That was wonderful. If we can have the panel members come up here so we can start our multidisciplinary tour board. So, for those who were here before, we're going to use that same polling site, and for those who weren't I'll reintroduce it. So, let me just get to the cases. It's going to be the same panel members, Dr. Gokasan, Dr. Bilski, Dr. Rines, Dr. Tatsui, and Dr. Zuroff will be joining us as well. So, we're going to be talking about the NOMS framework that was introduced previously, as well as the epidural spinal cord compression scale, as well as the SINs criteria. All right. So, let me start. So, for those who are here who were not here before, please go to this website, PollEV slash AANS2018525. The other way to access it is through SMS. You can text AANS2018525 to this number. And let me just show it to you again. So, either take your phone or your computer and go to PollEV.com slash AANS2018525. That number again. AANS2018525. Or you can text. So, you can text to this number, 22333, and type in AANS2018525. And so, when you get on, you don't need to put your name. You can skip. And so, whoever's on now, let's see if we can access this poll. Okay. It looks like it's working. All right. So, let's start with our cases then. We'll start with case one. A 62-year-old female with a history of carcinosarcoma of the uterus who presents to us with hand weakness and neck pain and on exam has four out of five hand strength, but no hyperreflexia, no gait issues. Relatively good function and presents. And we have a sagittal T2 and axial scan showing this lytic lesion at C7 with compression. And here's a CT showing the lytic component, kyphotic deformity, epidural disease. So, we'll go through the NOMS framework quickly. So, this patient has grade three compression, has neurologic deficit. From an oncologic standpoint, this patient has carcinosarcoma. This is a highly radioresistant tumor. Systemically, the patient has stable disease. They've been heavily treated with multiple other chemoregimens. And this area was actually previously radiated with conventional radiation. We'll go through the mechanical criteria. So, the SIN score, patient has C7, so junctional, three points. They have mechanical pain. It's a lytic disease with a kyphotic deformity and greater than 50% collapse. And I didn't show you, but there's no posterior element. This is an unstable fracture. SIN score of 13. So, just to summarize, grade three compression with neurologic deficits, stable systemic disease, histology is radioresistant, and it's unstable fracture. So, let's go to the audience and see what you recommend. Okay. Everyone seems to agree here. So, Dr. Ryans, what do you think? I'm very pleased with the audience response. It's unanimous, and I'm going to add to the unanimous vote. I agree with that. Okay. Any other comments? Spinal instability is a clear-cut indication for surgical fixation. And so, in my algorithmic approach, using the NOMS criteria, the first question that you have to answer, really, is whether or not the spine is stable or unstable. If the spine is unstable, the patient needs to go to surgery. And I think, I guess the audience is thinking along the same lines. Yes. All right. So, this is a straightforward one. We'll start with something easy. Can I just say one? Yes, Dr. Wilson. The one consideration is a burst fracture at C7, which is a little hard to access, but the biggest issue is that when you get a radiated conventional, we had four or five times where we went in to get the esophagus off the spine and couldn't get it mobilized. And that's really, in part, in the cervical spine, why we started going posterior only. So, a lot of people go anterior or maybe do a front-back on that. We would actually approach that posterior only and come around. A lot of times when those vertebral bodies collapse, the disc spaces sort of expand and fill the space. But if you have a hole, you can put cement in from the back and a long posterior fixation and a frame anatomy to get the tumor off the root. But we would do that as a posterior only, in part, because of the radiation, the prior radiation really makes it almost prohibitive to get the esophagus mobilized. That's a very good point. Thank you. Yes. Just making a point, that's a C7, so it would be very hard to go from posterior and perform anterior reconstruction of vertebral body from posterior on this. At least in my experience, I would say, you know, thinking on the amount of surgery, of course, you have to think about your reconstruction and your approach. But this is, you know, I think the biomechanical reconstruction has to last, you know, at least outweigh the patient's life expectation. I did it on Thursday. Yeah. All right. So in this case, given the, you know, so we end up doing a front and back in this case, followed by radiosurgery. And here's a pre-op and here's an expected post-op. Patient did really well from surgery, but their disease progressed systemically. It was started on doxorubicin and developed cardiac insufficiency and passed away after five months. So, you know, you have to always consider the systemic burden in these patients. All right. So going to the next case, a 60-year-old male with a history of prostate cancer, presents with a few days of gait instability and sensory changes. Completely intact strength-wise, but it's hyperreflexia. And he's high functioning, still working, presents with this disease, about T8, T9. Here's our sagittal and our axial scan. And going through the framework, he has grade 2 compression with myelopathy. He's got prostate cancer. Prostate cancer, as was discussed earlier, is a relatively radio-sensitive tumor. So we have to consider that. And just kind of bringing that same slide again, we all know lymphomas and myelomas are radio-sensitive, but breast and prostate tend to respond pretty well to conventional treatment as well. So we'll go through the SINs criteria. And just to make it quick here, patient is stable. Okay. And to summarize, a highly functioning male with prostate cancer with early signs of myelopathy and grade 2 compression. And overall, you have to, oncologically, he has a good chance for survival. So let's go to the next poll. I'm going to hide the answers so people don't cheat. All right. I'll give you guys a few seconds. See what people said. All right. Okay. Split opinions. We'll go to the next slide. Can you hit the next on yours, the arrow? Thank you. All right. So I'll go to the panel, see what you guys think. So I'll take this one. So prostate's one of the ones that's a little controversial in general because it is radio-sensitive. But there are subsets of prostate that don't respond as well, that are a little more aggressive. So you always have to take that in consideration. I know Dr. Pilsky has published a lot on the androgen-insensitive prostate that's being much more aggressive, less responsive to radiation. And you also have to have a good patient population. So it's a little up in the air for this. And it has to be, you know, it's not just radio-sensitive. It's how fast is it responds to radiation. Like lymphoma responds within hours. But prostate may be responsive to radiation, but it doesn't mean it's going to go away today or tomorrow. So if somebody has high neurologic deaths that, like, is weak, getting weaker by the day, you may have a different algorithm for treatment than if he's just a little myelopathic. So the radio surgery won this one. But I would probably, in somebody here like this who's just myelopathic, just give conventional radiation. Yes. Yes. Go ahead. No, go ahead. I think the one potentially not right answer, although you can make an argument, is actually radio surgery. Because, again, you can't conform the beams tightly enough to spare a spinal cord tolerance and get a dose across that tumor. And you can make the argument that radio-sensitive tumors don't need 24 gray at the margin of the cord. But we don't actually know that. And so if they have high-grade cord compression, not myelopathic prostate, we'll typically use conventional radiation. If they have high-grade cord compression, myelopathic, we'll typically take them for decompressive surgery first. Because, again, I think, as Nick said, you can't really get an effective immediate decompression. And so even if you irradiate, you're going to have this ongoing compression for a significant amount of time and have to treat with high-dose steroids. So I think high-grade cord compression with myelopathy in a relatively radio-sensitive, not myeloma lymphoma, but a relatively radio-sensitive, it's probably safer to take them, decompress them. Stabilization is probably important, although they usually have sclerotic bone disease. And then get into conventional radiation or radiosurgery as opposed to apagifu. Just one comment related to prostate cancer is that it's a relatively radio-sensitive tumor. But it also tends to involve multiple levels in the spinal column. It usually is not as localized as, let's say, breast cancer or renal cell carcinoma. And so sometimes, if it's stereotactic radiotherapy, it may be difficult to cover multiple levels. In many cases, if you are going to treat the patient with radiation to start with, it may be a better strategy to design something, as a matter of fact, hybrid, where it's more of a conventional for the most part of the spine and then have a local boost in the area where it's sort of the combination of the two. Thank you. So in this case, this patient did get, so, you know, as Dr. Bielski said, the radiation dose required with radiosurgery is not going to be acceptable, given the tolerance of the spinal cord. So in this case, the patient underwent external beam radiation and actually had a pretty good radiographic and clinical response. So this is, you know, pretreatment, and this is a couple months, a few months after. But again, like Dr. Zolich mentioned, there are patients, there are resistant pathologies. All right, let's go to the next case. A 47-year-old woman with a history of ductal carcinoma of the breast, diagnosed 12 years ago, presents with severe back pain. She's neuro-intact and highly functioning. This is her CT and MRI. And here's some axial images from the MRI. So we'll go through the NOMS criteria. She's neurologically intact, has some grade one disease. She has a history of breast cancer, treated with a lumpectomy. She gets a metastatic workup. CT, chest, and polyps are negative. MRI of the total spine is negative, so she only has an isolated lesion. And from a SINs criteria, kind of briefly go through it. She's a score of seven. She's essentially, she's stable. So, summarize, 48-year-old woman, high functioning, history of breast cancer 12 years ago. Possesses back pain, neuro intact. Restaging is negative. And she's, like I said, SIN seven. So let's go to the audience here, see what you guys think. I'm gonna hide the answers. Okay, let's see what people thought. All right. All right, so, let me go to the, can you hit next again? Thank you. All right, so, I'll go to the... So, I think this patient has a number of red flags. I think one needs to be aware of. Yes, the patient has a history of breast cancer, but it's important to note that there has been a prolonged disease-free stage since the initial diagnosis. So there's a long time that has passed since the initial diagnosis. That's number one. Number two, the patient has systemic workup done, which proved to be negative. And so, assuming that the patient has metastatic disease in the spine, whereas the rest of the body is entirely clean of metastatic disease, it's a bit unusual. The third, if you look at the images, it is not a typical, I would say, breast metastasis. The lesion is primarily in the foramen, not necessarily originating from the bone. It is T2 hyper-intense on axial images. This is not a typical radiographic appearance of the breast metastasis. If I were to guess what this would be, we not infrequently see patients with breast cancer, with concomitant and other malignancies, sometimes primary tumors, i.e. cordone. So, in this case, we, so, let's see. We recommend a biopsy and revealed cordoma. And so, this patient underwent a two-stage approach for on-block spinalectomy with a multidisciplinary team. So, just like Dr. Ryan's described, posterior approach, make your cuts, separation, and percutaneous fixation, or not percutaneous, open fixation, and then go from the front and take the piece out in one. And just to show you, here's the dura. Here's the end plates on both ends. You can see the nerve root, this is a muscle, and this is the tumor removed, obviously. And reconstruction with a cage and a fibular graft. Here's a post-op CT and x-rays. All right, thank you very much. Yes, please. So, in line with what Zia said, this is a case where you need to have that threshold to recognize that something doesn't smell right. And a biopsy is easy to get. It costs little. And for a patient like this, the difference is major. If you operate on this as if it's a metastasis or do a separation surgery from the back, maybe you get away with it, but the data suggests the patient will have a higher likelihood of having a local recurrence than if you do the operation that was shown. So, if the story doesn't add up, don't feel reluctant to get a biopsy. Make sure you have all the information you need before you plan a treatment. I absolutely agree with that. The only caveat I would say is that, and we see this a lot, certainly in community hospitals sometimes, that they're so focused on getting a diagnosis, but if you come in with high-grade core compression with significant myelopathy, first of all, oblox is not feasible even if it's a primary tumor for margins. And ultimately, even if it ends up being myeloma or lymphoma and you can't get a timely diagnosis, the right thing to do if they're myelopathic is probably to go ahead and take them to surgery, do separation surgery, create space, get them functionally as good as they can be and stabilize, and then worry about what kind of radiation you're gonna give afterwards. We've definitely seen some cases where people sat on lymphoma for months because they couldn't get a diagnosis and they kept getting steroid bullets, and ultimately the patients ended up paralyzed. And that's not really, we do want a diagnosis, we do want to diagnose primary tumors. In this case, it's an ESCC1B, you have plenty of time, and it was a low-stage breast cancer, and it looks like chordoma. I think that was pretty obvious. But I think what you have to worry about is if you don't know the oncology and they have high-grade cord compression, salvage the cord, stabilize, and then worry about the kind of treatment you're gonna give as an adjuvant therapy. I do agree with Mark in principle, just with one caveat, is that there are certain malignancies, if, i.e., lymphoma, Ewing's sarcoma in children, for example, whereas if you were to take the patient to the OR and end up doing an open surgical procedure rather than a biopsy to establish the diagnosis, and this should never be done at the expense of losing neurological function by the way, but nevertheless, if you were to do that, and if you were to get a post-operative complication, let's say in a patient with Ewing's sarcoma, post-OP1 infection, something along those lines, then that patient is not gonna be able to receive the chemotherapy, which is really the life-saving intervention for that individual, and that would be delayed significantly. So giving some thought to open surgical procedure if there's a high probability that you're dealing with a highly radiosensitive tumor where you can obtain the diagnosis with a CT-guided biopsy. So not at the expense of neurological deficit, but not necessarily jump into it. Thank you. All right, we'll go to the next and last case to let you guys go. 62-year-old woman presents with colon cancer, presents with mechanical pain without deficits. She's KPS 70. This is her MRI showing multiple lesions, but most relevant here, here's her axial scan. And so neurologically, patient has grade two compression, but no deficits and has multifocal spine mets. From an oncologic standpoint, she has colon cancer and newly diagnosed diffuse mets in the liver and the body and as well as the spine, and the oncologist wanna start her on chemo ASAP. So high disease burden, and also patient has DVTPE and they're anticoagulated. So from a mechanical standpoint, kind of go through it quickly. Potentially unstable, SIN score three, kind of high, high-end unstable, or high-end potentially unstable. So to summarize, 62-year-old, moderate function, metastatic colon cancer with severe back pain, but neurologically intact with colon cancer, which is not very radiosensitive and has significant disease burden systemically. And it's potentially unstable. So we'll go to the polls one last time. You might have to refresh your browser to let it go. Okay. Okay. All right. Okay, we'll go on to the next slide here. Can you hit? Thank you. All right, thank you guys for, so I'll let the panel discuss. You can take this one. So I see I'm not the only one that thought on laser ablation. So if there is a candidate for this procedure, I think this is a good example. This is a patient that has compromised systemic, high surgical risk. She's anticoagulated. She does have, it's a patient of mine, and she had like horrible liver metastasis. She has severe pain and she's unstable. So, you know, and if you put this patient to a major operation, even separation surgery, which is less aggressive tumor resection, still puts her into prone position. She's gonna lose blood. She's gonna have hypercoagulable state after the surgery. We have to stop anticoagulation for two weeks. Things can go wrong on this patient. So having a less aggressive approach to this type of patients, it can be an advantage. Sometimes less is more on this population. So in my thought process, I think the lesion is approachable from a oblique perspective, and we could potentially treat this patient with laser ablation and percutaneous stabilization like I showed on some of my cases. I think that's a brilliant solution. The problem is that not many people are doing SLIT, and you're gonna face these patients in your hospitals, and you have to make a decision about how you can actually treat them. I think SLIT will actually have a role ultimately, but for this patient, it's gonna be complicated to get that system set up. If they're not a candidate for open surgery, one of the solutions for instability, we do a lot of percutaneous pedicle screws at adjacent segments with cement augmentation, as Claudia showed, but hypofractionated radiation is three-fraction radiation has a much better therapeutic window for high-grade cord compression. So an ESCC2 in this setting might be a really good target for eight grade times three with a 24 gray cord Dmax, and you probably give up about 15% control on the tumor relative to single fraction, but where you don't have any other options because of medical comorbidities, et cetera, it may be a really good solution to get them stabilized without putting cement at level where you have high-grade compression. You can just do PERC screws at adjacent levels, cement augment, and then take them for three-fraction radiation with pretty good outcomes that are somewhat comparable, although not equivalent to single fraction. That's a great comment, thank you. Yeah, so one other option is, yes, the patient has a lot of morbidity, but doing a relatively small and a quick surgical procedure, i.e. a minimum invasive approach, percutaneous stabilization with bilateral Wilson approaches with tubular retractors and a spinal cord separation surgery, and then getting the patient to radiation therapy. That might be a reasonable strategy rather than subjecting the patient to a open surgical procedure and a major reconstruction. That was great. So in this case, many things were considered, recovered from the large surges, patient has significant systemic burden, and so we proceeded with separation with LIT followed by stereotactic radiosurgery with percutaneous fixation. Here's some intra-op images. So that's the pre-op, and that's the immediate post-op, and here's the radiation plan, and this is a X-ray, sorry, CT one year later, and these are the 15-month post-op MRI. So patient did really well with resolution of back pain, systemic disease is better controlled, and there's no signs of radiographic recurrence. I think that's all we have time for today. Thank you very much. Thank you so much to the panel. Thank you.

spinal metastases

treatment options

individualized treatment plans

multidisciplinary approach

minimally invasive procedures

risks and benefits