Susanne Selvadurai

Optimizing the management of patients with spinal myeloma disease

Myeloma is one of the most common malignancies that results in osteolytic lesions of the spine. Complications, including pathological fractures of the vertebrae and spinal cord compression, may cause severe pain, deformity and neurological sequelae. They may also have significant consequences for quality of life and prognosis for patients. For patients with known or newly diagnosed myeloma presenting with persistent back or radicular pain/weakness, early diagnosis of spinal myeloma disease is therefore essential to treat and prevent further deterioration. Magnetic resonance imaging is the initial imaging modality of choice for the evaluation of spinal disease. Treatment of the underlying malignancy with systemic chemotherapy together with supportive bisphosphonate treatment reduces further vertebral damage. Additional interventions such as cement augmentation, radiotherapy, or surgery are often necessary to prevent, treat and control spinal complications. However, optimal management is dependent on the individual nature of the spinal involvement and requires careful assessment and appropriate intervention throughout. This article reviews the treatment and management options for spinal myeloma disease and highlights the value of defined pathways to enable the proper management of patients affected by it.

A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes.

BACKGROUND CONTEXT A variety of surgical approaches have been used for cage insertion in lumbar interbody fusion surgery. The direct anterior approach requires mobilization of the great vessels to access the intervertebral disc spaces cranial to L5/S1. With the lateral retroperitoneal transpsoas approach, it is difficult to access the L4/L5 intervertebral disc space due to the lumbar plexus and iliac crest, and L5/S1 is inaccessible. We describe a new anterolateral retroperitoneal approach, which is safe and reproducible to access the disc spaces from L1 to S1 inclusive, obviating the need for a separate direct anterior approach to access L5/S1. PURPOSE This paper had the following objectives: first, to report a reproducible novel single-incision, muscle-splitting, anterolateral pre-psoas surgical approach to the lumbar spine from L1 to S1; second, to highlight the technical challenges of this approach and highlight approach-related complications; and third, to evaluate clinical outcomes using this surgical technique in a prospective series of L1 to S1 anterior lumbar interbody fusions (ALIFs) performed as part of a 360-degree fusion for adult spinal deformity correction. STUDY DESIGN This report used a prospective cohort study. PATIENT SAMPLE A prospective series of patients (n=64) having ALIF using porous tantalum cages as part of a two-stage complex spinal reconstruction from L1 to S1 were studied. OUTCOME MEASURES Data collected included blood loss, operative time, incision size, technical challenges, perioperative complications, and secondary procedures. Clinical outcome measures used included visual analogue scale (VAS) Back Pain, VAS Leg Pain, EuroQoL-5 Dimensions (EQ-5D), EQ-5D VAS, Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22). METHODS Pre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 1.8 years. RESULTS Mean blood loss was 68±9.6 mL. The mean VAS Back Pain score improved from 7.5±1.25 preoperatively to 2.5±1.7 at 3 months (p=.02), 1.2±0.5 at 6 months (p=.01), and 1.4±0.6 at 1 year (p=.02). The mean ODI improved from 64.3±31.8 preoperatively to 16.6±14.7 at 3 months (p>.05), 10.7±6.0 at 6 months (p=.02), and 6.7±6.1 at 1 year (p=.01). There were no permanent neurologic, vascular, or visceral injuries. One revision anterior procedure was required on a patient with rheumatoid arthritis and advanced systemic disease that sustained a sacral fracture and required revision ALIF at L5/S1. CONCLUSIONS The technique described is a safe, new, muscle-splitting, psoas-preserving, one-incision approach to provide access from L1 to S1 for multilevel anterior or oblique lumbar interbody fusion surgery.

Successful nonsurgical treatment for highly unstable fracture subluxation of the spine secondary to myeloma

BACKGROUND CONTEXT In multiple myeloma, patients may develop rapidly progressive, lytic, spinal lesions. These may result in spinal instability, but instrumented stabilization may fail because of poor bone quality. In addition, patients are immunocompromised and are therefore at increased risk of deep infection. PURPOSE The aim was to describe a patient presenting with an unstable fracture subluxation of the thoracic spine secondary to myeloma, successfully treated with non-surgical management. STUDY DESIGN/SETTING This is a case report of a patient seen in a specialist spinal myeloma service. METHODS A 74-year-old Caucasian woman presented with destructive myelomatous lesions of T9 and T10. Greater than 50% of the T9 vertebral body was involved, and there was subluxation and translation of T9 on T10 (Spinal Instability Neoplastic Score of 14). There was a single episode of transient paresthesia of both lower limbs. The patient was in considerable pain, requiring large quantities of opioid analgesia. She was treated non-surgically in a thoracolumbar sacral orthosis for a period of 3 months (strict bed rest for the first 3 weeks). RESULTS A computed tomography scan at 3 months demonstrated bony fusion and the brace was removed. The patient returned to her normal activities 5 months posttreatment. Her pain and patient-reported outcome scores were significantly improved. CONCLUSIONS We present a successful non-surgical management of an unstable myelomatous vertebral fracture without neurologic deficit. However, surgical stabilization remains the treatment of choice in unstable vertebral fractures and spinal surgical opinion should be sought in all cases.

The evolution of partial undercutting facetectomy in the treatment of lumbar spinal stenosis

Decompression of lumbar spinal stenosis is the most common spinal surgery in those over 60 years of age. While this procedure has shown immediate and durable benefits, improvements in outcome have not changed significantly. Technical aspects of surgical decompression have evolved significantly. The recently introduced ultrasonic bone cutter allows a precise and safe peri-neural bone resection. The principles of preservation of stability, as described by Getty et al. have remained as relevant as when these were described 40 years ago.

Managing the Cervical Spine in Multiple Myeloma patients

Discuss the relevant literature on surgical and nonsurgical treatments for multiple myeloma (MM) and their complementary effects on overall treatment. Existing surgical algorithms designed for neoplasia of the spine may not suit the management of spinal myeloma. Less than a fifth of metastatic, including myelomatous lesions, occur in the cervical spine but have a poorer prognosis and surgery in this area carries a higher morbidity. With the advances of chemotherapy, early access to radiotherapy, early orthosis management, and high definition imaging, including CT and MRI, surgical indications in MM have changed. Medical decompression (or oncolysis), including in the presence of neurological deficit and orthotic stabilization, are proving viable nonsurgical options to manage MM. A key to decision making is the assessment and monitoring of biomechanical spinal stability as part of a multidisciplinary approach.