and even reduce survival. Hence local recurrence is considered as the worst complication in the management of spinal tumours and the need to achieving adequate local tumour control cannot be overemphasised. Techniques like en bloc resections which significantly reduce the chances of local recurrence are always not possible due to anatomical and technical reasons and sometimes, not feasible in debilitated patients. Local administration of chemotherapeutic drugs has already been recognised as a treatment strategy in the management of bladder and brain tumours. In this literature review, an attempt is made to explore the available evidence in the English literature for local administration of chemotherapeutic drugs in the surgical management of primary, recurrent and metastatic spinal tumours.

Composite PEEK/Carbon fiber implants can increase the effectiveness of radiotherapy in the management of spine tumors.

Combination of surgery and radiotherapy in the treatment of primary spine tumour can be indicated in some cases where a satisfactory oncological margin cannot be achieved. The presence of metal hardware has always limited post-operative radiotherapy due to the scattering effects of ionizing radiation or particles. The use of a fixation system (including rods and screw) fully made in PEEK embedded Carbon fiber (CFR-PEEK) could make easier and more effective the post-operative radiotherapy as it is radiolucent and does not interfere with ionizing radiation and accelerated particles. An ambispective study was performed on the first 22 consecutive primary tumor patients, who underwent spinal surgery including a composite CFR-PEEK fixation system. Oncologic surgery was palliative decompression and fixation in 3 cases; tumor excision in 15; en bloc resection in 4. The incidence of complications (intra- and postoperative), local control (LC) and local recurrence (LR), and changes in neurological status were considered. Only one intraoperative screw breakage occurred and one case of loosening of sacral screws were found at 12 months in one patient. No rod breakage, neither any screw/rod disconnection was found. Post-operative RT has been performed in 19 patients. The overall number of progression of the tumour or LR was 7. The actuarial rate of LR or progression of the tumour, calculated according to the Kaplan-Meier method, was 17.6% at 12 months. The CFR-PEEK fixation system is comparable to standard titanium system in term of intraoperative complications, stability at weight bearing and at functional recovery. Thanks to radiolucency CFR-PEEK stabilization devices are more suitable in patients eligible for RT: the absence of image artifacts together with significantly less dose perturbation improve the treatment accuracy. Moreover the radiolucency is useful in the follow-up of patients thus allowing early detection of LR.

Technique and early clinical outcomes for spinal and paraspinal tumours treated with stereotactic body radiotherapy

We report technique and early clinical results of stereotactic body radiotherapy (SBRT) from Princess Alexandra Hospital. SBRT involves the precise delivery of highly conformal and image-guided external beam radiotherapy with high doses per fraction. It is increasingly being applied in management of spinal tumours. Thirty-six courses of spine SBRT in 34 patients were delivered between May 2010 and December 2013. Mean patient age was 58years. Treatment was predominantly for metastatic disease, applied in de novo (n=22), retreatment (n=14) and postoperative (n=8) settings. Prescribed doses included 18–30Gy in 1–5 fractions. SBRT technique evolved during the study period, resulting in a relative dose escalation. No severe acute toxicities were observed. At median follow-up of 7.4months (range: 1.7–22.2), no late radiation myelopathy was observed. Risk of new/worsening vertebral compression fractures was 22% (n=8) and was significantly associated with increasing Spinal Instability Neoplastic Scores (p=0.0002). In-field control was 86% with relapse occurring at a median interval of 2.8months (range: 1.9–4.7). Thirteen patients (36%) died and median overall survival has not been reached. SBRT is an evolving technology with promising early efficacy and safety results. The outcomes of this series are comparable with international literature, and await longer follow-up.

Blood Loss and Transfusion Requirement in Spine Tumor Surgery: 10 Years' Experience

Background Surgical management of spinal tumors is an essential component of the comprehensive care of patients with cancer. It is often of a prolonged duration, which makes the anticipation and replenishment of blood lost during the surgery quite significant. Till date, there has been no consensus regarding the typical volume of blood loss during spine tumor surgeries. As a result, blood products are often ordered preoperatively in excessive quantities because of the nonexistence of specific blood ordering guidelines. This study was conducted to investigate the extent of blood loss and transfusion requirement associated with various surgical approaches and vertebral levels for different types of spinal tumors so that it would facilitate preoperative planning and management of blood transfusion. Patients and Methods We retrospectively analyzed the patients who underwent spine tumor surgery at our institution from 2005 to 2014. Types of primary tumor (I: highly vascularized tumor, II: moderately vascularized tumor, III: hematological tumor, and IV: primary bone tumor), types of surgery (1: cervical corpectomy and stabilization; 2: thoracolumbar posterior decompression and instrumentation; 3: thoracolumbar corpectomy; and 4: minimally invasive surgery), level of instrumentation (&lt; 6, 6–, and &gt; 9 levels), and decompression (0, 1–2, 3–4, and &gt; 4) on the influence of blood loss were analyzed. The amount of blood transfused was also assessed. Generalized linear model was used for analysis. Results A total of 260 patients were evaluated. Mean blood loss was 660 mL (range, 20–6,000 mL). In multivariate analysis, there were statistically significant differences in the amount of blood loss in different subgroups of tumor types, type of surgical approaches, and groups of level of decompression. Multivariate analysis revealed that intraoperative blood loss rose significantly in proportion to increasing levels of decompression as well as instrumentation. Compared with highly vascularized tumor group, there was a significant reduction in mean blood loss in moderately vascularized and hematological tumor groups (−617 and −436 mL, respectively). Compared with open cervical approach, there was a significant reduction in mean blood loss in minimally invasive surgery (−614 mL) and a borderline increase in thoracolumbar corpectomy surgery (319 mL). Significant association between blood loss and blood transfusion were also observed. The mean blood loss of patients who received blood transfusion was 1,166 mL and that of patients who did not receive was 526 mL. Univariate analysis revealed that type of primary tumor and type of surgical approach were significant predictors of blood transfusion requirement. Multivariate analysis revealed that the amount of blood transfusion requirement was significantly lower in moderately vascularized tumors (1.2 units less) but significantly higher in primary bone tumors (1.8 units more) as compared with highly vascularized tumors. Minimally invasive surgical approach significantly reduced blood transfusion requirement by 1.3 units as compared with open cervical approach. Conclusions There was a significant variation in the amount of blood loss based on primary tumors and types of surgery. This study would help in preoperative planning to address the significant problem of blood loss during various spine tumor surgeries.

Trans-arterial Onyx Embolization of a Functional Thoracic Paraganglioma.

Paragangliomas are rare tumors of the endocrine system. They are highly vascular and in some cases hormonally active, making their management challenging. Although there is strong evidence of the safety and effectiveness of preoperative embolization in the management of spinal tumors, only five cases have been reported in the setting of thoracic paragangliomas. We present the case of a 19-year-old man with a large, primary, functional, malignant paraganglioma of the thoracic spine causing a vertebral fracture and spinal cord compression. To our knowledge this is the first report of preoperative trans-arterial balloon augmented Onyx embolization of a thoracic paraganglioma.

Preoperative embolization of hypervascular spinal tumors: current practice and center experience

Preoperative transarterial embolization of hypervascular spinal tumors has been extensively used, and is considered to be a highly effective adjuvant technique in reducing intraoperative blood loss during surgery. Moreover, it has been reported to increase the feasibility and safety of the surgical procedure, leading to better surgical outcomes. We review the English literature in an attempt to identify indications, appropriate timing of embolization in relation to surgery, technical aspects of the procedure, complications, and the contribution of embolization to the surgical management of spinal tumors. In addition, we report our experience with embolization of hypervascular metastases

Prognostic value and management of spinal tumors in neurofibromatosis type 2 patients

Neurofibromatosis type 2 (NF2) is a well-studied disease. Although spinal tumors are frequent, many issues concerning their prognosis and management still have to be clarified. The authors studied the clinical impact and radiological progression of spinal tumors in patients with NF2 to determine their prognostic value. A total of 80 NF2 patients were followed in the Lille University Hospital between 1987 and 2011. Clinical, radiological and genetic data were retrospectively recorded and analyzed. Patients underwent annual cranial and spinal MRI. Both the location and size of each tumor were reported. The diagnosis of NF2 was confirmed either because the patient met the Manchester criteria or by the presence of genetic mutation. The mean follow-up period was 8.8 years (range 1 to 24 years; SD: ±0.8), and the mean age at diagnosis was 27.2 years (range 6 to 73 years; SD: ±1.7). Among all patients, 48 harbored spinal tumors. Twenty of them were symptomatic, and 21 were operated on. Patients with spinal tumors had a lower age at diagnosis (p = 0.02), a higher number of intracranial meningiomas (p = 0.028) and schwannomas (p = 0.03), and more nonsense and frameshift mutations (p = 0.04). Spinal tumors are common in NF2, and all patients should be regularly monitored by spinal MRI. The presence of spinal tumors seems to be a factor indicating poor prognosis. Clinical and radiological monitoring of spinal tumors could lead to early treatment both when clinical symptoms are present and in case of proven radiological evolution, maintaining a favorable functional prognosis as long as possible.

The Management of Upper Thoracic Spine Tumors

The surgical management of primary and metastatic spine tumors is an essential treatment modality. Because the most spine tumors are metastatic, surgical management of spine tumors is often palliative. However, when indicated, decompression and stabilization can lead to improved quality of life. There are a variety of primary benign and malignant tumors that can involve the spine, and each has its own general management principles. For all tumor types, the diagnostic evaluation and staging of the tumor are essential to determine appropriate management. Surgical management, when indicated, is either palliative or curative, and the gold standard is en bloc spondylectomy. The upper thoracic spine represents a unique region with anatomical obstacles to adequate access, making complete surgical excision difficult. This region of the spine also has unique biomechanical considerations and requires instrumentation for stabilization. Because of the difficulty in accessing the upper thoracic spine, several different approaches have been developed and modified. The management of upper thoracic spine tumors will be presented here, including a case study involving a primary malignancy involving the T1 vertebral body.

Percutaneous Techniques in the Treatment of Spine Tumors

Systematic review of the literature. Should cement augmentation procedures such as vertebroplasty and kyphoplasty be used in patients with painful compression fractures associated with metastatic spine disease? What is the role of embolization in the treatment of metastatic spine disease? Vertebral augmentation is commonly employed in treating osteoporotic fractures and is now increasingly used in the management of pain in patients with spinal tumors. Intra-arterial and transcutaneous embolization techniques are also available in the management of spinal tumors. To date, the effectiveness and safety of these procedures have not been adequately demonstrated. A review of the English literature was performed in Pub-Med. One search was performed using the following keywords: cancer, tumor, vertebroplasty, kyphoplasty, vertebral augmentation, outcome, safety, pain, and quality of life. A Second search was performed using the keywords: embolization, spinal, and tumors. Original studies reporting on at least 10 patients were included and systematically reviewed. The results were reviewed and discussed through consensus among a multidisciplinary panel of expert members of the Spine Oncology Study Group. Recommendations were made according to the Guyatt Guidelines. A total of 1665 abstracts were identified. Twenty-eight articles using vertebroplasty reported on 877 patients and 1599 treated levels. Medical and neurologic complications varied from 0% to 7.1% and 0% to 8.1%, respectively. Twelve articles using kyphoplasty reported on 333 patients and 481 treated levels. Medical complication rates varied from 0% to 0.5%, without any neurologic complications. Pain and functional outcomes were universally successful using either technique. Ten studies on embolization reported on 330 patients. There were 4 permanent complications (1.4%). Complete or partial embolization was possible in 97.5% with an estimated reduction of intraoperative blood loss of 2.3 L. There is strong recommendation and moderate evidence for vertebral augmentation as safe and effective in providing pain relief and improving functional outcome in patients with vertebral body fractures and axial pain due to metastatic disease. There is a strong recommendation and very low evidence for embolization techniques as safe and effective in decreasing intraoperative blood loss in hypervascular tumors.

Percutaneous Spinal Tumor Management

Percutaneous thermal ablation has proven to be safe and effective in the management of spinal tumors. It is a treatment currently proposed with curative intent to patients with small painful benign tumors (e.g. osteoid osteoma and osteoblastoma), or in few selected patients with malignant tumors; and with palliative intent in most patients presenting with symptomatic malignant spinal tumors. In both scenarios, following the decision of a multidisciplinary tumor board, ablation is often tailored to the specific clinical needs of the patient and the features of the target tumor. In malignant cases, vertebral augmentation is often proposed in combination with thermal treatments in order to provide better symptom relief and prevention of secondary vertebral collapse.

Radiotherapy for Primary and Metastatic Spinal Tumors

Primary and metastatic spinal tumors as a group represent a heterogeneous mixture of benign and malignant processes. In general, primary tumors of the spine remain relatively uncommon, and the majority of spinal tumors that are treated annually represent systemic spread of extraosseous primary malignancy. The management of spinal tumors requires meticulous yet expedient attention as the consequences of failed or inappropriate treatment can be devastating. Radiotherapy has proven beneficial in many tumors of the spine, particularly metastatic lesions, Ewing's sarcoma, and myeloid malignancies. A review of the use of radiotherapy for the more common primary spinal malignancies and metastasis is presented.

Image-guided helical Tomotherapy for treatment of spine tumors

Objectives One of the most common indications for radiotherapy is treatment of the spine. The vast majority of cases are related to metastatic disease with primary tumors of the spine being rare. Conventional radiation therapy often plays an important role in the management of spine tumors although at times with significant side effects and disadvantages. Furthermore, retreatment of spine tumors is a challenge due to concerns over spinal cord toxicity. In this series, we examine the efficacy of using image-guided helical Tomotherapy and the possible advantages offered by this new technology. Patients and methods Eight patients at Hoag Memorial Hospital Presbyterian were treated between November 2005 and November 2006. The median age was 66 years. Of the eight patients, seven had metastatic disease with one patient having a primary neuroendocrine tumor of the spine. Five patients were previously treated to the spine with conventional radiation planning. Two patients received single fraction stereotactic radiosurgery (15 Gy) while the remaining patients received hypofractionated stereotactic radiotherapy to a median total dose of 2500 cGy in 500 cGy fractions. Results At the time of last follow-up, radiographic control was seen in all eight patients with a median local control rate of 2.5 months (range of 1–5.8 months). Four of the eight patients are still alive with median overall survival of 5.1 months (range 1.4–6.9 months). Acute toxicity ranged from Radiation Therapy Oncology Group (RTOG) score 0–2 and no patients experienced late complications of radiation myelitis. Conclusions The TomoTherapy Hi-ART system can be an alternative treatment option for upfront or retreatment of spine tumors. Minimal acute and late toxicity were seen in patients treated with Tomotherapy. Intensity-modulated radiation delivery combined with megavoltage CT image guidance offered by the TomoTherapy Hi-ART system allows for set-up and delivery accuracy that is required for stereotactic treatment of spine tumors and eliminates the need for any internal or external fiducial marker placement.

Advances in the evaluation and management of spine tumors

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA Correspondence to F.X. Pedlow, MD, Spine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA

Point of View: A System for Surgical Staging and Management of Spine Tumors

Point of View: A System for Surgical Staging and Management of Spine Tumors