HPI: The patient a 70-year-old male presents with one week of severe pain in the lower neck and upper thoracic spine. He also complains of upper extremity pain and numbness in the medial forearm, and medial two fingers. Patient has a primary diagnosis of small cell lung cancer (SCLC) for nine months currently on chemotherapy.
PMH: CAD with cardiac stents, 2005 . Hypertension, Depression, Rheumatoid arthritis, SCLC
Social History: Retired, married. Has a 30 pack year smoking history. No alcohol use.
Family History: Unremarkable.
Exam: Alert, oriented x 3. Cranial nerves II-XII non-focal. 4/5 muscle strength in hand grip and intrinsic hand muscles bilaterally. Sensation decreased to light touch in the medial forearm and medial two fingers. Reflexes symmetric not exaggerated. Local tenderness over the cervico-thoracic junction posterior midline.
Figure 1. Sagittal T1-weighted MRI images demonstrating spinal epidural enhancing mass involving the vertebral body with ventral soft tissue component.
Figure 2. Sagittal and axial T2 images demonstrating pathological compression fracture of T1 vertebra with soft tissue component ventral to the spinal cord
Figure 3. Sagittal CT scan demonstrating pathological fracture of T1 and C7-T1 anterolisthesis with angulation.
1. What would be your next step in managing this patient?
2. Given that your next step is a surgical procedure, how would you proceed?
3. If corpectomy is your surgical choice, which approach would you choose?
4. What do you do in your practice to adequately identify T1 intraoperatively
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Please add any suggestions or comments regarding this case:
- given the patient's history and current neurological status, it is best to treat him conservatively with orthoses, pain killers and if needed, a CT guided biopsy.
- Need information on prior treatment of SCLC including Radiotherapy and life expectancy
- Are you sure there are no other mets? If there are e.g. brain or other bone, then I would radiate for palliation and not operate.
- I need to know the progress this particular patient. Thanks.
- i would obtain an AP film / flouro image as well as at lateral film with a marker at the last disk space visualized with shoulder traction for the xray
- Would determine on pre-op ct scan the feasibility of anterior approach. If I was unable to access T1 adequately, then I would use a sternal splitting approach.
- I would start of with a full metastatic workup for a site that could be biopsed for a diagnosis. I would then consider a C4/5-T3/4 posterior fusion with an osteotomy/costotransversectomy in order to decompress the spinal cord and remove the extravertebral tumor. I would consult rad onc to see if the patient would be a candidate for stereotactic radiosurgery to the T1 vertebral body, particularly if the tumor is radiosensitive
- Really it is a diffcult case, but not imposible to help the pacient get better, and we can do the best for him, in the state of the art actually. I think that this kind of cases must be treat with both surgery and quemotherapy plus radiation. Doing just one or two of the procedures are not the same that the combination of three. It is not a heroic approach but it could be the best to make a comfortable long life as posible.
- best choice is vertebroplasty and radiation. It does not require general anhaestesia, does not exclude subsequent treatment if unsuccessful, a one-day access at the hospital is enough..
- opino por este caso, que la mejor opcion seria la cirugia debido a la integridad neuronal, para evitar el progreso de las funciones motoras. tecnica: corpectomia a t1 mas exceresis tumoral epidural mas laminectomia a ese nivel. en caso que presentara deficit como paraplejia no estaria indicado la cirugia
- A known case of secondary and proven by CT guided biopsy radiation therapy is my first choice.Along analgesic and cervical-thoracic orthoses.
- I had the similar case, patient with excessive compresion fracture of T1 with the repulsion to spinal canal, he has radiculopathy C7, 8 with the acral motoric lost of left hand digit, there is no oncohistory, so we decide to do combination of corpectomy + posterior fixation , although with the onco screening to find primary lesion.
- It would be important to know if there are other metastasis as this would influence decision making. Estimates of life expectancy also influence decision making. Small cell is very radiosensitive. If there were other mets, I would not biopsy it, but would place patient in a cervical thoracic brace, radiate and follow closely clinically. If there were no other mets and the patient had at least three months life expectancy, would operate.
- The options for the management of this patient indicate lack of awareness on the indications of surgical management of metastatic small cell carcinoma. It would be unfortunate to offer surgery to this male. It is one thing to discuss approaches to the C7-T1 region, but in this context it is unwarranted. Decision making in this case should put into consideration the age of the patient, the extent of his primary disease,his lack of signficant neurological deficit and so on. Please make cases more relevant!
- Getting T1 on him I suspect is doable from a conventional anterior approach with CAREFUL AND ONLY SLIGHT extension from his current position: a) under traction, b) with monitoring, and c) with live fluoro. He'd be at elevated risk of recurrent laryngeal nerve and maybe even thoracic duct injury, and part of C7 would have to go to make this work, but I think it's doable. Without adequate anterior support, especially given that he's already out of sagittal balance, he'll collapse. (Been there, done that).
- would like to establish mets to other organs and expected survival prior to offering treatment
- This is most likely metastasis.There is no point in performing radical surgery for mild-moderate neurological deficit. Important to obtain estimated life expectancy. Ill be inclined to apply a external stabilisation and radiate. If there is progressive neurological deficit then i'd perfrom a laminectomy and fusion bearing in mind that this would leave patient with significant loss of motion in a mobile segment of neck.Patient decision is very important.
- This is interesting!
- Clinical differentiation between cancer pain and instability pain is important and not mentioned in clinical description. Instability will need stabilisation Response to analgesics and steroids can be tried for a few days and radiation started which if effective will control pain and serve the purpose. Surgery is unlikely to benefit the patient.