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Management of Spinal Tumors

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Management of Spinal Tumors 1/9/2019 Management of Spinal The presenters have no conflict of interest to report regarding any commercial Tumors: Physical Therapy product/manufacturer that may be referenced Implications and during this presentation. Interventions All photos/illustrations are used with permission. Lauren Geib, PT, DPT Photos/illustrations are for the sole use of Amanda Molnar, PT, MSPT educational purposes and are not to be APTA Combined Sections Meeting replicated or redistributed in any manner. Thursday, January 24, 2019 Learning Objectives • To gain a general knowledge of both primary and metastatic spinal tumors • To review the various medical and surgical treatment options for patients with spinal tumors Overview of Primary and • To discuss the implications of rehabilitation’s vital role within the multi-disciplinary care team for Metastatic Spinal Tumors patients with spinal tumors • To identify safe and appropriate interventions and strategies throughout the continuum of care for this patient population Spinal Tumors 1,2,3,4 Anatomical Classification 1,2 • Primary spinal tumors: masses of abnormal cells • Intradural – within dura mater originating in the spinal cord, dura, or the vertebral • Intramedullary – within spinal cord bodies that grow out of control • Extramedullary – outside spinal cord • Metastatic spinal tumors: cancer cells originate in • Most often primary spinal tumors another area of the body and spread to the spinal • Extradural – outside dura mater cord, dura, or vertebral bodies via the bloodstream • Often arise in bony vertebrae or lymph vessels • Most common site for spinal tumors • Most often metastatic spinal tumors 1 1/9/2019 Spinal Tumors Histological Classification 1,3,5,6 Intradural (intramedullary) • Intradural lesion • Primary intramedullary Intradural (extramedullary) • Benign lesion • Ependymoma Epidural lesion arising from bone • Hemangioblastoma • Malignant • Astrocytoma Epidural lesion arising from • Primary extramedullary soft tissue • Benign • Meningioma • Nerve sheath tumor (schwannoma, neurofibroma) • Metastatic • Leptomeningeal disease (LMD) www.mskcc.org Demos Medical Publishing Histological Classification 6,7,8 Location of Spinal Tumors 4,9 • Extradural • Metastatic Cervical • Primary benign 10% Lumbosacral • Giant cell tumor (GCT) 20% • Osteochondroma • Osteoid osteoma/osteoblastoma • Primary malignant • Chordoma • Chondrosarcoma Thoracic • Osteosarcoma 70% • Ewing sarcoma • Lymphoma • Plasmacytoma Etiology 1,5,10 Statistics 10,11 • Primary spinal tumors • Metastatic spinal • One person in 100,000 (~10,000) people per year • Most tumors NOT linked tumors develop spinal tumors to any known factors or • Lung cancer • 15-20% of all CNS tumors occur in the spine causes • Breast cancer • Genetics • Primary spinal tumors • Prostate cancer • Familial/inherited • Benign tumors – 55-65% all primary spinal tumors syndromes • Renal cancer • Previous radiation • Thyroid cancer • Metastatic spinal tumors exposure • Multiple myeloma • Most common – 70% all spinal tumors • Lymphoma • Spinal metastases occur in 20% of all patients with cancer • 5-10% develop spinal cord compression 2 1/9/2019 Diagnosis 1,10,12 Signs & Symptoms • Signs and symptoms • Pain Syndromes 6,12,13,14 • Biological • Pain • Tumor related pain • Weakness • Deep, gnawing, aching • • Night or morning pain resolving over course of the day Sensory symptoms • Improves with activity or anti-inflammatories • Impaired coordination • Mechanical • Bowel/bladder dysfunction • Impending or existing spinal instability • Movement related pain – transitional movement, axial loading • Neurological exam • Unresponsive to medical management • Radiculopathy • Imaging • Pain (often radiating) from nerve root compression • Sharp, shooting, stabbing • Blood tests • Cervical –radiating unilaterally into UE • Thoracic – band-like bilaterally around chest/abdomen • Biopsy* • Lumbar – radiating unilaterally into LE Signs & Symptoms Treatment 1,4,12,14 • Myelopathy 12,14 • Primary spinal tumor • Indicates high-grade spinal cord compression • Goal of treatment curative • Symptoms – dependent on tumor location • Metastatic spinal tumor • Pain • Goal of treatment palliative • Weakness/paralysis • Loss of sensation (light touch, pin-prick, proprioception) • Treatment options • Abnormal reflexes • Surgical resection • Impaired balance and coordination • Radiation • Autonomic changes (bowel and bladder) • Chemotherapy • Other drugs Spinal Tumor Treatments 1,12,15 • Advances in medicine, technology, and techniques have improved safety and effectiveness of treatment of spinal tumors • Surgery Surgical and Medical • Minimally invasive complex procedures to remove tumors, decompress spinal cord, and stabilize spine Treatment Options • Radiation • Systemic therapy • Chemotherapy • Other drugs • Corticosteroids • Immunotherapy 3 1/9/2019 Primary Spinal Tumors 2,12,15 Metastatic Spinal Tumors 4,12 • Surgery • Medical treatment options • Dependent on distinct tumor border • • Clear border: gross total resection curative Radiation • Infiltrative tumor: subtotal resection +/- adjuvant therapy • EBRT, SBRT • Radiation • Chemotherapy • EBRT, SBRT • Other drugs • Dependent on tumor histology, extent of resection, and recurrence • Most often utilized following incomplete resections or with high grade, • Surgery infiltrative tumors • Chemotherapy • Dependent on tumor histology, extent of resection, and recurrence • Limited role • Most often utilized with systemic involvement and in pediatric population Metastatic Spinal Tumors Metastatic Spinal Tumors • NOMS – decision framework that facilitates • Radiation 1,12 treatment of metastatic spinal tumors4 • EBRT N - Neurologic • Used for radiosensitive tumors regardless degree of cord O - Oncologic compression • Lower dose, more fractions M - Mechanical instability • Risk of RT-induced toxicity and side effects S - Systemic disease • SBRT • Used for radioresistant tumors • More precise: higher dose, less fractions • RT-induced toxicity rare, mild complications/side effects Metastatic Spinal Tumors Metastatic Spinal Tumors Treatment Framework • Surgery 4,12 Radiosensitive Radioresistant • Dependent on • Mechanical instability • Degree of cord compression/neurological symptoms Low-grade ESCC • Radioresistant tumors – “separation” surgery EBRT SBRT • Minimal tumor resection carried out to separate tumor margin from spinal cord • Role of surgery to create “target” for SBRT • Bulk of tumor treated with SBRT High-grade ESCC EBRT Surgery + SBRT 4 1/9/2019 Surgical Procedures En-Bloc Resection 1,12 • En-bloc resection • Surgical technique removing tumor in a single piece • Percutaneous cement augmentation • Main goal = remove ALL cancer • Decompression with stabilization • Remove tumor + normal surrounding tissue clear margins • Sacrectomy • Often used to completely eliminate primary tumors • Complete resection correlates with progression-free survival Percutaneous Cement 1,12 1,12 Decompression with Stabilization Augmentation • Minimally invasive procedure to treat vertebral • Relieves pressure on spinal cord and nerve roots compression fractures • Often posterolateral approach - removing back part • Vertebroplasty –image-guided injection of bone cement into (lamina) of the vertebrae the fractured vertebra • Kyphoplasty – balloon-like device inserted/inflated to expand • Creates space to allow EBRT or SBRT without risking the compressed vertebra, space then filled with bone cement injury to spinal cord • May require additional stabilization such as • Spinal stability achieved by surgical fixation/fusion percutaneous screws for compression fractures • Pedicle screws and/or rods redistribute stress and extending past vertebral body maintain alignment of bones • Needed with significant spinal cord compression, collapsed vertebra, or severe burst fractures Laminectomy Spinal Post-op Precautions • Spinal precautions - activity restrictions to promote safe mobility and allow healing • Activity restrictions (No BLT) • No Bending (forced flexion/extension of spine) • No Lifting > 5-10lbs. • No Twisting of spine • Additional ROM restrictions for cervical upper/mid thoracic surgery • No reaching overhead • No horizontal adduction past midline • Generally followed 5-6 weeks post-op www.mskcc.org 5 1/9/2019 Sacrectomy 12 Sacrectomy Post-op Precautions • Partial to complete removal of the sacrum to • Activity determined by wound closure effectively remove/debulk tumors of the sacrum • Pressure-relieving mattress • Resection of sacral nerve roots • No SITTING (6 weeks) • Partial – removal of only a portion of the bony structure • No supine (rare) of the sacrum and potentially nerves • WB status – WBAT • Complete – removal of the entire sacrum AND the • nerves Orthostatic hypotension • Reconstruction • Wound closure from rectus abdominus muscle flap • Spinal instrumentation and bone grafts Post-op Complications 5,12,14 • Wound healing issues • Infection • Dehiscence • DVT/PE Rehabilitation of Patients • CSF leak • Neurological injury with Spinal Tumors • Pulmonary complications • Hardware migration/failure Role of Rehabilitation 13,16,17 Role of Rehabilitation • Rehabilitation of patients with spinal tumors • Functional mobility focuses on relieving symptoms, improving quality of life, enhancing functional independence, and • Pain management preventing further complications. • Bracing • Impairments may be caused by the cancer, treatment side effects, and/or co-morbidities • Neuromuscular re-education • Prognosis, POC, and goals of patient dictate
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