The document discusses the approach to spinal metastasis. It begins by noting that the spinal column is a common site for cancerous metastases. It then covers topics like the primary cancer sites that commonly metastasize to the spine, diagnostic testing approaches including imaging and biopsy, and management strategies such as medical treatments, radiotherapy, surgical decompression and stabilization, and pain management. The goal of treatment is largely palliation given the metastatic nature of the disease. Scoring systems can help guide treatment decisions between surgical and non-surgical options based on life expectancy and functional status.
A comprehensive presentation on the epidemiology, pathophysiology, clinical presentation, decision making and treatment options of spinal metastases. Supported with the best available evidence as of October 6, 2008
Presentation on Spinal Metastases Scorng system and Decision making
By
Dr.SHASHIDHAR B K
Bangalore Spine Specialist Clinic
www.spinesurgeonbangalore.com
drshashidharbk@gmail.com
A comprehensive presentation on the epidemiology, pathophysiology, clinical presentation, decision making and treatment options of spinal metastases. Supported with the best available evidence as of October 6, 2008
Presentation on Spinal Metastases Scorng system and Decision making
By
Dr.SHASHIDHAR B K
Bangalore Spine Specialist Clinic
www.spinesurgeonbangalore.com
drshashidharbk@gmail.com
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
Colorado spine surgeon, Dr. Donald Corenman, M.D., D.C. (http://neckandback.com), is an expert in treating spinal cord injuries associated with a traumatic fall, sports related injury or accident. Many spine fractures include a thoracolumbar fracture, which is a break in one or more of the thoracic and lumbar vertebrae. Spine fractures can be very serious but are also treatable in many cases. This presentation on spinal cord injuries, spine fractures and thoracolumbar fractures details events that can lead to this injury, symptoms and treatment options.
Dr. Corenman is a renowned Colorado spine surgeon and also is an expert at all spine conditions and disorders including scoliosis, degenerative disc disease, spinal stenosis, sciatica, herniated disc, slipped disc and spondylolythesis. He is also a sports medicine specialist and treats athletes with traumatic sports related injuries. He recently launched his own website (http://neckandback.com) to educate patients on spine disorders and to offer second opinions to physicians and colleagues who are seeking additional information on specific spine injuries and treatment options.
Pain from acute vertebral fracture appears to be due in part to instability (non-union or slow union at the fracture site), while more than 1/3 of patients become chronically painful.
Traditional treatment for patients with painful VCFs includes bed rest, narcotic analgesics and bracing, resulting in increased pain because of acceleration bone loss and muscle weakness.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
Colorado spine surgeon, Dr. Donald Corenman, M.D., D.C. (http://neckandback.com), is an expert in treating spinal cord injuries associated with a traumatic fall, sports related injury or accident. Many spine fractures include a thoracolumbar fracture, which is a break in one or more of the thoracic and lumbar vertebrae. Spine fractures can be very serious but are also treatable in many cases. This presentation on spinal cord injuries, spine fractures and thoracolumbar fractures details events that can lead to this injury, symptoms and treatment options.
Dr. Corenman is a renowned Colorado spine surgeon and also is an expert at all spine conditions and disorders including scoliosis, degenerative disc disease, spinal stenosis, sciatica, herniated disc, slipped disc and spondylolythesis. He is also a sports medicine specialist and treats athletes with traumatic sports related injuries. He recently launched his own website (http://neckandback.com) to educate patients on spine disorders and to offer second opinions to physicians and colleagues who are seeking additional information on specific spine injuries and treatment options.
Identified in 1921 by James Ewing
2nd most common bone tumor in children
Ewing’s Sarcoma Family of tumors:
Ewing’s sarcoma (Bone –87%)
Extraosseous Ewing’s sarcoma (8%)
Peripheral PNET(5%)
Askin’s tumor
A pathologic fracture is a bone fracture caused by disease that led to weakness of the bone structure. This process is most commonly due to osteoporosis, but may also be due to other pathologies such as: cancer, infection (such as osteomyelitis), inherited bone disorders, or a bone cyst. Only a small number of conditions are commonly responsible for pathological fractures, including osteoporosis, osteomalacia, Paget's disease, osteitis, osteogenesis imperfecta, benign bone tumours and cysts, secondary malignant bone tumours and primary malignant bone tumours
Highly malignant tumor of mesenchymal origin.Spindle shaped cells that produce osteoid.2nd most common primary malignant bone tumor after MM.Incidence – 1 to 3 per million per year
Treated by chemo,amputation or rotationplasty
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Approach To Spinal Metastasis
1. Approach to Spinal Metastasis
by
Nawaz Hussain b Mohd Amir
Spine Unit
Dept. of Orthopaedics
HUSM
8th August 2006
2. Introduction
Bone is a common site for carcinoma metastasis
Approximately 70% of pts with cancer have
evidence of metastasis at the time of their death
Spinal Column is the most common location for
osseous sites for metastatic deposits
Up to 40% of pts with cancer has spinal column
involvement.
3. Introduction
Not all spinal metastasis lead to neurologic
disorder
Spinal cord compression from epidural
metastasis occurs in 5-10 % of cancer pts
10-20% of this will be symptomatic
(25 000 pts a year in US –Klimo and Schmidt-2004)
4. Metastatic spine disease can involve one
of 3 locations
- Vertebral column – 85% - post. half
- Paravertebral region – 10-15%
- Epidural/subarachnoid/intramedullary
space - < 5%
5.
6. Intradural metastasis – extremely rare but
there are reported cases
Multiple level at noncontiguous levels –
10-40%
8. Primary site
Frequency of neurologic deficit secondary to epidural
spinal cord compression varies with the site of primary
disease
- Breast – 22%
- Lung - 15%
- Prostate -10%
Some pts present with neurologic dysfunction and
spinal pain without knowing primary site – in old literature
frequency is up to 70% and 50% of them found to be from
lung
9. Approach
History
i. General / conventional symptoms
- bony pain , back pain ,numbness ,
weakness – bladder / bowel control
- LOA , LOW
ii Specific history
-Breast – past history ,lumps ,pain, similiar family hx
-prostate – past hx , urinary Sx
-lung - past hx , smoking,cough,hemoptysis
- thyroid – past hx, swelling , hyperthyroidism
10. Physical Examination.
ii. General – general condition
- cachexia, anemia , hydration,
nutritional
vi. Potential primary site –
- breast , prostate, lung ,thyroid ,
abdomen ,etc
- lymph nodes
11. Approach…..
P/E……
iii. Full neurological examination
motor , sensory…etc.
13. Ix
Imaging
Plain x-ray
- Bone mets can be purely lytic, blastic ,mixed
i. Most metastasis are predominantly lytic
- lung,kidney,breast,GIT,melanoma
ii Blastic – prostate , bronch. carcinoids,bladder,stomach
iii. Mixed – breast ,lung,GIT
14. Plain X-ray
- In cancellous bone lytic lesion remain occult until it
completely destroys trabaculae and reach 2-3 cm in
diameter. Needs 30 – 50 % of destruction.
- In cortical bone – small lytic lesion can de detected
earlier
15. Plain x-ray
Depends on whether the primary is known or not
I . Primary is known
Asymptomatic – not for skeletal survey
- bone scan is method of choice
- if bone scan positive confine x-ray to
site of localisation
Symptomatic - Localised x-ray , skeletal survey
16. ii. Primary is unknown
- usually has local symptoms
- local x-ray , skeletal survey
During follow ups , course of tumour therapy
17. Ix
Imaging
Bone Scan
- Most sensitive diagnostic tool
- But it gives multiple levels of involvement without
clarifying the level
- All cancer pts regardless primary known ,unknown
- Follow ups
18. Ct scan
-Allows visualization of
i. even small areas of vertebral destruction
ii. Assessment of extent of paravertebral soft tissue
masses
iii. Extent and direction of impingement of spinal cord
by bone debris / tumour
- Limitation – failure to identify second site of mets.
- 10% of pts
19. MRI
Superior in evaluating
iii. soft tissue mass
iv. Neural elements
v. Multiple level of vertebral involvement
Findings – Hypointense T1 , hyperintense in T2 and
gadolinium enhanced T1
20. Biopsy
- Most literature suggest some type e.g ct guided
biopsyof biopsy in order to specify correctly the
type of malignancy
- Even in known primary
- However , here the problem of consent limits
the use of this method in establishing diagnosis
due to its invasiveness .
21. Management
General Mx
Medical Mx / Radiotherapy Mx
Surgical Mx
Pain Mx
22. General Mx.
- Anemia
- Nutritional Status
- Hydrational status
- Supplements
23. Medical Mx
i.Chemotherapy
ii.Hormonal
iii Biphosphonate
24. Chemotherapy
Given as therapeutic and palliative treatment especially in
Breast , lung , Renal cell ca. , prostate(less)
Needs multi disciplinary approach
25. Hormonal
- Breast , prostate and endometrial ca.
- Endocrine dependant organs.
- Regulate and manipulate regulatory hormones as
anti -tumour therapy
26. Biphosphonate
- Inhibit osteoclast-mediated resorption
- Induce osteoclast apoptosis
- Standard treatment in hypercalcemia in malignancy
- Reduces metastatic bone pain esp. clodronate and
pamidronate ( Ernst et al-1992 , Coleman et al -1996)
- Recalcification
27. Radiotherapy
- Pain relief – mode of action not really
understood – reduces tumour bulk,
reduces pain mediator (PG)releasing cells
- Post fixation irradiation
- Prevention of spinal cord compression-
recent vertebral collapse
- Pts with contraindication for surgery
28. Surgical Mx
Mostly Palliative
Indications
iii. Intractable pain unresponsive to non operative
measures
iv. Obvious spinal instability
v. Clinically significant neural compression from
retropulsed bone or spinal instability
vi. Radioresistant tumours
29. Depends on
iii. Pts tolerability to surgery e.g general
medical condition
iv. Estimated life expectancy
30. Goals of Surgery
ii. Correct and prevent deformity by
stabilizing deformity
iii. Decompressing neural structures
iv. Open biopsy if primary unknown
31. Pre-operative prognostic values/scoring
Score = < 5 dies within 3 months
> 9 survives average 12 mths
Surgery = <5 non surgical , > 9 surgical
32.
33. Category iii – grey area , either medical or surgical .
- if there is severe epidural cord compression
non radiosensistive , needs surgery
34. Score
2-3 – wide / marginal for long term survival
4-5 – marginal/intralesional
6-7 – palliative surgery for short term palliation
8-10 – non operative supportive care
35. Surgical approach
Anterior approach
- modern era
- Predominant area of metastasis
- Does not disturb posterior stability in
presence of the kyphosis
- Pain relief in 80 – 95% of pts
- Neurologic improvement in 75% of pts
36. Surgical approach……
Post decompressive laminectomy
- old era
- limited value in regaining neurologic
function
- Laminectomy + radiotx no more
effective than radiotx alone.
37. Anterior –posterior approach
- High grade instability
- Ant and posterior compression
- Contiguous vertebral involvement
- Need for en-bloc resection of tumour
39. VERTEBROPLASTY ( deramound 1990)
- Good stabilisation and analgesia to the
diseased vertebra.
- But must have intact cortex
- Used if contraindicated for surgery eg post
irradiated patient
40. Conclusion
Spine is the most frequent location for skeletal
metastasis
Mode of treatment and can be chosen by using the
many scoring systems(Tokuhashi , Harrington , Tomita
etc) but it must be tailored according to each patient
Advances in imaging and instrumentation allowed
improvements in the techniques of excision of tumour
and stabilisation.
Surgical decision making is a complex issue but the
treatment of spinal mets. remains largely palliative.