• HPI: 51-year-old woman with a history of stage IIIA mucinous ductal adenocarcinoma of the right breast status-post right mastectomy with axillary lymph node dissection and adjuvant chemotherapy 2 years ago now considered to be well-controlled on Tamoxifen. She has recently been suffering from low back pain centered in the midline for the past 4 months after doing some heavy lifting at a garage sale. She underwent chiropractic manipulation and some physical therapy with mild improvement in her symptoms. Because she was having persistence of her symptoms, she was evaluated by her PCP and a spine x-ray demonstrated a T12 compression fracture. She was subsequently admitted to the hospital for pain control and further work-up of possible metastatic disease. A CT and MRI were performed (see below). A neurosurgical consultation was requested further evaluation and management of her findings. 

    REVIEW OF SYSTEMS: Denies any constipation or incontinence of stool or urine and no pain, numbness, tingling, weakness or her lower limbs or upper limbs. She has no neck pain; she complains only of pain at her tailbone and sacrum but none in the thoracic spines. She has a diminished appetite with some weight loss in the past. 

    PMH: 
    1. Sinus surgery for history of polyps. 
    2. Tubal ligation. 
    3. History of stage IIIA mucinous ductal adenocarcinoma of the right breast, status post adjuvant chemotherapy. 

    SOCIAL HISTORY: She lives locally and has rare alcohol use; no illicit drug or tobacco use. 

    FAMILY HISTORY: Significant for breast cancer and lymphoma. There is no history of spinal tumors or other neurological diseases in the family. 

    CURRENT MEDICATIONS: 
    1. Tamoxifen. 
    2. Oxycodone. 

    ALLERGIES/MEDICATIONS: NKDA. 

    PHYSICAL EXAMINATION: She has full strength in her upper and lower limbs bilaterally. Reflexes are 3+ at both biceps, triceps, patella and Achilles (symmetric and stable according to the patient). She has normal rectal tone and perineal sensation. Palpation of the thoracic and lumbar spines reveals tenderness at the lumbosacral junction; there are no palpable step-offs or deformities. 

    LABS: WBC 11.3, Hct 40, Platelets 299, Sodium 136, Potassium 3.8, BUN 17, Cr 0.9, Calcium of 9.5. 

    RADIOGRAPHICAL FINDINGS: CT and MRI C/T/L spine: Evidence of pathologic compression fracture involving the T1 vertebral body resulting in mild compromise of the central canal and narrowing of the left neural foramen. Presumed metastatic soft tissue lesions extensively replaced bone marrow within the vertebral bodies at T12, and left pedicle and body of L1. There is narrowing of the spinal canal at the T1 level without evidence of acute compression. At the T12 level, tumor causes moderate to severe central stenosis and compresses the conus, although no obvious signal abnormality is present within the cord itself. There is evidence of epidural tumor extension inferiorly beneath the posterior longitudinal ligament which joins epidural tumor emanating from the left L1 vertebral body and pedicle metastasis. The other vertebral bodies to not appear to be grossly involved and no other areas of central stenosis are identified. 

    You ask the Oncologist about the patient’s prognosis. She states that the patient may live for several years with this particular metastatic disease process (bone-only breast cancer mets).

    Figure 1. Lateral C/T/L spine xray.

    Figure 2. CT Recons of the C/T/L spine without contrast.

    Figure 3. CT Recons of the C/T/L spine without contrast.

    Figure 4. CT Recons of the C/T/L spine without contrast.

    Figure 5. Sagittal MRI C/T/L spine with and without contrast.

    Figure 6. Sagittal MRI C/T/L spine with and without contrast.

    Figure 7. Sagittal MRI C/T/L spine with and without contrast.

    1. What is the next best step in management?

    2. Which lesion would you consider to be the most concerning?

    3. Her staging workup in the hospital is negative for other foci of metastatic disease. You discuss her treatment options and she wants to be aggressively managed to prevent any development of neurological problems. What is your surgical plan?

    4. Please add any suggestions or comments regarding this case:

    Aromatase inhibitor and radiotherapy to involved vertibrae. Vertibrae appear stable at t1. consider fusion and laminectomy at t12 L1 level to avoid sudden deterioration due to collapse and kyphosis.            

    T12/L1 anterior corpectomy and fusion. 2nd op 4-6 weeks later>Cy copectomy and anterior fusion.           

    We miss the axial images,that can give us more elements for a surgical planning. I think however that a correct management could be: anterior corpectomy and fusion of T1 and after some weeks anterior corpectomy and fusion of T12/L1 with posterior fusion as last procedure.             

    Deary, hence 3 columns are affected in T12/L1,i'd prefer both ant. and post approaches to fix the 3 columns; regarding C7 level I'd prefer to cinserve ,hard neck collar & pain management. this provides optimal decompression,shorter operation time,less blood loss best regards mostafa atteya, N.S. senior resident. damanhour,Egypt wish your kind reply after decision @ takelooknow@yahoo.com

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