Treatment

Spine fractures, also known as vertebral compression fractures, are a common and painful side effect of cancer that has originated in or spread to the spine. Used before or in conjunction with surgery and/or radiation therapy, our team often begins treatment using two minimally invasive, nonsurgical techniques -- vertebroplasty and kyphoplasty -- to stabilize these cancer-related spine fractures. These procedures are performed by our interventional radiologists.

In vertebroplasty, the physician injects a special kind of bone cement directly into a collapsed vertebra. Another technique is kyphoplasty, in which a small balloon called a tamp is inserted into the vertebral body and inflated. This creates a space into which the bone cement is then injected. The cement used in either technique can also serve as a marker for radiation oncologists if a patient is undergoing image-guided radiation therapy (IGRT) to his or her spine to treat metastatic disease.

These techniques are meant to improve a patient's quality of life by decreasing pain and increasing mobility.

In patients for whom kyphoplasty is not effective, our interventional radiology team is beginning to explore the efficacy of inserting a stabilizing rod through the skin to provide spine support and avoid the need for surgery.

	Spine Metastases: Decision Making and Treatment Options Neurosurgeon Mark H. Bilsky Runtime: 19 minutes

Because most patients respond to radiation therapy, only about 10 percent of patients require surgery. Surgery is usually recommended in cases where an operation is the only way to achieve pain relief or to improve neurologic symptoms that, for example, can impair a patient's ability to walk. Following surgery, most patients will require radiation therapy to prevent tumors from returning.

The role of surgery in patients with primary tumors, such as sacral chordoma, is often curative. Techniques have been developed to remove tumors in a single piece (a procedure called en bloc resection). To treat intradural extramedullary tumors, such as schwannomas and myxopapillary ependymomas, the cancerous tissue can be separated from nerve roots and the spinal cord, while preserving normal neurological function.

The most common intradural intramedullary tumors are ependymoma and astrocytoma. To remove ependymomas, which have cysts that develop adjacent to the tumor, surgery offers the possibility of cure. The most common treatment for astrocytomas is a biopsy or surgery followed by radiation therapy.

The role of surgery in patients with metastatic spine tumors is usually palliative to reduce pain and increase mobility. Most of these operations are performed from the back side of the body, meaning that a front incision is not necessary. Advanced techniques for tumor surgery, including spinal cord decompression and spinal instrumentation, have improved symptom relief. For patients with metastatic cancer to the spine, these techniques also allow patients to return to systemic therapy (such as chemotherapy) to treat their primary disease.

Stabilization of the spine following a spine tumor operation is one of the main goals of surgery. Surgical implants are frequently used to rebuild the spine.

• Intraoperative Monitoring

  The intricate structure of the nervous system -- of which the spinal cord is part -- may become disrupted due to tumor growth, which results in weakness or numbness. This can mean that during certain surgeries, particularly surgery on the spine, there is a greater danger of neurologic damage.

  At Memorial Sloan-Kettering, patients undergoing surgery for spine tumors are also monitored with a system called intraoperative neurophysiologic monitoring (IONM). By observing and monitoring motor and sensory pathways throughout the course of surgery, our neurologists are able to better assist the surgeon during complicated procedures.

  During surgery, neurologists use IONM to conduct motor and sensory tests, as well as electromyography and nerve stimulation. By monitoring for any changes in neurologic function during surgery, the neurologist is able to inform the surgeon of any changes, which if altered can prevent damage to essential neurologic structures.

• Spinal Angiogram & Embolization

  The risk of blood loss during surgery can be increased if the tumor contains a large number of blood vessels (what is known as a hypervascular tumor). To identify these abnormal blood vessels prior to surgery, an injection of dye is administered and an x-ray of the blood vessels -- called spinal angiography -- is taken. The dye makes the blood vessels visible in the x-rays.

  If the source of the blood supplying the tumor is found, an interventional radiologist can perform a procedure known as embolization to block the vessels, and surgery can be performed with less risk to the patient.

	Image-Guided Radiation Therapy (IGRT) Learn more about IGRT, an enhanced form of radiation used to treat cancer Runtime: 3 minutes

Radiation therapy is one of the most common treatments for spine tumors. Memorial Sloan-Kettering's radiation oncologists use image-guided radiation therapy (IGRT) to treat these tumors.¹

IGRT -- in which real-time image guidance is used to deliver high-dose radiation -- is very successful in treating primary and metastatic spine tumors. This technology enables doctors to pinpoint tumors with extreme accuracy while sparing healthy tissue and causing few side effects. IGRT is also useful to treat tumors that have not responded well to conventional radiation therapy.

Prior to treatment, doctors perform a computed tomography (CT) scan as well as a myelogram (an x-ray taken after an injection of dye into the space between the lining of the spinal cord and brain). Imaging the tumor just before the delivery of radiotherapy -- or during treatment -- enables radiation oncologists to verify the tumor's exact location, thereby reducing the margin of healthy tissue exposed to radiation to five millimeters, and in certain cases, to as little as one or two millimeters.

¹V. C. Prabhu, M. H. Bilsky, K. Jambhekar,K. S. Panageas, P. J. Boland, E. Lis, L. Heier, P. K. Nelson. Results of preoperative embolization for metastatic spinal neoplasms. Journal of Neurosurgery. Mar;98(2 Suppl), 2003: 156-64. [PubMed Abstract]

²M. H. Bilsky, P. Gerszten, I. Laufer, Y. Yamada. Radiation for primary spine tumors. Neurosurgery Clinics of North America. 2008 Jan;19(1):119-23. [PubMed Abstract]