Spinal Tumors: A Second Chance at Life

1. Spinal Tumors: A Second Chance at Life Angela Sarro, RN(EC), MN, CNN(c) Nurse Practitioner-Adult Spine Program Toronto Western Hospital University Health Network

2. Objectives • To understand decision making with spinal tumor resections • To appreciate surgical approaches and potential complications • Understand potential impact on quality of life • Integration of case study throughout

3. Diagnosis of spinal tumor can be overwhelming and anxiety provoking • Long term outcomes are variable depending on presenting symptoms, tumor type and treatment options • Treatment options depend on type and location of tumor: • Observation • Surgical resection • Chemotherapy • Radiation • Medications

4. Clinical Presentation • Back pain • Persistent and progressive • Worse at night • History of cancer** • Neurological symptoms • Loss of sensation or muscle weakness in arms or legs • Decreased sensitivity to pain, heat or cold • Difficulty walking, possible falls • Loss of bowel or bladder function • Paralysis

5. Case Study • Mr. S. • 58 year old male • Complaints of neck pain and mild dysphagia for 1 year • Worked up by family MD • Presents to spine clinic with dysphagia

6. PMHx • HTN • Glaucoma left eye • A-fib arrest 2003 • Cardiac stenting • No issues since • No known allergies

7. Radiological findings • Large retropharyngeal mass • Tumor largely anterior but did involve posterior elements • Involved C2 vertebral body and peg extending down to body C3 • Tumor encased vertebral artery bilaterally at C3 • Felt to be a chordoma

10. C3 vertebral body involvement C2-C3 with bilateral vertebral artery involvement

11. Primary Benign Tumors Osteoid osteoma Osteoblastoma Osteochondroma Aneurysmal bone cyst (ABC) Giant cell tumor Primary Malignant Tumors Chondrosarcoma Osteosarcoma Ewings sarcoma Chordoma Types of Tumors • Common Metastatic Spinal Tumors • Breast Prostate Lung Renal Gastric

12. En Bloc Resection • En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in cases of primary tumor • Goal: negative margins • No intra-lesional dissection • Chance for longer survival knowing that function will not be “normal”

13. Feasibility of en bloc resection is determined by careful surgical and oncologic staging • Key step in this process is obtaining a tissue diagnosis • Experienced, multidisciplinary teams should perform these surgeries

14. Surgical Approaches • Need to determine extent of involvement of tumor with spine, adjacent soft tissue or organs • Location of tumor will determine surgical approach/approaches • May require multidisciplinary approaches • Often done in two stages due to complexity • Stage 1 – Posterior • Stage 2 – Anterolateral/Posterior

15. Pre-op Preparation • Local and systemic staging to rule out nodal or distant disease especially in cases of metastatic disease • Sometimes treated with chemotherapy and radiation pre-op depending on tumor sensitivity and/or previous treatments • Restaged following treatment prior to en bloc excision to re-evaluate tumor size and minimize extent of surgery

16. Patient Selection • No epidural involvement • Reasonable medical condition • Patient awareness of magnitude of surgery and length of recovery

17. Patient Discussion • Magnitude of surgery • Complication rate up to 30% • UTI • Infection • Pneumonia • DVT/PE • Prolonged hospital stay • Likelihood for need of rehab following acute care

18. Many patients have NO pain pre-op • Need to be aware that there will be pain post-op and likely life-long • Possible deficits if nerve roots are part of dissection • Trade off for longer lifespan

19. Pre-op Discussion with Mr. S. • Primary malignant tumor – chordoma • Best approach would be en bloc resection • Complex procedure • Two stage process to enable en bloc resection • Functional loss • Long-term pain • Complications

20. Likelihood of adverse event 30% or higher • UTI • Pneumonia • Infection, CSF leak • Hardware failure • Brain stem or spinal cord stroke • Peri-operative tracheostomy and gastrostomy tube • Involvement of: • ENT • Neurosurgery • Spine • Length of hospital stay and need for rehab

21. En BlocTechnique • Evolved over review • Current preference: two stage procedure • 1st: posterior instrumentation, release of tumor • 2nd: combined anterior and posterior approach

22. Surgical Resection • Preserve superficial ± deep paraspinals to provide coverage post resection • Depending on tumor location: • Release discs, facets, ribs • Ipsilateral hemi- laminectomies, ligation nerve roots • Ligation of blood vessels • Removal of other organs

23. Length of surgical procedure is very long • Stage 1: 5-6 + hrs • Stage 2: Actual tumor resection and removal can be 10 + hours

24. Surgical Procedure Mr. S. • Stage 1 • Tracheostomy • Posterior approach • Vertebral artery bypass by neurosurgery • Left side bypass graft (easiest to access) utilizing right saphenous vein • Occlusion right vertebral artery • SSEP monitoring • Total OR: 24 hours

25. Stage 2 • Postponed for 4 weeks secondary to: • extensive facial swelling and coagulopathy (controlled) • CNS altered sensorium which resolved • Transmandibular split with en bloc resection of tumor • Small dural tear repaired at time of surgery • Vascularized fibular graft

26. Anterior Approach

27. Vascularized fibular graft

28. Posterior instrumentation Vascularized fibular graft Tracheosotomy

29. Post-op Considerations in General • Respiratory • Possible intubation post-op • Tracheostomy • Atelectasis • Pneumonia • Vascular • DVT/PE • Gastrointestinal • Nutritional support • Bowel function

30. Skin Integrity • Early mobilization • Astute skin assessment • Pressure relieving surfaces • Wound healing

32. Pain Management • Involvement of Acute Pain Service • Epidural catheter • IV Patient controlled analgesia • Transition to oral medications • Mobility • Followed by PT/OT • Likelihood of inpatient rehabilitation quite high

33. Complications Mr. S. • Decreased LOC post-op Stage 1 • r/o cerebral event • Facial swelling • Secondary to long prone position Stage 1 • GI bleed • Arrhythmia • Pneumonia • UTI • C-difficile infection

34. Dysphagia • G-tube insertion • Ongoing aspiration with attempts at oral feeds • Palatal fistula • Weak right vocal cords • Will require permanent g-feeds

35. Mr. S. sent to rehab in halo vest for added support to surgical reconstruction • Stage 3 • Done 7 months later to place posterior bone graft to augment anterior fibular graft for further anatomical support • 12 cm length of rib utilized • ENT also repaired palatal fistula at the same time

36. Pre-op CT prior to Stage 3

37. CT Post-op Stage 3 Posterior rib graft

38. CT at 2 yr

39. Overall Course Treatment • Initial hospitalization was 5 1/2 months • Followed by rehab for 5 weeks • Second hospitalization 4 weeks • Seen at regular intervals post-operatively • At 3 year mark (November 2011) remains cancer free • Continues to require g-feeds

40. Conclusion • Aggressive resections required • Curative resection obtainable • Lower complications seen with staged resection • Worse outcome attributable to morbidity of surgery or natural progression of disease • Probably not worth it if local disease cannot be fully controlled • Best outcome if respond to pre-op chemo and radiation • In the end, quality of life is often sacrificed for quantity