Advances In Treatment and Removal of Spinal Tumors

Significant advancements in the medical management of cancer mean more patients are living with the disease for longer periods of time. As a result, neurosurgeons are seeing a steady increase in the number of people with cancer who present for resection of metastatic spinal tumors. The good news is that, today, innovations in computerized navigation and intraoperative monitoring allow neurosurgeons to more safely and effectively treat a larger number of challenging spinal metastatic cases than in years past. This approach has been shown to be an effective treatment for these patients, in not only improving ambulation and preventing paralysis, but also extending life.1  “We can tackle more complicated situations with this technology than we were able to ten years or so ago,” says Dr. Eric Horn, a neurosurgeon specializing in spine surgery at Indiana University Health.

Indications for spinal tumor resection

For most patients, spinal metastases are treated with radiation, chemotherapy or medical management. However, when tumors begin to compress the spinal cord and cause symptoms, surgery may be indicated. According to Dr. Horn, people should consider surgery if their tumor is causing:

  1. Symptoms such as weakness, numbness or pain
  2. Spine instability because of bone erosion
  3. Spine deformity due to the tumor’s position or growth

The goal of surgery in these cases is to remove as much of the tumor as possible, and reconstruct the spine as needed.

The role of navigation in spinal tumor surgery

One of the innovations that allows for a more aggressive approach to metastatic spinal tumor resection is the use of computerized navigation technology. Navigation during surgery enables neurosurgeons to maneuver around the spine with an augmented margin of safety allowing them to more completely and safely remove even the most complex tumors. In addition, computerized navigation technology helps neurosurgeons determine the exact location and size of a tumor so they can visualize the boundaries and accurately determine what tissue to remove.

In many cases, neurosurgeons need to reconstruct a person’s spine following tumor resection, either due to a deformity or a void left by the tumor. Neuro-navigation aids surgeons in precisely placing the hardware needed to reconstruct the spine, especially in anatomically challenging areas such as the thoracic spine. “Placing pedicle screws in certain regions of the spine can be difficult,” acknowledges Dr. Horn. “Until neuro-navigation came along, it was fairly risky in terms of possibly damaging nerves in these areas. However, recent advances now allow for more precise placement of hardware, with a much higher degree of safety.”

Pairing innovations for better outcomes

Neuro-navigation is only part of the equation when it comes to delivering better outcomes in spinal surgery. Equally important are other technologies that can help surgeons gain additional insight into a patient’s condition.

Intraoperative imaging

Intraoperative imaging—such as that provided by the O-arm Surgical Imaging System—enables real-time, high-quality 2D and 3D images of a person’s anatomy. When combined with neuro-navigation, this technology allows surgeons to more completely remove a tumor and confirm placement of hardware before the patient leaves the operating room. “In the past, we could not see in the spine very well, so we would not offer surgery as an option because, in some circumstances, the actual surgery was just as risky as the tumor itself,” states Dr. Horn. “However, we are now able to treat these patients because our safety margins have increased.”

Intraoperative neuromonitoring 

In addition to intraoperative imaging, neuromonitoring has become increasingly valuable in spinal tumor surgery. This is especially true when removing tumors growing in the spinal cord, such as ependymomas. These generally slow-growing tumors are best treated with complete resection, yet allow for virtually no margin of error. In most instances, both motor- and somatosensory-evoked potentials are monitored to ensure the spinal manipulation is not having an adverse effect on the nerves. Changes in signals from the electrodes provide an early warning to surgeons if the nerves are starting to become irritated. This creates an increased safety margin that aids in avoiding nerve damage and paralysis. The result, says Dr. Horn, is that surgeons are able to obtain a more comprehensive feel for how the spinal cord is tolerating surgery.

 Neuromonitoring is not without limitations. Challenges with anesthesia can pose a problem with motor-evoked potentials. Dr. Horn states that having access to advanced neuro-anesthetic technology is paramount to effective monitoring. There are facilities—such as Indiana University Health Methodist Hospital—that provide a specific type of anesthetic that maintains sedation, yet does not fully paralyze the muscles, which allows surgeons to more effectively monitor motor-evoked potentials. Because intraoperative neuromonitoring is highly technical, the technique requires highly trained neurophysiological technicians who understand the nuances of the monitoring software and how to interpret the data. Patient history also plays a role in the success of monitoring. For instance, in cases of diabetes or neuropathy, surgeons may not be able to obtain interpretable signals. Existing nerve damage as a result of the tumor may also limit the usable data surgeons can record.

Postoperative treatments

Physicians regularly combine surgical techniques with post-operative treatments, such as stereotactic radiosurgery and proton beam therapy to deliver better care to patients with complex tumors. And research is currently being conducted to develop ways to insert chemotherapy agents immediately following tumor resection in an effort to eliminate any remaining cancer cells.

Impact of surgical spine innovations

While each of these innovations is individually impressive, the greatest value comes when they can be used in conjunction with one another. Together, these innovations enable physicians to deliver better outcomes and increased safety margins for patients with spinal tumors.

For more information on IU Health Neuroscience, visit http://iuhealth.org/neuroscience-center

1 Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. The Lancet. 2005;366:643-648.

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Advances In Treatment and Removal of Spinal Tumors

Significant advancements in the medical management of cancer mean more patients are living with the disease for longer periods of time. As a result, neurosurgeons are seeing a steady increase in the number of people with cancer who present for resection of metastatic spinal tumors. The good news is that, today, innovations in computerized navigation and intraoperative monitoring allow neurosurgeons to more safely and effectively treat a larger number of challenging spinal metastatic cases than in years past. This approach has been shown to be an effective treatment for these patients, in not only improving ambulation and preventing paralysis, but also extending life.1  “We can tackle more complicated situations with this technology than we were able to ten years or so ago,” says Dr. Eric Horn, a neurosurgeon specializing in spine surgery at Indiana University Health.

Indications for spinal tumor resection

For most patients, spinal metastases are treated with radiation, chemotherapy or medical management. However, when tumors begin to compress the spinal cord and cause symptoms, surgery may be indicated. According to Dr. Horn, people should consider surgery if their tumor is causing:

  1. Symptoms such as weakness, numbness or pain
  2. Spine instability because of bone erosion
  3. Spine deformity due to the tumor’s position or growth

The goal of surgery in these cases is to remove as much of the tumor as possible, and reconstruct the spine as needed.

The role of navigation in spinal tumor surgery

One of the innovations that allows for a more aggressive approach to metastatic spinal tumor resection is the use of computerized navigation technology. Navigation during surgery enables neurosurgeons to maneuver around the spine with an augmented margin of safety allowing them to more completely and safely remove even the most complex tumors. In addition, computerized navigation technology helps neurosurgeons determine the exact location and size of a tumor so they can visualize the boundaries and accurately determine what tissue to remove.

In many cases, neurosurgeons need to reconstruct a person’s spine following tumor resection, either due to a deformity or a void left by the tumor. Neuro-navigation aids surgeons in precisely placing the hardware needed to reconstruct the spine, especially in anatomically challenging areas such as the thoracic spine. “Placing pedicle screws in certain regions of the spine can be difficult,” acknowledges Dr. Horn. “Until neuro-navigation came along, it was fairly risky in terms of possibly damaging nerves in these areas. However, recent advances now allow for more precise placement of hardware, with a much higher degree of safety.”

Pairing innovations for better outcomes

Neuro-navigation is only part of the equation when it comes to delivering better outcomes in spinal surgery. Equally important are other technologies that can help surgeons gain additional insight into a patient’s condition.

Intraoperative imaging

Intraoperative imaging—such as that provided by the O-arm Surgical Imaging System—enables real-time, high-quality 2D and 3D images of a person’s anatomy. When combined with neuro-navigation, this technology allows surgeons to more completely remove a tumor and confirm placement of hardware before the patient leaves the operating room. “In the past, we could not see in the spine very well, so we would not offer surgery as an option because, in some circumstances, the actual surgery was just as risky as the tumor itself,” states Dr. Horn. “However, we are now able to treat these patients because our safety margins have increased.”

Intraoperative neuromonitoring 

In addition to intraoperative imaging, neuromonitoring has become increasingly valuable in spinal tumor surgery. This is especially true when removing tumors growing in the spinal cord, such as ependymomas. These generally slow-growing tumors are best treated with complete resection, yet allow for virtually no margin of error. In most instances, both motor- and somatosensory-evoked potentials are monitored to ensure the spinal manipulation is not having an adverse effect on the nerves. Changes in signals from the electrodes provide an early warning to surgeons if the nerves are starting to become irritated. This creates an increased safety margin that aids in avoiding nerve damage and paralysis. The result, says Dr. Horn, is that surgeons are able to obtain a more comprehensive feel for how the spinal cord is tolerating surgery.

 Neuromonitoring is not without limitations. Challenges with anesthesia can pose a problem with motor-evoked potentials. Dr. Horn states that having access to advanced neuro-anesthetic technology is paramount to effective monitoring. There are facilities—such as Indiana University Health Methodist Hospital—that provide a specific type of anesthetic that maintains sedation, yet does not fully paralyze the muscles, which allows surgeons to more effectively monitor motor-evoked potentials. Because intraoperative neuromonitoring is highly technical, the technique requires highly trained neurophysiological technicians who understand the nuances of the monitoring software and how to interpret the data. Patient history also plays a role in the success of monitoring. For instance, in cases of diabetes or neuropathy, surgeons may not be able to obtain interpretable signals. Existing nerve damage as a result of the tumor may also limit the usable data surgeons can record.

Postoperative treatments

Physicians regularly combine surgical techniques with post-operative treatments, such as stereotactic radiosurgery and proton beam therapy to deliver better care to patients with complex tumors. And research is currently being conducted to develop ways to insert chemotherapy agents immediately following tumor resection in an effort to eliminate any remaining cancer cells.

Impact of surgical spine innovations

While each of these innovations is individually impressive, the greatest value comes when they can be used in conjunction with one another. Together, these innovations enable physicians to deliver better outcomes and increased safety margins for patients with spinal tumors.

For more information on IU Health Neuroscience, visit http://iuhealth.org/neuroscience-center

1 Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. The Lancet. 2005;366:643-648.

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