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One of the severe complications of metastatic lesions of the spine is spinal cord compression syndrome. Refusal to carry out specific treatment leads to disability of the patient due to the development of disorders of the sensory and motor functions of the extremities, the function of the pelvic organs, and severe pain, which can be prevented by timely radiation therapy in an independent mode or as part of complex therapy. Restoring the nerve conduction of the spinal cord in the area of development of its compression can significantly improve the patient’s quality of life, as well as resume specific treatment, which is often stopped due to the severity of the patient’s condition.
One of the severe complications of metastatic lesions of the spine is spinal cord compression syndrome. Refusal to carry out specific treatment leads to disability of the patient due to the development of disorders of the sensory and motor functions of the limbs, the function of the pelvic organs, severe pain syndrome, which can be prevented by timely radiation therapy in an independent mode or as part of complex therapy. Restoring the nerve conduction of the spinal cord in the area of development of its compression can significantly improve the patient’s quality of life, as well as resume specific treatment, which is often stopped due to the severity of the patient’s condition.
Source
Meyer F, Börm W, Thomé C. Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment. Deutsches Ärzteblatt International. 2008 May;105(20):366. Lee MJ, Cassinelli EH, Riew KD. Prevalence of cervical spine stenosis: anatomic study in cadavers. J.B.J.S. 2007 Feb 1;89(2):376-80. João Levy M., António Fernandes F., João Lobo A. “Neurologic aspects of systemic disease part I.” Handbook of clinical neurology: Chapter 35- Spinal Stenosis (2014) Volume 119; pg 541-549 North American Spine Society Public Education Series. Cervical stenosis and myelopathy. https://www.spine.org/Documents/cervical_stenosis_2006.pdf(Accessed November 22, 2011). Williams SK, et al. Concomitant cervical and lumbar stenosis: Strategies for treatment and outcomes. Semin Spine Surg 2007;19(3):165-176. Congenital stenosis of the cervical spine: Diagnosis and management. J Natl Med Assoc 1979;71(3):257-264. L. Yang et Al., Plate-only Open-door Laminoplast Versus Laminectomy and Fusion fortification Treatment of Cervical Stenotic Myelopathy, Healio Orthopedics, Vol. 36, January 20132 Yeh et Al., Expansive open-door laminoplasty secured with titanium miniplates is a good surgical method for multiple-level cervical stenosi, Journal of Orthopedic Surgery and Research, August 2014 Chikuda et Al., Optimal treatment for Spinal Cord Injury associated with Cervical canal Stenosis(OSCIS): a study protocol for a randomized controlled trial comparing early verus delayed surgery, BioMed Central, 2013. Y. Yukawa et Al., Laminoplasty and Skip Laminoplasty for Cervical Compressive Myelopathy, Spine, 2007 May, S . & Comer, C. Is surgery more effective than non-surgical treatment for spinal stenosis, and which non-surgical treatment is more effective? A systematic review. Physiotherapy, 2013, 99(1), 12-20 Hu SS, et al. Cervical spondylosis section of Disorders, diseases, and injuries of the spine. In H. B. Skinner, ed., Current Diagnosis and Treatment in Orthopedics, 4th ed., pp. 238–242. New York: McGraw-Hill., 2006 Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006; 443:198.
Introduction
Metastatic damage to the skeletal bones develops in 50-70% of cases during dissemination of malignant tumors and is most often observed in patients with breast, prostate, lung, thyroid, and kidney cancer (37-84% of all cases of all bone metastases) [1]. In breast cancer, the most common sites of metastases are the lumbar vertebrae (59%) and thoracic vertebrae (57%) [2]. Spinal cord compression syndrome develops in 8% of patients with metastatic lesions of bone tissue [3] and occurs as a result of compression and/or formation of an extradural soft tissue component in metastatic lesions of the vertebrae: thoracic (70%), lumbosacral (20%) and cervical (10). %) [4]. The clinical picture is characterized by the development of neurological deficits of varying severity. The presence of these symptoms indicates spinal cord compression [5].
For patients experiencing the development of spinal cord compression syndrome, immediate dehydration therapy and surgical intervention or a course of external beam radiation therapy are indicated to achieve regression of clinical manifestations. In the case of developed paresis, early initiation of treatment allows us to hope for complete restoration of motor function of the limbs, therefore, surgical treatment or a course of radiation therapy should be carried out as early as possible from the onset and development of spinal cord compression syndrome, despite the effectiveness of the use of glucocorticosteroids. There are a number of rules and recommendations indicating the advantages of surgical intervention or radiation exposure in each clinical case. Candidates for surgical intervention are patients who are not somatically burdened, have good Karnofsky and ECOG index scores, and whose life expectancy exceeds 3 months. The presence of visceral metastases, the number of affected vertebrae, the degree of malignancy of the tumor [6], and its estimated radioresistance [7] are also taken into account. The use of combined treatment (surgery followed by a course of external beam radiation therapy) may have an advantage over radiation therapy alone [8]. However, external beam radiation therapy or complex conservative treatment (a combination of radiation therapy and drug therapy) plays a large role in the treatment of such patients. The administration of a sufficient dose, in addition to the analgesic effect, makes it possible to achieve regression of the soft tissue extradural component, complete or partial reparation of the affected vertebrae and restoration of bone tissue.
The article presents two clinical observations of patients who received treatment in the radiology department of the Federal State Budgetary Institution Russian Cancer Research Center named after N.N. Blokhina: a patient with breast cancer and a patient with prostate adenocarcinoma with bone metastases and pathological fracture of the vertebrae, leading to lower paraplegia.
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Patient L., 48 years old.
Diagnosis: cancer of the left breast, multiple metastatic lesions of the lungs, liver, skeletal bones, T4N3M1, stage IV.
He considers himself sick since January 2013, when complaints of back pain appeared. At the end of March 2013, the phenomena of lower paraparesis and dysfunction of the pelvic organs arose and gradually increased; paraplegia developed within 5-6 days.
Histological examination : infiltrative ductal cancer of the II degree of malignancy with cancer emboli in the lymphatic crevices. RE - 0 points; RP - 2 points out of 8; Her 2/neu — (+++); Ki67=35%.
mammography and ultrasound data dated 04/03/13, a tumor of up to 7.8×4.5 cm was detected in the left mammary gland; in the left axillary region - metastatically affected lymph nodes up to 2.0 cm, in the left supraclavicular region - up to 0.8 cm.
scintigraphy data dated 04/04/13, foci of increased accumulation of radiopharmaceuticals are identified in the area of the Th6 and Th8-9 vertebrae, the right ilium, the anterior segment of the 5th rib on the left, and the proximal femurs.
According to CT data of the chest dated March 14, 2013, destructive changes in the Th6-9 vertebrae are determined with the formation of a soft tissue component and stenosis of this component of the spinal canal at this level (Figure No. 1). Multiple metastatic foci up to 0.5 cm in both lungs and metastatic foci in the liver are also detected.
Consultation with a neurologist on April 15, 2013: clinical picture of spinal cord compression at the Th6 level. Objectively: lower central paraplegia with conduction disorders of all types of sensitivity from the level of Th6-8 dermatomes. Babinski's sign on both sides. Disorders of the pelvic organs.
Due to the general spread of the tumor process (large primary tumor, metastases in the lungs, liver, skeletal bones), requiring the earliest possible start of systemic therapy, and the potential effectiveness of conservative treatment methods (including targeted therapy), a decision was made to carry out treatment in the scope of a combination of chemotherapy and targeted therapy with simultaneous irradiation of metastatically affected thoracic vertebrae.
From 04/18/13 to 05/20/13, two courses of chemotherapy with doxorubicin (25 mg/m2) in combination with Herceptin administration were carried out.
Radiation therapy:
Simultaneously with the start of chemotherapy, from 04/18/13 to 04/30/13, a palliative course of image-guided conformal external beam radiation therapy (IGRT) was carried out at the Varian Clinac 2300iX electron accelerator with 6 MeV photons using three-dimensional planning (3D CRT), a Milenium 120 multileaf collimator and dynamic wedge filters.
Irradiation area:
- vertebrae Th4-9 using RapidArc technology (ATOMI), ROD 4 Gy, 5 times a week, SOD 36 Gy (Figure No. 2).
A course of external beam radiation therapy was carried out in combination with drug therapy with doxorubicin and Herceptin against the background of dehydration therapy with dexamethasone (16 mg IM in the morning + 8 mg IM in the evening).
Among the negative side effects of the treatment, the phenomena of acute radiation esophagitis of I-II degrees were noted.
During the course of external beam radiation therapy, the appearance of voluntary movements in the fingers of the lower extremities began to be noted. On 12/31/13, the patient reported complete restoration of the functions of the pelvic organs and strength in the lower extremities. On 05/17/14, the patient reported the ability to move independently with the help of support.
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Patient X., 74 years old.
Diagnosis: prostate cancer, metastatic lesions of the lungs, skeletal bones, TxNxM1, stage IV.
In May 2014, I began to experience pain in the lumbar region. In August, prostate cancer was verified; PSA was 152 ng/ml.
On August 25, 2014, hormonal therapy with Casodex (150 mg per day daily) and Zoladex (3.6 mg once every 28 days) was started.
Despite hormonal therapy, from 08/28/14 weakness in the lower extremities began to be noted and increased; on 09/05/14 lower paraparesis was diagnosed (muscle strength in the lower extremities - 1 point), however, the functions of the pelvic organs were preserved, sensitivity in the lower extremities was partially preserved. The pain in the lower back and pelvic bones also increased.
Histological examination: acinar adenocarcinoma, Gleason index 4+4=8.
CT data from September 10, 2014, foci from 0.4-0.7 cm are detected in both lungs, in S6 of the left lung subpleurally - up to 1.7 cm. Metastases are also detected in the posterior segments of the 5th rib on the left and the 6th rib on the right, in the manubrium sternum, bodies Th1, 8, L1, 2, lateral masses of the sacrum, bodies of the ilium. Also noted are metastatic lesions of the left lateral and spinous processes of the L1 vertebra, as well as deformation of the L2 vertebral body—probably a manifestation of a pathological fracture.
According to MRI of the pelvic organs dated September 10, 2014, the prostate gland is enlarged in size to 5.2×3.8×4.2 cm, mainly due to the left lobe. The tumor spreads beyond the capsule to the seminal vesicles. In the structure of the visible parts of the lumbosacral spine, pelvic bones and femurs, metastases from 0.2 to 5.0 cm are determined.
According to MRI of the lumbosacral spine dated September 14, 2014, multiple metastases of various sizes are visualized in the Th11-S1 vertebrae (up to total damage to the vertebra). These changes extend to the arch and processes of the L1 vertebra with their expansion and deformation, with pronounced perifocal edema of paravertebral soft tissues and muff-like narrowing of the spinal canal at this level by 79% - up to 0.3 cm. Elements of the cauda equina are compressed and deformed at this level ( Figure No. 3).
Due to multiple metastatic lesions of the skeletal bones, pain syndrome in the lumbar spine and pelvic bones and the potential effectiveness of conservative treatment methods, a decision was made to conduct irradiation of the lumbar spine and areas of metastatic lesions of the pelvic bones in combination with already ongoing hormonal therapy in the amount of MAB.
Radiation therapy:
From 09.15.14 to 09.25.14, a palliative course of image-guided conformal external beam radiation therapy (IGRT) was conducted on the Varian Clinac 2300iX electron accelerator with 18 MeV photons using three-dimensional planning (3D CRT), a Milenium 120 multi-leaf collimator and dynamic wedge filters.
Irradiation area:
- vertebrae L1-L5, ROD 4 Gy, 5 times a week, SOD 24 Gy; then:
- locally vertebra L1, ROD 4 Gy, 5 times a week, SOD 8 Gy (Figure No. 4).
In addition, the right half of the pelvis with the sacrum and the left half of the pelvis were sequentially irradiated, excluding significant volumes of the wings of the iliac bones from the irradiation volume.
During the course of external beam radiation therapy, I began to notice the appearance of first spontaneous movements in the lower extremities, then conscious ones. On 09/29/14 he began to lean on his legs with outside help, and on 10/03/14 he took the first independent step under the supervision of medical personnel. During follow-up examinations on October 18 and 31, 2014, he reported that he moved around the house with a walker and noted a systematic increase in strength in the lower extremities and confidence in his gait.
MRI data from 12/06/14, in comparison with the study data from 09/14/14, there is a decrease in the size of the extraosseous component in the area of the L1 vertebra and a decrease in the degree of spinal canal stenosis at this level (the lumen of the spinal canal increased from 0.3 to 0.6 cm). The affected areas in the vertebrae acquired clearer contours, a component with a low signal in all study modes grew in their structure (plastic component - partial repair), the intensity of perifocal edema of the bone marrow and paravertebral soft tissues at the level of the L1 vertebra decreased (Figure No. 4).
Upon contact with the patient’s relatives on May 13, 2021, they reported control of PSA levels within normal limits during the observation period (hormonal therapy at the time of contact had not been carried out for more than two years), no signs of progression of the metastatic process (according to regularly performed scintigraphy of skeletal bones ), the absence of significant complaints about the manifestations of cancer and the consequences of the treatment (including: according to clinical and biochemical blood tests, no significant deviations from the norm were noted during the observation period, despite the total volume of irradiation, which included not only the lumbar spine, but also both halves of the pelvis with the sacrum with the exception of part of the wings of the ilium). During the period of time elapsed from the moment of treatment, the patient was active, moved a lot (at least 3 km per day), however, after a knee injury and the subsequent increase in body weight during the rehabilitation period, he currently leads a sedentary lifestyle and in the absence of restrictions on independent movement, he prefers to walk using support (the patient himself explains this by the fear of getting a new injury).
Clinic
Cervical stenosis does not always cause symptoms, but when they do occur, they are always associated with cervical radiculopathy or cervical myelopathy. The following symptoms may occur:
- pain in the neck and arms; - dysfunction of arms and legs; - weakness, stiffness or clumsiness in the hands; - weakness in the legs; - walking impairment; - frequent falls; - increased urge to urinate, which can lead to incontinence; - violation of proprioception.
The progression of the disease can occur in different ways:
- slow and constant deterioration; - deterioration to a certain point and stabilization; - rapid progression.
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