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Lower Lumbar Spine Complex Solitary Metastatic Disease

History

The patient is a 62-year-old male with a known history of stage IV non-small cell lung adenocarcinoma with metastasis to the L4 vertebral body. His initial complaint was back pain, which was progressive in nature, and a left L4 radiculopathy with weakness.

Prior Treatment

He had previously undergone a course of Cyberknife treatment to L4 totaling 24 Gy, followed several months later with kyphoplasty and radiofrequency ablation. Unfortunately, his pain persisted, and an additional 30 Gy of Cyberknife was administered to the area, which was also unsuccessful in controlling his pain. His pain continued to progress further.

Pre-operative Imaging

Pre-operative lumbar sagittal T1 MRI with contrast (Fig. 1).

Pre-operative lumbar sagittal T1 MRI with contrastFigure 1. Pre-operative lumbar sagittal T1 MRI with contrast.

Pre-operative lumbar sagittal T2 MRI without contrast (Fig. 2).

pre-operative lumbar sagittal T2 MRI without contrastFigure 2. Pre-operative lumbar sagittal T2 MRI without contrast.

Pre-operative axial T2 MRI without contrast at level of L4 pedicle (Fig. 3).

Pre-operative axial T2 MRI without contrast at level of L4 pedicleFigure 3. Pre-operative axial T2 MRI without contrast at level of L4 pedicle.

Pre-operative lumbar sagittal CT scan (Fig. 4).

Pre-operative lumbar sagittal CT scan (Fig. 4).Figure 4. Pre-operative lumbar sagittal CT scan.

Progressive Symptoms

At the time of surgery, there was new proximal left lower extremity weakness of 2/5 strength; distal muscle groups were 4/5 strength. There were also painful paresthesias in the left L4 distribution.

Sensation to light touch was grossly intact throughout the lower extremities. These symptoms were making ambulation difficult.

The patient had previously elected to avoid surgery, but his progressive pain in the face of new left lower extremity weakness influenced his decision toward undergoing surgery.

Diagnosis

Cancerous metastasis into the L4 vertebra.

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Selected Treatment

Ultimately, a two-stage surgery was planned.

Stage 1 consisted of a posterior L2-iliac fusion with L4 corpectomy (Fig. 5). A posterior procedure was selected first to adequately remove the extensive amounts of scar tissue and bone cement from the kyphoplasty, which was felt may not have been entirely possible through a lateral approach.

post-operative lumbar sagittal CT scan following Stage 1 spine surgeryFigure 5. Stage 1 post-operative lumbar sagittal CT scan.

Following a successful stage 1, the patient returned to the OR the following day for completion of a left lateral transpsoas L4 corpectomy and placement of expandable cage (Fig. 6A, 6B). There were twenty-one minutes of retractor time in the lateral position. A lateral approach was selected in order for placement of a large interbody device with adequate endplate surface area in the face of neoplastic disease.

post-operative (Stage 2) lumbar coronal CT scanFigure 6A. Lumbar coronal CT scan following Stage 2 spine surgery.

Lumbar sagittal CT scan following Stage 2 spine surgeryFigure 6B. Lumbar sagittal CT scan following Stage 2 spine surgery.

Outcome

Immediately after surgery, the patient did very well. His previous back pain resolved, although his left lower extremity weakness persisted.

Authors' Treatment Rationale and Discussion

Metastatic lung adenocarcinoma travels to the spine in 42% of cases and to the lumbar spine in 17% of those.1

Lateral transpsoas lumbar corpectomies at L4 are relatively uncommon procedures due to the wide exposure required of a corpectomy versus an interbody fusion and the risk this places on the lumbosacral plexus at such an inferior level. In a recent series of lumbar burst fractures treated by a transpsoas corpectomy, there were no cases of surgeries performed at L4, likely because of this reason.2

Additionally, there is very little in the way of describing lumbar corpectomies after failed kyphoplasty, particularly from the lateral approach. In a case with ample scar tissue due to prior radiotherapy and kyphoplasty, and because of the necessity for minimizing retractor time via the transpsoas approach at L4, a posterior approach was chosen first in order to safely remove as much of the L4 vertebral body as possible while decreasing risk to the lumbosacral plexus.

This allowed the subsequent transpsoas procedure to utilize only 21 minutes of retractor time for placement of a large L4 cage while accomplishing direct decompression of the affected nerve roots posteriorly, which were heavily encased in radiation-related scar and epidural disease. Instrumentation was carried down to the pelvis posteriorly in order to reinforce the stress of a large anterior column reconstruction at a highly mobile segment.

References:
1. Sugiura H, Yamada K, Sugiura T, Hida T, Mitsudomi T. Predictor of survival in patients with bone metastasis of lung cancer. Clin Orthop Relat Res. 2008;466(3):729-736.

2. Theologis AA, Tabaraee E, Toogood P, Kennedy A, Birk H, McClellan RT, Pekmezci M. Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction. JNS: Spine. 2016;24(1):60-68. Published online October 2, 2015; DOI: 10.3171/2015.4.SPINE14944.

Disclosures: The authors have no relevant financial disclosures to report.

Case Peer Discussion

The authors present a case of a patient with L4 vertebral body metastasis with back pain and weakness. Pain persisted despite radiosurgery treatment. The patient underwent a two-stage procedure for decompression and vertebral column reconstruction. The patient had no immediate post-operative complications.

The authors should be commended on the excellent technical outcome. A complete vertebrectomy in the lower lumbar spine is indeed challenging, regardless of approach. A large, expandable cage with a wide footprint is an excellent option to provide anterior column support.

The technical aspects notwithstanding, it is important to ensure that surgical goals are adequately and thoroughly analyzed in patients with metastatic spine disease before major reconstruction surgery is undertaken. I recommend a multidisciplinary approach with input from the patient’s medical and radiation oncologist before proceeding with major surgery. Extent of disease, prognosis and life expectancy all influence the nature of intervention in this condition. In patients with solitary metastasis and good prognosis, it is reasonable to pursue major resection and reconstruction. Alternatively, if the spinal disease is diffuse, it is unlikely that a major surgical intervention will improve the patient’s quality of life in the short or long-term.

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