Removal of a Vertebral Metastatic Tumor Compressing the Spinal Nerve Roots via a Single-Port, Transforaminal, Endoscopic Approach Under Monitored Anesthesia Care

Abstract

Spinal cord or nerve root compression from an epidural metastasis occurs in 5-10% of patients with cancer and in up to 40% of patients with preexisting nonspinal bone metastases. Most metastatic spine diseases arise from the vertebral column, with the posterior half of the vertebral body being the most common initial focus, and/or the paravertebral region, tracking along the spinal nerves to enter the spinal column via the intervertebral foramina. An 82-year-old man diagnosed with sigmoid colon cancer and liver metastases experienced intractable pain described as being like an electric shock on the right T11 dermatome. Imaging studies revealed a huge metastatic mass destroying the right posterior T11 body and pedicle and compressing the right posterior spinal cord and nerve roots. Even after using neuropathic medication and a neural blockade, the extreme paroxysmal pain continued. Considering his elderly, debilitated state and life expectancy, removal of the vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach and percutaneous vertebroplasty (PVP) under monitored anesthetic care (MAC), rather than 3-port endoscopic surgery and corpectomy with or without fusion under general anesthesia with lung deflation, was decided upon and scheduled prior to radiotherapy. A needle was placed into the intervertebral foramen under fluoroscopy in the same manner as a transforaminal epidural block at T11. A guidewire was inserted into the needle after the needle stylet had been removed. An obturator dilator was inserted over theguidewire, and a working sleeve was inserted over the dilator. After the dilator was removed, a spinal endoscope with a 2.7 mm working channel was placed over the guidewire. Careful removal of the tumor emboli during verbal interaction with the patient was performed under MAC using dexmedetomidine, fentanyl, and ketorolac. PVP at T11 was performed through the right osteolytic pedicle. The paroxysmal pain disappeared immediately after the operation without any complications. Removal of a vertebral metastatic tumor compressing the spinal nerve roots via a single-port, transforaminal, endoscopic approach under monitored anesthesia care without lung deflation may be an effective and safe modality for minimally invasive pain management of a single-level spinal tumor metastasis causing intractable radicular pain in patients with cancer who have generalized debilitation. Key words: Combined anesthetics, endoscope, intractable pain, minimally invasive, neoplasm metastasis, palliative care, radiotherapy, spinal nerve roots, surgical procedures, vertebroplasty

Complete Endoscopic Resection of an Osteoid Osteoma in the Body of a Thoracic Vertebra

“…The full-endoscopic techniques have been reported since 2012 3 . Their use was aimed at treating neuropathic pain by decompression of nervous structures compressed by an expansive metastatic lesion.…”

“…Their use was aimed at treating neuropathic pain by decompression of nervous structures compressed by an expansive metastatic lesion. Biopsy and decompression of metastatic lesions of the spine were performed by transforaminal endoscopic access 3,7,19 . In 2015, a study demonstrated the possibility of complete resection of a lesion in the lumbar spine for the first time 16 .…”

“…Structurally, they contain osteoblasts that produce immature bone tissue and secrete prostaglandin E2 within the lesion nidus (producing local pain; one of the main symptoms) 6 . In the spine, the posterior elements of the thoracolumbar section are the most commonly involved 3,7 . The incidence is higher in males (2:1-4:1) 5 .…”

“…However, in the early 1990s, percutaneous (ablation) techniques were introduced, and these have been increasingly advocated as a treatment alternative for the resolution of these lesions, especially benign tumors 2 . Since 2012, some reports have described the usage of complete endoscopic techniques 3 . However, the literature regarding the successful application of these minimally invasive procedures, especially in spinal lesions, remains scarce 4 .…”

Full Endoscopy Combined with Allogeneic Bone Grafting for Benign Spinal Lesions: Technical Notes and Preliminary Clinical Results

“…With the development of spinal endoscopic techniques in recent years, the indications have expanded from degenerative spinal diseases to spinal infections and even spinal neoplastic diseases [12][13][14]. Depending on the number and size of working channels, spinal endoscopy can be divided into several different systems, including microendoscopic and percutaneous endoscopic surgery.…”