Management of Unstable Pathological Spinal Fractures Secondary to Lymphoma John F. Hamilton MD PhD; James Boddu; Joy A. Rostron PA-C

1. Department of Neurosciences, Division of , Inova Fairfax Hospital, Northern Virginia Campus of Virginia Commonwealth University School of . 2. The George Washington University School of Medicine and Health Sciences

INTRODUCTION: Lymphoma is a systemic OUTCOME: Patient developed an PLAN: C4 Corpectomy via anterior : Multiple lytic lesions disease that has widespread impact on the enterocutaneous fistula at anterior surgical approach. Placement of intervertebral body throughout T & L spine. T7 is hyperintense body’s baseline homeostasis. Standard site ~1 week after . The wound biomechanical cage extending from C3 to throughout. It has approximately 40% treatments for the disease – i.e. was I&D and a JP Drain was placed at the C5 filled with allograft. Placement of height loss of the vertebral body anteriorly chemotherapy, radiation , high-dose site. Patient also had a GJ tube placed at anterior cervical plate with vertebral body and posteriorly with retropulsion. There is steroids, and marrow transplantation, that time. 4 months Post Op Visit – 5/5 screws at C3 and C5. growth of the lesion along the pedicles drastically decrease fusion rates in those strength and sensation in BUE and BLE. bilaterally causing a focal narrowing of the patients with unstable pathologic spinal No pain/weakness/numbness. Mild spinal canal at that level with posterior fractures requiring surgical management. dysphagia. Still using CTO brace and bone displacement of the spinal cord. This potential for decreased fusion can stimulator. 6 month Post op imaging lead to an increased risk of hardware showed solid fusion with stable CLINICAL COURSE & SURGICAL PLAN: failure, and the need for additional hardware placement and resolved Patient initially had improvement of back . Herein, the authors present a fistula. pain and BLE weakness/numbness with unique case series highlighting the steroids and radiation treatment. However, management of 4 patients with unstable CASE #2 they did not continue to improve but rather pathologic fractures secondary to RESULTS HISTORY: 44yo M h/o progressive neck worsened therefore prompting surgical lymphoma in the cervico-thoracic spine that From this study, the authors determined that pain with radiation down his RUE with POSTOP CARE: External Orthosis intervention. – RT Anterolateral required surgical management. patients requiring more than a one-level associated weakness. (Aspen). Steroids, radiation, intensive Thoracotomy: T7 Corpectomy. Placement corpectomy, also required posterior fusion PHYSICAL EXAM: Motor: 5/5 BLE & LUE, chemotherapy. of intervertebral biomechanical cage. with postoperative external orthosis in order METHODS: All patients underwent an 5/5 RUE except 4/5 grip. Sensory: OUTCOME: At 10 months Post Op Visit – Lateral rod and vertebral body screws in T6 to obtain solid fusion. However, in patients anterior corpectomy followed by either 1) Sensation intact except RUE ulnar 5/5 strength and sensation in BUE and & T8, reinforced with additional bone from where only a one-level corpectomy was posterior fusion with postoperative external distribution. Reflexes: 1+ brachioradialis BLE. No radicular symptoms. No harvested T6 rib. needed, a postoperative external orthosis orthosis, or 2) only postoperative external B/L, 1+ patellar BL. No midline TTP of weakness or numbness. No dysphagia. was sufficient to help facilitate solid fusion. orthosis. spine No Pain. They did have posterior neck POSTOP CARE: TLSO brace, steroids, Furthermore stimulators were utilized in all RADIOLOGY: Metastatic disease with stiffness, but had not followed up with chemotherapy, & of the patients who underwent posterior pathological fracture at T1 resulting in physical therapy. Post op imaging CASE #1: HISTORY: 47yo RT hand fusion. The authors also propose that an complete collapse of the vertebral body showed solid fusion with stable dominant male with an extensive PMHx anterior followed by a posterior fusion is with kyphotic deformity, subluxation, and hardware placement. OUTCOME: 1 Month postoperatively, presents with severe neck and RT scapular indicated for any pathologic fracture compression on the spinal cord secondary patient was readmitted to the hospital for pain with associated radiation of pain and involving the thoracic spine, irrespective of to disk bone fragments and metastatic back pain. At that time, he was noted to numbness into their RUE down to the level CASE #4 the number of levels involved. From our tumor. Also with tumor encroaching have multiple compression fractures of the RT elbow. He notes associated HISTORY: 47yo M h/o anemia c/o experience this seems to promote a more upwardly into the inferior aspect of the C7 throughout the T & L spine. Imaging also decreased ROM in RUE and swallowing progressively worsening mid-to-low back robust fusion. Postoperatively, all patients vertebral body. shows that the T7 cage construct had difficulty due to chin-on-chest deformity. pain with associated BLE pain/paresthesias showed improvement of preoperative PLAN: Two-Stage surgical approach over subsided into the superior endplate of PAST MEDICAL HISTORY: Lymphoma over 7-8 months with worsening BLE neurological symptoms. Average follow up 2 days. Stage 1: Anterior T1, T2 T8. The lateral plate and screws did not (2011) with C7-T1 pathologic fracture, weakness over 1 month prior to admission. was 9.5 months, with demonstrated solid corpectomy, with tumor resection. have any change in position, and there was sepsis, organ failure, endocarditis resulting He reported difficulty ambulating and fusion, substantial improvement in pain, as Placement of an expandable intervertebral no retropulsion. SURGICAL LESSON: in aortic valve replacement, and stem cell getting out of bed due to the back pain. No well as improvement in functional ability. PEEK cage C7 –T3 arthrodesis with This patient would've benefitted from transplantation. The pathologic fracture bowel or bladder incontinence. No upper CONCLUSION correction of subluxation. Stage 2: posterior fusion to further stabilize was initially managed nonoperatively. extremity symptoms. He had tried This case series demonstrates that though Posterior segmental fixation with lateral anterior construct. After ~10 months in During recuperation from , conservative outpatient measures (ie difficult, solid fusion is possible in lymphoma mass screws at C5, C6, and pedicle screw the TLSO brace, patient was noted to have patient deteriorated from C7-T1 physical therapy and chiropractic patients with unstable pathologic spinal fixation at T3 and T4. Posterolateral 5/5 strength and sensation in all involvement. Therefore, C6-T2 anterior manipulations) but these did not work. fractures despite standard adjuvant arthrodesis at C5-T4. extremities. He was ambulating with a partial corpectomy was done at another treatment for the disease. walker. Follow up imaging showed no institution. Subsequently, the patient had PHYSICAL EXAM: Motor: 5/5 strength in interval change in compression worsening pain over several months. PET all extremities EXCEPT RLE - iliopsoas of fractures or amount of cage subsidence. scan showed involvement of the C5 4+/5 strength, quadriceps 4+/5 strength, vertebral body, with a pathological fracture hamstring 4-/5 strength foot dorsal and and kyphosis. In addition it was noted that plantar flexion 4+/5 strength, and great toe the patient had subsidence of the PEEK flexion and extension 4+/5 strength. cage into the C6 vertebral body with the Sensory: Diminished to light touch in BLE, instrumentation eccentric to the right. but still present. Decreased sensation PHYSICAL EXAM: Chin-on-Chest POSTOP CARE: Bone Stimulator and below the level of approximately T8 deformity, Short bulky neck. Breathy External Orthosis (Aspen & CTO). Steroids bilaterally. Reflexes: 2+ and symmetric in quality voice, consistent with prior recurrent and intensive chemotherapy. Plan for stem the biceps, 3+ and symmetric on the laryngeal nerve injury. Motor: 5/5 BUE and cell therapy. quadriceps, 2+ and symmetric in the BLE, EXCEPT for RT hand with thenar and OUTCOME: At 4.5 months Post Op Visit –