1. Outcome of Embolized Vascular Metastatic Spinal Tumours causing Cord Compression Outcome of Embolized Vascular Metastatic Spinal Tumours causing Cord Compression N A Quraishi, FRCS (Tr & Orth), LLM S Purushothamdas, FRCS (Tr & Orth) R Lenthall, FRCR M P Grevitt, FRCS (Tr & Orth) Eurospine, Milan 2011 Centre for Spinal Studies & Surgery Department of Radiology Queens Medical Centre, Nottingham

2. Background Vascular metastatic spinal tumours with cord compression have a high risk of morbidity & mortality Vascular metastatic spinal tumours with cord compression have a high risk of morbidity & mortality Role of pre-operative embolisation is well recognised Role of pre-operative embolisation is well recognised Multiple factors (size of tumour, extent of surgical intervention, degree of vascularity and extent of embolisation) influence the blood loss and clinical outcome Multiple factors (size of tumour, extent of surgical intervention, degree of vascularity and extent of embolisation) influence the blood loss and clinical outcome Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk Study the effect of embolisation of vascular metastatic tumours causing spinal cord compression and their outcome Study the effect of embolisation of vascular metastatic tumours causing spinal cord compression and their outcome Aim

3. Patient and Methods Retrospective cohort study Retrospective cohort study Period: January 2004 to September 2010 Period: January 2004 to September 2010 23 patients (14 males : 19 females) 23 patients (14 males : 19 females) Average Age 59.2 years (24-78) Average Age 59.2 years (24-78) Follow-up: 7.3 months (3-23.3) Follow-up: 7.3 months (3-23.3) Primary diagnosis: Primary diagnosis: Renal cell carcinoma: 21 Renal cell carcinoma: 21 Paraganglioma: 1 Paraganglioma: 1 Carcinoid: 1 Carcinoid: 1 Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

4. Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk Clinical presentation Most patients presented with both pain and deteriorating neurology Most patients presented with both pain and deteriorating neurology

5. Operative Details Ave. blood loss: 2211 (400-10,000) mls Ave. blood loss: 2211 (400-10,000) mls Ave. operating time: 291 (90-840)mins Ave. operating time: 291 (90-840)mins Ave. blood transfusion: 3.5 (max.19)units Ave. blood transfusion: 3.5 (max.19)units Ave. pre-operative Hb : 12.6 (9.5-16 ) g/dl Ave. pre-operative Hb : 12.6 (9.5-16 ) g/dl Ave. post-operative Hb : 9.6 (6.9-14.6) g/dl Ave. post-operative Hb : 9.6 (6.9-14.6) g/dl Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

6. Embolisation details (performed by senior interventional radiologist) Endovascular, transarterial; combination of liquid & particulate agents Endovascular, transarterial; combination of liquid & particulate agents Angiography grade: Angiography grade: Grade 0: Normal vascularisation Grade 0: Normal vascularisation Grade I: Homogenous blush (normal feeding arteries) Grade I: Homogenous blush (normal feeding arteries) Grade II: Hypervascularisation (dilated feeding arteries) Grade II: Hypervascularisation (dilated feeding arteries) Grade III: Arterio-venous fistula Grade III: Arterio-venous fistula Embolisation grade: Embolisation grade: Not embolised Not embolised <50% embolisation <50% embolisation 51-90% embolisation 51-90% embolisation 90-100% embolisation 90-100% embolisation Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

7. Embolisation Grade 0 (Normal vascularisation)0 (0%) Grade I (Homogenous blush)1 (4.4%) Grade II (Hypervascular)11 (47.8%) Grade III (AV fistula)10 (43.5%) None4 (17.4%) <50%3 (13.1%) 51-90%4 (17.4%) 91-100%14(60.9%) Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

8. Neurological change by Frankel grades Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

9. Neurological change by Frankel Grid AA 0 AB 0 AC 0 AD 0 AE 0 BA 0 BB 0 BC 0 BD 0 BE 0 CA 0 CB 0 CC 5 CD 1 CE 1 DA 0 DB 0 DC 2 DD 5 DE 5 EA 0 EB 0 EC 1 ED 2 EE 1 Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

10. Timing of embolisation to surgery Immediate (n = 10) 24 hours (n=10)p value Blood loss (mls)1537.52058.3p = 0.49 Op time (minutes)261301p =0.44 Transfusion (units)2.62.9p = 0.77 Survival (months)16.116.5p = 0.97 Extent of embolisation >90% (n = 14) <90% (n=9)p value Blood loss (mls)1902.52588.9p = 0.54 Op time (minutes)236370p =0.12 Transfusion (units)2.64.6p = 0.86 Survival (months)17.114.5p = 0.71

11. Complications 9/23, 39.1% (major: 2/23,8.7% ; minor: 7/23, 30.4%) No. of Patients Wound infection 1 Urinary retention 2 Chest infection 2 Metal ware failure 2 Septicaemia 1 Pneumothorax1 Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

12. Conclusions Blood loss remains a major concern in vascular metastatic spinal tumours with cord compression Blood loss remains a major concern in vascular metastatic spinal tumours with cord compression No statistical significance is observed in amount of blood loss, operation time, blood transfusion and survival in terms of time of surgery since embolisation and also extent of embolisation No statistical significance is observed in amount of blood loss, operation time, blood transfusion and survival in terms of time of surgery since embolisation and also extent of embolisation Higher complication rate is observed in such tumours Higher complication rate is observed in such tumours Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk Financial Disclosure: None of the authors have None of the authors have received from any commercial entity any payments or any pecuniary, in kind, or other professional or personal benefits including stock, honoraria, or royalties (collectively, “Benefits”) or any commitment or agreement to provide such Benefits