Results of preoperative embolization for metastatic spinal neoplasms

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> Arterial embolization reduces blood loss in patients undergoing surgery for hypervascular spinal tumors. The objectives of this study were twofold: 1) to evaluate the role of magnetic resonance (MR) imaging in predicting tumor vascularity and 2) to assess the effectiveness of preoperative embolization in devascularizing these tumors.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Fifty-one patients with metastatic spinal neoplasms underwent angiography, preoperative embolization, and excision of the lesion between 1995 and 2000. The MR imaging studies were correlated with tumor vascularity on angiograms. Embolization was angiographically graded on a five-point scale ranging from no embolization (Grade A) to total embolization (Grade E). The embolization grade was correlated with intraoperative blood loss.</jats:p> <jats:p content-type="fine-print">The mean age was 57 years, the male/female ratio was 1.2:1, and back pain was present in all patients. Metastatic renal cell carcinoma (30 cases) and thoracic spine involvement (33 cases) were most frequent. The positive predictive value of MR imaging in determining tumor vascularity was 77%, whereas the negative predictive value was 21%. Total embolization (Grade E) was achieved in 34 patients. A shared vascular pedicle between a radiculomedullary artery (RMA) and a tumor diminished the likelihood of complete embolization (p = 0.02). Small asymptomatic cerebellar infarctions were demonstrated in two cases. The mean intraoperative blood loss was 2586 ml. Following Grade D or E embolization, intraoperative bleeding was largely related to unembolized epidural veins.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> Tumor histology and MR imaging findings are predictive of hypervascularity; however, hypervascular tumors may not be detected by standard MR imaging sequences. Superselective catheterization permits Grade D or E embolization in 80% of patients. Shared blood supply with an RMA is the most important factor precluding complete embolization.</jats:p>

Outcome of embolised vascular metastatic renal cell tumours causing spinal cord compression

“…Most of our patients had their surgery for metastases in thoracic spine (21), and it is not really possible to compare this with the small number at other sites-cervical (2) and lumbar (2). However, Prabhu et al [13], in their series of 51 patients, found thoracic (2,300 ml) and lumbosacral tumours (3,700 ml) to be associated with significantly more blood loss than those of the cervical region (1,500 ml; p = 0.015).…”

“…Of the 19 patients with neurological deficit, 13 had a progressive neurological deficit and were operated on at a mean of 26 (1-60 days) from the onset of symptoms. Neurological status at presentation, evaluated on the basis of Frankel grade was Frankel C (6), Frankel D (13) and Frankel E (6). The mean estimated blood loss in all patients was 1,696 (400-5,000) ml; mean operating time was 276 (90-690) min and an average of 2.3 (0-7) units of whole blood was transfused.…”

“…The authors of previous reports have shown efficacy for renal and non-renal spinal metastases such as melanoma, sarcoma, thyroid, breast, prostate, hepatic carcinoma, and neuroendocrine tumours such as paragangliomas [6][7][8][9][10][11][12][13]. Nevertheless, the amount of blood loss is variable [13,[17][18][19][20]. The procedure is associated with minimal morbidity when performed by experienced interventional radiologists.…”

“…an estimate of the extent of tumour blush visible after treatment. The grading scale used in this study was similar to that used by others, including the very experienced unit in Memorial SloanKettering, New York [7,13].…”

“…Pre-operative embolisation of such hypervascular tumours aims to reduce intra-operative blood loss and improves the surgeon's ability to decompress the spinal cord and maximize tumour resection [4][5][6][7][8][9][10][11][12]. Other potential benefits include reducing mass effect, arresting tumour growth, alleviating pain, and shortening hospital stays [3,13].…”