Metastatic Disease of the Spine - Justin Paquette, MD

Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopodTV. Today I have with me as my guest Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, CA. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete a residency in neurosurgery at the Harvard Tufts Combined Program in Boston, MA. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar Sinai. Good afternoon Dr. Paquette.

Paquette: Good afternoon.

Sechrest: Today what I would like to talk about is unfortunately a more common problem than we would like think, but that's the problem of metastatic disease of the spine. And, what I'm talking about is when a patient has cancer and then that cancer, wherever it is in the body, whether it's breast, lung, bladder cancer, moves and spreads across the body and there's special problems when that cancer lodges in the spine. So, describe a little bit about what some of those special problems are when we see cancer move to the spine.

Paquette: Spinal metastatic disease is actually a very common thing in the US as you eluded to. And, in fact, it's one of the, often times the first places that a new tumor will metastasize towards. In addition to the fact that there are many tumors that grow initially in the spine itself, localized tumors. The problem comes down to a couple of different things. Number one, most metastatic lesions will go to the bone itself. Sometimes the bone in the front of the spine, sometimes the bone in the back. But, what they generally do is to eat away and dissolve the bone that's there. And, that in and of itself can cause a lot of back pain and so people will start to complain of worsening and worsening back pain. Classically it may wake them up at night, severe night back pain is the first thing you need to think of is a tumor for that. But, as the tumor advances and takes over more of the bone and sometimes the disc or the joints, it can now destabilize the spine. And, this is concerning for a couple different reasons. Number one, the pain will get much worse as the spine destabilizes but it can also begin to pinch the nerves or the spinal cord itself and cause neurologic deficits. As the disease continues and as more and more the bone becomes involved with tumor, you can now develop compression fractures. Essentially the foundation of the bone is no longer strong enough to hold the vertebrae up and it collapses down like this. Causing severe pain for the patient. A lot of times tilting the patient forwards because now it's tilted on that broken vertebrae and in addition, often times it will push tumor material and bone backwards against the spinal cord causing a spinal cord injury. And, so now you've got an individual who has essentially an unstable spine, a large amount of tumor in the spine itself and also pressing against the spinal cord with potentially nerve pain and also spinal cord dysfunction based upon the pressure.

Sechrest: A couple of questions that come to mind, one is why the spine? Why does cancer have a propensity to going to the spine or moving to the spine? And the second question I guess, is a similar question, that is are there any specific tumors that are particularly common in the spine.

Paquette: The bones themselves, when we think about, we just think they're just strong hard bones when in fact bone are full of blood vessels. Blood vessels all over the place, especially in the marrow, but throughout there. And so, when the tumor cells get into the blood, they're going to pass through many, many, many bone channels and vessels within the bone with many opportunities to kind of sit off instead of shop at that level there. There is not gates to block tumor cells from going in and out of bone as there is sometimes with the brain and the spinal cord. The bone itself it totally open to the environment and so given the vast blood supply, that's why sometimes they're more likely to get tumors to go there. However, there are certain tumors that for whatever reason, much more prefer to go to the bone and some of these things are going to be prostate, we often times see go here. Sometimes breast will go there. We can get thyroid cancers sometimes go in there as well and certainly prostate cancer will often times show up in the bone as well.

Sechrest: Now is it more common in the low back, in the mid back or in the neck? Is there any difference in those two areas of the spine?

Paquette: Because of it's overall larger size relative to the cervical and the lumbar spine, the thoracic spine just seems to have more metastatic lesions. However, it is also very common to see multiple lesions throughout the spine and not just one. When we do see one lesion, sometimes we think of just a common isolated bone tumor, sometimes called the plasma cytoma or other varieties of benign bone tumors.

Sechrest: And, what we're talking about is not something that has spread into the spine, but something that started there. So we're looking at things that actually originated there whether they're benign or malignant for that matter. So, if you've got a patient in your office, I guess the first question is, is what normally brings them to your office? When they're referred from their oncologist, their family practitioner with back pain and maybe they know they have cancer. What typically brings them into the office? Is it the pain or is it more commonly problems with the spinal cord or problems with the nerves or all of the above?

Paquette: I would have to say that certainly all of the above can potentially happen. Back pain is usually what's going to be bothering the patient the most personally, especially because they're having difficulty standing upright or any position is just really causing them extreme pain. Metastatic lesion to the spine can be demoralizingly painful, unbelievably painful. However, certainly there are often times associated problems with the spinal cord with the nerve so there may be some walking problems, balance problems, weakness in the bowels and the bladder, weakness in the legs. Oncologists will also refer patient's to us just to see how should we best manage this? You know, does this patient need radiation? Does this patient need surgery? And then we have to decide based upon the patient's situation where the best course lies.

Sechrest: And, how do you begin that process of evaluation? If I am a cancer patient and now I have an x-ray, for example, that shows that I may have a metastatic lesion in my thoracic spine, what are you going to do when I come to your office?

Paquette: So, when you first come to my office with a diagnosis of cancer and a possible diagnosis in the back, the first thing is just to get the clinical history. So, where was the cancer before? Do we have a diagnosed cancer? Sometimes we may not have and ID yet. And then specifically looking for the pain itself, a tumor lesion in the back when tapped on will hurt. And so, basically, you press on the entire spine to see if there are other lesions that may be effected or if it's just that one that's just bothersome and then a full neurologic examination to see if any nerves or the spinal cord are being effected because that obviously changes the treatment program as well. Once you have a full detailed history on the patient and an examination of the patient, then we need to get x-rays. And more than just straight x-rays, at this point we need to get both an MRI scan and a CT scan. The MRI scan, especially one done with contrast will show us specifically the dimensions of the tumor, the extent of the tumor and how it's effecting the soft tissues of the spine, whether it be the disc, whether it be the joints, whether it be the muscles, nerves. The CT scan is very important showing how much of the bone has been eroded by the tumor and will give me an idea of the level of instability in the spine as well.

Sechrest: Now you mentioned that not all spine tumors that move to the spine require surgery right away. There's radiation, there's chemotherapy, there may be other things that are done. What drives you to decide that, no this person needs to have a surgical procedure? What's different about that person?

Paquette: When you're looking at a patient with metastatic disease, if the patient has minimal back pain, has no problems for nerve or spinal cord dysfunction, that's a person that can very easily be handled by my fellow oncologists and radiation therapist either through chemotherapy or radiation and followed closely. Indications for surgery come up when either A, the patient is having severe uncontrollable pain, or B, there's any kind of neurologic compromise evident on either his examination or his history. He's got walking problems, his spinal cord is being injured, nerves are being injured. If any of those things are occurring then surgery is warranted and has been shown in literature to be most effective as an ealry treatment for decompressing the neural structures, taking out as much tumor as possible and then fixing the spine to the proper position.

Sechrest: So in the case where you see nerve involvement, you're most likely going to be recommending surgery for that patient?

Paquette: Most likely, yes.

Sechrest: Fairly quickly.

Paquette: Yes.

Sechrest: Okay. Well, tell me a little bit about how you approach that then. We're going to surgery, you've convinced me as a patient that surgery is in my best interest and you can help me with my pain and hopefully reduce the complications of nerve problems. Now, I'm assuming that you're not promising me that you can cure my cancer or that you can prolong my life necessarily. Is that accurate?

Paquette: That's correct. Yeah. In fact there's no possible way for us to go in there and remove all the tumor. We can remove 99% of the tumor that we can see, but there's still going to be microscopic cells that are left and so the goal in the surgery is to decompress the neural structures, especially the spinal cord, to restore the normal balance of the spine, so if there's been a compression fracture or some kind of abnormality to fix that and correct it. To get a piece of pathology specimen so we can further define the exact specifics of the tumor and to help with the pain. But then the ultimate treatment is going to be with the radiation oncologist and the oncologist as to what types of chemotherapeutics or hormones or radiation are necessary to kill the remaining tumor.

Sechrest: Okay. So, tell me how you approach this surgically. And I'm certain that there's so many variations of this, you know, depending on where it is, what you're goals are and that sort of thing, but in general, what we're trying to do is, like you said, stabilize the spine, reduce the injury to the nerves or the damage to the nerves or the threat to the nerves and then hopefully try to reduce pain. How do you do that?

Paquette: Sure. So the first step is just to make sure we're ready for surgery. So, I need my patient to be completely cleared from all medical aspects, check the heart very closely, lung very closely, make sure that they're going to be able to sustain a longer surgery and have no problems. The first step of surgery for me is to stabilize the spine. In other words, we use either steel or titanium screws to go at least a few vertebrae above and at least a few vertebrae below the level of the actual tumor. I put that in first to make sure that the spine is stable because once you start taking out the tumor, you can now very significantly destabilize the spine and things can move. We don't want that to happen so the screws and rods go in first to lock it all into position. Once that' s done and we're safe, then becomes the issue of taking out the tumor. If I can take it out all from the back, I'll do it all from the same incision and then use a combination of different types of tools, using the microscope to go in there and remove all the tumor that we can, okay. Sometimes we have to do a different approach to get the tumor out. If it's all very far in the front or two levels are involved, sometimes we'll do a minimally invasive approach from the side, the small little tube retractor and basically do what's called the vertebrectomy and take out the entire tumor, and the entire vertebrae all in one spot.

Sechrest: So, let me get this straight, what you've done is you first put in your metal struts from the back and then you're doing a second operation or a second approach or incision from the front to actually take the tumor out.

Paquette: Correct if you can't get it all from the back.

Sechrest: Okay, but your preference would be, as you said earlier, everything from the back if at all possible.

Paquette: Correct.

Sechrest: So, let's say you're working away, you're on a search and destroy mission, you're trying to get rid of as much tumor as you possibly can, the tumor's gone now. You've got your metal struts, you've got a whole vertebral body that's gone. What do you do?

Paquette: I usually try to replace that body also with some kind of a device that would allow for some structural integrity in the front of the spine. We can use a variety of things. Sometimes we can use cadaver femur graft or we have now expandable cages whether they be metal or they be plastic that will span the area where the tumor was to allow for the important structural integrity of the spine.

Sechrest: So, you're really trying to replace that with some tissue, not necessarily expecting this tissue to have to __????__?

Paquette: Not necessarily, we'd like it, but depending upon the prognosis and the type of the tumor, the more important thing is that we just have the structural integrity there.

Sechrest: Okay. And, how successful is this? I mean, what does a patient expect after having this procedure? What is your definition of success?

Paquette: Sure. I think what's very important is you have a good long discussion with the patient discussing what are the realistic expectations of this. My realistic expectations are that we don't make anybody worse, that we make the back pain significantly better, hopefully make the leg pain or the radicular pain if not totally gone, at least better and make the spinal imbalance improved so that we can hopefully get down off medications, make them much more functional up walking around much better etc. What we have to realize that is non realistic is we're not, again, not going to cure the tumor, we're not going to transplant you a new spine and, you know, you're probably still going to have some pain. We all have back pain and especially after surgery for that much of a problem, still going to have some pain. And, we want that to be at a much lower level.

Sechrest: Now, what can patient's expect, and again this is varied so much in terms of how much surgery is required to actually accomplish those goals that I'm assuming how that patient recovers really depends on how much you've done. But, what's a normal sort of recovery? How are you're patients doing after these approaches to metastatic disease?

Paquette: Sure. In general, if you took the same exact surgery in a normal person for degenerative reasons and then a cancer patient. The cancer patient is always going to have much more issues. They're going to be nutritionally behind the normal person, their healing process is going to be affected. They're probably on lots of other medications that may affect the healing process as well. They may get radiation etc. What I say to them basically is I'd like to have you up and walking hopefully the next day, if not within a couple of days. Be in the hospital for about a week. Now, that would be varied depending upon what the oncology team wanted to also, if they wanted to start tests before then or afterwards. That kind of makes a little bit of an impact upon the actual discharge time. The actual pain from the surgery, the muscle spasms will be similar to any other surgery in the back. In other words they'll be there for a few weeks. By about 4-6 weeks out start to feel a whole lot better. We usually like to delay radiation or other major ajuvent therapies until about six weeks after surgery. That's one of the main downsides of surgery that it delays sometimes the therapist either using radiation or chemotherapy.

Sechrest: And that's because you're afraid those things are going to delay healing or interfere with healing.

Paquette: They definitely do. They affect not only the wound healing that we see on the outside, the skin, in the muscle, but it also affects the wound healing of the bone and can cause a failed fusion soemtimes.

Sechrest: Let's talk a little bit about potential complications, and again this obviously is so varied in terms of the surgery necessary, but in general, what do you worry about as a spine surgeon when you go and start one of these cases? What are your worries about complications and potential complications, both at the time of surgery and down the road?

Paquette: Sure. So, some of the concerns that I have. Number one is just the tumor itself. Some tumors are very easy to take out and don't cause much problems. Some tumors can be very bloody and very difficult to remove. And, in fact, sometimes in those cases I'll have one of my interventional radiology colleagues do an angiogram of the tumor and if it looks very, very vascular, have them kind of embolize material in there to kind of shut down some of the blood vessels.

Sechrest: So you really want to inject blood clots or something to clot off and block those blood vessels so that tumor begins to die.

Paquette: To help to minimize the blood loss.

Sechrest: Right, right.

Paquette: Exactly. Other things that concern me are many times the tumor is going to be wrapped around the spinal cord or the nerves and the way the tumor is, is that it gets very stuck to the spinal cord and so you have to take your time and be very careful about peeling off all that tumor away from the spinal cord. If you do too much manipulation of the spinal cord, you can cause a worsening in the patient's numbness or weakness afterwards and so you have to be very cautious and very careful about doing that while your working. Another concern is that, you know, as you're taking it out, is there a chance that you could be pushing tumor cells elsewhere and it's kind of a theoretical chance but, as you're taking it out, people have commented that maybe some of those cells now get back into the blood supply and can travel elsewhere. It has not been shown but I would be concerned a little bit about that.

Sechrest: And that's pretty much true for any tumor surgery.

Paquette: Correct.

Sechrest: I mean, anytime you do tumor surgery you run that risk. In terms of success of your approach, have you found that this is successful? Are you having pretty good results from this approach to metastatic disease? I would have to say that in general, yes I have found this to be a very successful approach. In fact, the recent literature, which has been coming out of the major cancer centers in the US shows that early surgical intervention is critical in restoring the patient's long-term functionality and even prognosis. Because for a long time there's been a debate as to is it better to radiate or better to do surgery, and the recent studies have shown that surgery actually is very important and almost superior in the abilities to get back on their feet and at least enjoy whatever life they have left for them. I personally have found it to be the case as well in my surgeries.

Sechrest: So really, your definition of a success, if we come back to that is one not to have life threatening complications and that sort of thing and get a good solid surgery. But, you're definition of success is really trying to, I guess optimize the quality of life. Even if you don't extend life, you may optimize the quality of life for that person as their cancer runs it natural course and is treated with other ways. Is that accurate?

Paquette: That's absolutely right.

Sechrest: Okay. Any suggestions to patient's who are faced with this incredibly devastating decision, and that is, I have cancer, now the cancer has spread to my spine. What do I do? Any pearls of wisdom for those folks that we have not covered up to this point?

Paquette: Sure. I think certainly a very important thing is to be as informed as you can be and I certainly, with the patient's that I have met, they're all over the Internet reading and trying to find as much information as they can about possible treatments and possible therapies. Because each person has their preference and I think it is important for individuals to realize that even though surgery is a big thing sometimes, surgery can actually significantly improve the functional outcome for patient's. We're also currently coming up with new treatments which are going to be much better in helping the patient's pain and neurologic problems but not being antagonistic to their options with chemotherapy or radiation therapy. As I was describing, part of the problem with deciding to go with a big major surgery means we often times have to delay chemo or radiation for a good period of time until the back is all healed up. Obviously that's important time lost during which the patient could be getting treatment for their tumor. We have now a technique through which just a little pinhole needles we can go into an infected vertebrae, we can use a special plasma coblation technique which basically vaporizes tumor cells in a large comb within the vertebral body, vaporize a giant area, reexpand a compression fracture then at that point and then inject a bunch of cement which will solidify the spine, stabilize the spine and make a dramatic affect upon the patient's pain level and also decompress the nerves while we're doing that. Now this can be done while a patient's awake as an outpatient procedure. It also allows us to get a biopsy of the tumor so that the pathologist can get definitive diagnosis. This is not any kind of a major surgery though and the advantages of we can do a major debulking of the tumor, solidify the back, make the patient feel good and the next day they can go to radiation therapy or chemotherapy. So, my hope is that this particular procedure is going to become really very commonly used in the treatment of back pain in cancer patients.

Sechrest: So you're really trying to extend those minimally invasive techniques that you're working on now to include what used to be a very wide open surgery to go in and get the tumor, see it and that sort of stuff.

Paquette: Absolutely.

Sechrest: Okay, thanks a lot.

Paquette: Thank you.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.