All right, our next talk is Spine Tumor Surgery in the Elderly, Dean Chow. Thank you very much, Marjorie, for having me. So I'm going to change it up a little bit, and we'll go to spine tumors in the elderly. We had a talk about this yesterday. Who was at the dinner talk yesterday, anybody? So I can show you the case I showed yesterday, and you won't know the answer. How's that, okay? So here's my consult, so this, I'll just tell you, show you this case here. Gentleman comes to you in your clinic with weakness of the legs. That's his MRI, T2 MRI cord compression. You can see he's got stenosis. He's got erosion into the vertebral body. You can see here's his CT scan. He's got vertebral body destruction, and he's got erosion of the transverse process and the spinous process by this pathologic entity here. So he's basically four minus out of five in bilateral IPs, and he's five out of five. This is Friday. So do you have any, what would anybody do with this patient? Just shout it out. What would you do? Who would just operate? It's Friday, 5 o'clock, just take him to the OR. Anybody? Just operate him, okay? Any other treatments you can do? Any medical treatments? Anybody? Who would give steroids? Steroids, yeah. Who says there's another option? Who says besides surgery, there's another option? Anybody? Who would want to get a biopsy? CT got a biopsy? So this is a great question, because this is what happens to us, right? We get this patient, he's kind of weak, but he's not paraplegic, and you don't know what it is, and you don't know what you're going to get into. So the reality of it is, if you have time to get a biopsy, get a biopsy. And that will make your life so much easier in terms of what you do for that patient. So if you get a biopsy, if you, so the way you should approach it is you blast him with some steroids, four milligrams of decadron. There's studies that have shown you don't have to give 100 milligrams of decadron. There's no rationale for giving massive doses of decadron. Just give the standard four milligrams of decadron. You could probably push it higher, but if they get better, or if they are neurologically stable, you should get the biopsy. So as long as your patient is not declining on you, if they come in at five o'clock Friday and they're four out of five, and then on Monday they're still four out of five, that's okay because they haven't actually lost anything. Or if they get improvement to five out of five, they're okay. You have that time to get the biopsy. Get a biopsy. Yeah, Juan. What about the Asia A patient? Asia A, totally paralyzed? Yeah, that one is Asia A. What would the biopsy of this be? That's a great question. So he's totally out. I don't think there's good data, but as a general rule, if they are within 24 hours, I will operate on them. No biopsy. No biopsy. If they're after 24 hours, then no surgery. You mean if you... Then just I would take out as much as I can? Well, you still got to take it out because you have to keep in mind, your surgery delays the definitive treatment of that tumor. Your surgery is not the definitive treatment. So you've delayed that case. So if you take a biopsy and close and say, we'll radiate, it's going to grow within the next month and it's going to look horrible. If they're already Asia A, it probably won't make a difference, but you've basically delayed the definitive treatment for the lymphoma by operating that patient. So if you're going to do that, buy that patient as much time as possible and take out as much tumor as possible and decompress it, and then while you're delaying chemo and radiation, then you'll have time to, at least you'll have room for the cord. So CT got a biopsy. Plasma cytoma. What's the next step, guys? Say it louder. Radiation. Radiation. Exactly. So plasma cytoma, radiation. So remember, the exquisitely sensitive ones, radiation or plasma cytoma or the variant multiple myeloma, lymphoma, any type of germ cell tumor, those are exquisitely radio sensitive. The ones that are quite radio sensitive are prostate and breast. Always keep that in mind. And the ones that are moderately radio sensitive are going to be the other ones. So like lung, not great radio sensitivity. Things that are not radio sensitive are renal cell, colorectal carcinoma, sarcomas. So basically he had an operation after two years of, after two, these slides aren't showing up properly, but basically you can see he got radiated on the left, this is when he presented on the left, on the right, that's after radiation. So the tumor progressed, it got worse, and he had more cord compression. So I'm going to skip through this case and just kind of get through the, is there an audio visual guy here? Can you see what's going on? Because these slides are just adding on top of each other, there's no, it doesn't actually change the slide. Great, thanks. Good. So I'm going to talk real briefly about your considerations in spine tumors. So again, you want to think about the physiologic age, not the chronologic age. We all know there are people who are out there who are 80, who are healthy as a horse, and there are people who are in their 50s who are sick as dogs. And so really it's not the chronologic age, it is the physiologic age. Life expectancy, always to get a multidisciplinary consult. You see somebody with a tumor, get ONC involved, get RadONC involved. They're probably going to say refer to the clinic as an outpatient, but you want them involved with your decision. And then you always want to think about quality of life. You get an 80-year-old who's in a nursing home and barely moves versus a person who's playing tennis every day, you really want to think about their quality of life. So again, it's really important that you go through, there are a lot of grading scales and scores, but I think whenever you come up with a spine tumor, think about all your options, right? Because it's not just surgery, right? That patient, we initially didn't do surgery, but your options are radiation, chemo, stereotactic radiation, surgery, or ablation. And surgery is only one arm of that picture. And you have to keep in mind, again, your surgery is not the cure for that patient in metastatic disease. So the NOMS framework, I think it's a nice way to look at it. Neurologic, oncologic, mechanical instability, and systemic disease. You take all these together, and I think it's very nice. So if you look at the patients here, so if a patient has high-grade epidural steroid compression, and they have a sensitive tumor or moderately sensitive tumor, such as lymphoma, myeloma, or breast cancer, radiation and steroids is a reasonable option. If someone has something that's moderately resistant or highly resistant, such as colon cancer, renal cell, and there's low-grade epidural spinal cord compression, then stereotactic radiosurgery. And then if they have high-grade epidural spinal cord compression with a radio resistant tumor, you want to give stereotactic radiosurgery some room. And so the whole concept of separation surgery or giving the spinal cord some room with an operation followed by SBRT. So you've got to think, you know, this is an on-block resection T12 on-block renal cell. Is this something you want to be doing to grandma, right? So you have to keep in mind your patient, what you're going to be doing to that patient, what they can tolerate. So if you have access to SBRT, I think it's a great option. And it's really changed the way we manage tumors. There's so much data now showing that for renal cell carcinoma, the control rate is very, very good. You can see that the control rate is 87, 90 percent, 87 percent, 90 percent. One-year control of renal cell carcinoma, 82 percent. And you can see multiple studies show great control rates of renal cell carcinoma. And if you look at stereotactic radiosurgery, the local control is 92 percent. On-block is 96. But look at the major complication rate from on-blocking these patients, right? It's a pretty morbid operation to take someone through this, to on-block for a metastatic case. So, again, I think this is really changing the way that we approach these tumors. And really understanding the biology of these tumors is really critical. Again, SRS, as we know, there's multiple ways you can do this, whether you do it with a linear accelerator, whether you do it with a cyber knife, whatever way you do it. As long as your radiation oncologist can deliver a high enough dose to that tumor, that's the important thing. It doesn't always work. This is one of my patients. You can see December 2016, April 2017. You can see he got stereotactic radiosurgery here, and the tumor progressed and eventually caused cord compression. So, again, you can see it doesn't always work. It's a great place to start, however, but it does not always work. And you can see how this is 2016, liposarcoma metastatic, and, again, you can see 2017 now causing canal compromise. So, even with the margin, you always have to continue to follow these patients. I'm going to talk about other things because we know all about all the techniques that we do, but there are other things you can do. Ablation of tumors, again, you've got to think about the ablation of tumors with cryoablation, laser ablation. Now, people are using LIT in the brain, so this is something to consider and then think about. So, radiofrequency, again, as we all know, basically just as a heat probe, heats up the temperature, kills the tumor. Cryoablation, as you know about, and this is something you really use near the cord or spine, but this is something to consider. Laser ablation, again, much more used in the brain now, but this is also something you can use. Alcohol, you don't want to use, really, because it's going to spread all over the nerves and it's going to be uncontrollable. PMMA, as you know about, for pathologic fractures, and it can help with pain relief from the bony compression and the heat to kill the tumor. Microwave, probably less useful, and then radiation for these treatments. And then you can use certain types of ablative procedures for pain. If there's no spinal cord compression but it's really pain, certainly it's a reasonable operation, a reasonable procedure to do. Separation surgery, like we talked about, again, really published out of the Sloan Kettering Group, 95% control rate. Very, very good early studies. And then, again, looking at stereotactic radiosurgery has great studies. So the other thing that we do is minimally invasive corpectomy, which I'm just going to go through quickly here in the interest of time and basically put percutaneous screws above, percutaneous screws below. And then we open only over the corpectomy site over. And you can see here the screws going in, tap going in. And then there's your opening. So your opening is basically like a laminectomy opening. And then you pass your temporary rod, just like you would an open case. Do your corpectomy through, you know, how Juan was talking about, your PSO is really only over a certain site. Same thing with your corpectomy. Really, you need just that little area to do your operation. And then once you pass one rod, you take those towers out, and you can see your exposure is very nice. And you can get this fairly large cage as long as you go lateral to the spinal cord towards the chest and push the rib away. And you can get a nice expandable cage in there. So, again, you can see the difference of the exposure, the mini-open versus the open. These are the results you can look up online from JNS. Basically, it showed that they had lower blood loss and shorter hospital stay. So, in conclusion, the elderly, you really want to think about the physiologic age. Really, quality of life and life expectancy are paramount. And people really live longer and longer. And multiple non-surgical modalities are available. And the treatment must be individualized. Thank you.

spine tumor surgery

elderly

legs weakness

cord compression

vertebral body erosion