Waleed Awwad, MD, FRCSC. Red Flags: Red Flags: History of cancer History of cancer Unexplained weight loss >10 kg within 6 months Unexplained weight.

Spine TumorsWaleed Awwad, MD, FRCSC

HistoryRed Flags:

HistoryRed Flags:

History of cancer

Unexplained weight loss >10 kg within 6 months

Age over 50 years or under 17 years old

Failure to improve with therapy

Pain persists for more than 4 to 6 weeks

Night pain or pain at rest

Fever

Physical examFull Spine exam

General exam if unknown primary.

What are the primary tumor that most likely to metastasize to spine?

InvestigationLocal.

Systemic.

Blood and Urine.

Tissue diagnosis.

Investigation

.Enneking classification

.Tomita classification

Investigation Weinstein

Boriani Biagini (WBB) Staging system

The more extensive the less likely a surgical cure

Most useful staging system for spineEasy to

rememberCentred on

what's important

InvestigationSign of instability:

1.Loss of Hight.

2.Focal angular deformity.

3. Kostuik Stability Classification6 columns (2 anterior,2 middle and 2

posterior)Unstable if 3 or more columns involved.

Spine TumorsPrimary benign.

Primary malignant.

Metastatic lesion.

What is the mode of spread?

Spine TumorsPrimary benign.

Spine TumorsPrimary benign.

Aneurysmal Bone Cyst

Giant Cell Tumor

Hemangioma

Osteoblastoma

Osteoid Osteoma

Spine TumorsPrimary malignant

Spine TumorsPrimary malignant

Chondrosarcoma

Chordoma

Ewing’s Sarcoma

Multiple Myeloma

Osteosarcoma

Spine TumorBody Neural element

MM.

Chordoma

GCT

Hemangioma

EG

Osteosarcoma

Spine TumorBody Neural element

ABC

Osteoid osteoma

Osteoblastoma

Osteochondroma

What is this sign?

What is the diagnosis?

What is this radiologic feature called?

What is your diagnosis?

What this radiologic feature called?What is your

DDx?

What is this radiologic feature?

What is your DDx?

MELT.

What is the most

cause?

What is this radiologic sign?

What is your diagnosis?

Treatment of spinal tumors

Non-Surgical Treatment

Surgical Treatment

Treatment of spinal tumorsPre-operative evaluation?

Solitary or multiple

Diagnosis (tissue) if solitary or unknown.

Life expectancy.

Medical fitness.

Patent wishes.

Treatment of spinal tumorsWhat are the indication to operate for

spine tumor?

A. For disease cure or control.

B. Other causes are: Intractable painNeurologic changes (unless long-standing) Instability – impending fractureNeed of open biopsy

Treatment of spinal tumors

Pre-operative embolization.

Radiosensitive tumors.

Chemo sensitive tumors.

Hormone sensitive.

Chemo and radio resisitant.

Post operative?

What is your management?

Cases41 Y/O M

Immigrant from China

No significant PMHx

4 yr Hx of LBP

2 yr Hx of LBP with Rt Leg pain

Neuro exam was N 4 yrs agoNumbness X 1.5 yrsMild weaknes in EHL X .5 yrs

What is your Diagnosis?

How Would you manage this patient?

Bone and Gallium Test hot bone scan, neg gallium, not infection.

Biopsy, fibrous tissue with occ giant cells.

Serology for parasites (echinococcus) neg.

Patient now disabled by pain and cannot work.

Surgery: percutaneous, transpedicular, with currettes, cement, L3&4 followed by L5 w Rt L5 decomp 2 weeks later

2nd Case

45 yo Male6 mo History of LBP with radiation left

leg

2 mo Hx of paraesthesias

1 mo mild Lt Quad weakness requiring a cane

Past History of enbloc resection of Lt buttock Liposarcoma 3 years earlier

Bone Scan

X-Ray

MRI

Other TestsCBC, ESR, CRP all Normal

CT chest Normal

Whole body MRI normal except for L3

Needle Biopsy L3, Liposarcoma same as in hip (myxomatous)

What Would You Do?

Two Stage En Bloc ResectionStage 1 Posterior

Stage 2 Anterior

Surgical Plan, Stage 1-Posterior

Surgical Plan, Stage 1-Posterior

Surgical Plan, Stage 1-Posterior

Head

Screws

Surgical Plan, Stage 1-Posterior

Posterior Surgery:Laminectomy L2,3,4

Facetectomy L2-3-4

Pedicle instrumentation L2-4

Transverse process resection L3 bilat.

Surgical Plan, Stage 2 - Anterior

Surgical Plan, Stage 2 - Anterior

Surgical Plan, Stage 2 - Anterior

Vertebral Body L3

AnteriorEpiduralLiposarcoma

Intra-operative Imaging

Post-operative Imaging

Thank you