title: Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care.
abstract: Spinal cord or nerve root compression from an epidural metastasis occurs in 5-10% of patients with cancer and in up to 40% of patients with preexisting nonspinal bone metastases. Most metastatic spine diseases arise from the vertebral column, with the posterior half of the vertebral body being the most common initial focus, and/or the paravertebral region, tracking along the spinal nerves to enter the spinal column via the intervertebral foramina.  An 82-year-old man diagnosed with sigmoid colon cancer and liver metastases experienced intractable pain described as being like an electric shock on the right T11 dermatome. Imaging studies revealed a huge metastatic mass destroying the right posterior T11 body and pedicle and compressing the right posterior spinal cord and nerve roots. Even after using neuropathic medication and a neural blockade, the extreme paroxysmal pain continued. Considering his elderly, debilitated state and life expectancy, removal of the vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach and percutaneous vertebroplasty (PVP) under monitored anesthetic care (MAC), rather than 3-port endoscopic surgery and corpectomy with or without fusion under general anesthesia with lung deflation, was decided upon and scheduled prior to radiotherapy.  A needle was placed into the intervertebral foramen under fluoroscopy in the same manner as a transforaminal epidural block at T11. A guidewire was inserted into the needle after the needle stylet had been removed. An obturator dilator was inserted over the guidewire, and a working sleeve was inserted over the dilator. After the dilator was removed, a spinal endoscope with a 2.7 mm working channel was placed over the guidewire. Careful removal of the tumor emboli during verbal interaction with the patient was performed under MAC using dexmedetomidine, fentanyl, and ketorolac. PVP at T11 was performed through the right osteolytic pedicle. The paroxysmal pain disappeared immediately after the operation without any complications. Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care without lung deflation may be an effective and safe modality for minimally invasive pain management of a single-level spinal tumor metastasis causing intractable radicular pain in patients with cancer who have generalized debilitation.
authors: Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University Korea.
authors: Young-Chan
authors: YC
authors: Joo
authors: Whoi-Kyung
authors: WK
authors: Ok
authors: Seong-Hoon
authors: SH
authors: Baik
authors: Hae-Jin
authors: HJ
authors: Kim
authors: Oh-Sun
authors: OS
authors: Kwon
authors: Kyung-Hoon
authors: KH
authors: Kim
mesh_terms: D000230:Adenocarcinoma / Q000150:complications / Q000556:secondary / Q000601:surgery; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000473:pathology; D054810:Deep Sedation / Q000379:methods; D004724:Endoscopy / Q000295:instrumentation / Q000379:methods*; D015174:Epidural Neoplasms / Q000150:complications / Q000556:secondary / Q000601:surgery*; D005471:Fluoroscopy; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D011843:Radiculopathy / Q000209:etiology / Q000601:surgery*; D013117:Spinal Cord Compression / Q000209:etiology / Q000601:surgery*