Complete percutaneous treatment of vertebral body tumors causing spinal canal compromise using a transpedicular cavitation, cement augmentation, and radiosurgical technique.
OBJECTIVE
Patients with symptomatic pathological compression fractures require spinal stabilization surgery for mechanical back pain control and radiation therapy for the underlying malignant process. Spinal radiosurgery provides excellent long-term radiographic control for vertebral metastases. Percutaneous cement augmentation using polymethylmethacrylate (PMMA) may be contraindicated in lesions with spinal canal compromise due to the risk of displacement of tumor resulting in spinal cord or cauda equina injury. However, there is also significant morbidity associated with open corpectomy procedures in patients with metastatic cancer, especially in those who subsequently require adjuvant radiotherapy. This study evaluated a treatment paradigm for malignant vertebral compression fractures consisting of transpedicular coblation corpectomy combined with closed fracture reduction and fixation, followed by spinal radiosurgery.


METHODS
Eleven patients (6 men and 5 women, mean age 58 years) with symptomatic vertebral body metastatic tumors associated with moderate spinal canal compromise were included in this study (8 thoracic levels, 3 lumbar levels). Primary histologies included 4 lung, 2 breast, 2 renal, and 1 each of thyroid, bladder, and hepatocellular carcinomas. All patients underwent percutaneous transpedicular coblation corpectomy immediately followed by balloon kyphoplasty through the same 8-gauge cannula under fluoroscopic guidance. Patients subsequently underwent radiosurgery to the affected vertebral body (mean time to treatment 14 days). Postoperatively, patients were assessed for pain reduction and neurological morbidity.


RESULTS
There were no complications associated with any part of the procedure. Adequate cement augmentation within the vertebral body was achieved in all cases. The mean radiosurgical tumor dose was 19 Gy covering the entire vertebral body. The procedure provided long-term pain improvement and radiographic tumor control in all patients (follow-up range 7-44 months). No patient later required open surgery. No radiation-induced toxicity or new neurological deficit occurred during the follow-up period. CONCLUSIONS This treatment paradigm for pathological fractures of percutaneous transpedicular corpectomy combined with cement augmentation followed by radiosurgery was found to be safe and clinically effective. This technique combines minimally invasive procedures that avoid the morbidity associated with open surgery while providing spinal canal decompression and immediate fracture stabilization, and then administering a single-fraction tumoricidal radiation dose.
Gerszten
Peter C
PC
Departments of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA. gersztenpc@upmc.edu
Monaco
Edward A
EA
D001843:Bone Cements / Q000627:therapeutic use; D019299:Decompression, Surgical / Q000379:methods; D005260:Female; D005593:Fracture Fixation, Internal; D050815:Fractures, Compression / Q000601:surgery; D005598:Fractures, Spontaneous / Q000601:surgery; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D016634:Radiosurgery / Q000379:methods*; D016103:Spinal Fractures / Q000601:surgery; D013125:Spinal Neoplasms / Q000556:secondary* / Q000601:surgery; D013904:Thoracic Vertebrae / Q000601:surgery; D016896:Treatment Outcome; D054854:Vertebroplasty
D001843:Bone Cements