Challenge of the Week / Spine / 08.06.2021

A 68-year-old male patient with a history of prostate cancer presents with a several day history of progressive back pain, difficulty walking, and left lower-extremity weakness. On examination, he has difficulty with a tandem gait, left hip flexion and knee extension weakness, and hyperreflexic quadriceps. He has left lower-extremity sensory dysesthesia. Cervical, thoracic, and lumbar magnetic resonance imaging show an isolated metastatic lesion involving the T10 vertebral body with moderate compression of the spinal cord. Which of the following is the best next step in management?
    • Radiation therapy
    • The patient has a high BMI and a segmental fracture. This patient is best treated with surgery, and an intramedullary nail is the best option.

 

    • Intravenous corticosteroids and change in the chemotherapy protocol
    • Isolated metastatic lesion causing thoracic myelopathy should be managed with surgical decompression and stabilization. followed by adjuvant radiation therapy.

 

    • Operative decompression, instrumented spinal fusion, and postoperative radiotherapy
    • An isolated metastatic lesion causing thoracic myelopathy should be managed with operative decompression and stabilization, followed by adjuvant radiation therapy (RT). Patchell, et al. (2005) demonstrated that surgery and then RT, if indicated, results in better neurological outcome (walking ability/improvement) compared with RT alone or first.

 

    • Thoracic laminectomy
    • Thoracic laminectomy alone will yield inadequate decompression since the metastatic lesion is anterior (T10 vertebral body). Additionally, metastatic bone lacks structural integrity and, therefore, stabilization is typically required, especially when radiation therapy is to follow.

     

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