1. Malignant Cervical
Spine Tumors
Operative treatment
G. SAPKAS
Professor in Orthopedics
Orthopaedic Department
for
Spinal and Musculoskeletal Disorders
“Metropolitan” Hospital
3. Primary tumorsPrimary tumors
of the spine are rareof the spine are rare
especially of theespecially of the
cervical spine.cervical spine.
However it is quiteHowever it is quite
consideralbeconsideralbe
the incidencethe incidence
of metastasisof metastasis
A.B.CA.B.C
4. Benign tumors of the spineBenign tumors of the spine
The most common benign tumorsThe most common benign tumors
are:are:
– HemangiomaHemangioma
– OsteoblastomaOsteoblastoma
– Giant cell tumorGiant cell tumor
– ChondroblastomaChondroblastoma
– Osteoid osteomaOsteoid osteoma
Their incidence is estimated to beTheir incidence is estimated to be
11% – 14%11% – 14%
A lot of them remain asymptomaticA lot of them remain asymptomatic
and are diagnosed accidentallyand are diagnosed accidentally
Osteochondroma
5. Malignant tumors of the spineMalignant tumors of the spine
(primary and metastatic)(primary and metastatic)
The primary malignant tumors areThe primary malignant tumors are
rare in the spinerare in the spine
The most common are:The most common are:
– OsteosarcomaOsteosarcoma
– ChondroblastomaChondroblastoma
– Ewing’s sarcomaEwing’s sarcoma
– ChordomaChordoma
– LymphomaLymphoma
Ewing’s sarcoma
6. Are the most commonAre the most common
in the spinein the spine
The life expectancyThe life expectancy
contributescontributes
to the increasedto the increased
incidenceincidence
of spinal metastasesof spinal metastases
Breast metatstasis
Metastatic spinal tumorsMetastatic spinal tumors
8. The most common locationThe most common location
for skeletal metastasis:for skeletal metastasis:
• ThoracolumbarThoracolumbar
regionregion ~~ 70%70%
• Lumbar and sacralLumbar and sacral
spinespine ~~ 20%20%
• Cervical spineCervical spine ~~ 10%10%
Gilbert R.W. et al.
Ann. Neural. 1998 Stomach metastasisStomach metastasis
10. PAIN
Is the most
common
symptom related
to the existence
of a primary or
metastatic spinal
tumor
Breast metastasisBreast metastasis
11. The spinal pain may be due:The spinal pain may be due:
In destruction of the anatomicIn destruction of the anatomic
vertebral elements as a resultvertebral elements as a result
of metastasesof metastases
Resulting spinal instabilityResulting spinal instability
The pain is possible to occurThe pain is possible to occur
as a result of compression oras a result of compression or
infiltration of the spinalinfiltration of the spinal
cord – nerves fromcord – nerves from
neoplasmatic masses.neoplasmatic masses.
Stomach metastasisStomach metastasis
26. Factors for evaluationFactors for evaluation::
– The biology of the tumorThe biology of the tumor
– The locationThe location
– The painThe pain
– The neurologic deficitThe neurologic deficit
– The spinal instabilityThe spinal instability
– Life expectancyLife expectancy
– Overall condition of the patientOverall condition of the patient
Aboulafia A. Levine A., OKU Spine 2, 2004
27. 1. Spinal instability
2. Pain resistible to
conservative treatment
(radiotherapy –
chemotherapy)
3. Incomplete neurologic
deficit resistible to any
type of conservative
treatment
4. Rapid deterioration of the
neurologic deficit
Indications for operative treatmentIndications for operative treatment
30. Tomita’s staging classification systemTomita’s staging classification system
for the primary tumors of the spinefor the primary tumors of the spine
Intra-compartmental Extra-compartmental Multiple skip
lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site
(1 or 2 or 3)
Anterior or posterior
Lesion in situ
Site
(1 +2 or 3 + 2)
Extension to pedicle
Site
(1 +2 +r 3)
Anterio-posterior
development
(any site + 4)
Epidural extension
(any site + 5)
Paravertebral
development
Involvement to
adjacent vertbra
Tomita T, et al, Spine 2001
31. ChondrosarcomaChondrosarcoma
The most commonThe most common
malignant tumor ofmalignant tumor of
the bone in thethe bone in the
spinespine
7% - 12% of all7% - 12% of all
spine tumorsspine tumors
M. Riz.
F 41
15-6-1997
34. Tokuhashi
scoring system
Tomita
surgical staging
Karnofsky
performance status
scale definitions
rating (%) criteria
Methods of evaluation
E. Kar.
F 52
4-6-1991
35. Tokuhashi’sTokuhashi’s Evaluation System forEvaluation System for
prognosis of metastatic spinal tumorsprognosis of metastatic spinal tumors
SymptomsSymptoms 00 11 22
General conditionGeneral condition
performance statusperformance status
PoorPoor
(PS 10% to 40%)(PS 10% to 40%)
ModerateModerate
(50% to 70%)(50% to 70%)
GoodGood
(80% to 100%)(80% to 100%)
No of extraspinalNo of extraspinal
skeletal metastasesskeletal metastases
>3>3 1 to 21 to 2 00
Metastases toMetastases to
internal organsinternal organs
UnremovableUnremovable RemovableRemovable No metastasesNo metastases
Primary site of tumorPrimary site of tumor Lung stomachLung stomach Kidney liver uterusKidney liver uterus
unknownunknown
Thyroid prostateThyroid prostate
breast rectumbreast rectum
Number ofNumber of
metastasesmetastases
>3>3 22 11
Spinal cord palsySpinal cord palsy CompleteComplete IncompleteIncomplete NoneNone
Tokuhashi, Y. et al, Spine 1990
Total score versus survival period:
9 to 12 points > 12 months survival
0 to 5 points < 3 months survival
36. These criteria allow the definition of a
pre-operative strategy and therefore
considerable variability in the choice of
treatment ranging:
• excisional operation should be performed
on those who scored above 9 points
• a palliative operation should be performed
on those who scored under 5 points
Tokuhashi Y. et al.
Spine 1990
37. Simpler system of preoperative
evaluation based on only three
parameters:
• the degree of malignacy
• the presence of visceral metastases
• the presence of bony metastases.
Tomita K. et al.
Spine 2001
Bauer H. et al.
Spine 2002
38. Tomita’s classification systemTomita’s classification system
Intra-compartmental Extra-compartmental Multiple skip
lesion
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Site
(1 or 2 or 3)
Anterior or posterior
Lesion in situ
Site
(1 +2 or 3 + 2)
Extension to pedicle
Site
(1 +2 +r 3)
Anterio-posterior
development
(any site + 4)
Epidural extension
(any site + 5)
Paravertebral
development
Involvement to
adjacent vertbra
Tomita T, et al, Spine 2001
39.
40. Palliative treatment, generally
produces modest results, but
contributes greatly to the quality
of life.
Moreover, it is reasonable to use
palliative means when life
expectancy is only:
4 to 15 months.
Wise J.F. et al Spine 1999.
Bouer H. et al. Spine 2002.
Palliative treatmentPalliative treatment
Pneumon’ s metastasis
Posterior
decompression & stabilization
42. Vast majority can be managedVast majority can be managed
with dorsal fixationwith dorsal fixation
Rarely is ventral decompressionRarely is ventral decompression
indicated or necessaryindicated or necessary
Preoperative spinal fracturePreoperative spinal fracture
reduction may be attemptedreduction may be attempted
with awake tractionwith awake traction
Ventral decompression may beVentral decompression may be
indicated to decompressindicated to decompress
significant ventral tumor causingsignificant ventral tumor causing
persistent spinal cordpersistent spinal cord
compressioncompression
Moulopoulos et al, Clin Imaging 1997
Poynton Asley et al, Cancer in the spine, 2006
Atlanto-axial metastaticAtlanto-axial metastatic
spinal tumorsspinal tumors
44. a. Posterior decompression and
Occipitocervical stabilization
b. Post-operative adjuvant
chemotherapy - radiotherapy
N(-)
N(-)
3 yrs pop
A. St
F-84 yrs
14-7-2011
45. Metastastic disease of theMetastastic disease of the
subaxial cervical spine issubaxial cervical spine is
more common than themore common than the
atlanto-axial spineatlanto-axial spine
As with atlanto-axial tumorsAs with atlanto-axial tumors
the majority of the patientsthe majority of the patients
can be managed withcan be managed with
radiation therapyradiation therapy
Sub-axial cervical spineSub-axial cervical spine
metastatic tumorsmetastatic tumors
57. is treated successfully
only by operative
procedure
Spinal instability due to
bone destruction
Breast’s metastasisBreast’s metastasis
C3
58. Prosthetic replacementProsthetic replacement
is indicated in case ofis indicated in case of
vertebral destructionvertebral destruction
at one or twoat one or two
consecutive vertebraeconsecutive vertebrae
Benign spinal tumorsBenign spinal tumors
Malignant primary spinalMalignant primary spinal
tumorstumors
Selected cases ofSelected cases of
metastatic spinal tumorsmetastatic spinal tumors
60. Anterior vertebral replacement andAnterior vertebral replacement and
anterior – posterior stabilizationanterior – posterior stabilization
1. Is indicated
in excessively
unstable spine
and
2. It gives the best
overall results
