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63 Metastatic Lesions oftheSpine

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spine are employed, bone allograft, autograft, and graft substitutes are available. Hardware with low artifact potential (carbon ber, polyetheretherketone PEEK) should be used to facilitate planning for adjuvant radiation and MRI follow-up.

Adjuvant treatment following surgical therapy is essential for local tumor control. The standard therapy is conventional external beam radiation therapy (cEBRT). Advances in technology have brought other techniques, such as stereotactic radiosurgery (SRS) into the eld, with the advantage of a higher biologically effective dose (BED) on the tumor eld while reducing the dose delivered to tissues surrounding the radiation site. Moreover, SRS has shown to overcome the radioresistance of some tumor types. In selected palliative cases, cEBRT for pain control alone can be evaluated. Systemic tumor therapy should be planned in interdisciplinary oncological settings according to the guidelines of the underlying malignancies.

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63.7 Expected Outcomes

With the occurrence of spinal metastases in advanced malignant disease, the therapeutic setting is mostly palliative. Primary goals of surgery are neurological stabilization, pain control, spinal stabilization, and local tumor control. Thanks to evolving oncologic therapies like immunotherapy, the statistical life expectancy of patients suffering from metastatic disease are increasing. Patients suffering from spinal metastases present a very heterogenic group. Overall, the prognosis is limited and dependent on systemic metastases, underlying malignancy, previous therapies, clinical status, and comorbidities.

63.8 Potential Complications

The most dreaded complication of spinal metastases is MESCC.Fast-developing neurological decits decrease statistic life expectancy and HRQOL for the patient. The perioperative complication rate in surgery of spinal metastases is high. Most complications arise from surgical site infections or systemic infections and cardiovascular complications, increasing patient morbidity and mortality. In case of surgical instrumentation, material displacement or dislocation and hardware failure during follow-up is possible, potentially necessitating revision surgery. Local tumor recurrence is common, and adjuvant radiation and frequent follow-up imaging is therefore necessary.

63.9 What Should Patient andFamily Know?

Spinal metastases frequently occur in advanced malignant disease. Mostly dreaded is MESCC, leading to fast-developing neurological decits and a decreased statistic life expectancy. Fast diagnosis and interdisciplinary decision-making in the

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V. Hubertus et al.

treatment of spinal metastases are essential. Therapy options have evolved towards an interdisciplinary concept including surgery, adjuvant radiation therapy, SRS, and systemic treatment according to the underlying malignancy, with a trend towards prolonged overall survival, thanks to evolving oncologic therapy options.

Further Readings

1. Fehlings MG, etal. Survival and clinical outcomes in surgically treated patients with metastatic

epidural spinal cord compression: results of the prospective multicenter AOSpine study. J Clin

Oncol. 2016;34(3):268–76.

2. Laufer I, etal. The NOMS framework: approach to the treatment of spinal metastatic tumors.

Oncologist. 2013;18:744–51.

3. Fisher CG, etal. A novel classication system for spinal instability in neoplastic disease. Spine.

2010;35(22):E1221–9.

Tuberculosis ofSpine

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Yat-WaWong

64.1 Definition

Tuberculosis of the spine (TB spine) is caused by Mycobacterium species, of which Mycobacterium tuberculosis (M. tuberculosis) is the most common. Respiratory

and genitourinary systems are frequent primary foci. The TB infections spread to the spine through hematogenous or lymphatic routes. In contrast to pyogenic infections (bacteria destroy local tissues by proteolytic enzymes), tuberculosis infection induces type IV delayed hypersensitivity reaction which is a cell-mediated response. Macrophages engulf M. tuberculosis bacilli and are subsequently activated to recruit monocytes which differentiate into epithelioid cells and then Langerhans giant cells. The resulting granulomatous inammation causes local tissue destruction, caseous necrosis, and cold abscess formation. TB spine originates from pulmonary or renal tuberculosis as a secondary infection.

64.2 Natural History

Most patients present with a chronic course with an insidious onset of pain and constitutional symptoms. Vertebral column destruction, cold abscesses, and debris compressing on the spinal cord or nerves, pachymeningitis, and meningomyelitis may cause neurological deterioration. The cold abscesses may nd their ways to be

Supplementary Information The online version contains supplementary material available at [https://doi.org/10.1007/978- 3- 030- 80356- 8_64].

Y.-W. Wong (*) The University of Hong Kong, Queen Marry Hospital, Hong Kong, China e-mail: yatwa@hku.hk

https://doi.org/10.1007/978-3-030-80356-8_64

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discharged such as to the paraspinal muscles or externally through sinus tracts. Without effective treatment, TB spine tends to affect multiple vertebral levels and results in severe kyphosis. In adults, the severity of kyphosis relates directly to the severity of vertebral body destruction. In children, kyphosis may deteriorate during their growth even the TB spine is adequately treated.

Pott’s paraplegia refers to the neurological deterioration related to the TB spine. It may occur at the acute phase (early onset) or many years after apparent quiescence (late onset) due to reactivation of tuberculosis or spinal cord atrophy as a result of chronic stretching over the internal kyphosis, healed bony bars, calcied caseous material, brosis, increasing kyphosis, or instability.

Y.-W. Wong

64.3 Physical Examination

Depending on the stage and extensiveness of the disease, the physical examination may reveal local tenderness, paraspinal swelling indicating cold abscess, discharging sinus, sinus scars, sharp kyphosis (gibbus), or neurological decit (Video 64.4).

64.3.1 Imaging

There is no pathognomonic radiological feature to distinguish TB spine from other spinal infections (Chap. 65). The initial radiographic nding is osteopenia due to the chronic nature of the disease. Later, fusiform paravertebral soft tissue swelling and psoas shadow may cold abscesses (Fig.64.1). Reduction of the intervertebral disc height and destruction of the adjacent vertebral bodies are similar to pyogenic spondylodiscitis. However, it is relatively more common for TB spine to have vertebral body destruction without affecting the intervertebral disc and multiple levels of involvement due to the afnity of the bacteria to the well-perfused tissues such as bone marrow (Fig.64.2). Plain radiographs are useful to detect instability and assess spinal alignment. Computed tomography (CT) scan or magnetic resonance imaging may show elevation of the anterior or posterior longitudinal ligament with subligamental spread of abscesses. Scalloping of the anterior or posterior walls of the vertebral bodies is a common feature.

64.4 Differential Diagnosis

Neoplasms or other spinal infections are common differential diagnoses. There is no clinical, serological, and radiological feature that is diagnostic of TB spine. Biopsy under uoroscopic, CT, or ultrasonic guidance is frequently required to conrm the diagnosis and guide antituberculous drug treatment (Videos 64.7 and 64.8).

64 Tuberculosis ofSpine

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Fig. 64.1 Anteroposterior radiograph showing the fusiform paravertebral soft tissue swelling and bilateral psoas shadow enlargement due to TB cold abscesses (and bilateral psoas shadow enlargement due to TB cold abscesses)

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It is diagnostic of TB spine if biopsy specimens show mycobacterium bacilli with Ziehl-Neelsen staining, positive TB polymerase chain reaction, or typical histological features of epithelioid granuloma, Langerhans multinucleated giant cells, and caseation. Identication of mycobacterium bacilli is only possible in about 50% of cases, and it takes 6 to 8 weeks to get the culture and sensitivity results.

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abc

Y.-W. Wong

Fig. 64.2 (a–c) Sagittal reconstructed CT scans showing the progressive anterior column destruc- tion. (a) Only T6 was infected by TB and collapsed. (b) T5–T7 collapsed 1 year later. (c) T5–T7 collapsed further with increasing kyphosis in 2 years

64.5 Treatment Options

Most TB spine can be successfully treated by nonoperative treatment. The rst-line anti-TB treatment at author’s region is isoniazid 300mg oral daily 9 to 12 months; rifampicin 450mg (body weight <50kg) or 600mg (body weight ≥50kg) oral daily for 9 to 12 months; pyrazinamide 25–30mg/kg/day oral for 2 months; and ethambutol 15mg/kg/day oral for 2 months. Apart from regular monitoring of complete blood count, liver function and renal function, clinicians should look for specic side effects such as peripheral neuropathy (isoniazid), high serum urate (pyrazinamide), and decreased vision (ethambutol). Apart from regular monitoring of complete blood count, liver function and renal function for active TB spine, surgery is indicated if there are signicant neurological decits, severe spinal deformity, huge cold abscess not responding to anti-TB drugs and percutaneous drainage, or intractable mechanical pain not responding to nonoperative treatment. Surgical options include anterior radical debridement and strut graft fusion (Fig.64.3, Hong Kong operation), posterior decompression and instrumented fusion with or without

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Fig. 64.3 (a–c) This T8–T9 TB spine patient received anterior debridement and fusion using autogenous rib grafts through left thoracotomy. (a) Lateral thoracic spine radiograph. (b) T2-weighted sagittal MRI. (c) Postoperative lateral thoracic radiograph

anterior column debridement and support, and combined anterior and posterior surgery (Fig.64.4). The choice is based on the location, extensiveness, indications of the surgery, and expertise. Application of metallic implants is safe provided that adequate anti-TB treatment is given (Fig.64.5). Instrumentation is generally indicated for the more extensive disease to restore spinal stability and alignment. Combined approaches are the preferred option if the disease is extensive with multilevel involvement.

Patients may develop severe kyphosis in the TB spine even they have good functional status. Apart from cosmetic issues, it may compromise cardiopulmonary function, limit the abdominal volume, and cause pain by rib on iliac crest impingement. Deformity correction is feasible in selected cases. Preoperative halo traction may help the correction. Pedicle subtraction osteotomy or vertebral column resection (VCR) is the surgical options depending on the severity of the kyphosis. To avoid excessive shortening or lengthening of the spinal cord, VCR is usually followed by lengthening of the anterior column and shortening of the posterior column during the kyphosis correction.

For Pott’s paraplegia of late onset, it is sometimes associated with severe rigid kyphosis, compromised cardiopulmonary function, myelomalacia, and spinal cord atrophy. Correction of severe rigid kyphosis is difcult if not impossible for older patients, but adequate decompression can be achieved through costotransversectomy approach with or without fusion. Prognosis of neurologic recovery is poor even with adequate spinal cord decompression and deformity correction if there is associated spinal cord atrophy. Most of these patients acquire TB spine in childhood, and their deformities progress during growth. Early stabilization and deformity correction may prevent late-onset paraplegia.

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Y.-W. Wong

Fig. 64.4 This patient suffered from tuberculous thoracolumbar spine affecting multiple levels and bilateral psoas abscesses. (a) Lateral standing radiograph showing the thoracolumbar kyphosis. (b) Sagittal reconstructed CT spine demonstrating the multilevel involvement. (c, d) Axial CT scans showing the bilateral psoas abscesses. (e) T2-weighted sagittal MRI demonstrating the thoracolumbar TB spine causing conus compression. (f) Lateral postoperative standing radiograph after anterior debridement, drainage of abscesses, anterior fusion using rib grafts, and posterior instrumented fusion

64.6 Expected Outcomes

Most patients respond to anti-TB drug treatment alone with a favorable outcome. Spinal decompression and stabilization give favorable results for patients with neurological decits in acute disease. The surgical difculty and risk increase with increasing deformity, chronicity, and extensiveness of diseases. Pott’s paraplegia of late onset carries a poor prognosis for neurologic recovery.

64 Tuberculosis ofSpine

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Fig. 64.5 (a, b). T1-weighted sagittal and axial contrast MRI showing the subligamental spread of abscess in TB spine. (c, d) Standing lateral and anteroposterior radiographs after anterior radical debridement, fusion by titanium mesh cage packed with autogenous bone graft, and anterior instrumentation. There is no contraindication for applying metallic implants in TB

Prevention of severe kyphosis and nonunion reduces the risk of late-onset neurological deterioration.

64.7 Potential Complications

Severe complications include death due to disseminated tuberculosis, paraplegia, angular kyphosis (Appendix Q), and persistent discharging sinuses.

64.8 What Should Patient andFamily Know?

Compliance with anti-TB drug treatment is the key of successful treatment.