J Korean Neurosurg Soc.  2019 Jan;62(1):106-113. 10.3340/jkns.2018.0073.

Clinical Significance of Preoperative Embolization for Non-Hypervascular Metastatic Spine Tumors

• Yoo SL
• Kim YH
• Park HY
• Kim SI
• Ha KY
• Min HK
• Seo JY
• Oh IS
• Chang DG
• Ahn JH
• Kim YW

• KMID: 2434352
• DOI: http://doi.org/10.3340/jkns.2018.0073

Abstract

OBJECTIVE
The efficacy of preoperative embolization for hypervascular metastatic spine disease (MSD) such as renal cell and thyroid cancers has been reported. However, the debate on the efficacy of preoperative embolization for non-hypervascular MSD still remains unsettled. The purpose of this study is to determine whether preoperative embolization for non-hypervascular MSD decreases perioperative blood loss.
METHODS
A total of 79 patients (36 cases of preoperative embolization and 43 cases of non-embolization) who underwent surgery for metastatic spine lesions were included. Representative hypervascular tumors such as renal cell and thyroid cancers were excluded. Intraoperative and perioperative estimated blood losses (EBL), total number of transfusion and calibrated EBL were recorded in the embolization and non-embolization groups. The differences in EBL were also compared along with the type of surgery. In addition, the incidence of Adamkiewicz artery and complications of embolization were assessed.
RESULTS
The average age of 50 males and 29 females was 57.6±13.5 years. Lung (30), hepatocellular (14), gastrointestinal (nine) and others (26) were the primary cancers. The demographic data was not significantly different between the embolization and the non-embolization groups. There were no significant differences in intraoperative EBL, perioperative EBL, total transfusion and calibrated EBL between two groups. However, intraoperative EBL and total transfusion in patients with preoperative embolization were significantly lower than in non-embolization in the corpectomy group (1645.5 vs. 892.6 mL, p=0.017 for intraoperative EBL and 6.1 vs. 3.9, p=0.018 for number of transfusion). In addition, the presence of Adamkiewicz artery at the index level was noted in two patients. Disruption of this major feeder artery resulted in significant changes in intraoperative neuromonitoring.
CONCLUSION
Preoperative embolization for non-hypervascular MSD did not reduce perioperative blood loss. However, the embolization significantly reduced intraoperative bleeding and total transfusion in corpectomy group. Moreover, the procedure provided insights into the anatomy of tumor and spinal cord vasculature.

Keyword

Neoplasm metastasis; Spine; Embolization therapeutic; Postoperative hemorrhage; Complications

MeSH Terms

Arteries
Female
Hemorrhage
Humans
Incidence
Lung
Male
Neoplasm Metastasis
Postoperative Hemorrhage
Spinal Cord
Spine*
Thyroid Neoplasms

Figure

• 

  Fig. 1. A case of metastatic spine disease from lung cancer. A : A 58-year-old female patient with lung cancer presented with dorsal back pain and impending cord compression sign. Preoperative sagittal and axial magnetic resonance images showed metastatic lesions resulting in instability and spinal cord compression at T6. B : Palliative surgery (T6 corpectomy, T5–7 anterior interbody graft with posterior instrumentation and posterior fusion) was carried out after preoperative embolization. During the operation, the left side 6th intercostal artery was clamped. It resulted in loss of MEP in intraoperative neuromonitoring (see also Supplementary Video 1).

• 

  Fig. 2. A case of metastatic spine disease from hepatocellular carcinoma. A : A 61-year-old male with hepatocellular carcinoma presented with progressive L2 metastatic lesions even after radiotherapy. B : Arteriography during preoperative embolization showed the presence of Adamkiewicz artery arising from the left side of L2 segmental artery. Arrowheads indicate the characteristic hairpin turn of the Adamkiewicz artery. C : Palliative surgery (L2 corpectomy, L1–3 anterior interbody graft with posterior instrumentation and posterolateral fusion) was performed. D : However, loss of motor evoked potential in intraoperative neuromonitoring was noted during the excision of tumor and L2 vertebral body.

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