severe kyphosis with spinal cord compression after ... 10.pdf · we describe a patient who...
TRANSCRIPT
CHAPTER 10SEVERE KYPHOSIS WITH SPINAL CORD COMPRESSION
AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
Cornelis G. Vos
Koen J. Hartemink
Tim U. Jiya
Ricardo E. Feller
J. Wolter A. Oosterhuis
Marinus A. Paul
Ann Thorac Surg. 2012;94:1003-6
CHAPTER 10 SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
132
ABSTRACT
Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors.
We describe a patient who developed a kyphoscoliosis with spinal cord compression after
resection of a superior sulcus tumor that invaded the vertebral column. Risk factors for
spinal instability and indications for stabilization are discussed.
CHAPTER 10SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
133
INTRODUCTION
Vertebral involvement is no longer a contraindication for resection of superior sulcus tumors.
In selected patients, en bloc resection of the tumor and invaded vertebra by partial or total
vertebrectomy is feasible and improves survival compared with historical control patients.1-3
The need for additional stabilization after (partial) resection of vertebrae is determined by
the extent of the resection. Resections that do not compromise the mechanical integrity
of the spinal segment involved will not require additional instrumental stabilization. In
cases of hemivertebrectomy or total vertebrectomy reconstruction with dorsal and ventral
stabilization is recommended.1-3
We describe a patient who developed a severe kyphosis with spinal cord compression after
resection of a superior sulcus tumor invading the vertebral column.
CASE REPORT
A 54-year-old Caucasian woman with no past medical history presented with continuous
radiating pain of the right arm for 5 months. There were no other complaints. She had smoked
20 cigarettes a day for 25 years. Physical examination demonstrated no abnormalities.
A chest X-ray demonstrated a solid mass in the right upper lobe. Computed tomographic
(CT) scanning and magnetic resonance imaging (MRI) of the cervicothoracic junction
demonstrated a right upper lobe tumor invading the chest wall (rib 1 - 3) and the right
neuroforamen of the first and second thoracic vertebrae (Figure 1).
A CT-guided core biopsy demonstrated a squamous cell carcinoma. Positron emission
tomography scanning demonstrated a fluorodeoxyglucose-avid tumor. There were no
distant metastases. Brain metastases were excluded by MRI. Clinical staging was cT4N0M0,
stage IIIB. The patient was treated with concurrent chemoradiation induction therapy (3
cycles of cisplatin and etoposide; radiotherapy dose 50 Gray).
Post-induction chest CT showed a significant reduction in tumor size, but still invasion of the
chest wall and right neuroforamen of the upper 2 thoracic vertebra. Staging after induction
was unchanged; cT4N0M0, stage IIIB. Six weeks after completion of the radiotherapy a
lobectomy of the right upper lobe was performed with en bloc resection of the right
transverse processes, hemilamina and facet joints of the first and second thoracic vertebrae,
the first 3 right ribs, and the first branch of the brachial plexus (T1) using an extended right
posterolateral thoracotomy (Figure 2).
CHAPTER 10 SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
134
The vertebral pedicles and the dural sac remained intact during the operation. Mediastinal
lymph node dissection and bronchial stump reinforcement with an intercostal muscle flap
was performed. The remaining cervico-thoracic junction was considered stable and no
stabilization was performed.
In the first postoperative week, she developed a kyphosis at the cervico-thoracic junction of
15 to 20 degrees. There were no complaints and no neurologic deficit. She was diagnosed
with torticollis due to muscle weakness and pain, which was treated with physiotherapy.
Further postoperative course was uneventful and she was discharged 10 days after surgery.
Final histopathologic classification was ypT1N0M0R0.
After 18 months she slowly developed progressive numbness from the C8/T1 level with
paresthesia (tingling and burning sensations). She also had subtle weakness of both legs,
altered sensation during micturition, and minimal fecal incontinence. On neurologic
examination no evident paresis was found. A clonus was found on knee and Achilles tendon
reflex testing. The Babinski sign was positive on both sides. Sensation, both vital and gnostic,
was reduced from the T1 level and below. An MRI of the spine demonstrated progressive
kyphosis with anterior dislocation of the T1 vertebra with compression of the myelum
(Figure 3 and 4).
Because of the symptomatic spinal cord compression, reduction under traction was
performed using a halo frame. Two weeks later a dorsal laminectomy and anterior (C7 - T1)
and posterior spondylodesis (C5 - T4) were performed (Figure 5). Postoperative course was
Figure 1. Magnetic resonance image demonstrating a superior sulcus tumor in the right upper lobe with invasion of the first and second thoracic vertebrae and the chest wall (rib 1 - 3).
Figure 2. The thick black lines demonstrate the extent of the resection performed on the first and second thoracic vertebrae.
CHAPTER 10SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
135
uneventful and the patient was discharged 7 days after surgery. On follow-up visits there
was only minimal remaining loss of sensation in the left leg without any paresis and normal
continence. The kyphosis was corrected and the scoliosis evidently improved.
Figure 3. Magnetic resonance image 18 months after surgery showing a remarkable kyphosis of 60 degrees at the Th1-2 level with spinal cord compression (arrow).
Figure 4. Three-dimensional reconstruction of the cervico-thoracic spine computed tomography demonstrating the kyphosis of 60 degrees at the Th1 - 2 level.
Figure 5. Postoperative roentgenogram demonstrating the dorsal and ventral spondylodesis instrumentation.
CHAPTER 10 SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
136
COMMENT
Due to multimodality treatment and improved surgical techniques, survival is improved
and more patients become amenable for curative resection.4,5 Vertebral involvement is no
longer a contraindication for surgery.4,5 Because of improved survival, spinal osteosynthesis
and reconstructions should be durable.
In case of extensive resection such as (multilevel) total vertebrectomy or hemicorporectomy,
stabilization or spinal reconstruction is indicated.6,7 Stabilization seems unnecessary in case
of resections limited to the transverse processes or facet joints.1-3
Jain and colleagues2 described 3 tumor types with the required extent of resection and the
need for stabilization and reconstruction in superior sulcus tumor patients. Type A lesions
require resection of the transverse process and no stabilization is needed. Type B lesions
invade the neural foramen and lateral part of the vertebral body and resection of the facet
joint and partial vertebral body is required. Posterior stabilization is advocated for type B
lesions. In type C lesions vertebral body involvement is more extensive and requires (near)
total vertebrectomy. For these lesions both posterior and anterior stabilization is
recommended.2
Taneichi and colleagues8 developed a model to predict impending collapse of a vertebral
body caused by vertebral metastases. Risk factors included the following: (1) percentage of
vertebral body invaded by metastasis; (2) destruction of the pedicle; (3) posterior elements;
and (4) the costo-vertebral joint. Vertebral involvement was graded from A to F, with increasing
probability of collapse. Multivariate logistic regression analysis identified destruction of the
costo-vertebral joint as the most important risk factor for vertebral collapse in the thoracic
spine. From a mechanical point of view these risk factors for vertebral body collapse could
probably be applied to (partial) resections of the vertebra as well.
In our patient the affected spine segment was included in the radiation field during induction
treatment. Chemoradiation is known to impair bone mineral metabolism and is associated
with an increased risk of (osteoporotic) fractures.3,9,10 The impaired bone quality might have
had an additional effect on the instability and subsequent collapse of the spine segment in
this case.
Retrospectively, the resection performed in our patient should have been followed by
additional spinal stabilization. In cases where stabilization is not performed, early correction
should be considered at the first signs of angulation because deformity can increase over
time, with the risk of spinal cord compression. A multidisciplinary approach is recommended.
CHAPTER 10SPINAL CORD COMPRESSION AFTER RESECTION OF A SUPERIOR SULCUS TUMOR
137
REFERENCES
1. Bolton WD, Rice DC, Goodyear A, Correa AM, Erasmus J, Hofstetter W, Komaki R, Mehran R,
Pisters K, Roth JA, Swisher SG, Vaporciyan AA, Walsh GL, Weaver J, Rhines L. Superior sulcus
tumors with vertebral body involvement: a multimodality approach. J Thorac Cardiovasc Surg.
2009;137:1379-87.
2. Jain S, Sommers E, Setzer M, Vrionis F. Posterior midline approach for single-stage en bloc resection
and circumferential spinal stabilization for locally advanced Pancoast tumors. J Neurosurg Spine.
2008;9:71-82.
3. Fadel E, Missenard G, Court C, Mercier O, Mussot S, Fabre D, Dartevelle P. Long-term outcomes of
en bloc resection of non-small cell lung cancer invading the thoracic inlet and spine. Ann Thorac
Surg. 2011;92:1024-30.
4. Acosta FL Jr, Aryan HE, Ames CP. Successful outcome of six-level cervicothoracic corpectomy and
circumferential reconstruction: case report and review of literature on multilevel cervicothoracic
corpectomy. Eur Spine J. 2006;15 Suppl 5:S670-4.
5. Rusch VW. Management of Pancoast tumours. Lancet Oncol. 2006;7:997-1005.
6. Peedell C, Dunning J, Bapusamy A. Is there a standard of care for the radical management of
non-small cell lung cancer involving the apical chest wall (Pancoast tumours)? Clin Oncol (R Coll
Radiol). 2010;22:334-46.
7. Winters HA, van Engeland AE, Jiya TU, van Royen BJ. The use of free vascularised bone grafts in
spinal reconstruction. J Plast Reconstr Aesthet Surg. 2010;63:516-23.
8. Taneichi H, Kaneda K, Takeda N, Abumi K, Satoh S. Risk factors and probability of vertebral body
collapse in metastases of the thoracic and lumbar spine. Spine. 1997;22:239-45.
9. Hwang JH, Song SH, Lee JK, Lee NW, Lee KW. Bone mineral density after concurrent chemoradiation
in patients with uterine cervical cancer. Menopause. 2010;17:416-20.
10. Elliott SP, Jarosek SL, Alanee SR, Konety BR, Dusenbery KE, Virnig BA. Three-dimensional external
beam radiotherapy for prostate cancer increases the risk of hip fracture. Cancer. 2011;117:4557-65.