1) Malignant cervical spine tumors can be primary tumors of the spine or metastatic tumors that spread from other locations like the lung, breast, or prostate. 2) Primary malignant tumors of the cervical spine are rare but include osteosarcoma, chordoma, and lymphoma. Metastatic tumors to the cervical spine are more common. 3) Clinical symptoms of metastatic spinal tumors include pain, neurologic deficits, and pathologic spinal fractures caused by tumor infiltration or compression of the spinal cord or nerves.

1. Malignant Cervical
Spine Tumors
Operative treatment
G. SAPKAS
Professor in Orthopedics
Orthopaedic Department
for
Spinal and Musculoskeletal Disorders
“Metropolitan” Hospital

2. EpidemiologyEpidemiology
Lung metastasisLung metastasis

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

7. Incidence
SkeletalSkeletal MetastasesMetastases
 Breast 45-85%
 Pneumon 35-60%
 Kidney 35-40%
 Prostate 35-85%
 Thyroid 30-60%

Skull 35%
Cervical spine 22%
Humerus 10%
Ribs 57%
Thoracic spine 37%
Lumbar spine 53%
Sacrum 6%
Pelvis 19%
Femur 22%

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

9. Clinical symptomsClinical symptoms
of spinalof spinal
metastasismetastasis
Pain
Neurologic deficit
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

12. Pathologic spinalPathologic spinal
fracturefracture
Spinal painSpinal pain
InstabilityInstability CompressionCompression
of the neuralof the neural
tissuestissues
NeurologicNeurologic
deficitdeficit
Thyroid metastasis

13. Neurologic deficitNeurologic deficit

14. DiagnosisDiagnosis
ofof
spinal tumorsspinal tumors
Plain x-rays

15. CT - scan

16. 3D

17. M.R.I.

18. SCANNING
Tc 99 MDP

19. P.E.T.P.E.T.

20. C.T. – guided
percutaneous
needle - biopsy
Biopsy of the spine

21. Angiography

22. ManagementManagement
ChemotherapyChemotherapy
Radiation therapyRadiation therapy
SurgerySurgery

23. Pre - radiation Post - radiation
Chordoma
Radiotherapy 60g
(proton therapy)
Courtesy Ath. Dimopoulos (Metropolitan)

24. RadiotherapyRadiotherapy
Stereotactic radio intervention following kyphoplasty
Courtesy Ath. Dimopoulos (Metropolitan)

25. Malignant primary tumorsMalignant primary tumors
of theof the
cervical spinecervical spine

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

28. Enneking’s surgicalEnneking’s surgical
staging classification systemstaging classification system
Enneking, WF et al, Clin Orth, 1980

29. Weinstein-Boriani-BiagniniWeinstein-Boriani-Biagnini
Surgical classification systemSurgical classification system
Weinstein et al, 21st
ISSSL annual meeting 1994

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

33. Metastatic tumorsMetastatic tumors
of theof the
cervical spinecervical spine
Lung metastasisLung metastasis

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

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

41. Surgical procedures

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

43. Breast’s cancer
A. St.
F: 81
N(+)
Mastectomies
35 yrs ago

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

46. El. Za
M 56
14-10-2009
N(+)ve
Pneumon’s
metastasis

48. Anterior procedureAnterior procedure
– CorpectomyCorpectomy
– Vertebral bodyVertebral body
replacement byreplacement by
expandable cage -expandable cage -
Peek E.C.S. (Zimmer)Peek E.C.S. (Zimmer)
– Stabilization with plateStabilization with plate
and screwsand screws
Zephyr (Medtronic)Zephyr (Medtronic)

49. 1st
op.

50. PosteriorPosterior
procedureprocedure
– Cervico thoracicCervico thoracic
levellevel
– StabilizationStabilization

52. ComplicationsComplications
Intra-operative
Postoperative

53. Intra-operativeIntra-operative
complicationscomplications

54. Wound dehiscence
Neurologic deterioration
Implants dislodgement or broken
infections
Post-operative
complications

55. Post-operative
complementary
treatment
Radiation therapy
of spinal metastases
Tombolini Y. et al 1994
Ortho - Athens
Best to start
> 3wks post - op

56. Conclusions:Conclusions:

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

59. Posterior
stabilization is
recommended:
• For multiple
metastases
• Poor general
condition
• Short life
expectancy
Thyroid metastasis

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

61. University Hospital “ATTIKON”