Aims. This study aimed to evaluate the incidence and prognosis of patients with spinal metastasis as the initial manifestation of malignancy (SM-IMM). Patients and Methods. We retrospectively reviewed the electronic medical records of 338 patients who underwent surgical treatment for metastatic spinal disease. The enrolled patients were divided into two groups. The SM-IMM group included patients with no history of malignancy whose site of primary malignancy was diagnosed after the identification of spinal metastasis. The other group included patients with a history of treatment for primary malignancy who then developed spinal metastasis (SM-DTM). The incidence of SM-IMM by site of primary malignancy was calculated. The difference between prognoses after surgical treatment for SM-IMM and SM-DTM was established. Results. The median follow-up period was 11.5 months (interquartile range (IQR) 3.2 to 13.4) after surgical treatment. During the follow-up period, 264 patients died; 74 patients survived. The SM-IMM group consisted of 94 patients (27.8%). The site of primary malignancy in the SM-IMM group was lung in 35/103 patients (34.0%), liver in 8/45 patients (17.8%), kidney in 10/33 patients (30.3%), colorectum in 3/29 patients (10.3%), breast in 3/22 patients (13.6%), prostate in 3/10 patients (30%), thyroid in 4/8 patients (50%), and ‘other’ in 28/88 patients (31.8%). On Kaplan–Meier survival analysis, the SM-IMM group showed a significantly longer survival than the SM-DTM group (p = 0.013). The mean survival time was 23.0 months (95% confidence interval (CI) 15.5 to 30.5) in the SM-IMM group and 15.5 months (95% CI 11.8 to 19.2) in the SM-DTM group. Conclusion. Of the 338 enrolled patients who underwent surgical treatment for spinal metastasis, 94 patients (27.8%) underwent surgical treatment for SM-IMM. The SM-IMM group had an acceptable prognosis with surgical treatment. Cite this article: Bone Joint J 2019;101-B:1379–1384

Aims. Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS. Methods. A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis. Results. Overall, 123 patients with 127 spinal metastases from NSCLC who underwent decompression surgery followed by postoperative systemic therapy were included. A total of 43 lesions were treated with stereotactic body radiotherapy (SBRT) after surgery and 84 lesions were not. Survival rate at one, two, and three years was 83.4%, 58.9%, and 48.2%, respectively, and LC rate was 87.8%, 78.8%, and 78.8%, respectively. Histological type was the only significant associated factor for both LC (p = 0.007) and OS (p < 0.001). Treatment with targeted therapy was significantly associated with longer survival (p = 0.039). The risk factors associated with worse survival were abnormal laboratory data (p = 0.021), lesions located in the thoracic spine (p = 0.047), and lumbar spine (p = 0.044). This study also revealed that postoperative radiotherapy had little effect in improving OS or LC. Conclusion. Tumour histological type was significantly associated with the prognosis in spinal NSCLC metastasis patients. In the presence of post-surgical systemic therapy, radiotherapy appeared to be less effective in improving LC, OS, or quality of life in spinal NSCLC metastasis patients. Cite this article: Bone Jt Open 2024;5(4):350–360

Aims

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

Aims

With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values.

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss.

We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger’s test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I² = 90%; p < 0.001).

Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.

Cite this article: Bone Joint J 2013;95-B:683–8.

Evaluate the complications and outcomes of off-hours spinal metastasis surgery. Retrospective analysis of a prospective collected data. Preoperative, operative and post-operative data were collected as well as the complications and Frankel score at all time checkpoints. Off-hours surgery was defined as surgery starting between 17:00 and 8:00 the following day or surgery during the weekend. p < 0 .05 was defined as statistical significance threshold. 376 patients were included with an incidence of off-hours surgery of 32%. There was an increase of neurologic complication in the off hours group. This was associated with a higher ASA score and older population group. Oddly, there was decreased operative time with off-hours surgery with no difference in bleeding and number of fusion levels. Nonetheless, there was a higher percentage of neurologic improvement with off hours surgery compared to in-hours surgery. Finally, there were no effect on patients' survival in this patient population. To our knowledge, this is the first report of the effect of off-hours surgery on complications and outcomes of spinal metastasis. Greater neurological compromise and higher age and ASA scores were associated with higher incidence of off-hours surgery. It is associated with decreased surgical time with higher percentage of neurological improvement. Finally, there is no effect of surgical timing on survival rates

En bloc resection for primary bone tumours and isolated metastasis are complex surgeries associated with a high rate of adverse events (AEs). The primary objective of this study was to explore the relationship between frailty/sarcopenia and major perioperative AEs following en bloc resection for primary bone tumours or isolated metastases of the spine. Secondary objectives were to report the prevalence and distribution of frailty and sarcopenia, and determine the relationship between these factors and length of stay (LOS), unplanned reoperation, and 1-year postoperative mortality in this population. This is a retrospective study of prospectively collected data from a single quaternary care referral center consisting of patients undergoing an elective en bloc resection for a primary bone tumour or an isolated spinal metastasis between January 1st, 2009 and February 28th, 2020. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia, determined by the total psoas area (TPA) vertebral body (VB) ratio (TPA/VB), was measured at L3 and L4. Regression analysis produced ORs, IRRs, and HRs that quantified the association between frailty/sarcopenia and major perioperative AEs, LOS, unplanned reoperation and 1-year postoperative mortality. One hundred twelve patients met the inclusion criteria. Using the mFI, five patients (5%) were frail (mFI ³ 0.21), while the STFI identified 21 patients (19%) as frail (STFI ³ 2). The mean CT ratios were 1.45 (SD 0.05) and 1.81 (SD 0.06) at L3 and L4 respectively. Unadjusted analysis demonstrated that sarcopenia and frailty were not significant predictors of major perioperative AEs, LOS or unplanned reoperation. Sarcopenia defined by the CT L3 TPA/VB and CT L4 TPA/VB ratios significantly predicted 1-year mortality (HR of 0.32 per one unit increase, 95% CI 0.11-0.93, p=0.04 vs. HR of 0.28 per one unit increase, 95% CI 0.11-0.69, p=0.01) following unadjusted analysis. Frailty defined by an STFI score ≥ 2 predicted 1-year postoperative mortality (OR of 2.10, 95% CI 1.02-4.30, p=0.04). The mFI was not predictive of any clinical outcome in patients undergoing en bloc resection for primary bone tumours or isolated metastases of the spine. Sarcopenia defined by the CT L3 TPA/VB and L4 TPA/VB and frailty assessed with the STFI predicted 1-year postoperative mortality on univariate analysis but not major perioperative AEs, LOS or reoperation. Further investigation with a larger cohort is needed to identify the optimal measure for assessing frailty and sarcopenia in this spine population

Summary. Neurological deficits resulting from spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy. Introduction. Nasopharyngeal carcinoma has been reported to have a higher incidence of distant metastases to the spine. This study was conducted to evaluate the incidence, presentation and management of neurological involvement related to spinal metastasis from nasopharyngeal carcinoma. Patients and Methods. 814 patients with the diagnosis of NPC who presented to the National University Hospital (NUH), Singapore, over a 5-year period (2007–2011) were recruited for this study. Case records from clinics, wards, operating theatres at NUH and nationwide electronic records of polyclinics and Emergency Medical Department (EMD) were obtained and reviewed. The data collected included demographics, medical history, radiologic and histopathology reports. Results. Of 814 patients with NPC, 99 had spinal metastasis. 26 were treated with radiotherapy, 25 with chemotherapy, 5 with both chemo and radiotherapy and 6 with surgery. Out of 6 patients requiring spinal surgical procedure, 3 had neurological deficits in the form of focal sensory or motor deficits and 4 had symptoms of pathologic fracture. One patient had both neurological deficit and pathological fracture. All these 6 patients were treated with a spinal surgical procedure of stabilization and/or decompression. Discussion/Conclusion. Spinal metastasis is common in patients with NPC and back pain is the usual presentation. Neurological deficits resulting from nerve root or spinal cord compression occur infrequently. When presented with neurological compromise, the most common management was radiotherapy, with surgery only being offered to patients who developed neurological deficit or pathological fracture resulting in unresolved severe pain post radiotherapy

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

Spinal metastases are seen in 10–30% of cancer patients. Twenty percent of these metastases occur in the lumbo-sacral spine. Lumbo-sacral spine has different mechanical properties and encloses the cauda equina. Few studies took interest in this spinal segment. The objective of this study is to evaluate prognostic factors of lumbo-sacral spinal metastasis treated in our center. We retrospectively reviewed 376 patients who were operated in our center from 2010 to 2018. Eighty-nine patients presented lumbo-sacral metastases and thus were included. Data collected included age, smoking, tumor histology, American spinal injury association (ASIA) score, modified Tokuhashi score, modified Bauer score, ambulation status and adjuvant treatment. The mean population age was 60.9 years old (35–85). The tumor histology was predominantly lung (19 patients, 21.3%), breast (13 patients, 14.6%), kidney (11 patients, 12.4%) and prostate (9 patients 10.1%). Twenty-two patients (24.7%) were unable to walk preoperatively. Seventy-nine patients (88.8%) underwent a posterior open approach with corpectomy in 65 patients (73%). Eighteen patients regained ambulation post-operatively (81.8%). The mean survival was 24.03 months (CI95% 17,38–30,67, Range 0–90) and the median of survival was 9 months (CI95% 4.38–13.62). Better preoperative ASIA score had a significant favorable effect (p=0.03) on survival. Patients who regained their ability to walk had better survival (25.1 months (CI95% 18.2–32) VS 0.5 months (CI95% 0–1.1). Postoperative radiotherapy had a benefic effect on survival (p=0.019): Survival Increased from 10.5 months (CI95% 2.4–18.7) to 27.6 months (CI95% 19.5–35.8). The modified Tokuhashi and the modified Bauer scores underestimated the survival of the patients with lumbosacral metastases. Lumbosacral spinal metastases has better survival than expected by Tokuhashi and Bauer score. Surgical procedure have an important impact on survival and the ability to walk

A province-wide study designed to use administrative data to determine the rate of post-operative complications, the survival duration and predictors of outcome among patients undergoing surgery for metastatic disease of the spine. Surgery for patients with spinal metastasis is primarily palliative. It is often fraught with complications, which may in fact diminish quality of life. Quantification of survival rates and the risk of potential complications following surgery is important to the clinician and the patient’s families for decision making. All patients that underwent surgery for spinal metastasis between 1991 and 1998 were identified using the Ontario health insurance database and a hospital discharge registry. The mean age at surgery was 60. 3 years (range: 13–92 years). The mortality files identified patients who were dead by October 1999. Information about individual inpatient admissions including post-operative complications was then collected. The survival rates and complications following surgery were quantified and the effect of several variables on these two parameters was computed. The median and mean survival was 227 days and 793. 4 days respectively. The 30-day and 3-month mortality were 9% and 29% respectively. Advanced age at surgery, male sex, presence of a pre-operative neurological deficit and primary cancers of lung, gastrointestinal tract & melanoma are predictive of poor survival. 39% patients had complications. Pre-operative neurological deficit was associated with a 71% higher risk of developing post-op. wound infection. In the past, surgery has been recommended in patients with an anticipated survival of at least three to six months. The current study shows that even patients preselected on the basis of predictions of longer survival, there is a potential for early mortality and significant complications. Hence, a careful estimation of the benefits of surgery versus surgery related morbidity must be made prior to offering surgery for palliation

Introduction An international six-centre prospective observational cohort study. Objective. To assess the feasibility of radical surgical excisional treatment of spinal metastasis. Materials and methods. Patients with histologically confirmed spinal metastasis originating from epithelial primary site mostly treated with instrumented surgery were studied. Surgical strategies were either radical excisional (enbloc and debulking) or palliative decompressive surgery. Outcomes assessed were measures of quality of life including pain, mobility, sphincter and neurological functions. Results. A total of 223 patients with a mean age of 61 years and equal number of males and females were studied. Breast, renal, lung and prostate accounted for three quarters of tumours and 60% had metastasis that extended beyond one vertebra. Most patients presented with pain (92%), paraparesis (24%) and abnormal urinary sphincter 22% (5% were incontinent). Seventy four percent of patients underwent radical surgery, 92% of all patients had instrumented fixation. 73% of the radical group had improved pain control (63% for palliative group), 72% regained ability to walk (45% for palliative group), 92% maintained a functional neurological function of Frankel E/D (64% for palliative) and 55% had improved sphincter control (21% for palliative group). Overall of all petients who underwent surgery, 71% had improved pain control, 53% regained mobility, 64% improved by at least one Frankel grade or maintained normal neurology and 39% regained normal urinary sphincter function. While 18% were bed bound preoperatively, only 5% were still in bed postoperatively. Perioperative mortality rate was 5.8% and morbidity was 21%. The median survival for the cohort was 352 days (11.7 months). The radical surgery group had a median survival of 438 days and the palliative group 112 days (P = 0.003). Conclusion. Surgical treatment of spinal metastatic tumour is feasible with low mortality, an acceptably low morbidity and affords patients better quality of remaining life. Radical surgical excision has better outcome than palliative surgery in pain control and in neurological function rescue including regaining mobility and improvement in sphincter control

Photodynamic therapy (PDT) uses the strong cytotoxicity of singlet oxygen and hyperthermia produced by irradiating excitation light on a photosensitizer. The phototoxic effects of indocyanine green (ICG) and near-infrared light (NIR) have been studied in different types of cancer cells. Plasma proteins bind strongly to ICG, followed by rapid clearance by the liver, resulting in no tumor-selective accumulation after systemic administration. Kimura et al. have proposed using a novel nanoparticle labeled with ICG (ICG-lactosome) that has tumor selective accumulation owing to enhanced permeability and retention (EPR) effect. In this study, we investigated the efficacy of PDT using ICG-lactosome and NIR for a bone metastatic mouse model of breast cancer. Cells from the human breast cancer cell line, MDA-MB-231 were injected into the right tibia of 26 anesthetized BALB/C nu/nu mice at a concentration. The mice were then randomly divided into three groups: the PDT group (n = 9), the laser (laser irradiation only) group (n = 9), and the control group (n = 8). PDT was performed thrice (7, 21, 35 days after cell inoculation) following ICG-lactosome administration via the tail vein 24 hours before irradiation. The mice were percutaneously irradiated with an 810-nm medical diode laser for 10 min. In the laser group, mice were irradiated following saline administration 24 hours before irradiation. Radiographic analysis was performed for 49 days after cell inoculation. The area of osteolytic lesion was quantified. The right hind legs of 3 mice were amputated 24 hours after the third treatment. Histological analysis was performed using hematoxylin-eosin staining and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining of sagittal sections. The data was analyzed using Tukey-Kramer post-hoc test. P-value of <0.05 was considered significant. X-ray on day 49 of the three groups are considered. The area of osteolytic lesion in the PDT group (7.9 ± 1.2 mm. 2. : mean ± SD) was significantly smaller than that of the control (11.4 ± 1.4 mm. 2. ) and laser (11.9 ± 1.2 mm. 2. ) groups. In histological findings, we observed many TUNEL-positive cells in the metastatic tissue 24 hours after PDT. In the control and laser groups, TUNEL-positive cells were occasionally observed. We have previously reported the effect of ICG-lactosome-enhanced PDT on the cytotoxicity of human breast cancer cells in vitroand on the delay of paralysis in a rat spinal metastasis model. In this study, we demonstrated the inhibitory effect of ICG-lactosome-enhanced PDT on bone destruction caused by human breast cancer cells in vivo. This PDT induced apoptosis and necrosis in the tumor cells. Intralesional resection is often performed for spinal metastases in an emergency. The residual tumor may regrow and cause neurological deficits. We believe that ICG-lactosome-enhanced PDT can decrease the rate of local recurrence through reduction of the residual tumor. PDT with ICG-lactosome and NIR had an inhibitory effect on the growth of bone metastasis of a human breast cancer

Aims

Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments.

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

A prospective study was performed to evaluate the efficacy and safety of percutaneous kyphoplasty in patients with osteolytic tumours of thoracic and lumbar spine. To our knowledge this is the only study so far that has followed a cohort of patients prospectively until death. Prospective study of patients with lytic tumours of spine treated with kyphoplasty. A total of 13 patients with osteolytic tumours of spine were treated with kyhpoplasty. There were 8 female and 5 male patients. The age range was 52-81 years with average age of 65 years. A total of 25 vertebrae, from T2 to L3, were treated. The types of tumours included; non-Hodgkin lymphoma (2), myeloma (2), gastric-carcinoma (1), cervix-carcinoma (1), breast-carcinoma (3), prostate-carcinoma (2), small cell lung-carcinoma (1), bladder-carcinoma (1). Outcome was assessed prospectively by visual analogue scale (VAS) for pain, ECOG performance status, walking distance, standing and sitting time. The preoperative average VAS was 7.5 (range: 2.6 – 10). This dropped to 3.0 five days postoperatively and remained below 5 for the duration of follow-up. Average walking distance, standing and sitting time and ECOG performance score showed improvement. The survival time ranged from 2 to 293 weeks. The average survival time was 82 weeks. All patients were able to return home following the procedure. No patient required reoperation or readmission for spinal metastasis. Kyphoplasty is a suitable palliative treatment option for patients with advanced metastatic disease of the spine

Percutaneous vertebroplasty is an effective procedure for the treatment of osteoporotic vertebral compression fractures, spinal metastasis and other pathologic spinal diseases. However, there has been no mention in the relevant literature of the use of percutaneous vertebroplasty for the treatment of spinal pseudarthrosis in ankylosing sponyloarthritis. A 58-year-old male with a long standing ankylosing spondylitis presented with increasing, intolerable and non-intractable back pain. There was a 16- month-old history of a non-significant minor fall. Various radiological imaging technicques showed spinal pseudarthrosis with extensive discovertebral destruction and fracture of the posterior elements at the level T11–T12. Under local anaesthesia, and through a transpedicular approach with the guidance of CT, the cannula of a large bore needle was introduced into the level of spinal pseudarthrosis. Bone cement was then instilled into the affected spinal level. Results were documented by spiral CT and with sagittal reconstructions. Extraosseous cement leakage was seen at the puncture site of the vertebra and in the epidural veins and the paravertebral vessels. However, the patient did not present any immediate or late neurological and systemic complications. Percutaneous vertebroplasty of spinal pseudarthrosis in patients with ankylosing spondylitis is an effective procedure for stabilization of the affected spine segments and pain management

The use of cervical pedicle screws as anchors in posterior reconstruction surgery has not been widely accepted due to the neurological or vascular injury. We thus sought to investigate the accuracy of free-handed pedicle screw placement in the cervical and upper thoracic spine at the early stage of clinical application. Eight patients (five males and three females) were included in this study. Mean age was 63 years (31 to 78 years). There were three patients with rheumatoid arthritis, three with cervical fracture-dislocation, and two with spinal metastasis. Twenty-four pedicle screws (3.5 mm diameter: Vertex, Medtronic Sofamordanek) were placed into the pedicle from C2 to T2 level by free-handed technique2). Grade of breaching of pedicle cortex was divided into four groups (Grade 0–3). In addition, screw axis angle (SAA) were calculated from the horizontal and sagittal CT images and compared with pedicle transverse angle (PTA). Furthermore, perioperative complications were also examined. Our free-handed pedicle screw placement with carving technique is as follows: A longitudinal gutter was created at the lamina-lateral mass junction and then transverse gutter perpendicular to the longitudinal gutter was made at the lateral notch of lateral mass. The entry point of the pedicle screw was on the midline of lateral mass. Medial pedicle cortex through the ventral lamina was identified using the probes to create the hole within the pedicle. The hole was tapped and the screw was gently introduced into the pedicle to ensure the sagittal trajectory using fluoroscopy. In the transverse direction, 22 out of 24 screws (92%) were entirely contained within the pedicle (Grade 0). In contrast, only teo screws (8%) produced breaches less than half the screw diameter (Grade 1). In the sagittal direction, all screws were within the pedicle (Grade 0). Screw trajectories were not consistent with anatomical pedicle axis angle; the mean SAA were smaller than the mean PTA at all levels. The pedicle diameter ranged from 3.9 to 9.2 mm. The mean value gradually increased toward the caudal level. There were no neurological and vascular complications related to screw placement

Study Design: A retrospective review of case notes and histology reports. Summary of Background Data: Up to 8% of cancer patients develop second malignancies. The vertebral column is frequently involved in metastatic disease and may represent the first manifestation of malignancy in up to 40% of patients. The rate of vertebral metastasis from a second tumour in patients with a known primary is not well known. Objective: We sought to identify the incidence of a second primary in patients referred to our unit with spinal malignancy and a previously diagnosed primary tumour. Subjects: 222 patients underwent definitive surgery for spinal metastatic disease of whom 135 had a prior history of malignancy. Outcome measures: Histological tissue of origin of spinal metastasis in light of previous known malignancy. Results: In 16 patients (11.9%) the vertebral histology differed from the initial primary. The period between first and second malignancies varied widely (19 months – 22 years). Thirteen patients (9.6%) had identifiable tissue origins for the metastasis that was not in keeping with the previous malignancy. Three further patients showed sufficient histological and imunohistochemical differences such that a further tumour of unknown origin and not de-differentiation of the previous tumour was suspected. Three previously unrecognised tumours were diagnosed on biopsy and eight on tissue obtained at definitive surgery. Conclusion: The incidence of second primaries, in particular myeloma, presenting with vertebral metastases is significant and should always be borne in mind when assessing patients and planning treatment. Biopsy should be performed when possible. Comparison needs to be made between the histological features of the previous primary and metastasis

Kyphoplasty is an efficient tool in the treatment of primary tumours (plasmocytoma) and osteolytic metastasis. Especially in plasmocytoma the current chemotherapy has increased life expectancy significantly. Therefore minimal-invasive stabilisation is not only a palliative treatment but really increases quality of life in those cases. Kyphoplasty offers several special tools and techniques to lower the leakage rate which is especially high with other cementoplasty techniques in the osteolytic spine. Materials and Methods: Prospective study of all vertebral tumours compared to osteoporotic fractures treated with kyphoplasty in 2004. 6 months follow up with VAS, SF36 and Oswestry score. Results: In 2004 we performed 67 Kyphoplasties. 12 kyphoplasties were performed in tumour cases (5 plasmocytoma and 7 metastasis). No complications occurred during surgery and during hospital stay. Follow-up included 11 tumours (1 death during F/U) and 46 osteoporotic fractures. 1 patient was treated with combined decompression/kyphoplasty. The pain level (VAS) was significantly reduced in all cases within 2 days (osteoporotic group 2,2 – tumour group 5,4) and reached nearly the same result after 6 weeks which persisted for 6 months (osteoporotic group 1,6, tumour group 2,1). The SF 36/Oswestry Score improved accordingly in both groups. At 6 weeks and 6 months F/U no statistical difference in the scores was seen. Conclusion: Kyphoplasty is a safe treatment method for osteolytic vertebral tumours with vertebral collapse. Clinically the results don’t differ from conventional cases. In cases with canal compromise, a combination with open techniques is possible. Special kyphoplasty techniques allow a reconstruction of the lytic wall and minimise leakage and cement dislocation. Significant improvement of life quality can be achieved offering the spine surgeon a valuable tool in the treatment of spinal metastasis