1. Modern Treatment of Spinal metastases
Maxwell Boakye, MD MPH FACS FAANS
Associate Professor of Neurosurgery
Nelson Endowed Chair
Center for Advanced Neurosurgery, University of Louisville

2. My Background
Neurosurgeon
Residency 2002
Fellowships-complex spine-Emory and Spine Oncology-Sloan Kettering-2003
Stanford worked with cyberknife
Special interest in spine tumors and spine radiosurgery

3. Goals
Epidemiology
Presentation
Imaging
Role of Surgery
Emerging Treatment paradigms
Decision making and Frameworks
Memorial Sloan Kettering NOMS criteria
Cases

4. Epidemiology
20000 new cases of metastatic epidural cord compression each year
10% of cancer patients will develop spinal metastatic
About 70% of all cancer deaths occur in elderly patients aged over 65
Postmortem studies metastases present in 90% of patients with systemic cancer

5. Epidemiology
Number of elderly patients dying from cancer will double by 2030
By age 2050, the number of newly diagnosed patients aged 85 will quadruple

6. Myelopathy-Motor, Sensory, Bowel/Bladder Pain
Signs and symptoms
Myelopathy-Motor, Sensory, Bowel/Bladder
Usually from epidural cord compression
Pain
Biologic
nocturnal/early morning-resolves during day-usually from tumor infiltration, Steroid responsive
Mechanical-movement related
Radicular-usually epidural disease in foramen
Other Symptoms e.g LOC or AMS from brain

7. Imaging
X-rays CT
MRI
PET

8. Imaging findings Imaging Epidural disease only Vertebral disease only
Vertebral disease with epidural
Cord compression
Mechanical instability
Pathological fractures
Single level, Multiple level, Distant metastases

9. Treatment options
Surgery
Radiation therapy
Radiosurgery
Chemotherapy

10. Main surgical approaches
Anterior Transthoracic, Retroperitoneal
Posterior Laminectomy
Posterior transpedicular, costotransversectomy approach

12. Epidural Compression: Surgery is superior to radiation
Patchell et. al, Lancet Vol 366: , 2005

13. Patchell study

14. Surgery vs. radiation-Patchell

15. Surgery improves quality of life outcomes
Quan et. Al., Eur Spine Journal 2011 Jun 26

16. Surgical complications

17. Price of surgery: High Morbidity and mortality
Complication rates-20-40%

19. Emerging Treatment Patterns
Vertebral augmentation
Vertebroplasty
Kyphoplasty
Radiosurgery
Combined kyphoplasty and radiosurgery

20. KYPHOPLASTY

21. KYPHOPLASTY

22. CAFÉ TRIAL

23. CAFÉ trial

24. Berenson et. Al., Lancet Oncology 2011 Mar;12(3):225-35.

25. CYBERKNIFE RADIOSURGERY
The CyberKnife® a robotic manipulator to move a compact linear accelerator with six degrees of freedom
Real-Time Image Guidance Throughout the Treatment
Dynamic Motion Tracking
Allows for accuracy and conformality
Louisville is getting one!!

28. Other radiosurgery systems

31. Concept of Separation surgery

32. Separation surgery

35. DECISION MAKING
Who should be operated on?
Frameworks for prognosis
Algorithms and Decision aids

36. Tokuhashi score 􀂃≥9:•Excision•Survival > 12 months
􀂃≤5:•Palliative•Survival < 3 months

37. Decision Making-NOMS criteria
Neurologic
Oncologic
Mechanical
Systemic

38. NOMS criteria
Neurologic-myelopathy, degree of epidural cord compression
Oncologic- radiosensitivity of tumor
Mechanical instability-movement related pain
Systemic disease and medical comorbidities

39. Neurologic-Classification of Epidural compression

40. Neurologic-Classification of epidural compression
Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317

41. Oncologic-Radiosensitivity
–Myeloma & Lymphoma: most radiosensitive
–Prostate, Breast, Lung and Colon: moderately
–Thyroid, Kidney, Melanoma: not radiosensitive

42. Mechanical Instability

44. Systemic factors

45. SINS score
Ranges 0-18
0-6, Stable
7-12, indeterminate, possibly impending instability
13-18-Instability
Surgical consultation is recommended for SINS score > 7.
Fisher CG, Spine Vol 35(22): , 2010

46. Oncologic factors-Impact of Comorbidities

47. Oncologic and Systemic factors-survival

50. Predictors of Survival
VAriable
Hazard ratio
95% CI
P-value
Age
1.001
0.90
Ambulatory status
2.355
0.0001
Cervical mets
1.07
0.76
Comorbidity
2.96
0.007
Epidural compression
1.20
0.52
Pathologic fracture
1.41
0.08
Radiosensitivity
2.56
<0.0001
Radiotherapy
0.98
0.91
Urinary incontinence
1.16
0.47
Visceral mets
1.09
0.65

51. NOMS decision framework.
Bilsky M, Hematol Oncol Clin N Am 20 (2006) 1307–1317