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Metastatic Spinal Cord Compression for Postgraduate Orthopaedic Exams
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Metastatic Spinal Cord Compression for Postgraduate Orthopaedic Exams
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Language: EN.
Segment:0 .
So good evening, everyone, and welcome to our joint webinar with truck this evening, which is on metastatic spinal cord compression. My name is Nicky Evans and I'll be your host for this evening. We have the pleasure of Mr Michael McEwen as our guest lecturer, lecturer.
He's a consultant, spinal surgeon at the Royal National orthopedic hospital and has completed fellowships in Leeds, covering the whole breadth of spinal surgery, as well as fellowships in pediatric and adult spinal deformity and spinal tumor surgery at the Royal National orthopedic hospital. Joining me this evening is Ruth and Hannah from the UK. And our mentors this evening, or Jo and David, so our program this evening is as follows.
We will have the lecture on metastatic spinal cord compression, followed by some MKZ, which we'd like you to complete as soon as possible. Please, and we'll talk through them will then ask the invited questions. So if you have a question during the lecture or afterwards, if you pop it in the chat, we will keep an eye on that and we will ask Mr. McGowan at the end. Will then go on to some cases and some top tips for survivors, and then we will move on to the vyver practice and stop the recording.
If you missed any part of this lecture, don't worry about it. It will be on the Fox mentor website as well as the UK website, so you can watch it at your leisure. Just like to mention that we have the upcoming Viva courses in conjunction with our UK on the 20th of February, 6th of March and the 17th of April. There are upcoming webinars on both the FRCS mentor website, which is farke's mentor, echo UK and the UK website, which is our UK org.
Finally, I'd just like to recommend our books, which are the two books at the bottom from our UK, which I have used both for my exams and they're excellent and obviously the ones written by the FRCS mentors. So Ruth and Hannah will be sending you feedback forms and we'd be grateful if you could fill them in so that we can continue to improve. And if you require a CPD certificate, then get in touch with Ruth and Hannah, and we'll be able to help you out with that as well.
So without any further delays, I'm going to hand you over to Mr McCowan. Thank you. He good evening, everyone. My name is Michael McComb, a consultant, spinal surgery at the Royal National Hospital in stanmore, London. Thank you very much for joining and for inviting me to give this talk.
This evening. So the talk is on metastatic spinal cord compression, which we know is really very common. And you may ask, well, why is this within your curriculum? We'll explore those and we'll discuss exactly why it is in your curriculum. Listen, we'll look at why metastatic spinal cord compression has become very important within orthopedic and spinal surgery.
We'll look at the background to that, discuss some of the NICE guidelines. We'll have a brief discussion of MRI interpretation, which I know you'll probably be very familiar with because that's preparation for your forensics exam. That's one of the key topics we'll discuss some of the patient pathways, how these patients are managed. Some of the evidence which led to where we are today with spinal cord compression.
And then we'll discuss the management strategies, what surgery offers. We'll look at some questions and run through a few cases. And by the end of that, I'm sure you will be bored of me. So why metastatic spinal cord compression? Well, because it is devastating to patients or potentially devastating, and getting it right makes a world of difference to the patients and whether that in terms of their prognosis, but also sometimes it makes a huge difference to the quality of life when they are nearing the end of life, there's a huge difference in someone who retains continents and retains the ability to walk or to transfer.
And the other scenario where the patient loses the ability to walk and loses their continents. So it fits into the spinal red flags. We always talk of spinal reflex, and there are different lists depending on which literature you read, but register MSK is history of cancer often in these patients and the acute neurological deficit. And that can be sensory, motor, or bladder and bowel involvement.
When we look at carcinomas that commonly spread to bone, and I'm sure this comes up in a lot of your preparation for the fast, yes, but we know that breast, lung, thyroid, renal and prostate or the five carcinomas that most commonly spread to boom. It is important to remember that virtually any tumor can spread to bone, and especially the. Don't forget about the tumors, such as lymphoma, plasma, sintoma, myeloma, but any tumor can spread to bone.
And about a third of patients who have breast carcinoma will end up with spinal metastases. Only the liver and the lung are more common site of metastases than the spine, the spine is the most common bone where we'll find metastases and the thoracic spine is the most common region. So if we go back to.
Around 2005 and before metastatic spinal cord compression was not really on the horizon of orthopedic surgery and spinal surgery because these patients all received radiotherapy and steroids. And then there was some evidence to support. Surgery being involved in playing a major role in these patients. And we'll look at that evidence in a short while, but looking at the nice guy, bless these NICE guidelines.
It's a technical guideline. I'm 75, which is published. Now quite some time ago, 12 years ago, but not much has changed. And if we look at. What these guidelines are about, will they talk about metastatic spinal cord compression, which is the cord compression, but also called recliner compression?
This could be either due to direct compression by the tumor. A fracture, a pathological fracture leading to neurological injury of either the spinal cord or the cord recliner. And this threatens or causes neurological disability. We see approximately 4,000 cases each year, and I think that's probably about right at the edge. We get between 5 and 10 referrals a week and not all of those are truly make a lot of them will be, well, this patient's deteriorating.
Would you give us an opinion? But I think there are around 4,000 cases a year in the UK. Often they diagnosed late. And 50% of patients who are diagnosed with MSK are unable to walk in the time of diagnosis, and clearly this leaves them with a poor prognosis if they are walking when they are diagnosed, about 80% will continue walking. So let's briefly just talk about MRI interpretation in the spine.
Well, I'm sure you're very familiar with MRI scans by now. And so if you look at T2 images, so T2 is usually the image that we look at, and what we're really trying to identify is whether the spinal cord within the canal is at risk. And so here you can see that's a normal level. You see the spinal cord surrounded by the CSF, which shows up a lot brighter because this is a T2 image and clearly there is no risk here to the spinal cord.
This patient has a bit of degenerative change, but there is no acute risk to the spinal cord. And if you look at it in an axial view, you can see the spinal cord surrounded by the CSF and the nerve roots leaving into the pheromone at each side. So that's a normal cervical spine MRI with some degenerative change. If you look at the lumbar spine, so remember, the commonest will be around the 2 1 level and that just behind L2 here.
So again, the spinal cord itself is not threatened in any way. There's a good volume of CSF, there is some degenerative change and there is one level, which has severe stenosis and you can see this tenodesis there with a spinal cord. All of this, the quality not being significantly compressed. But this is a degenerative condition. So just to. Highlight the fact that we need to understand what a normal MRI will look like before we see what the pathological MRI will look like.
And that will see, in our case, discussion toward the end of the evening. Of note, metastatic spinal cord compression is managed along AF patient pathway. These patients are managed in a multidisciplinary setting, so that's usually the oncologists as well as the spinal surgeons, and they're managed within a network, and that's very important. Every region has a spinal surgery network, and there should be rapid access for patients into that spinal surgery network, and there's usually very good communication between the oncology service and the spinal surgery service.
And this is from the Royal National orthopedic hospital's website. You don't need to know this patient flow. It's just to give you an idea of the network aspect and the patient pathways that we try to aim for. So if you're going into. The 46 exam metastatic spinal cord compression should be bread and butter.
Question for you, but you want to make it your home run question. You have to know something about the actual paper because this was a landmark paper. This is published in The Lancet Journal in 2005. And this changed the way metastatic spinal cord compression patients are managed. As I mentioned prior to 2005, these patients had radiotherapy and steroids, and they did not really do very well at all.
But the right patch or paper patch is a neurologist. I mean, Kentucky, and this showed that it was a randomized controlled trial. There are around 50 patients in each group. They looked at surgery plus radiotherapy versus radiotherapy and steroids, which was the standard treatment at the time. If you looked at the ability to walk after treatment, the group who had surgery around 84 of them retained the ability to walk in.
They if you read the nuances of the paper, the ability to walk means they could take two steps with or without a walking aid. And so that's not great walking, but it makes a great difference to a patient who's got significant co-morbidities is facing potentially the last phase of their life if they can stand for transfer to take a couple of steps and retain continent. So there was a significant difference.
But what really highlighted it was the walking longevity. If you looked at patients who had surgery, they walked for an average of 122 days after their treatment had been completed. The patients had standard treatment walked for 13 days. That's a huge difference, you know, especially, as I say, the patients facing the last phase of their life. And what happens if the patients can't walk? Of course they are bedridden.
They then more at risk of developing life threatening complications. So the pulmonary embolism, or DVT, keeps urinary tract infections, chest infections, pressure ulcers. All of these lead to earlier demise. Of the patients who came in not able to walk. 62% return to walking had surgery versus 19% who did not have surgery, and then the corticosteroid and opioid use in the patients who had surgery were significantly reduced.
So this paper, the patch or paper, is the one and 0. This is the landmark paper. The study was stopped early because there was such a significant clinical difference, and radiotherapy and steroids alone pretty much disappeared in patients who could qualify for surgical intervention. The other aspects when you go into an exam scenarios, you need to have a few items in your toolbox that you can use.
And as with. Most classification systems and scoring systems, it can be argued that they're not always that clinically useful or they are they practical, do they actually get used in practice and probably most of them. The answer will be no. But you do need to just have some of these items in your toolbox that you can augment your answers with.
And so the Takahashi's score is a prognostic scoring system for spinal metastases, and it looks at the general condition of the patient. So they pay their performance status. It looks at the number of extra spinal makes the number of METs within the virtual body, Mets to the major internal organs, the primary site of cancer and the patient's neurological function. And in this case, the higher the score, the better your expected to do.
So the total score here, a total score of up to eight. Prognosis is estimated at less than six months. Score of 9 to 11. Your prognosis is estimated between 6 and 12 months and a score of 12 to 15. The prognosis is estimated at a year or more in practice. Usually, when these referrals come through, you speak with the oncologist and you take their view. And of course, oncologists are notoriously optimistic about patients, but it's usually more of a clinical discussion consultant to consult and discussion than putting them formally on a Takahashi scoring system.
And one of the reasons for that is especially the options of oncological management continue to expand. And so oncologists will say to you, well, they're there or they've had their first line, but they're still we've got second line, third line, fourth line. And so it's always it's very difficult to accurately predict the prognosis when there are potential options of management. And you know, so that's why it's important to have this as a clinical discussion.
And sometimes patients need a clinical review and an anesthetic review before you can take the final decision as to whether the appropriate surgical candidate, the next scoring system you need to have a working knowledge of is the spinal instability in your plastic score. So the synth score. So this is a disease that tries to identify or determine the tumor related spinal instability. But let's look at the location.
Um, of the lesion, it looks at whether patients have dynamic instability, so mechanical pain. It looks at whether the bone lesion is lytic, mixed or plastic. It looks at the alignment. So acute changes in alignment, essentially whether the patient developed a deformity due to a fracture, so the collapse of the bone. It looks at if there is collapse, how much collapse has there been and then whether the posterior aspect of the spine or involved whether the posterior column is also compromised.
And in this instance? The total score in the higher the score, the worse it is, the higher scores predict instability and you know, the score of 7 or more, you should consider surgical intervention. Laser shot. So all patients with neurological compromise or threatened neurological compromise should be formally documented on an aged chart, and this is within the spinal unit.
This is usually done as standard. Sometimes the physiotherapists are excellent at doing this and other times you know it's a medical examination. But whoever does it, patients need to be documented on an Asia Chart prior. So on admission usually. And then at any point when you think that there may be a delay to surgery or to be definitive treatment and then following surgery, they should also be documented in the editorial because you want to understand whether your intervention as at worst not been detrimental to the patient.
And hopefully there'll be either plateauing or an improvement in patients symptoms. So back to the nice guidelines, what are the key priorities for implementation? Well, it's really the service configuration and the urgency of treatment. So that's why it is. It is a multi-disciplinary approach and rapid access into networks.
And so every oncology unit will have a good working relationship with their spinal surgery network and refer these patients in and. The next aspect is early detection, so these patients present with symptoms and the oncologists are usually very good at patients now get a lot of information through the oncologists. And so we are seeing a better.
The information reaching patients and then presenting earlier to the oncologist, but that's not always the case. The ideal is for early access back to their oncologist. Rapid evaluation and then appropriate referral, if needed imaging. So these patients should all have whole spine MRI scans. Interestingly, most oncology units, just because of the demands in the MRI scanner, they'll probably only do they'll do sagittal T2 image, probably do a sagittal T1 weighted image, and they may do a stereo image as well.
They don't always give you, they don't very rarely give you axilo unless they spot something in the scanner. So a lot of patients who present with potential lesions within the spine and where there's a concern regarding MSK will have essentially what is a sort of whole spine scan, which is a sagittal image and not a complete scan. But that's fine. If that's the local decision, that's OK.
The treatment of spinal metastases. The risk this, we look on. We look into shortly, but this is really the rapid access, rapid access within the spinal surgery networks and following their surgery, these patients need to have supportive care rehabilitation, whether that is rehabilitation to a spinal cord injuries center, if they have a persistent neurological deficit, whether it's return back to the oncologist for the ongoing pharmacological management to potentially radiotherapy, chemotherapy or social care.
So treatment of mark, if you look at the pain aspect, these patients, you first need to manage their pain and that's analgesia, which can either just be simple analgesia, according to your letter. Sometimes there needs to be some pain management. Bisphosphonates can be very useful in patients who have myeloma or breast cancer. Only use it in prostate cancer if regular analgesia fails.
And this is to both reduce the pain and to decrease the risk of fracture. Radiotherapy can be very effective for non mechanical pain. But radiotherapy should not be given if patients are asymptomatic. This is due to the fact that radiotherapy will essentially kill the burn and kill the surrounding tissue, and it potentially then limits your options of future surgical intervention.
What about vertebral plastic cups, a vertebra plastic defect, plastic, which you're probably are familiar with, but that's essentially injecting cement into the vertebral body to provide stability and safe mechanical pain is a problem due to vertebral body metastatic disease. Then the vertebral plastic can be very useful if the patients are resistant to analgesia or if they've had a fracture.
And then, of course, we get on to surgery, which aims to stabilize the spine so that the patients are suitable for surgery and can stabilize the spine, and that should reduce their overall pain. If the spinal cord is threatened, they should be nursed in bed with spinal precautions until you have a definitive plan. Corticosteroids should be started. So who should receive them?
Well, all patients should receive dexamethasone, usually a 16 milligrams loading dose and then 16 milligrams daily, and that is continued until there is a definitive treatment either decision or the treatment has taken place. If the patient's having radiotherapy, you continue with the dexamethasone, because they're going to still have some swelling around and within the spinal cord if they have surgery.
Once you've appropriately decompress the spine, you can consider them stopping or at least weaning. The dexamethasone and the treatment decision is really made on whether the spine is then stable, potentially unstable or unstable. And this is we often have most units will have a pro forma which you complete and what they really the treating team want to in their referring hospital is, is the spine stable?
Is it potentially unstable or is unstable? If it's stable, they can mobilize the patient if it's potentially unstable. What are you going to do to make it stable? Is that a brace when the patients are mobilizing so that they can normally put it on when they in a sitting position and they can mobilize? Or is it unstable enough? It's unstable.
Generally, you have to stabilize it surgically. But if the patients are too unwell to have surgery, then they might have to wear a brace. Or you can look at a halo jacket or a CT also something like that. So the brace destabilize the spine. Surgery for me. So if a patient is referred. And they have.
Proven spinal metastatic spinal cord compression on an MRI scan. They should be considered for surgery. The only exceptions are really if they. As we discussed with the fact is that if their general performance status is prayer, if their physiology is that poor, that the oncologists say will their prognosis is expected to be less than three months. As always, they've got associated medical co-morbidities where the anesthetist says no way is this patient fit for an anesthetic.
If you decide to perform surgery, it should be within 24 hours. You should take samples for histology. Most of them will have his proven histology, but it's always good practice to take appropriate samples for histology. They should have staging done now. Normally that will be done by the oncology team. So that's just the pelvis CT.
Some of them will have they would have had pet scans, they would have had appropriate MRI scans, they would have had their blood investigations, they would have had all the appropriate staging investigations. But it's about liaising with the oncologists to ensure that. That has taken place. And then it's a formal assessment, these patients, usually it's best to get them across and for them to be evaluated formally in the unit where they can have their surgery.
It is a balance because you don't want to have a wasted journey, you don't want to bring a patient across who is never going to be fit for an operation, but sometimes you can only take that decision. Having met the patient and. Giving the patient the opportunity with the appropriate information to make a decision as to whether they believe surgery is the right option for them.
And it's a combined decision. As we mentioned, it's a multidisciplinary approach, but always at the center of that decision is the patient because these are difficult, difficult decisions and they come at very stressful times for the patient and for the family, especially at the moment with the COVID restrictions. It's horrendous for these patients to be in the situation where they don't have supportive family accompanying them.
It is really difficult time, but the patient has to always be at the center of making the decision. And some patients will rightly say, well, you know, I I've had enough, I don't want surgery, and if they have capacity and they know what they're choosing with all the information, that's fine, but they should have the opportunity to make that decision. And then when you assess them, you're looking at their neurological function, their general function, their general health, what treatment they've previously had.
Clearly, if they've previously had radiotherapy to the same area that comes into play, it doesn't necessarily mean you can't operate on them. But you know that they're going to be wound problems because the surrounding zone of tissue is dead. The magnitude of surgeries, these patients need to understand the scale of surgery. You know, sometimes it's a relatively straightforward procedure, but other times it's not.
If you're doing anterior and posterior approach, the magnitude of surgery and the morbidity that comes with it and the increased length of hospital stay potentially is something that needs to be considered carefully the risks associated with surgery and then the prognosis. And as I've mentioned, surgery should only be offered to patients when the expectation is that they will survive for more than three months.
What about the goals of surgical, the goals of surgery or to decompress the spinal cord or cord recliner and provide stability if there is complete loss of neurological function for more than 24 hours? You should only offer surgery if the stabilization is needed for pain relief. But I would say this isn't set in stone. You know, I think if there is an opportunity to operate on a patient and it's 30 hours down the line, you know, I think we should consider that strongly.
You know, I wouldn't stick to this rigorously. You want to achieve a wide decompression and debunking of the tumor. You're not going for an en bloc resection. You want to achieve stabilization. And if there is a involvement, you want to inform reinforce the virtual body, and that may be by putting some cement and PMMA cement in the front.
It may be by using a cage or really a bone graft, but it's usually PMMA cement or a cage. And there's just one question about the role of soul mate role. Nowadays, it's a steroid called methylprednisolone. So are you using it routinely for spinal cord compression, metastatic spinal cord compression, or you're relying to other steroids or none? So as far as I know, we are only using dexamethasone.
I've not seen them come through on different steroids. That decision is usually made. The oncologists are pretty good at this. I mean, they often start patients on steroids before they've even got the MRI and know they've got a patient that's got no spinal met comes in with deteriorating neurology. They'll start the patient on steroids. And as far as I've, I've only seen them use dexamethasone and then scan the patient and then refer the patient on.
So that decision is usually made at the referring institution. Yeah, totally agree. And what is the criteria to diagnose a threatened spinal cord? So treating spinal cord is someone who has pain, so so no spinal metastases, and there is canal compromise on an MRI scan. So but neurological function is still intact.
So that's what is meant by a threatened spinal cord to the spinal cord is actually being compressed. So there is no compression due to metastatic lesion, but the neurological function is still intact and these are the best patients to act quickly on because if you get it right, these patients will retain their neurological function. And so that's what's meant by threatened spinal cord. Yes and for the oncologist to walk out workup.
Do you prefer your own institute? Institute oncologist or you can accept the referrals the referring hospital's oncologist if they have one. We accept any oncologists referral. So I think the, you know, the workup we really for MSK management. So this is not primary bone tumors that we're discussing. So for NSCLC, we really are supporting the oncologists in their management of these patients.
You know, so so our services is really there to provide support when it is needed because they seeing thousands of these patients and a number of them will end up needing our support. But we really support them and are happy for them to take the lead in the overall management. And then it's a consultant consultant discussion, usually as to whether the patient is appropriate. And we also do, you know, when pay, when referrals come through.
They were discussed in a multidisciplinary team meeting so that the orange, for instance, we would discuss these patients every day. We have an M.D. team. And so these patients would be discussed in the MDT. And then it's usually, you know, a lot of patients would be we would acknowledge that they have metastatic disease, but they don't have significant cannot compromise the spinal cord or cord requirement not being compressed.
It's more a decision on the spinal stability and then we feed that back to them. But it's sometimes, you know, the almost always, I should say, is that the best decision is made when you've come up with a recommendation and you get on the phone and you speak to the oncologist directly. Yep, I totally agree, sir. And for well, there is three questions, mostly with the same meaning.
So first is trauma the same as metastatic spinal cord compression? Do you use dexamethasone is not trauma? And is there any guidelines in using dexamethasone in trauma, as well as the metastatic spinal cord compression? So in the UK practice, we do not use any steroids in trauma.
So there's no good evidence to use steroids in trauma in us practice. That probably differs. My understanding is that they do use steroids, but in UK practice, we do not use steroids in trauma in spinal cord injuries. Yeah, thank you. And when consenting for potential complications, what are you highlighting and the frequency they occur?
OK, so the firstly, the main benefit of surgery to highlight to the patient is to try and preserve what they currently have, and they need to understand that it's not. They mustn't make the decision on surgery because of potential improvement in their neurological function. The primary goal is to retain what they have. The secondary goal is to give the spinal cord the best chance.
Of recovery, if there is going to be any recovery. And the third goal is to provide stability. And so when I look at what are the risks, then so that no one risk will be ongoing neurological deficit. There could be a deterioration of the neurological function, which could be either due to an injury at the time of the surgery or due to an evolving spinal cord injury. And then the other risks are the same as for any spinal surgical procedure, so it will be a general risk, such as infection.
Blood clots. The blood clots, especially if they're not going to be mobilizing for infection. Blood clots, bleeding and to some of these tumors can bleed quite a lot. So I always said bleeding, potentially life threatening bleeding. Specifically with this surgery, it's nerve injury, spinal cord injury, non-union failure of metalwork so screws can cut out.
Rods can break, especially if they're going to have radiotherapy where this is unlikely to ever unite. So nonunion is a big risk wound breakdown, especially in the presence of a site which has had radiotherapy. All potentially will have radiotherapy quite soon after. And then the other risks are additional injury because you're doing a decompression, so you're working against the residual injury recurrence of tumor anesthetic related risks and the risk to life.
And I think that encompasses most of the risks that I would discuss with patients having this operation. What I also discussed with them is the implication of surgery and what impact will it have on them, I say. So most patients, if they come to us walking, the expectation is that within five days they will leave hospital back to their referring unit. If they come to us bedbound. That probably a bit more complicated because that recovery is going to be a bit longer.
When you have a good working relationship with the oncology unit, though, the ideal situation is to fix them, send so they come to you, they have their surgery, and as soon as the acute risks dissipate, you send them back for them to have their ongoing systemic management because then your job is done due to agree. And if there is established paralysis over 24 hours and there is no instability, but the life expectancy is over 4 months, will you still do any surgery for it?
So they completely paralyzed. Yes, no instability, no instability and long life expectancy. Well, would you still decompress? No, it's a difficult one. I think these decisions are individualized. You know, this is where you have the discussion with the oncologist and and sometimes where it warrants, you know, face to face discussion with the patient because it depends on, you know, as an oncologist, I'm notoriously optimistic with their life expectancy.
And if it's genuinely a patient who's on first line therapy, or maybe it's a first time, it's an initial diagnosis. We don't have a histologic diagnosis. Those are factors that come into play. And then you could take the view that doing an operation to decompress the spine, you know, if it's 26 hours, that's probably different from if it's two weeks. The patient's been completely paralyzed with two weeks.
So that comes into play. You can get good samples, you can stabilize the spine. Is it an isolated metastatic lesion or their multiple metastatic lesions? You know, what's the overall burden of disease for the patient? So all these factors come into play, but often that sort of scenario. I always think you try and give the patient the benefit of the doubt.
And if there is a chance of making a bit of difference to the patient because the truth is that not all patients will present, it's not a Black and white scenario, you know, some patients will present with some retention of function. Continence is another big aspect, you know, so there may be parallels. But if they've got even just bladder continents, it makes a huge difference to these patients to try and retain continents.
Thank you. And would you recommend embolization before operation to Metz of renal cell carcinoma? That's a very, very good question. So if you look at the evidence, the only tumor that strongly advised to use embolization is renal cell carcinoma, and so almost always we would aim to embarrass a patient who has no renal cell carcinoma.
And when you look at the evidence, it probably makes about a 50% difference in terms of the blood loss and the need for transfusion. But I was looking at some of the evidence recently, and I must say it's not conclusive. It's not conclusive. But in UK practice, we probably do embolization, if not all in almost all patients with renal cell carcinoma. Thank you.
Thank you very much, I think that's all. You either answer directly or indirectly by answering the questions. Thank you very much. Yeah, thank you so much. I really enjoyed that lecture. It brings back some memories of me, vyver and Joe. I think the classification systems Takahashi's score, we did, didn't we?
So and I think it was really important. The way that you kind of, you know, emphasize the MDT role and the importance of, you know, involving the patient and their family in their treatment, you know, because it's a really lovely way of dealing with it. And you know, I suggest to the people that are listening, that's the kind of approach and the kind of manner that you want to have when you get asked a question like this in your vivas.
So if you weren't paying attention to that side of it, watch it again, because I think that's really important. So Ruth tells me that we are going to do the MCU's next, and then we'll move on to some cases just in case discussion. Sorry, first, and then we'll move on to IVUS so we can all answer as quickly as you can. It's all anonymous and then we can carry on. With the interesting cases, very much the majority of people managed to complete this right.
So question number one. Reut pexels paper was a randomized controlled trial. Choose the incorrect statement. This is just to emphasize again, right paper. You know, if you do take that away from tonight, because that's if you mention that you're getting onto your, then doing it fast. Yes so no one is compared to the standard radiotherapy on steroids versus surgery plus radiotherapy.
Yes, that's right. It was stopped early due to clear superiority in the group having surgery. Yes, that's right. Patients treated with surgery retained walking ability for a median 122 days. Yes, that's right. That was compared to 13 days in the group who had the standard radiotherapy plus steroids.
The surgery group required higher doses of opiate analgesia. No, they didn't. So that that's the incorrect statement. So the surgery group did not require higher doses of either opioid analgesia or steroids. And finally, there was no excess mortality morbidity due to surgery. That's correct, actually, the surgery.
Interestingly, the patients did not spend longer in hospital and they had no excess mortality or morbidity reported. Question number two, which type of surgery is not appropriate for MSK due to vertebral body tumor pressure decompression stabilization with screws and rods that almost always what you would do posterior decompression without stabilization?
That is the correct answer because in the question, says metastatic lesion in the vertebral body. So when the vertebral body is involved, a.t. And I think, you know, if you can. In my spine model, but you know, it's a vertical body is involved. So if you imagine that there's a compromise to the structure AD and you then go and do a posterior decompression at the back, you don't have to do relatively wide decompression, so you take away the facet joint.
So you've now disrupted the posterior column and you then compromise the stability of the spine, which is why you should not generally, you should not do that without stabilization. And the other answers are correct to post here decompression and stabilization with screws and rods, plus vertebral body augmentation with Mason cement that would be very reasonable to do to stage decompression instrumented stabilization.
It can be an appropriate approach as well. So the majority of. The delegates who responded got that correct. So question number three, patients who have MSK due to the following tumor should not have steroids. And again, the majority of the delegates responding. Got that, got that right.
So even in lymphoma, if there is CC so metastatic spinal cord compression, they should have steroids. So well done there, everyone gets a case number one. The 78-year-old male patient he presents to his oncology team with a two week history of deteriorating walking. He uses two sticks.
He has known prostate cancer. He's he's between first and second line treatment. It's not the most reliable patient, but I believe his initial diagnosis was about two to three years before this presentation. So he's referred with the MRI scans that we can see. So there's such a tool and an axial T2 image. This is of the thoracic spine and the top of the lumbar spine.
What you can see is that he's got multiple vertebrae that have some infiltration. But the main focus of the problem is in the thoracic spine. He has a significant canal infiltration of the tumour, and the spinal cord is significantly compromised. You can see the spinal cord above and below the tumour, and you can see cerebrospinal fluid above and below.
When you look at it, an axial view, you can see the spinal cord is completely surrounded by tumor, which has extended into the canal. And the tumor you can see is it has eroded through the posterior wall of the virtual body into the canal. So one of the aspects I wanted to highlight to you is when I trained one of the radiologists in Leeds. It always talked about good disks of bad news and bad disks of good news.
And so what does that mean? Well? if the disk is preserved, as you see here. It really is cancer authorities to preserve it, most commonly is cancer. It really is infection. If the disks are destroyed, it most commonly is infection and really is cancer. The only real.
The only condition that doesn't fit into that is tuberculosis, because tuberculosis will preserve the disks. But but you know, it's an infection. And what does that mean? So if it's good disks of bad news, if the disks look good, it's bad news because it's likely to be cancer. If the disks are bad, so bad disks are good news because it's likely to be infection and likely to get better.
So this has all the features of an aggressive lesion, and this is all features of aggression in a patient with known prostate cancer. This is almost certainly a metastatic lesion, and he has metastatic spinal cord compression. So this patient got across, I saw him. He was actually, not surprisingly, you often are surprised to me as he was walking quite well using his two sticks.
He was continent. And so he was a good surgical candidate. But this is the operation that I did for him. So this is a view under the microscope that superior and that's the inferior. And so this is the canal has been cleared out now. You can see the deer are coming through. And I've done a lot of not a very wide decompression, but it's a reasonable decompression.
The court actually looked quite nice and healthy of just pulsating and just additional stability. So one level up, one level down because I did not destroy the facet joints. He did. He did really well. He was discharged back to the oncologist. Three days later, he retained the ability to walk. You retained his continence and he went on to have radiotherapy.
Any questions on case number one? OK, I'll move on to case number two, and then I think you're probably I think there is. A question, OK. Did you have a CT scan to plan surgery beforehand? That's a very good question, actually. In this case, we did have a CT scan and that raises a very good point.
So ideally you should have a CT scan. It's not always the case, though, but ideally you should have a CT scan. And often these patients have had CT scans not too long ago because it's part of their surveillance, imaging and prostate cancer. This this is a sclerotic lesion. It's a plastic lesion. And so it's there wasn't a big concern for stability.
And that's the other reason why you can get away with short fixation. So you can just do one level up, one level down because you revert back to your typekit, your son's scoring. This would be, you know, this is a plastic lesion. It wouldn't be. It won't be very unstable. It's it's a stable lesion. But in this case, we did have a recent CT scan.
You mostly do, but not always. But if you do need it for surgical planning, then by all means obtain it. Thank you. And you did only a posterior decompression, I presume that it is because it's a sclerotic lesion more than osteolytic lesion that. Yeah, and he was going to have radiotherapy, and they thought that this would be quite radiosensitive.
So I did go reasonably wide around the lateral recesses. But it's always a balance, you know, in a patient who has. Who has quite good neurologist neurological function. There's always a risk in doing more. You know, it's a balance you want to achieve a decent decompression. But you know, going around the spinal cord at this level, you have to go quite wide because you can't.
It's not like cord recliner level where you can retract the dura. So at the cord level, you have to go around, you've got to be very careful around the cord. And so it's a balance, you know, to have gotten a to it. From the posterior side, I would have had to take the facet joint, gone quite wide to access the vertebral body. And that would be that's a very reasonable approach.
And if someone had an evolving neurological function that has lost their neurological function, I'd probably be more aggressive with my decompression. But in this case, I need a posterior. Thank you. And do you have do you decide when to start the radiotherapy or is it the oncologist? That's usually a combined decision. Normally you want the wound to be healed, and so it's typically a minimum of three, you know, probably six weeks if possible.
But it depends on the burden of disease. And you know, that's normally a discussion. But ideally, you want the wound to be healed because if they give radiotherapy to a wound which has not healed and it breaks down, it's a disaster. Then it's never going to heal. And you're looking at plastic surgery flaps, which you sometimes have to get.
But it's just never a good result. This case is inviting more and more questions, actually. And is there any criteria for surgery versus radiotherapy? Sort of criteria for surgery versus radiotherapy therapy. I think this is decision making and whether or not there is any compression. Is that correct? Yeah, well, he had said, if you look at I mean.
So he is losing neurological function, he's walking have been deteriorating over a period of about two weeks. He's definitely got significant disease within the central canal. And so if you look at Roy petrol's paper, which admittedly is not a huge series, you know, there's not a great deal to support that or to dispute it, but that's the best evidence we have.
If you only do radiotherapy to this patient, almost certainly his outcome will be worse. Yeah and so adding surgery is definitely the right option here. And did you take a biopsy during the. I always said biopsies. So it's more than a biopsy. Usually, you know, you get a lot of tumor. You just follow the tumor and send it away.
Yeah, and is that the open door policy? I don't think so, is it? Obviously, this is just this. This is a lemon at the back of the spine. Thank you. That's that's all the questions, I think. Yeah so the last case, I'm going to run through is a testament to 63-year-old male patient. So this is a slightly different scenario, so he's bedbound, his left leg at ground zero motive power, his right leg is greed, one motive power.
He was still continent, although he had been categorized just because of his mobility. But he did have bladder sensation. And this is prostate. So he'd been bed bound for about 48 hours by the time he came to see me. And so we took the view that is 63-year-old male, the oncologists felt he still had his prognosis was pretty good.
He had a few lines of treatment left and mainly because of the continent. Um, I decided to operate on him, and you can see on the axilo vessel on the sagittal view, that's significant degenerative change in his cervical spine, but the spinal cord is OK and the main area is here. This is a metastatic lesion in the thoracic spine with significant encroachment into the canal.
And if you look at it so it doesn't look too bad on the sagittal, it looks like there is CSF there. But if you look at it on the axilo, you can see again, it comes in at like this curtain sign almost. It sort of comes in surrounding the spinal cord and spinal cord is significantly threatened here. It's not only threatened here, it has lost neurological function. And so I proceeded to operate.
And on this occasion, the surgery was a bit more extensive because he had lost neurological function, and the aim here was to do a wide decompression. So what you can see is that the superior that's inferior to wide leg connectome, the spinal cord is under the dura here. These are the nerve roots coming out to the facet. Joints have been taken.
And I went anterior to the spinal cord in this zone, compressed it down, got as much tumor as possible and then achieve the anterior decompression. And when three levels up three levels down to provide stability. He did not improve, but he retained his continence. And so, you know, I think that's what you often have to accept in these patients.
OK, that's great, thank you so much, Michael, I hope that was. Hope you guys find that really useful because that's the kind of stuff you will get in the exams. So I think that we are going to move on to the vivas now, so I will stop recording.
Segment:0 .
So good evening, everyone, and welcome to our joint webinar with truck this evening, which is on metastatic spinal cord compression. My name is Nicky Evans and I'll be your host for this evening. We have the pleasure of Mr Michael McEwen as our guest lecturer, lecturer.
He's a consultant, spinal surgeon at the Royal National orthopedic hospital and has completed fellowships in Leeds, covering the whole breadth of spinal surgery, as well as fellowships in pediatric and adult spinal deformity and spinal tumor surgery at the Royal National orthopedic hospital. Joining me this evening is Ruth and Hannah from the UK. And our mentors this evening, or Jo and David, so our program this evening is as follows.
We will have the lecture on metastatic spinal cord compression, followed by some MKZ, which we'd like you to complete as soon as possible. Please, and we'll talk through them will then ask the invited questions. So if you have a question during the lecture or afterwards, if you pop it in the chat, we will keep an eye on that and we will ask Mr. McGowan at the end. Will then go on to some cases and some top tips for survivors, and then we will move on to the vyver practice and stop the recording.
If you missed any part of this lecture, don't worry about it. It will be on the Fox mentor website as well as the UK website, so you can watch it at your leisure. Just like to mention that we have the upcoming Viva courses in conjunction with our UK on the 20th of February, 6th of March and the 17th of April. There are upcoming webinars on both the FRCS mentor website, which is farke's mentor, echo UK and the UK website, which is our UK org.
Finally, I'd just like to recommend our books, which are the two books at the bottom from our UK, which I have used both for my exams and they're excellent and obviously the ones written by the FRCS mentors. So Ruth and Hannah will be sending you feedback forms and we'd be grateful if you could fill them in so that we can continue to improve. And if you require a CPD certificate, then get in touch with Ruth and Hannah, and we'll be able to help you out with that as well.
So without any further delays, I'm going to hand you over to Mr McCowan. Thank you. He good evening, everyone. My name is Michael McComb, a consultant, spinal surgery at the Royal National Hospital in stanmore, London. Thank you very much for joining and for inviting me to give this talk.
This evening. So the talk is on metastatic spinal cord compression, which we know is really very common. And you may ask, well, why is this within your curriculum? We'll explore those and we'll discuss exactly why it is in your curriculum. Listen, we'll look at why metastatic spinal cord compression has become very important within orthopedic and spinal surgery.
We'll look at the background to that, discuss some of the NICE guidelines. We'll have a brief discussion of MRI interpretation, which I know you'll probably be very familiar with because that's preparation for your forensics exam. That's one of the key topics we'll discuss some of the patient pathways, how these patients are managed. Some of the evidence which led to where we are today with spinal cord compression.
And then we'll discuss the management strategies, what surgery offers. We'll look at some questions and run through a few cases. And by the end of that, I'm sure you will be bored of me. So why metastatic spinal cord compression? Well, because it is devastating to patients or potentially devastating, and getting it right makes a world of difference to the patients and whether that in terms of their prognosis, but also sometimes it makes a huge difference to the quality of life when they are nearing the end of life, there's a huge difference in someone who retains continents and retains the ability to walk or to transfer.
And the other scenario where the patient loses the ability to walk and loses their continents. So it fits into the spinal red flags. We always talk of spinal reflex, and there are different lists depending on which literature you read, but register MSK is history of cancer often in these patients and the acute neurological deficit. And that can be sensory, motor, or bladder and bowel involvement.
When we look at carcinomas that commonly spread to bone, and I'm sure this comes up in a lot of your preparation for the fast, yes, but we know that breast, lung, thyroid, renal and prostate or the five carcinomas that most commonly spread to boom. It is important to remember that virtually any tumor can spread to bone, and especially the. Don't forget about the tumors, such as lymphoma, plasma, sintoma, myeloma, but any tumor can spread to bone.
And about a third of patients who have breast carcinoma will end up with spinal metastases. Only the liver and the lung are more common site of metastases than the spine, the spine is the most common bone where we'll find metastases and the thoracic spine is the most common region. So if we go back to.
Around 2005 and before metastatic spinal cord compression was not really on the horizon of orthopedic surgery and spinal surgery because these patients all received radiotherapy and steroids. And then there was some evidence to support. Surgery being involved in playing a major role in these patients. And we'll look at that evidence in a short while, but looking at the nice guy, bless these NICE guidelines.
It's a technical guideline. I'm 75, which is published. Now quite some time ago, 12 years ago, but not much has changed. And if we look at. What these guidelines are about, will they talk about metastatic spinal cord compression, which is the cord compression, but also called recliner compression?
This could be either due to direct compression by the tumor. A fracture, a pathological fracture leading to neurological injury of either the spinal cord or the cord recliner. And this threatens or causes neurological disability. We see approximately 4,000 cases each year, and I think that's probably about right at the edge. We get between 5 and 10 referrals a week and not all of those are truly make a lot of them will be, well, this patient's deteriorating.
Would you give us an opinion? But I think there are around 4,000 cases a year in the UK. Often they diagnosed late. And 50% of patients who are diagnosed with MSK are unable to walk in the time of diagnosis, and clearly this leaves them with a poor prognosis if they are walking when they are diagnosed, about 80% will continue walking. So let's briefly just talk about MRI interpretation in the spine.
Well, I'm sure you're very familiar with MRI scans by now. And so if you look at T2 images, so T2 is usually the image that we look at, and what we're really trying to identify is whether the spinal cord within the canal is at risk. And so here you can see that's a normal level. You see the spinal cord surrounded by the CSF, which shows up a lot brighter because this is a T2 image and clearly there is no risk here to the spinal cord.
This patient has a bit of degenerative change, but there is no acute risk to the spinal cord. And if you look at it in an axial view, you can see the spinal cord surrounded by the CSF and the nerve roots leaving into the pheromone at each side. So that's a normal cervical spine MRI with some degenerative change. If you look at the lumbar spine, so remember, the commonest will be around the 2 1 level and that just behind L2 here.
So again, the spinal cord itself is not threatened in any way. There's a good volume of CSF, there is some degenerative change and there is one level, which has severe stenosis and you can see this tenodesis there with a spinal cord. All of this, the quality not being significantly compressed. But this is a degenerative condition. So just to. Highlight the fact that we need to understand what a normal MRI will look like before we see what the pathological MRI will look like.
And that will see, in our case, discussion toward the end of the evening. Of note, metastatic spinal cord compression is managed along AF patient pathway. These patients are managed in a multidisciplinary setting, so that's usually the oncologists as well as the spinal surgeons, and they're managed within a network, and that's very important. Every region has a spinal surgery network, and there should be rapid access for patients into that spinal surgery network, and there's usually very good communication between the oncology service and the spinal surgery service.
And this is from the Royal National orthopedic hospital's website. You don't need to know this patient flow. It's just to give you an idea of the network aspect and the patient pathways that we try to aim for. So if you're going into. The 46 exam metastatic spinal cord compression should be bread and butter.
Question for you, but you want to make it your home run question. You have to know something about the actual paper because this was a landmark paper. This is published in The Lancet Journal in 2005. And this changed the way metastatic spinal cord compression patients are managed. As I mentioned prior to 2005, these patients had radiotherapy and steroids, and they did not really do very well at all.
But the right patch or paper patch is a neurologist. I mean, Kentucky, and this showed that it was a randomized controlled trial. There are around 50 patients in each group. They looked at surgery plus radiotherapy versus radiotherapy and steroids, which was the standard treatment at the time. If you looked at the ability to walk after treatment, the group who had surgery around 84 of them retained the ability to walk in.
They if you read the nuances of the paper, the ability to walk means they could take two steps with or without a walking aid. And so that's not great walking, but it makes a great difference to a patient who's got significant co-morbidities is facing potentially the last phase of their life if they can stand for transfer to take a couple of steps and retain continent. So there was a significant difference.
But what really highlighted it was the walking longevity. If you looked at patients who had surgery, they walked for an average of 122 days after their treatment had been completed. The patients had standard treatment walked for 13 days. That's a huge difference, you know, especially, as I say, the patients facing the last phase of their life. And what happens if the patients can't walk? Of course they are bedridden.
They then more at risk of developing life threatening complications. So the pulmonary embolism, or DVT, keeps urinary tract infections, chest infections, pressure ulcers. All of these lead to earlier demise. Of the patients who came in not able to walk. 62% return to walking had surgery versus 19% who did not have surgery, and then the corticosteroid and opioid use in the patients who had surgery were significantly reduced.
So this paper, the patch or paper, is the one and 0. This is the landmark paper. The study was stopped early because there was such a significant clinical difference, and radiotherapy and steroids alone pretty much disappeared in patients who could qualify for surgical intervention. The other aspects when you go into an exam scenarios, you need to have a few items in your toolbox that you can use.
And as with. Most classification systems and scoring systems, it can be argued that they're not always that clinically useful or they are they practical, do they actually get used in practice and probably most of them. The answer will be no. But you do need to just have some of these items in your toolbox that you can augment your answers with.
And so the Takahashi's score is a prognostic scoring system for spinal metastases, and it looks at the general condition of the patient. So they pay their performance status. It looks at the number of extra spinal makes the number of METs within the virtual body, Mets to the major internal organs, the primary site of cancer and the patient's neurological function. And in this case, the higher the score, the better your expected to do.
So the total score here, a total score of up to eight. Prognosis is estimated at less than six months. Score of 9 to 11. Your prognosis is estimated between 6 and 12 months and a score of 12 to 15. The prognosis is estimated at a year or more in practice. Usually, when these referrals come through, you speak with the oncologist and you take their view. And of course, oncologists are notoriously optimistic about patients, but it's usually more of a clinical discussion consultant to consult and discussion than putting them formally on a Takahashi scoring system.
And one of the reasons for that is especially the options of oncological management continue to expand. And so oncologists will say to you, well, they're there or they've had their first line, but they're still we've got second line, third line, fourth line. And so it's always it's very difficult to accurately predict the prognosis when there are potential options of management. And you know, so that's why it's important to have this as a clinical discussion.
And sometimes patients need a clinical review and an anesthetic review before you can take the final decision as to whether the appropriate surgical candidate, the next scoring system you need to have a working knowledge of is the spinal instability in your plastic score. So the synth score. So this is a disease that tries to identify or determine the tumor related spinal instability. But let's look at the location.
Um, of the lesion, it looks at whether patients have dynamic instability, so mechanical pain. It looks at whether the bone lesion is lytic, mixed or plastic. It looks at the alignment. So acute changes in alignment, essentially whether the patient developed a deformity due to a fracture, so the collapse of the bone. It looks at if there is collapse, how much collapse has there been and then whether the posterior aspect of the spine or involved whether the posterior column is also compromised.
And in this instance? The total score in the higher the score, the worse it is, the higher scores predict instability and you know, the score of 7 or more, you should consider surgical intervention. Laser shot. So all patients with neurological compromise or threatened neurological compromise should be formally documented on an aged chart, and this is within the spinal unit.
This is usually done as standard. Sometimes the physiotherapists are excellent at doing this and other times you know it's a medical examination. But whoever does it, patients need to be documented on an Asia Chart prior. So on admission usually. And then at any point when you think that there may be a delay to surgery or to be definitive treatment and then following surgery, they should also be documented in the editorial because you want to understand whether your intervention as at worst not been detrimental to the patient.
And hopefully there'll be either plateauing or an improvement in patients symptoms. So back to the nice guidelines, what are the key priorities for implementation? Well, it's really the service configuration and the urgency of treatment. So that's why it is. It is a multi-disciplinary approach and rapid access into networks.
And so every oncology unit will have a good working relationship with their spinal surgery network and refer these patients in and. The next aspect is early detection, so these patients present with symptoms and the oncologists are usually very good at patients now get a lot of information through the oncologists. And so we are seeing a better.
The information reaching patients and then presenting earlier to the oncologist, but that's not always the case. The ideal is for early access back to their oncologist. Rapid evaluation and then appropriate referral, if needed imaging. So these patients should all have whole spine MRI scans. Interestingly, most oncology units, just because of the demands in the MRI scanner, they'll probably only do they'll do sagittal T2 image, probably do a sagittal T1 weighted image, and they may do a stereo image as well.
They don't always give you, they don't very rarely give you axilo unless they spot something in the scanner. So a lot of patients who present with potential lesions within the spine and where there's a concern regarding MSK will have essentially what is a sort of whole spine scan, which is a sagittal image and not a complete scan. But that's fine. If that's the local decision, that's OK.
The treatment of spinal metastases. The risk this, we look on. We look into shortly, but this is really the rapid access, rapid access within the spinal surgery networks and following their surgery, these patients need to have supportive care rehabilitation, whether that is rehabilitation to a spinal cord injuries center, if they have a persistent neurological deficit, whether it's return back to the oncologist for the ongoing pharmacological management to potentially radiotherapy, chemotherapy or social care.
So treatment of mark, if you look at the pain aspect, these patients, you first need to manage their pain and that's analgesia, which can either just be simple analgesia, according to your letter. Sometimes there needs to be some pain management. Bisphosphonates can be very useful in patients who have myeloma or breast cancer. Only use it in prostate cancer if regular analgesia fails.
And this is to both reduce the pain and to decrease the risk of fracture. Radiotherapy can be very effective for non mechanical pain. But radiotherapy should not be given if patients are asymptomatic. This is due to the fact that radiotherapy will essentially kill the burn and kill the surrounding tissue, and it potentially then limits your options of future surgical intervention.
What about vertebral plastic cups, a vertebra plastic defect, plastic, which you're probably are familiar with, but that's essentially injecting cement into the vertebral body to provide stability and safe mechanical pain is a problem due to vertebral body metastatic disease. Then the vertebral plastic can be very useful if the patients are resistant to analgesia or if they've had a fracture.
And then, of course, we get on to surgery, which aims to stabilize the spine so that the patients are suitable for surgery and can stabilize the spine, and that should reduce their overall pain. If the spinal cord is threatened, they should be nursed in bed with spinal precautions until you have a definitive plan. Corticosteroids should be started. So who should receive them?
Well, all patients should receive dexamethasone, usually a 16 milligrams loading dose and then 16 milligrams daily, and that is continued until there is a definitive treatment either decision or the treatment has taken place. If the patient's having radiotherapy, you continue with the dexamethasone, because they're going to still have some swelling around and within the spinal cord if they have surgery.
Once you've appropriately decompress the spine, you can consider them stopping or at least weaning. The dexamethasone and the treatment decision is really made on whether the spine is then stable, potentially unstable or unstable. And this is we often have most units will have a pro forma which you complete and what they really the treating team want to in their referring hospital is, is the spine stable?
Is it potentially unstable or is unstable? If it's stable, they can mobilize the patient if it's potentially unstable. What are you going to do to make it stable? Is that a brace when the patients are mobilizing so that they can normally put it on when they in a sitting position and they can mobilize? Or is it unstable enough? It's unstable.
Generally, you have to stabilize it surgically. But if the patients are too unwell to have surgery, then they might have to wear a brace. Or you can look at a halo jacket or a CT also something like that. So the brace destabilize the spine. Surgery for me. So if a patient is referred. And they have.
Proven spinal metastatic spinal cord compression on an MRI scan. They should be considered for surgery. The only exceptions are really if they. As we discussed with the fact is that if their general performance status is prayer, if their physiology is that poor, that the oncologists say will their prognosis is expected to be less than three months. As always, they've got associated medical co-morbidities where the anesthetist says no way is this patient fit for an anesthetic.
If you decide to perform surgery, it should be within 24 hours. You should take samples for histology. Most of them will have his proven histology, but it's always good practice to take appropriate samples for histology. They should have staging done now. Normally that will be done by the oncology team. So that's just the pelvis CT.
Some of them will have they would have had pet scans, they would have had appropriate MRI scans, they would have had their blood investigations, they would have had all the appropriate staging investigations. But it's about liaising with the oncologists to ensure that. That has taken place. And then it's a formal assessment, these patients, usually it's best to get them across and for them to be evaluated formally in the unit where they can have their surgery.
It is a balance because you don't want to have a wasted journey, you don't want to bring a patient across who is never going to be fit for an operation, but sometimes you can only take that decision. Having met the patient and. Giving the patient the opportunity with the appropriate information to make a decision as to whether they believe surgery is the right option for them.
And it's a combined decision. As we mentioned, it's a multidisciplinary approach, but always at the center of that decision is the patient because these are difficult, difficult decisions and they come at very stressful times for the patient and for the family, especially at the moment with the COVID restrictions. It's horrendous for these patients to be in the situation where they don't have supportive family accompanying them.
It is really difficult time, but the patient has to always be at the center of making the decision. And some patients will rightly say, well, you know, I I've had enough, I don't want surgery, and if they have capacity and they know what they're choosing with all the information, that's fine, but they should have the opportunity to make that decision. And then when you assess them, you're looking at their neurological function, their general function, their general health, what treatment they've previously had.
Clearly, if they've previously had radiotherapy to the same area that comes into play, it doesn't necessarily mean you can't operate on them. But you know that they're going to be wound problems because the surrounding zone of tissue is dead. The magnitude of surgeries, these patients need to understand the scale of surgery. You know, sometimes it's a relatively straightforward procedure, but other times it's not.
If you're doing anterior and posterior approach, the magnitude of surgery and the morbidity that comes with it and the increased length of hospital stay potentially is something that needs to be considered carefully the risks associated with surgery and then the prognosis. And as I've mentioned, surgery should only be offered to patients when the expectation is that they will survive for more than three months.
What about the goals of surgical, the goals of surgery or to decompress the spinal cord or cord recliner and provide stability if there is complete loss of neurological function for more than 24 hours? You should only offer surgery if the stabilization is needed for pain relief. But I would say this isn't set in stone. You know, I think if there is an opportunity to operate on a patient and it's 30 hours down the line, you know, I think we should consider that strongly.
You know, I wouldn't stick to this rigorously. You want to achieve a wide decompression and debunking of the tumor. You're not going for an en bloc resection. You want to achieve stabilization. And if there is a involvement, you want to inform reinforce the virtual body, and that may be by putting some cement and PMMA cement in the front.
It may be by using a cage or really a bone graft, but it's usually PMMA cement or a cage. And there's just one question about the role of soul mate role. Nowadays, it's a steroid called methylprednisolone. So are you using it routinely for spinal cord compression, metastatic spinal cord compression, or you're relying to other steroids or none? So as far as I know, we are only using dexamethasone.
I've not seen them come through on different steroids. That decision is usually made. The oncologists are pretty good at this. I mean, they often start patients on steroids before they've even got the MRI and know they've got a patient that's got no spinal met comes in with deteriorating neurology. They'll start the patient on steroids. And as far as I've, I've only seen them use dexamethasone and then scan the patient and then refer the patient on.
So that decision is usually made at the referring institution. Yeah, totally agree. And what is the criteria to diagnose a threatened spinal cord? So treating spinal cord is someone who has pain, so so no spinal metastases, and there is canal compromise on an MRI scan. So but neurological function is still intact.
So that's what is meant by a threatened spinal cord to the spinal cord is actually being compressed. So there is no compression due to metastatic lesion, but the neurological function is still intact and these are the best patients to act quickly on because if you get it right, these patients will retain their neurological function. And so that's what's meant by threatened spinal cord. Yes and for the oncologist to walk out workup.
Do you prefer your own institute? Institute oncologist or you can accept the referrals the referring hospital's oncologist if they have one. We accept any oncologists referral. So I think the, you know, the workup we really for MSK management. So this is not primary bone tumors that we're discussing. So for NSCLC, we really are supporting the oncologists in their management of these patients.
You know, so so our services is really there to provide support when it is needed because they seeing thousands of these patients and a number of them will end up needing our support. But we really support them and are happy for them to take the lead in the overall management. And then it's a consultant consultant discussion, usually as to whether the patient is appropriate. And we also do, you know, when pay, when referrals come through.
They were discussed in a multidisciplinary team meeting so that the orange, for instance, we would discuss these patients every day. We have an M.D. team. And so these patients would be discussed in the MDT. And then it's usually, you know, a lot of patients would be we would acknowledge that they have metastatic disease, but they don't have significant cannot compromise the spinal cord or cord requirement not being compressed.
It's more a decision on the spinal stability and then we feed that back to them. But it's sometimes, you know, the almost always, I should say, is that the best decision is made when you've come up with a recommendation and you get on the phone and you speak to the oncologist directly. Yep, I totally agree, sir. And for well, there is three questions, mostly with the same meaning.
So first is trauma the same as metastatic spinal cord compression? Do you use dexamethasone is not trauma? And is there any guidelines in using dexamethasone in trauma, as well as the metastatic spinal cord compression? So in the UK practice, we do not use any steroids in trauma.
So there's no good evidence to use steroids in trauma in us practice. That probably differs. My understanding is that they do use steroids, but in UK practice, we do not use steroids in trauma in spinal cord injuries. Yeah, thank you. And when consenting for potential complications, what are you highlighting and the frequency they occur?
OK, so the firstly, the main benefit of surgery to highlight to the patient is to try and preserve what they currently have, and they need to understand that it's not. They mustn't make the decision on surgery because of potential improvement in their neurological function. The primary goal is to retain what they have. The secondary goal is to give the spinal cord the best chance.
Of recovery, if there is going to be any recovery. And the third goal is to provide stability. And so when I look at what are the risks, then so that no one risk will be ongoing neurological deficit. There could be a deterioration of the neurological function, which could be either due to an injury at the time of the surgery or due to an evolving spinal cord injury. And then the other risks are the same as for any spinal surgical procedure, so it will be a general risk, such as infection.
Blood clots. The blood clots, especially if they're not going to be mobilizing for infection. Blood clots, bleeding and to some of these tumors can bleed quite a lot. So I always said bleeding, potentially life threatening bleeding. Specifically with this surgery, it's nerve injury, spinal cord injury, non-union failure of metalwork so screws can cut out.
Rods can break, especially if they're going to have radiotherapy where this is unlikely to ever unite. So nonunion is a big risk wound breakdown, especially in the presence of a site which has had radiotherapy. All potentially will have radiotherapy quite soon after. And then the other risks are additional injury because you're doing a decompression, so you're working against the residual injury recurrence of tumor anesthetic related risks and the risk to life.
And I think that encompasses most of the risks that I would discuss with patients having this operation. What I also discussed with them is the implication of surgery and what impact will it have on them, I say. So most patients, if they come to us walking, the expectation is that within five days they will leave hospital back to their referring unit. If they come to us bedbound. That probably a bit more complicated because that recovery is going to be a bit longer.
When you have a good working relationship with the oncology unit, though, the ideal situation is to fix them, send so they come to you, they have their surgery, and as soon as the acute risks dissipate, you send them back for them to have their ongoing systemic management because then your job is done due to agree. And if there is established paralysis over 24 hours and there is no instability, but the life expectancy is over 4 months, will you still do any surgery for it?
So they completely paralyzed. Yes, no instability, no instability and long life expectancy. Well, would you still decompress? No, it's a difficult one. I think these decisions are individualized. You know, this is where you have the discussion with the oncologist and and sometimes where it warrants, you know, face to face discussion with the patient because it depends on, you know, as an oncologist, I'm notoriously optimistic with their life expectancy.
And if it's genuinely a patient who's on first line therapy, or maybe it's a first time, it's an initial diagnosis. We don't have a histologic diagnosis. Those are factors that come into play. And then you could take the view that doing an operation to decompress the spine, you know, if it's 26 hours, that's probably different from if it's two weeks. The patient's been completely paralyzed with two weeks.
So that comes into play. You can get good samples, you can stabilize the spine. Is it an isolated metastatic lesion or their multiple metastatic lesions? You know, what's the overall burden of disease for the patient? So all these factors come into play, but often that sort of scenario. I always think you try and give the patient the benefit of the doubt.
And if there is a chance of making a bit of difference to the patient because the truth is that not all patients will present, it's not a Black and white scenario, you know, some patients will present with some retention of function. Continence is another big aspect, you know, so there may be parallels. But if they've got even just bladder continents, it makes a huge difference to these patients to try and retain continents.
Thank you. And would you recommend embolization before operation to Metz of renal cell carcinoma? That's a very, very good question. So if you look at the evidence, the only tumor that strongly advised to use embolization is renal cell carcinoma, and so almost always we would aim to embarrass a patient who has no renal cell carcinoma.
And when you look at the evidence, it probably makes about a 50% difference in terms of the blood loss and the need for transfusion. But I was looking at some of the evidence recently, and I must say it's not conclusive. It's not conclusive. But in UK practice, we probably do embolization, if not all in almost all patients with renal cell carcinoma. Thank you.
Thank you very much, I think that's all. You either answer directly or indirectly by answering the questions. Thank you very much. Yeah, thank you so much. I really enjoyed that lecture. It brings back some memories of me, vyver and Joe. I think the classification systems Takahashi's score, we did, didn't we?
So and I think it was really important. The way that you kind of, you know, emphasize the MDT role and the importance of, you know, involving the patient and their family in their treatment, you know, because it's a really lovely way of dealing with it. And you know, I suggest to the people that are listening, that's the kind of approach and the kind of manner that you want to have when you get asked a question like this in your vivas.
So if you weren't paying attention to that side of it, watch it again, because I think that's really important. So Ruth tells me that we are going to do the MCU's next, and then we'll move on to some cases just in case discussion. Sorry, first, and then we'll move on to IVUS so we can all answer as quickly as you can. It's all anonymous and then we can carry on. With the interesting cases, very much the majority of people managed to complete this right.
So question number one. Reut pexels paper was a randomized controlled trial. Choose the incorrect statement. This is just to emphasize again, right paper. You know, if you do take that away from tonight, because that's if you mention that you're getting onto your, then doing it fast. Yes so no one is compared to the standard radiotherapy on steroids versus surgery plus radiotherapy.
Yes, that's right. It was stopped early due to clear superiority in the group having surgery. Yes, that's right. Patients treated with surgery retained walking ability for a median 122 days. Yes, that's right. That was compared to 13 days in the group who had the standard radiotherapy plus steroids.
The surgery group required higher doses of opiate analgesia. No, they didn't. So that that's the incorrect statement. So the surgery group did not require higher doses of either opioid analgesia or steroids. And finally, there was no excess mortality morbidity due to surgery. That's correct, actually, the surgery.
Interestingly, the patients did not spend longer in hospital and they had no excess mortality or morbidity reported. Question number two, which type of surgery is not appropriate for MSK due to vertebral body tumor pressure decompression stabilization with screws and rods that almost always what you would do posterior decompression without stabilization?
That is the correct answer because in the question, says metastatic lesion in the vertebral body. So when the vertebral body is involved, a.t. And I think, you know, if you can. In my spine model, but you know, it's a vertical body is involved. So if you imagine that there's a compromise to the structure AD and you then go and do a posterior decompression at the back, you don't have to do relatively wide decompression, so you take away the facet joint.
So you've now disrupted the posterior column and you then compromise the stability of the spine, which is why you should not generally, you should not do that without stabilization. And the other answers are correct to post here decompression and stabilization with screws and rods, plus vertebral body augmentation with Mason cement that would be very reasonable to do to stage decompression instrumented stabilization.
It can be an appropriate approach as well. So the majority of. The delegates who responded got that correct. So question number three, patients who have MSK due to the following tumor should not have steroids. And again, the majority of the delegates responding. Got that, got that right.
So even in lymphoma, if there is CC so metastatic spinal cord compression, they should have steroids. So well done there, everyone gets a case number one. The 78-year-old male patient he presents to his oncology team with a two week history of deteriorating walking. He uses two sticks.
He has known prostate cancer. He's he's between first and second line treatment. It's not the most reliable patient, but I believe his initial diagnosis was about two to three years before this presentation. So he's referred with the MRI scans that we can see. So there's such a tool and an axial T2 image. This is of the thoracic spine and the top of the lumbar spine.
What you can see is that he's got multiple vertebrae that have some infiltration. But the main focus of the problem is in the thoracic spine. He has a significant canal infiltration of the tumour, and the spinal cord is significantly compromised. You can see the spinal cord above and below the tumour, and you can see cerebrospinal fluid above and below.
When you look at it, an axial view, you can see the spinal cord is completely surrounded by tumor, which has extended into the canal. And the tumor you can see is it has eroded through the posterior wall of the virtual body into the canal. So one of the aspects I wanted to highlight to you is when I trained one of the radiologists in Leeds. It always talked about good disks of bad news and bad disks of good news.
And so what does that mean? Well? if the disk is preserved, as you see here. It really is cancer authorities to preserve it, most commonly is cancer. It really is infection. If the disks are destroyed, it most commonly is infection and really is cancer. The only real.
The only condition that doesn't fit into that is tuberculosis, because tuberculosis will preserve the disks. But but you know, it's an infection. And what does that mean? So if it's good disks of bad news, if the disks look good, it's bad news because it's likely to be cancer. If the disks are bad, so bad disks are good news because it's likely to be infection and likely to get better.
So this has all the features of an aggressive lesion, and this is all features of aggression in a patient with known prostate cancer. This is almost certainly a metastatic lesion, and he has metastatic spinal cord compression. So this patient got across, I saw him. He was actually, not surprisingly, you often are surprised to me as he was walking quite well using his two sticks.
He was continent. And so he was a good surgical candidate. But this is the operation that I did for him. So this is a view under the microscope that superior and that's the inferior. And so this is the canal has been cleared out now. You can see the deer are coming through. And I've done a lot of not a very wide decompression, but it's a reasonable decompression.
The court actually looked quite nice and healthy of just pulsating and just additional stability. So one level up, one level down because I did not destroy the facet joints. He did. He did really well. He was discharged back to the oncologist. Three days later, he retained the ability to walk. You retained his continence and he went on to have radiotherapy.
Any questions on case number one? OK, I'll move on to case number two, and then I think you're probably I think there is. A question, OK. Did you have a CT scan to plan surgery beforehand? That's a very good question, actually. In this case, we did have a CT scan and that raises a very good point.
So ideally you should have a CT scan. It's not always the case, though, but ideally you should have a CT scan. And often these patients have had CT scans not too long ago because it's part of their surveillance, imaging and prostate cancer. This this is a sclerotic lesion. It's a plastic lesion. And so it's there wasn't a big concern for stability.
And that's the other reason why you can get away with short fixation. So you can just do one level up, one level down because you revert back to your typekit, your son's scoring. This would be, you know, this is a plastic lesion. It wouldn't be. It won't be very unstable. It's it's a stable lesion. But in this case, we did have a recent CT scan.
You mostly do, but not always. But if you do need it for surgical planning, then by all means obtain it. Thank you. And you did only a posterior decompression, I presume that it is because it's a sclerotic lesion more than osteolytic lesion that. Yeah, and he was going to have radiotherapy, and they thought that this would be quite radiosensitive.
So I did go reasonably wide around the lateral recesses. But it's always a balance, you know, in a patient who has. Who has quite good neurologist neurological function. There's always a risk in doing more. You know, it's a balance you want to achieve a decent decompression. But you know, going around the spinal cord at this level, you have to go quite wide because you can't.
It's not like cord recliner level where you can retract the dura. So at the cord level, you have to go around, you've got to be very careful around the cord. And so it's a balance, you know, to have gotten a to it. From the posterior side, I would have had to take the facet joint, gone quite wide to access the vertebral body. And that would be that's a very reasonable approach.
And if someone had an evolving neurological function that has lost their neurological function, I'd probably be more aggressive with my decompression. But in this case, I need a posterior. Thank you. And do you have do you decide when to start the radiotherapy or is it the oncologist? That's usually a combined decision. Normally you want the wound to be healed, and so it's typically a minimum of three, you know, probably six weeks if possible.
But it depends on the burden of disease. And you know, that's normally a discussion. But ideally, you want the wound to be healed because if they give radiotherapy to a wound which has not healed and it breaks down, it's a disaster. Then it's never going to heal. And you're looking at plastic surgery flaps, which you sometimes have to get.
But it's just never a good result. This case is inviting more and more questions, actually. And is there any criteria for surgery versus radiotherapy? Sort of criteria for surgery versus radiotherapy therapy. I think this is decision making and whether or not there is any compression. Is that correct? Yeah, well, he had said, if you look at I mean.
So he is losing neurological function, he's walking have been deteriorating over a period of about two weeks. He's definitely got significant disease within the central canal. And so if you look at Roy petrol's paper, which admittedly is not a huge series, you know, there's not a great deal to support that or to dispute it, but that's the best evidence we have.
If you only do radiotherapy to this patient, almost certainly his outcome will be worse. Yeah and so adding surgery is definitely the right option here. And did you take a biopsy during the. I always said biopsies. So it's more than a biopsy. Usually, you know, you get a lot of tumor. You just follow the tumor and send it away.
Yeah, and is that the open door policy? I don't think so, is it? Obviously, this is just this. This is a lemon at the back of the spine. Thank you. That's that's all the questions, I think. Yeah so the last case, I'm going to run through is a testament to 63-year-old male patient. So this is a slightly different scenario, so he's bedbound, his left leg at ground zero motive power, his right leg is greed, one motive power.
He was still continent, although he had been categorized just because of his mobility. But he did have bladder sensation. And this is prostate. So he'd been bed bound for about 48 hours by the time he came to see me. And so we took the view that is 63-year-old male, the oncologists felt he still had his prognosis was pretty good.
He had a few lines of treatment left and mainly because of the continent. Um, I decided to operate on him, and you can see on the axilo vessel on the sagittal view, that's significant degenerative change in his cervical spine, but the spinal cord is OK and the main area is here. This is a metastatic lesion in the thoracic spine with significant encroachment into the canal.
And if you look at it so it doesn't look too bad on the sagittal, it looks like there is CSF there. But if you look at it on the axilo, you can see again, it comes in at like this curtain sign almost. It sort of comes in surrounding the spinal cord and spinal cord is significantly threatened here. It's not only threatened here, it has lost neurological function. And so I proceeded to operate.
And on this occasion, the surgery was a bit more extensive because he had lost neurological function, and the aim here was to do a wide decompression. So what you can see is that the superior that's inferior to wide leg connectome, the spinal cord is under the dura here. These are the nerve roots coming out to the facet. Joints have been taken.
And I went anterior to the spinal cord in this zone, compressed it down, got as much tumor as possible and then achieve the anterior decompression. And when three levels up three levels down to provide stability. He did not improve, but he retained his continence. And so, you know, I think that's what you often have to accept in these patients.
OK, that's great, thank you so much, Michael, I hope that was. Hope you guys find that really useful because that's the kind of stuff you will get in the exams. So I think that we are going to move on to the vivas now, so I will stop recording.
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