Masafumi Maseda

Analysis of the Relationship Between the Epidural Spinal Cord Compression (escc) Scale and Paralysis Caused by Metastatic Spine Tumors

Study Design. A retrospective, single-institute, and radiographic study. Objective. To evaluate the relationship between the epidural spinal cord compression (ESCC) scale and the severity of metastatic spine tumor–induced paralysis. Summary of Background Data. The ESCC scale is used to evaluate the grade of spinal cord compression on T2-weighted magnetic resonance imaging (MRI). However, few studies have investigated the relationship between such MRI findings and paralysis. Methods. The subjects were 467 patients with metastatic spine tumors and grade 1b or worse spinal cord compression according to the ESCC scale. Evaluations using this scale were performed by three spine surgeons, and results that were obtained by two or more surgeons were adopted. We also examined patients whose spinal cord compression deteriorated by one grade or more to American Spinal Injury Association (ASIA) grade C or worse within the first 3 weeks after MRI. Results. The kappa coefficients for inter- and intraexaminer variability were 0.90 and 0.95, respectively. ASIA grade D or worse paralysis developed in at least 50% of the patients with ESCC grade 1b or worse spinal cord compression at the C1-T2 and at least 50% of those with ESCC grade 1c or worse spinal cord compression at the T3-L5. The frequency of ASIA grade C or worse paralysis was high among the patients with ESCC grade 2 or worse spinal cord compression at the C7-L1. Nineteen patients experienced rapid deterioration of one grade or more to ASIA grade C or worse paralysis within the first 3 weeks after MRI. Of these, paralysis occurred in at least 30% of the patients with anterolateral or circumferential cord compression combined with ESCC grade 2 or 3 compression at the C7-L1. Conclusion. The severity of paralysis was not correlated with the ESCC scale. Patients with anterolateral or circumferential ESCC grade 2 or 3 cord compression at the C7-L1 are at high risk of rapidly progressive paralysis. Level of Evidence: 4

Treatment Outcome of Metastatic Spine Tumor in Lung Cancer Patients: Did the Treatments Improve Their Outcomes?

Study Design. A retrospective, single-center study. Objective. Investigation of the changes in the treatment outcomes of patients with lung cancer derived metastatic spine tumors. Summary of Background Data. Metastatic spine tumors derived from lung cancer had been progressive, and their prognosis is poor. It has recently been reported that the use of molecularly targeted drugs and bone-modifying agents (BMAs) improved the treatment outcomes of patients with lung cancer, but no detailed information about the treatment of metastatic spine tumors has been reported. Methods. Two hundred seven patients with lung cancer derived metastatic spine tumors who were examined after 2000 were analyzed. They were divided into 54 patients who were treated in or before 2005 (surgical treatment: 25 patients, conservative treatment: 29 patients) (group B) and 153 patients who were treated from 2006 onwards, when a molecularly targeted drug and BMA were introduced (surgical treatment: 24, conservative treatment: 129) (group A), and the treatment outcomes of the two groups were compared. Results. Significant differences in age and the affected vertebral level, paralysis grade, and Tokuhashi score (general condition, the number of vertebral metastases, and the total score) were detected between the groups. Regarding treatment outcomes, the mean duration of the post-treatment survival period was 5.1 and 9.3 months in groups B and A, respectively, that is, it was significantly longer in group A (P < 0.05). No significant intergroup difference in pain improvement was noted, and no significant post-treatment improvement in paralysis was achieved in either group. The post-treatment discharge-to-home eligibility rate did not differ significantly between the groups, but the Barthel Index improved significantly after treatment in group A (P < 0.05). Conclusion. After molecularly targeted drugs and BMA were introduced as treatments for lung cancer derived metastatic spine tumors, the survival periods of patients with such tumors increased, and their activity of daily living after treatment improved. Level of Evidence: 4

Idiopathic Hypertrophic Spinal Pachymeningitis.

A 63-year-old man revealed a four-month history of muscle weakness of the lower limbs, hypoesthesia of the L5 and S1 area and ischuria. On MRI, the spinal cord was compressed by an encircled mass, which showed hypointensity on T1- and T2-weighted images with gadolinium enhancement at the Th11 to Th12 vertebra. Because of the rapid progression of myelopathy, posterior decompression was performed and idiopathic hypertrophic spinal pachymeningitis (HSP) was finally diagnosed. The patients neurological signs markedly improved with postoperative corticosteroid treatment. Idiopathic HSP is a clinical emergency and early surgical intervention is essential to prevent irreversible damage to the nervous system.

Efficacy of posterior decompression and fixation based on ossification-kyphosis angle criteria for multilevel ossification of the posterior longitudinal ligament in the thoracic spine

OBJECTIVE The range of decompression in posterior decompression and fixation for ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL) can be established using an index of spinal cord decompression based on the ossification-kyphosis angle (OKA) measured in the sagittal view on MRI. However, an appropriate OKA cannot be achieved in some cases, and posterior fixation is applied in cases with insufficient decompression. Moreover, it is unclear whether spinal cord decompression of the ventral side is essential for the treatment of OPLL. In this retrospective analysis, the efficacy of posterior decompression and fixation performed for T-OPLL was investigated after the range of posterior decompression had been set using the OKA. METHODS The MRI-based OKA is the angle from the superior margin at the cranial vertebral body of the decompression site and from the lower posterior margin at the caudal vertebral body of the decompression site to the prominence of the maximum OPLL. Posterior decompression and fixation were performed in 20 patients. The decompression range was set so that the OKA was ≤ 23° or the minimum if this value could not be achieved. Cases in which an OKA ≤ 23° could and could not be achieved were designated as groups U (13 patients) and O (7 patients), respectively. The mean patient ages were 50.5 and 62.1 years (p = 0.03) and the mean preoperative Japanese Orthopaedic Association (JOA) scores were 5.9 and 6.0 (p = 0.9) in groups U and O, respectively. The postoperative JOA score, rate of improvement of the JOA score, number of levels fused, number of decompression levels, presence of an echo-free space during surgery, operative time, intraoperative blood loss, and perioperative complications were examined. RESULTS In groups U and O, the mean rates of improvement in the JOA score were 50.0% and 45.6% (p = 0.3), the numbers of levels fused were 6.7 and 6.4 (p = 0.8), the numbers of decompression levels were 5.9 and 7.4 (p = 0.3), an echo-free space was noted during surgery in 92.3% and 42.9% of cases (p = 0.03), the operative times were 292 and 238 minutes (p = 0.3), and the intraoperative blood losses were 422 and 649 ml (p = 0.7), and transient aggravation of paralysis occurred as a perioperative complication in 2 and 1 patient, respectively. CONCLUSIONS There was no significant difference with regard to the recovery rate of the JOA score between patients with (group U) and without (group O) sufficient spinal cord decompression. The first-line surgical procedure of posterior decompression and fixation with the range of posterior decompression set as an OKA ≤ 23° before surgery involves less risk of postoperative aggravation of paralysis and may result in a better outcome.

Surgical management of coincidental metastases to upper cervical spine and skull from hepatocellular carcinoma: a case report

Metastases to the skull or upper cervical spine from hepatocellular carcinoma (HCC) are very rare. We herein report a unique case of two-site surgery for both skull and upper cervical spine metastases from HCC. The patient was a 64-year-old man with cervical pain. Computed tomography (CT) revealed osteolytic change related to metastatic cervical spine and occipital bone tumors. Two-stage surgery involving posterior occipitocervical fusion and occipital bone tumor resection was performed. The patient’s pain decreased in severity, and postoperative radiotherapy and chemotherapy could be conducted. The postoperative course was favorable, and the patient exhibited improvement in his activities of daily living. Neither cervical spine X-ray examination nor CT showed any instrumentation failure, such as screw loosening, before the patient died of liver failure 13 months after surgery. Patients with both skull and upper cervical spine metastases from liver cancer may have a markedly unfavorable prognosis. Even in these patients, however, surgery as an aggressive palliative treatment may prolong the survival period or maintain the quality of life as long as the patient’s general condition permits.