Metastases - Long Bone and Spine

General

SPINE METS

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What is the pathogenesis of Hematogenous spread mets/ infection/ TB to spine? Usually which part affected first?

• Due to valveless venous system of Batson’s Found within the spinal canal
• The spinal veins, pelvic and thoracic veins drain into the batson’s plexus which is valveless
• ➔ Seeding at end plate where there are "low flow vascular anastamoses" ➔ infection spread across endplate ➔ Spread to VB

• Usually going to vertebral body first then pedicles (so affects MOTOR first)
• So we get the Tuli’s 5 stages of Pott’s Paralysis

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What is your definitive management? Any framework?

• I utilize the NOMS frame work to guide my treatment by Bilksy et al. in 2013
• It incorporates the Neurologic, Oncologic, mechanical and systemic considerations to facilitate decision making

• https://www.google.com/search?q=tokuhashi+score&rlz=1C5CHFA_enSG957SG957&sxsrf=AOaemvLe8L4mlWAI8Gl8SSoie1Vmw1RICw:1642321154937&source=lnms&tbm=isch&sa=X&sqi=2&ved=2ahUKEwiwuK-I67X1AhUSIUQIHaoLB1wQ_AUoAXoECAEQAw&biw=730&bih=634&dpr=2#imgrc=7BjU8ug9CoPbVM

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How do you assess the Neurological component?

• Assessing the degree of epidural spinal cord compression (ESCC)

• I can use the Bilsky scoring system
• Grade 0 = bone only disease (A)
• Grade 1 = encroach into spinal canal or epidural sac but No cord compression
• Grade 2, spinal cord compression, but with cerebrospinal fluid (CSF) visible around the cord. (E)
• Grade 3, spinal cord compression, no CSF visible around the cord. (F)
• Grades 2, 3 = High grade ESCC

LONG BONE METS

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What is the Mirel's score?

• Based on 4 things - location, pain, matrix and size
• Prophylactic nail if ≥ 9

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What scenarios?

• Known bone mets ➔ Fix
• Known cancer but no known bone mets ➔ Restage with local imaging, open biopsy, frozen section to confirm it is mets and not new primary before fixation
• No known cancer ➔ diagnostic investigations, local and systemic staging, open biopsy, frozen section to confirm it is mets and not new primary before fixation

CASE: PATHOLOGICAL FRACTURE

Case: Open pathological fracture

• 2. Ex fix for temporary stability while waiting for definitive treatment
• 3. Complete work up after ex fix- local and systemic staging