Outcome of Embolized Outcome of Embolized Vascular Metastatic Spinal Vascular Metastatic Spinal

Tumours causing Cord Tumours causing Cord CompressionCompression  

N A Quraishi, FRCS (Tr & Orth), LLMS Purushothamdas, FRCS (Tr & Orth)

R Lenthall , FRCRM P Grevitt , FRCS (Tr & Orth)

Eurospine, Milan Eurospine, Milan 20112011

Centre for Spinal Studies & Surgery Department of RadiologyQueens Medical Centre, Nottingham

BackgroundBackground Vascular metastatic spinal tumours with cord compression have a high Vascular metastatic spinal tumours with cord compression have a high

risk of morbidity & mortalityrisk of morbidity & mortality

Role of pre-operative embolisation is well recognisedRole of pre-operative embolisation is well recognised

Multiple factors (size of tumour, extent of surgical intervention, degree of Multiple factors (size of tumour, extent of surgical intervention, degree of vascularity and extent of embolisation) influence the blood loss and vascularity and extent of embolisation) influence the blood loss and clinical outcomeclinical outcome

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

Study the effect of embolisation of vascular Study the effect of embolisation of vascular metastatic tumours causing spinal cord metastatic tumours causing spinal cord compression and their outcomecompression and their outcome

AimAim

Patient and MethodsPatient and Methods

Retrospective cohort studyRetrospective cohort study Period: January 2004 to September Period: January 2004 to September

20102010 23 patients (14 males : 19 females)23 patients (14 males : 19 females) Average Age 59.2 years (24-78)Average Age 59.2 years (24-78) Follow-up: 7.3 months (3-23.3)Follow-up: 7.3 months (3-23.3) Primary diagnosis: Primary diagnosis:

Renal cell carcinomaRenal cell carcinoma : 21: 21 ParagangliomaParaganglioma : 1: 1 CarcinoidCarcinoid : 1: 1

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

15%

15%

66%

4%

PainNeurologyBothAsymptomatic

Clinical presentationClinical presentation

Most patients presented with both Most patients presented with both pain and deteriorating neurologypain and deteriorating neurology

Operative DetailsOperative Details Ave. blood lossAve. blood loss : 2211 (400-10,000) mls: 2211 (400-10,000) mls Ave. operating timeAve. operating time : 291 (90-840)mins: 291 (90-840)mins Ave. blood transfusionAve. blood transfusion : 3.5 (max.19)units: 3.5 (max.19)units Ave. pre-operative Hb Ave. pre-operative Hb : 12.6 (9.5-16 ) g/dl: 12.6 (9.5-16 ) g/dl Ave. post-operative Hb Ave. post-operative Hb : 9.6 (6.9-14.6) g/dl: 9.6 (6.9-14.6) g/dl

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

Type of surgery

0

2

4

6

8

10

12

14

16

Corpectomy Decom/stabil Debulking

No

. of

pat

ien

ts

Embolisation details Embolisation details (performed by senior interventional (performed by senior interventional

radiologist)radiologist) Endovascular, transarterial; combination of liquid & particulate Endovascular, transarterial; combination of liquid & particulate

agentsagents

Angiography grade: Angiography grade: Grade 0Grade 0 : Normal vascularisation: Normal vascularisation Grade IGrade I : Homogenous blush (normal feeding arteries): Homogenous blush (normal feeding arteries) Grade IIGrade II : Hypervascularisation (dilated feeding : Hypervascularisation (dilated feeding

arteries)arteries) Grade IIIGrade III : Arterio-venous fistula: Arterio-venous fistula

Embolisation grade: Embolisation grade: Not embolisedNot embolised <50% embolisation<50% embolisation 51-90% embolisation51-90% embolisation 90-100% embolisation90-100% embolisation

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

EmbolisationEmbolisation

Grade 0 (Normal vascularisation) 0 (0%)

Grade I (Homogenous blush) 1 (4.4%)

Grade II (Hypervascular) 11 (47.8%)

Grade III (AV fistula) 10 (43.5%)

Angiography grade

0

2

4

6

8

10

12

Grade 0 (Normalvascularisation)

Grade I (Homogenousblush)

Grade II (Hypervascular) Grade III (AV fistula)

No

. o

f p

atie

nts

Embolisation Grade

0

2

4

6

8

10

12

14

16

None <50% 51-90% 91-100%

No

. o

f p

atie

nts

None 4 (17.4%)

<50% 3 (13.1%)

51-90% 4 (17.4%)

91-100% 14(60.9%)

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

Neurological change by Neurological change by Frankel gradesFrankel grades

Change of Frankel Grade

0

2

4

6

8

10

12

No change 1 + 2 + 1 - 2 -

No

. o

f p

atie

nts

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

Neurological status

0

2

4

6

8

10

12

14

A B C D E

Frankel Grade

No

. of

pa

tie

nts

Pre-op

Post-op

Neurological change by Neurological change by Frankel GridFrankel Grid

AAAA00 ABAB00 ACAC00 ADAD00 AEAE00

BABA00 BBBB00 BCBC00 BDBD00 BEBE00

CACA00 CBCB00 CCCC55 CDCD11 CECE11

DADA00 DBDB00 DCDC22 DDDD55 DEDE55

EAEA00 EBEB00 ECEC11 EDED22 EEEE11

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Timing of embolisation to surgery

 Immediate

(n = 10)24 hours

(n=10) p value

Blood loss (mls) 1537.5 2058.3 p = 0.49

Op time (minutes) 261 301 p =0.44

Transfusion (units) 2.6 2.9 p = 0.77

Survival (months) 16.1 16.5 p = 0.97

Extent of embolisation 

>90%(n = 14)

<90%(n=9) p value

Blood loss (mls) 1902.5 2588.9 p = 0.54

Op time (minutes) 236 370 p =0.12

Transfusion (units) 2.6 4.6 p = 0.86

Survival (months) 17.1 14.5 p = 0.71

Complications 9/23, 39.1%Complications 9/23, 39.1%((major: 2/23,8.7%major: 2/23,8.7% ; minor: 7/23, ; minor: 7/23,

30.4%)30.4%)No. of No. of

PatientPatientss

Wound infectionWound infection 11

Urinary retentionUrinary retention 22

Chest infectionChest infection   22

Metal ware failureMetal ware failure   22

SepticaemiaSepticaemia   11

PneumothoraxPneumothorax 11

Centre for Spinal Studies & Surgery, Nottingham www.nottinghamspine.co.uk

ConclusionsConclusions Blood loss remains a major concern in vascular Blood loss remains a major concern in vascular

metastatic spinal tumours with cord metastatic spinal tumours with cord compressioncompression

No statistical significance is observed in amount No statistical significance is observed in amount of blood loss, operation time, blood transfusion of blood loss, operation time, blood transfusion and survival in terms of time of surgery since and survival in terms of time of surgery since embolisation and also extent of embolisationembolisation and also extent of embolisation

Higher complication rate is observed in such Higher complication rate is observed in such tumourstumours

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Financial Disclosure:Financial Disclosure:None of the authors have None of the authors have received from any commercial entity any payments or any pecuniary, in kind, or other professional or personal benefits including stock, honoraria, or royalties (collectively, “Benefits”) or any commitment or agreement to provide such Benefits