Updates in the Management of Metastatic Spine Disease.

The number of cancer diagnoses continues to increase each year in the United States, and given the propensity for bone metastases from solid organ malignancies, orthopaedic spine surgeons will inevitably encounter patients with metastatic spine disease and need to have a framework for approaching the evaluation and treatment of these complex patients. Many patients seeking care for spinal metastases already have a history of disseminated malignancy, but metastatic spine disease itself will be the presenting symptom of cancer in approximately 20% of patients. Because the first presentation of cancer may be to a spine surgeon, an appropriate strategy for the initial evaluation of a patient with a new spinal lesion is critical to establish the diagnosis of metastatic disease before undergoing treatment. Once the diagnosis of metastatic spine disease is confirmed, decisions regarding treatment should be made in coordination with a multidisciplinary team including radiation oncology and medical oncology. Spinal metastases are most often treated with radiation therapy. Direct circumferential decompression of the spinal cord with postoperative radiation therapy is considered for high-grade epidural spinal cord compression to preserve neurologic function. Mechanical spinal instability is another potential indication for surgery. When considering surgery, the patient's medical fitness, systemic burden of cancer, and overall prognosis all must be accounted for, and the importance of multidisciplinary evaluation and shared decision making cannot be overstated.

Preoperative Embolization of Metastatic Spinal Cord Compression with n-Butyl Cyanoacrylate: Safety and Effectiveness in Limiting Blood Loss.

PURPOSE: To evaluate the safety and effectiveness of preoperative embolization with n-butyl cyanoacrylate (nBCA) performed for metastatic spinal cord compression (MSCC) in limiting blood loss (BL). MATERIALS AND METHODS: In this institutional review board-approved retrospective study, clinical records from 2017 to 2022 were reviewed. Twenty consecutive patients (11 men and 9 women; mean age, 65.8 years ± 10.0; range, 45-82 years) underwent 21 preoperative spine tumor embolizations with nBCA. Angiograms were used to calculate the percentage reduction in tumor vascularity, and relevant clinical data (levels studied and embolized, fluoroscopy time [FT], reference dose [RD], and Kerma area product [KAP]) and operative data (BL and operative time [OT]) were analyzed. Adverse events and outcomes were recorded. RESULTS: A median of 2 levels were embolized per procedure (range, 1-5) but 4.9 were studied (range, 1-10). After embolization, tumor blush was reduced by a median of 87.3% (range, 50%-90%). The mean FT was 41 minutes ± 15.4 (range, 16-67 minutes), the mean RD was 1,977.1 mGy ± 1,794.3 (range, 450.2-6,319 mGy), and the mean KAP was 180.5 Gy·cm2 ± 166.2 (range, 30.4-504 Gy·cm2). The adverse event rate was 1 (4.7%) of the 21 embolizations because a weakness of lower extremities related to swelling was observed. Surgery was performed at a mean of 1.4 days ± 1 (range, 1-5 days) after embolization. The mean surgical estimated BL was 432.5 mL ± 328.5 (range, 25-1,100 mL), and the mean OT was 210.1 minutes ± 97.4 (range, 57-489 minutes). CONCLUSIONS: Preoperative embolization of tumors resected for MSCC with nBCA is a safe procedure allowing for performance of surgery with acceptable BL.

Should Postoperative Radiation for Long Bone Metastases Cover Part or All of the Orthopedic Hardware? Results of a Large Retrospective Analysis.

PURPOSE: For patients with long bone metastases who undergo orthopedic stabilization surgery followed by radiotherapy (RT), it is unclear what extent of hardware coverage by the radiation field is needed for optimal tumor control. METHODS AND MATERIALS: Long bone metastases treated with surgical intervention followed by radiation between August 2011 to May 2019 from a single institution were reviewed. Local recurrence, defined as any in-bone recurrence, was identified by chart review. Accompanying demographic and treatment characteristics were recorded. Statistical analysis to evaluate factors associated with tumor recurrence included univariate analysis, multivariate analysis, and propensity score matching. RESULTS: Among 138 patients with 145 long bone metastases undergoing postoperative RT with a median follow-up of 29.5 months, 36 bone metastases experienced a local recurrence. Most patients (92%) were treated with conventional RT and the median delivered dose was 30 Gy (interquarile range, 20-30 Gy). On univariate analysis, whole hardware RT field coverage and higher dose (biologically effective dose 10 ≥39 Gy) were associated with reduced local recurrence (0.44 hazard ratio [HR]; 95% confidence interval [CI], 0.22%-0.86%; P = .017; 0.5 HR; 95% CI, 0.26%-0.96%; P = .038, respectively). Covariates of time from surgery to RT start, histology of primary tumor (categorized as resistant vs sensitive), intramedullary hardware placement, reaming procedure, and margin status did not reach statistical significance. To adjust for confounding effects, we also conducted a propensity score matched analysis which confirmed that whole hardware coverage was statistically associated with a decreased risk of recurrence on the matched dataset (0.24 HR; 95% CI, 0.07%-0.84%; P = .026). CONCLUSIONS: In this analysis of mostly patients undergoing conventional radiation, coverage of the whole hardware was associated with reduced local recurrence for patients with long bone metastases, consistent with prior reports. Investigation of approaches to further reduce local recurrence, such as preoperative stereotactic radiation, may be warranted.

Polyarticular gout attacks following cerebrovascular accidents: is hemiparesis in fact protective? 2 cases and a review of the literature.

Cerebrovascular disease appears to have implications on rheumatic diseases, including gout. Accumulating evidence suggests that hemiparesis exerts a protective effect against gout via the down-regulation of mechanical and neural modulators of inflammation in neurologically impaired extremities. We present 2 divergent cases of unilateral gout following cerebrovascular events. One patient with a hemorrhagic stroke developed polyarticular gout only on the ipsilateral side to his hemiparesis, while another patient with basilar artery thrombosis and locked-in syndrome suffered a polyarticular gout flare only on the side that had regained limited function. As suggested by these cases, the effect of hemiparesis on gout is complex. Further insight into the interplay between gouty flares and hemiparesis may lead to novel therapeutic strategies for gout.