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Journal of Peking University (Health Sciences) ›› 2023, Vol. 55 ›› Issue (3): 530-536. doi: 10.19723/j.issn.1671-167X.2023.03.020

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Percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of spinal metastases

Yun-peng CUI1,Xue-dong SHI1,*(),Jia LIU2,Chuan MI1,Bing WANG1,Yuan-xing PAN1,Yun-fei LIN1   

  1. 1. Department of Orthopaedics, Peking University First Hospital, Beijing 100034, China
    2. Department of Radiology, Peking University First Hospital, Beijing 100034, China
  • Received:2020-10-22 Online:2023-06-18 Published:2023-06-12
  • Contact: Xue-dong SHI E-mail:992516215@qq.com

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Abstract:

Objective: To investigate the effectiveness of percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of patients with spinal metastases. Methods: In the study, 12 patients of spinal metastases treated with percutaneous pedicle screw fixation combined expandable tubular retractor in our hospital were retrospectively reviewed between June 2017 and October 2019. Among the 12 patients, 9 were males and 3 were females; the median age was 62.5 years [(65.1±2.9) years]. The decompression segment of 7 patients was located at the lower thoracic spine (including 1 patient with incomplete paraplegia) and the decompression segment of 5 patients was located at the lumbar spine; Tomita score was 6.0±0.6. Perioperative data of the patients were reviewed. Visual analog scale (VAS score), Karnofsky score, and Eastern Cooperative Oncology Group (ECOG) score were compared before and after surgery. The patient's survival, adjuvant treatment, and internal fixation failure were observed in the follow-up period. Results: All the 12 patients had a successful operation with percuta-neous pedicle screw fixation combined expandable tubular retractor. The average operative time, blood loss, and blood transfused of the patients were (247.0±14.6) min, (804.2±222.3) mL and (500.0±100.0) mL, respectively. The average amount of drainage was (240.8±79.3) mL. Drainage tubes were pulled out early postoperative [(3.2±0.3) d], allowing early mobilization. The patients discharged (7.8±0.8) d postoperative. All the patients were followed up for 6-30 months, and the average overall survival time was (13.6±2.4) months. During the follow-up period, 2 patients experienced screw displacement, the internal fixation was stable after conservative treatment and no revision surgery was performed. The VAS of the patients was 7.1±0.2 before surgery, which decreased to 2.3±0.1 and 2.8±0.4 at 3 and 6 months after surgery (P < 0.05). The Karnofsky score of the patients was 59.2±1.9 before surgery, which increased to 75.0±1.9 and 74.2±3.1 at 3 and 6 months after surgery (P < 0.05). The ECOG of the patients was 2.3±0.2 before surgery, which decreased to 1.7±0.1 and 1.7±0.2 at 3 and 6 months after surgery (P < 0.05). Conclusion: For selected patients with spinal metastases, minimally invasive surgical treatment of spinal metastases (percutaneous pedicle screw internal fixation combined with expandable tubular retractor) can effectively relieve the clinical symptoms and improve the quality of life, with satisfactory clinical outcome.

Key words: Spinal, Metastasectomy, Minimally invasive surgical procedures, Percutaneous pedicle screw fixation

CLC Number: 

  • R738.1

Table 1

Demographics and preoperative data of 12 patients with spinal metastases"

Items Minimally invasive spine surgery (n=12)
Gender
  Female 3
  Male 9
Age/years, ${\bar x}$±s 65.1±2.9
Primary tumor
  Renal 3
  Lung 3
  Prostate 2
  Multiple myeloma 2
  Uroepithelium 1
  Esophageal 1
Bilsky compression grade
  1c 3
  2 8
  3 1
ASIA grade
  D 1
  E 4
  Lesion locate below L1 7
Location of the lesion
  Lumbar 7
  Thoracic 5
Tomita score, ${\bar x}$±s 6.0±0.6
SINS score, ${\bar x}$±s 10.3±0.3
Karnofsky score, ${\bar x}$±s 59.2±1.9
ECOG grade, ${\bar x}$±s 2.3±0.2
VAS, ${\bar x}$±s 7.8±0.2

Figure 1

Long segment percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of patients with spinal metastases A 78-year-old female with uroepithelium cell carcinoma and multiple metastases suffered intractable low back and radiating pain. The patient performed percutaneous vertebro plasty (PVP) 2 months ago because of L4 metastasis, long-segment fixation. A, preoperative lumbar X-rays, MRI show bone destruction of the L4 vertebra, and an abnormal signal appears in the L4 vertebral body and spinal canal. The dural sac is significantly compressed. Chest CT showed left pleural effusion with atelectasis. B, during the operation, pedicle screws were inserted percutaneously, the scope of resection was confirmed under fluoroscopy, photos under the tubular retractor (dural sac compression was relieved) and the skin incision. C, postoperative X-ray shows stable internal fixation and bone cement position. D, postoperative CT and MRI shows the extent of surgical resection and degree of decompression."

Table 2

Surgical results of 12 patients with spinal metastases"

Items Minimally invasive spine surgery (n=12)
Operative time/min 247.0±14.6
  Tumors originating from the renal 282.7±33.7
  Others 235.1±15.0
Estimated blood loss/mL 804.2±222.3
  Tumors originating from the renal 1 900.0±458.3
  Others 438.9±79.8
Number of patients transfused 10 (83.3%)
Blood transfusion/mL 500.0±100.0
  Tumors originating from the renal 666.7±352.8
  Others 444.5±80.1
Perioperative complications
  Dural injury 2 (16.7%)
  Urinary tract infection 0
  Deep vein thrombosis 0
  Pneumonia 0
  Screw malposition 0
  Wound problem 0
Total amount of drainage/mL
  All patients 240.8±79.3
  Patients without dural injury 127.5±24.4
Postoperative drainage tube removal/d 3.2±0.3
Postoperative hospital stay/d 7.8±0.8

Figure 2

Short segment percutaneous pedicle screw fixation combined expandable tubular retractor in the treatment of patients with spinal metastases An 80-year-old male with multiple myeloma presented intractable right lower extremity radiation pain, short-segment fixation. A, preoperative lumbar X-rays and MRI showed bone destruction of the L4 vertebra and abnormal signal appeared in L4 vertebral body and intervertebral foramen, L4 nerve root was squeezed. B, photos under the tubular retractor (nerve root compression was relieved) and the skin incision. C, postoperative X-ray shows good internal fixation and bone cement position. D, 12 months postoperation, radiology showed screws displacement at L3 and fresh vertebral compression fracture at L2. Percutaneous vertebra plasty (PVP) was performed at L2 and bone cement was used to increase the holding force of pedicle screws at L3. E, 24 months postoperation, X-ray shows screws was maintained stable. F, postoperative CT shows the extent of surgical resection."

Table 3

Follow-up data of 12 patients with spinal metastases"

Items Minimally invasive spine surgery (n=12)
Overall survival/months, ${\bar x}$±s 13.6±2.4
Screw displacement 2 (16.7%)
ASIA grade
  D 0
  E 5
  Lesion locate below L1 7
Subsequent treatment
  Targeted therapy 4
  Systemic therapy 4
  Radiotherapy 2
  None 2
Number of deaths 3 (25%)

Table 4

VAS and Karnofsky score before surgery and 6 months after surgery of 12 patients with spinal metastases"

Items Minimally invasive spine surgery (n=12)
VAS, ${\bar x}$±s
  Preoperation 7.1±0.2
  Discharge 2.6±0.1*
  3 months postoperation 2.3±0.1*
  6 months postoperation 2.8±0.4*
Karnofsky score, ${\bar x}$±s
  Preoperation 59.2±1.9
  3 months postoperation 75.0±1.9*
  6 months postoperation 74.2±3.1*
ECOG grade, ${\bar x}$±s
  Preoperation 2.3±0.2
  3 months postoperation 1.7±0.1*
  6 months postoperation 1.7±0.2*

Figure 3

Diagram of tubular retractor placement A, the tumor invaded the pedicle and facet joints, the retractor was placed close to the facet joint with a small tilt angle; B, the tumor does not invade the facet joint, but invades parts of the pedicle, the retractor was placed far away from the facet joint and had a larger tilt angle."

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