COMPLICATIONS OF SURGICAL TREATMENT OF SPINAL METASTASES

ABSTRACT Objectives: To evaluate the complications of surgical treatment in a group of patients with spinal metastasis with epidural compression, undergoing surgical treatment. Methods: This is a comparative retrospective study (level of evidence III), which evaluated 96 patients with spinal metastases undergoing surgical treatment. Intra- and postoperative complications were obtained from the patients’ medical records and correlated with the following clinical characteristics: tumor type, tumor location, neurological deficit, age, number of affected vertebrae, Tokuhashi scale, Tomita scale, Karnofsky performance scale, and type of approach. Results: Complications of surgical treatment were observed in 29 (30.20%) patients. Surgical wound infection was the most frequent complication, observed in 15% of patients. Conclusions: Surgical treatment of spinal metastases presents complications in about 30% of patients and their occurrence should be considered in the treatment planning, weighing the risks and benefits for achieving the treatment goals. Level III evidence; Retrospective Study.

Correlation of Nogo A release with glia scar formation in spinal cord injury

Several axonal growth inhibitors have already been identified following spinal cord injury, the most known being myelin-derived proteins, such as Nogo-A. The present study aimed to correlate the formation of glial scar with the beginning of growth inhibitor, Nogo-A, release in rats previously submitted to compressive spinal cord injury. For this, 12 male and female Wistar rats (250 ± 50g) were divided into 3 groups of 4 animals each, according to the animals' euthanasia time after spinal cord injury (G3 - three days; G5 - five days; G7 - seven days). Spinal cord injuries were induced by means of dorsal laminectomy of the T10 vertebra and epidural compression. Histopathological evaluation and immunoreactivity of the Nogo-A axonal growth inhibitor were performed. It was observed that there was the release of the axonal inhibitor Nogo-A after 24h after the occurrence of spinal cord injury, and that the glial scar must be maintained, in this time interval, in order to guarantee the rebalancing of the post-trauma environment. Thus, it is suggested that the glial scar should be maintained in the acute phase of the lesion, guaranteeing its numerous benefits for the rebalancing of the post-injured environment and, after 24 hours, when the release of the studied axonal growth inhibitor begins, it should be removed.

UNKNOWN PRIMARY TUMOR SITES IN SPINAL METASTASIS

ABSTRACT Objective: The goal of the study was to report the prevalence of spinal metastasis with unknown primary tumor, clinical features, treatment results and patient survival. Methods: A retrospective evaluation of 103 patients with spinal metastasis and epidural compression, who underwent surgical treatment between March 2009 and August 2015. The prevalence of metastatic spinal tumor with unknown primary tumor was evaluated, as well clinical features, survival and treatment results. Results: Of 103 patients with spinal metastasis and epidural compression, seven patients (6.8%) with unknown primary tumor site were identified; five (71.4%) male and two (28.6%) female, with ages ranging from 37 to 67 years (50.7 years). The metastasis was located in the thoracic spine in six of the patients (85.7%) and in the cervical spine in one (14.3%). The mean survival time was 44.8 days. Conclusion: Spinal metastasis with unknown primary tumor was found in 6.8% of patients. The prognosis and outcomes were poor, and patients had poor survival rates. Level of evidence III; Experimental study.

Epidural compression in infants less than 6 months of life with neuroblastoma: experience of Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology

Neuroblastoma (NB) can manifest through neurological symptoms caused by tumor extension into the spinal canal and the resulting epidural compression (EC). Clinical symptoms and management in patients with epidural compression depend on its level and duration, the severity of spinal cord compression, the patient's age and other factors. One of the biggest challenges is the diagnosis and treatment of EC in infants in the first months of life. Our retrospective analysis included 13 patients with NB complicated by spinal cord EC who had been diagnosed at the age of 0–6 months and treated at the D. Rogachev NMRCPHOI over the period from 01.01.2012 to 01.12.2018 (82 months). The study was approved by the Independent Ethics Committee and the Scientific Council of the D. Rogachev NMRCPHOI of the Ministry of Healthcare of the Russian Federation. The diagnosis of NB was based on the international diagnostic criteria. The tumors were staged in accordance with the INSS classification. The patients were stratified into risk groups and treated according to the modified NB-2004 protocol of the German Oncology Group. All the patients underwent diagnostic testing for neurogenic tumors as well as contrast-enhanced magnetic resonance imaging of the spinal cord with the assessment of the level of tumor invasion and the degree of spinal cord compression. The children were evaluated by a neurologist at admission and at follow-up visits. The median age at diagnosis of NB was 3.9 (0.5–6) months. At disease onset, 53.8% of patients had neurological symptoms, with motor deficiencies being the most common ones. In this group of patients, the median time from first neurological symptoms to diagnosis of NB was 1.56 months. Neurological symptoms at disease onset were not present or diagnosed at local healthcare facilities in 46.2% of infants. Extra-organic retroperitoneal primary tumors were found in 61.6% of patients; 30.7% of primary tumors were located in the posterior mediastinum, and 7.7% of primary tumors – in the lesser pelvis. No patients had MYCN-amplified tumors; in 1 case the MYCN gene status was evaluated as Gain; neither 1p nor 11q deletions were detected. The distribution of patients by INSS stages was as follows: stage 2 – 15.3%, stage 3 – 46.1%, stage 4 – 23.3% and stage 4S – 15.3%. The majority of patients (77.7%) were stratified into an observation group, the remaining patients (23.3%) were allocated to a medium risk group in accordance with the NB-2004 protocol. The level of tumor invasion into the spinal cord canal varied. Tumor invasion at the level of the cervicothoracic spine was observed in 15.4% of patients, at the level of the thoracic spine – in 15.4%, at the level of the thoracolumbar spine – in 46.2%, at the level of the lumbar spine – in 15.4%, and at the level of the sacral spine – in 7.7%. Neurosurgical intervention (laminotomy) was performed in 4 cases (30.7%). In one patient, laminotomy was the only treatment option (chemotherapy was not given). In two patients, neurosurgery was performed because of the deterioration of neurological symptoms caused by the start of the first polychemotherapy (PCHT) cycle. Chemotherapy was carried out in 92.3% patients. The patients from the observation group received 1–3 PCHT cycles (the median number of cycles was 2). Only one patient from the observation group did not receive PCHT. This patient underwent 2 surgeries. Currently, 10/13 (77%) patients are alive, 3/13 (33%) patients are dead (2/3 patients died of therapy-related infectious complications, and 1/3 – of acute heart failure in the early postoperative period). The median follow-up was 37.3 months. According to the assessment of late effects, neurological disorders were found in all the analyzed patients (n = 9), and orthopedic disorders were found in 66.6% (6/9) patients. The results of our analysis illustrate both the difficulty of diagnosis and management of EC in patients with NB and the need¬ for uniform testing and treatment standards with established follow-up and rehabilitation strategies for this group of patients.

A COMPARISON OF THE TOMITA AND TOKUHASHI SCORES IN SPINAL METASTASIS

ABSTRACT Objective To compare Tokuhashi and Tomita scores in patients with epidural spinal metastasis who underwent surgical treatment. Methods A retrospective evaluation of 103 patients with spinal metastasis and epidural compression who underwent surgical treatment. An analysis was performed of agreement between the survival rates observed in the study sample and the survival rate estimated by the Tomita and Tokuhashi scales. Results The overall accuracy was 39.03% for the Tomita scale and 61.75% for the Tokuhashi scale. Fair agreement (0.38 weighted Cohen’s Kappa coefficient) was observed between patient survival and the Tokuhashi score, and slight agreement (0.25 weighted Kappa coefficient) for the Tomita score. The agreement for both scales was higher for patients with less than six months’ survival, with general accuracy of 79.17% for the Tomita and 70.59% for the Tokuhashi scoring system. Conclusion There was fair and slight agreement between the Tokuhashi and Tomita scores with patient survival group. The agreement was higher for patients with less than six months’ survival. Level of evidence III; Comparative retrospective study.