Diseases, Disorders information

In the few minutes that remain, I would like to go over some of the less common, but arguably some of the most important features of the differential, share with you what I hope are some clinical pearls that you will find valuable, and just review the current thought on how to treat these things. The first is metastatic disease, and that is something you certainly don’t want to miss in the differential, remembering that figure of 10% presenting with back pain as their first symptom of metastatic disease due to spinal spread. The spine is the most frequent site of metastatic disease, metastatic disease is the most common tumor in the spine. The site of origin is really not significant, virtually all areas will refer to the spine, there are some predilections of different anatomical regions, and it is almost always anterior. You will almost always find the metastases starts in the body and then will proceed to the pedicle or posterior elements. The reasons for that lie in the arrangement of volvulus plexus which provides a perfect one way highway for metastatic disease to the spine following the reasoning of the seed and soil hypothesis. You will see lumbar vertebrae most frequently involved, neurologic involvement, however, is most frequent in thoracic metastases.
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The blood supply to the thoracic spine is not as extensive as cervical or lumbar, so that is far more at risk for neurologic insult with a thoracic fracture, infection, or certainly a metastatic disease, so you are much more likely to see neurologic involvement in the thoracic spine. Most of the primaries come from these five categories, breasts, thyroid, prostate, kidney and then the hematopoietic. Breasts tend to go to cervicothoracic; lungs cervicothoracic; prostate has a predilection for lumbosacral and pelvis; prostate can be identified with a little bit more facility on plain films because that frequently is a blastic lesion, almost all these others are lytic lesions, so if you see something that’s making bone in a male patient in the lumbar spine, thing about a prostatic metastasis. Most of these present with pain, atypical pain, not mechanical pain, but the pain awakens me at night, it is unremitting, it is unresponsive to nonsteroidals, it is unresponsive to narcotics. Neurologic impairments comparatively rare, under 10%. Deformity, actual collapse with kyphosis, spondylolisthesis, scoliosis due to metastatic disease comparatively rare as well. It is also extremely unreliable. If you look in an elderly patient population, the incidents of some wedging or compression deformities, particularly in the setting of osteoporosis is extremely high, so that is a very, very inaccurate way to determine whether or not metastatic disease is present. Pain thought to be due to the enlarging mass within the body, canal encroachment and then of course neurologic issues as well as instability and cord compression.
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We classify this, according to the matter of Harrington and really, there are five different categories as to whether bone is involved, whether the neurologic structure is involved, or both, the most important thing is just to draw a line right here, and that is basically if there is no evidence of collapse. Those patient’s can be treated nonoperatively, usually with radiation therapy. If there is evidence of vertebral collapse with structural problems, or structural problems and collapse with neurologic involvement, those are the patient’s who usually go to surgery assuming that their survivorship justifies that and they have been appropriately staged. Most of surgery for this is anterior, and that is supported in the literature because again, that’s where the problem is, it’s the Willie Sutton principal, why do you rob banks, because that’s where the money is. Why do you go anteriorly, because that’s where the tumor is. You can see someone here with a clear metastatic lesion at L5, this appears to be kind of a pseudoblastic lesion because of the collapse of the L5 vertebral body, you can see posterior expansion into the canal, this is an individual with known breast disease and metastatic disease, in other aspects of the spine, who presented basically with a cauda equina syndrome, and here you can see the collapse on the AP, you can see the posterior extent of the tumor here virtually obliterating what is left of the cauda equina, metastatic disease elsewhere in the spine, very important thing to think of that with skip areas, that is very, very common. If you have one metastasis, it is pretty likely you will have another, and this patient was managed with an anterior and posterior decompression. Unfortunately at L5, there is really no good anterior instrumentation system. We now have a number, we can do everything from the front, but this patient required a fairly gib operation of front and back, removal of the L5 body, there is a fibular strut and then subsequent posterior instrumentation.