Current trends in mini-invasive management of spine metastases

Abstract

The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.

Keywords: CT; MRI; Spinal metastasis; Weinstein–Boriani–Biagini classification; nuclear medicine bone scan; percutaneous mini-invasive procedure; polymethylmethacrylate; radiofrequency; spinal instability; vertebroplasty.

Figure 1.

A 65-year-old male affected by multiple myeloma involving different metamers at thoraco-lumbar level; CT and MRI (a–e) showed a sclerotic reaction of multiple vertebral bodies infiltrated by tumour. VP was performed at T12-L1 segment with good pain relief (f–g). Symptoms were not caused by tumour infiltrations but by biomechanical alteration at T12-L1.

Figure 2.

A 60-year-old female affected by renal carcinoma. MPR-MDCT (a–f) showed lytic metastases involving C1 and C2. VP was performed at C1–C2 levels under general anaesthesia and fluoroscopy guidance by the trans-oral approach (g–p).The lytic lesion involving the left lateral mass of C1 was performed by VP with a direct approach under fluoro-CT control. The post-treatment C1–C2 MPR-MDCT showed complete filling of both lesions without leakage, with vertebral stabilization and pain relief effects.

Figure 2.

A 60-year-old female affected by renal carcinoma. MPR-MDCT (a–f) showed lytic metastases involving C1 and C2. VP was performed at C1–C2 levels under general anaesthesia and fluoroscopy guidance by the trans-oral approach (g–p).The lytic lesion involving the left lateral mass of C1 was performed by VP with a direct approach under fluoro-CT control. The post-treatment C1–C2 MPR-MDCT showed complete filling of both lesions without leakage, with vertebral stabilization and pain relief effects.

Figure 3.

A 69-year-old male affected by lung cancer. CT (a–c) showed a lytic metastases involving the left peduncle/soma of L4 and right soma of L3. RF ablation + VP was performed at L3–L4 with a monopeduncular approach (d–i) with tumour ablation. The post-treatment CT showed a good filling of the lesions without leakage (l--n).