Spinal metastatic lesions: bridging the gap between imaging and

Spinal metastatic lesions: bridging the gap between imaging and interventions Bassem A. Georgy, M.D.,
North County Radiology
Assistant Clinical Professor,
University of California, San Diego
Background
• Not how to read MRI
• It is about how the interventionalist or surgeons read MRI
Tomita Classification
Spine 2001
The WBB (Weinstein‐Boriani‐Biagini) 1997
Pre‐surgical planning for Malignant lesions
Excisional procedure for metastatic spine tumor
(A)intralesional excision or debulking, complete removal of the
tumor piece-by-piece,
(B) en bloc resection, the tumor is removed in a single piece
Gasbarrini Cappuccio M, Mirabile L, et al.. Eur Rev Med Pharmacol Sci 2004;8:269;
Posterior decompression and stabilization is
This procedure does not necessarily involve
a direct approach to the tumor.
Gasbarrini Cappuccio M, Mirabile L, et al.. Eur Rev Med Pharmacol Sci 2004;8:269
En bloc tumor excision of the vertebral bodies can be performed with appropriate
margins if the tumor is confined to zones 4–8 or 5–9, with one pedicle that is not
involved by tumor.
67 years-old-women with primary breast cancer
and diagnosed Multiple Myeloma
Percutaneous Tumor Management
• Complete ablation
– Osteoid Osteoma
– Single metastasis
• Palliative treatment: Pain management
– Cementoplasty
– Ablation
• RF ablation
• Coblation
• Cryoablation
– Combined techniques
RF for
Osteoid Osteoma
RF
Single Metastasis
RFA
Schaefer Ablation umages
Schaefer Ablation umages
Schaefer Ablation umages
Schaefer Ablation umages
Schaefer et al. AJR 2003;180:1075-77
Spinal Metastasis, Good Candidates
AJNR Nov 08
Pre‐Procedure
(CT, MRI)
•No Cortical Disruption
•No Epidural Extension
Para‐spinal Soft Tissue Extension
•Cortical Disruption
•Epidural Extension
Conventional VP or KP
RFA ,Cryo
Augmentation
Coblation with
Augmentation
Conventional VP or KP
Type 1 & 2
Coblation with
Augmentation
Type 3, 4, ?5
RFA ,Cryo
Augmentation
Type 5
77 years old women
History of Melanoma
T6 NIM
89 year-old- woman; Myeloma, breast and stomach cancer
Breast metastasis
67 year old women with lung metastasis
Selective Nerve Root Block
YA
Spinal Metastasis, Good Candidates
AJNR Nov 08
Pre‐Procedure
(CT, MRI)
•No Cortical Disruption
•No Epidural Extension
Para‐spinal Soft Tissue Extension
•Cortical Disruption
•Epidural Extension
Conventional VP or KP
RFA ,Cryo
Augmentation
Coblation with
Augmentation
Coblation Technology
•Unique RF wave shape and frequency
•Low energy Radiofrequency
•Creates a layer of high energy plasma field
comprised of highly ionized particles
•Break organic molecular bonds in tissue •Converts the tissue into gas and create a volumetric space
• It is the plasma that ablates the tissue at low temperatures and not the radio‐frequency itself.
Ablation By‐products
• Tissue is broken down into elementary molecules and low molecular weight gases, i.e. oxygen, nitrogen, hydrogen, carbon dioxide, etc.
• For Nucleoplasty/vertebroplasty, gases exit disc through introducer needle
Volumetric removal of target tissue results
Vertebroplasty Meeting
Electrocautery
Coblation
• In‐Vivo rabbit model; simulating PLIF exposure
•
Presented at NASS annual meeting, Nov. 2001 Paul McAfee, MD, et. al.
Vertebroplasty Meeting
Cavity Tumor Procedure 1
• Insert Access Cannula
Cavity Tumor Procedure 2
• Deploy CAVITY SpineWand
Cavity Tumor Procedure 3
• Create Void
Cavity Tumor Procedure 4
• Augment with Cement
cancer 71 years old women with
Undefrentiated cancer and sacral lesion
55 years old Women with biopsy proven Plasmacytoma
76 years old woman with back pain
489001
Material and Methods
•
•
•
•
•
•
Retrospective
44 levels in 37 patients Epidural extension and or cortical disruption
Different metastatic lesions
CT before and after procedure
Plasma‐mediated RF ablation followed by cement injection
AJNR July 2009
Results
• 43%, 90‐100% of the cement was seen in the anterior 2/3
• 36%, 75% of the cement was seen in the anterior 2/3
• 13/15 levels cement deposited anterior to a posrteriorly located lesions
• 30% no leakage
• 89% reported pain relief
AJNR July 2009
74 years old women with breast cancer
63 years old with lung cancer
Less is only more
where more is no
good.
Frank Lloyd Wright 60 years old women with Breast cancer
High viscosity Confidence cement
Peak at the future
Height Restoration “Height Maintenance”
Percutaneous Reconstruction
Spine Waves
Fenestrated cannulated screws
Percutaneous Posterior fusion
Viper II
StabiliT Vertebral Augmentation System
Purpose: Deliver Ultra‐high viscosity cement to Osteoporotic VCF
Iman Maleki