Spinal tumors account for approximately 6-10% of all bone tumors in the body. Almost all types of bone tumors can be seen in the spine, such as osteosarcoma, osteoid osteoma, and aneurysmal bone cysts, while metastatic bone tumors account for more than half of spinal tumors. Early diagnosis of spinal tumors is important because the functional outcome is dependent on the neurological status at the time of presentation. In contrast, spinal metastases themselves are often asymptomatic and are often detected only on routine bone scans.
The presence of symptoms may be the result of one or more of the following.
1. invasion of the paravertebral soft tissues by a progressively larger mass within the vertebral body that breaks through the bone cortex.
2, compression or invasion of adjacent nerve roots.
3, destruction of the vertebral body secondary to a pathologic fracture.
4, spinal instability following a pathological fracture, especially when complicated by osteolytic destruction of the posterior lateral attachments
5, spinal cord compression.
Back pain is the most common symptom in patients with spinal metastases, often preceding other neurological symptoms by weeks or months. Two types of back pain of different nature can be seen: tumor-related pain and mechanical pain.
1. Tumor-related pain: It mainly presents as nocturnal or early morning pain and is usually relieved by activity during the day. This pain may be caused by inflammatory mediators or the tumor stretching the periosteum of the vertebral body. Small doses of hormones (e.g., 12 mg of dexamethasone daily) are effective for this pain. Definitive treatment of the tumor with radiation therapy or surgery may relieve this pain. Recurrence of pain after treatment is indicative of local recurrence of the tumor.
2. Mechanical pain: It arises from structural abnormalities of the spine, such as pathological compression fractures leading to instability of the spine. This pain is motion-related, as sitting or standing position increases the longitudinal load on the spine, thus aggravating the pain. In addition, if the patient has a posterior protrusion deformity due to a compression fracture of the thoracic or thoracolumbar spine, the pain is severe in the prone position and the patient often has a history of sleeping in a sitting position. Hormonal therapy is ineffective for mechanical pain, and pain can be relieved with narcotic analgesics or external bracing. Pain due to pathologic compression fractures of the thoracic spine usually lasts for several days, and if the tumor does not invade the posterior lateral attachments, the pain usually resolves after several days.
Currently, the treatment of spinal tumors generally requires a definitive diagnosis through biopsy first. The principles of treatment for primary spinal tumors are the same as those for limb tumors.
There are three main approaches to the treatment of spinal metastases: chemotherapy, radiation therapy and surgery. The goal of both medical and surgical treatment of metastases is to maximize the quality of life. Once the diagnosis of metastases is established, the role of surgery or surgery in combination with other treatments is to relieve pain, improve or maintain neurological function, and restore the structural integrity of the spine. Determining the treatment plan for spinal metastases requires multidisciplinary involvement such as medical oncology, general medicine, radiology, radiation therapy, neurology and orthopedics.
I. Disease examination
1.Computed tomography (CT) scan: For those who are clinically suspected but the diagnosis cannot be confirmed by X-ray, CT examination can be performed. It can clearly show the sacroiliac joint space, and facilitate the determination of whether there is widening, narrowing, ankylosis or partial ankylosis of the joint space, which is unique.
2.Magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) examination with SPECT: 38% of inflammatory lower back pain was found to have sacroiliac arthritis, while no such finding was found in the group with mechanical causes. the positive finding rate was significantly higher with simultaneous examination of MRI and SPECT. Sacroiliac arthritis was present in 58% of patients with inflammatory lower back pain and 17% of patients with mechanical lower back pain. Therefore, the investigators concluded that MRI and sPECT scintigraphy of the sacroiliac joint is very helpful for very early diagnosis and treatment.
Differential diagnosis
1, spinal tumors are mostly present as pain, neurological impairment, masses, pathological fractures, etc., and can also be detected by incidental physical examination.
The patient’s skin boils or other septic foci are more abrupt, high temperature, obvious toxic symptoms, pain in the affected part, limited movement, local soft tissue swelling and pressure pain before the onset of septic inflammation of the spine.
3, degenerative spinal lesions: intervertebral discs, ligaments protrude into the spinal canal causing spinal cord and nerve compression. Almost all imaging signs of spinal degeneration exist after middle age, and the differential diagnosis of spinal cord tumors depends on careful neurological evaluation, supplemented by imaging.
4. Spinal tuberculosis: chronic toxic symptoms such as low fever and night sweats, lesions that mostly erode the intervertebral discs and the corresponding vertebral body margins, and paravertebral cold-shaped pustules help in the differential diagnosis.
Third, the disease complications
1, incision infection, fissure: poor general condition, poor healing ability of the incision or cerebrospinal fluid leakage is prone to occur. Intraoperative attention should be paid to aseptic operation. In addition to postoperative antibiotic treatment, the systemic condition should be actively improved, with special attention to protein and multivitamin supplementation.
2, spinal cord edema: often caused by surgical operation damage to the spinal cord, clinical manifestations similar to hematoma, treatment is based on dehydration, hormones, severe cases can be re-operated, open the dura.
3, epidural hematoma: incomplete hemostasis of the paravertebral muscles, vertebrae and dural venous plexus can result in postoperative hematoma, causing increased limb paralysis, which mostly occurs within 72h postoperatively, even with the placement of drainage tubes. If this phenomenon occurs, it should be actively explored to remove the hematoma and completely stop the hemorrhage.
IV. Preventive care
1, pay attention to your health, if you feel numbness, pain and other symptoms, you should communicate with your doctor and do the examination early to confirm the diagnosis.
2, electromagnetic radiation from cell phones, computers, TV, microwave supplies, try to use more wired phones, use the computer should be at an arm’s length from the screen, do not watch TV for too long.
3, develop good posture habits, pay attention to warmth, prevent the wind and cold, protect the cervical vertebrae, lumbar vertebrae, thoracic vertebrae, etc.
4, reduce and avoid radioactive radiation, especially in the period of adolescent bone development.
5.Avoid trauma, especially in the long epiphysis of the developing adolescent.
6.Strengthen physical exercise, enhance physical fitness, improve resistance to diseases, strengthen immune function and prevent viral infections.
7.It is advisable to eat more foods with anti-myelopathy and osteosarcoma, such as kelp, nori, tamari, sea clam, wakame, almond, peach kernel and plum. Bone pain is advisable to eat turtle plate, turtle meat, perforated shell, oyster, crab, shrimp, walnuts. Avoid smoking, alcohol and spicy stimulating food, moldy, pickled, fried, fatty food, lamb, goose, pig’s head and other hairy things.
8, less smoking and drinking, try to avoid tobacco and alcohol to stimulate the body. More exercise.
V. Pathogenesis
1.Progressively enlarged masses in the vertebral body break through the bone cortex and invade the paravertebral soft tissues.
2, compression or invasion of adjacent nerve roots.
3, destruction of the vertebral body secondary to pathological fracture.
4. spinal instability following a pathological fracture, especially when complicated by osteolytic destruction of the posterior attachment.
5. Spinal cord compression. Spinal cord compression has been reported to occur in approximately 5% of patients with extensive metastatic cancer. Metastatic tumor foci infiltrate the vertebral body and reduce its strength, resulting in partial collapse of the vertebral body and subsequent invasion of tumor tissue or bone fragments into the spinal canal, which is the most common cause of spinal cord or nerve root compression.
Prognosis
1. Site of lesion: The difficulty of spinal malignant tumors appearing in different parts of the spine varies in terms of the ease of surgical resection. The lower cervical, lower thoracic, thoracolumbar and lumbar segments of the spine are relatively easy to reveal surgically, and surgical resection is relatively easy to perform, and the corresponding recurrence rate is low. Malignant tumors located in the upper cervical segment, upper thoracic segment of the spine or lamentable bone area are relatively difficult to be revealed surgically, and surgical resection is relatively difficult to be performed, and the corresponding recurrence rate is higher and the prognosis is relatively poor.
2.The scope of metastasis invasion: According to the MRI sagittal classification of spinal malignant tumor causing spinal deformity, spinal malignant tumor of type I and E, the lesion is still confined to the vertebral body, and surgical excision is relatively easy and the recurrence rate is relatively low. For spinal malignant tumors of type I and E, the lesions are still confined to the vertebral body, so surgical resection is relatively easy and the recurrence rate is relatively high. In concave type of spinal malignant tumor, the bone marrow and bone trabeculae in the vertebral body are completely replaced by metastases, and the tumor develops further, infiltrating and destroying the vertebral plate, making surgical resection more difficult, with a higher recurrence rate and poorer prognosis.
3.Pathological grading: Due to the different malignancy and biological behavior of primary tumors of the spine, their prognosis is also very different. The prognosis is better if the malignancy of the tumor is relatively low; the prognosis is worse if the malignancy of the tumor is relatively high.
4.Number of metastases: The number of metastases and the presence or absence of combined metastases from other organs have a greater impact on the prognosis.
5.Surgical treatment: The surgical treatment of spinal malignant tumor is difficult to perform radical resection because of its deep location, complicated anatomical structure and great surgical difficulty, and there is often a certain risk of tumor removal. In general, it is believed that resection of the diseased segment and removal of the tumor is more complete and the prognosis is better than scraping and bone grafting.