Preoperative Embolization of Spinal Metastatic Disease: Rationale and Technical Considerations

ABSTRACT

The spine is the most common site of bony metastatic disease, with the incidence of spinal metastatic disease increasing, likely as a result of improved survivorship in patients with cancer. Although occasionally incidentally identified through cancer screening/staging or studies done for other reasons, spinal metastatic disease often is symptomatic. The three key points to consider when devising a treatment algorithm are neurological compromise, spinal instability, and individual patient factors. Because the goal of treatment is almost always palliation, a multidisciplinary approach is taken to offer the best chance at alleviating the patient's symptoms. Consideration is given to various treatment choices, such as radiation therapy, chemotherapy, as well as locoregional management strategies, such as thermal ablation (radiofrequency and cryoablation). However, the mainstay of accepted management, especially in those whose life expectancy is > 12 weeks where other strategies have failed, is surgical resection and local stabilization. In this article we review the role and rationale for preoperative embolization of spinal metastatic disease and discuss various related issues, including determining who is most likely to benefit from preoperative embolization, important anatomical considerations, and other technical points, such as timing of surgery and accepted methods of achieving effective local tumor devascularization.

KEYWORDS

Embolization - spine - metastatic - preoperative

REFERENCES

• 1 White A P, Kwon B K, Lindskog D M, Friedlaender G E, Grauer J N. Metastatic disease of the spine.  J Am Acad Orthop Surg. 2006;  14 (11) 587-598
• 2 Truumees E, Dodwad S-N, Kazmierczak C D. Preoperative embolization in the treatment of spinal metastasis.  J Am Acad Orthop Surg. 2010;  18 (8) 449-453
• 3 Wirbel R J, Roth R, Schulte M, Kramann B, Mutschler W. Preoperative embolization in spinal and pelvic metastases.  J Orthop Sci. 2005;  10 (3) 253-257
• 4 Jacobs W B, Perrin R G. Evaluation and treatment of spinal metastases: an overview.  Neurosurg Focus. 2001;  11 (6) e10
• 5 Owen R JT. Embolization of musculoskeletal tumors.  Radiol Clin North Am. 2008;  46 (3) 535-543 vi
• 6 Heary R F, Bono C M. Metastatic spinal tumors.  Neurosurg Focus. 2001;  11 (6) e1
• 7 Prabhu V C, Bilsky M H, Jambhekar K et al.. Results of preoperative embolization for metastatic spinal neoplasms.  J Neurosurg. 2003;  98 (2, Suppl) 156-164
• 8 Jones K, Meyers P, Gobin P, Liu A-H. Embolization of spinal tumors. In: Operative Techniques in Neurosurgery. New York, NY: Elsevier Science; 2003: 156-162
• 9 Shi H, Jin Z, Suh D C, Lee H K, Li L. Preoperative transarterial embolization of hypervascular vertebral tumor with permanent particles.  Chin Med J (Engl). 2002;  115 (11) 1683-1686
• 10 Reuter M, Heller M, Heise U, Beese M. Transcatheter embolization of tumors of the muscular and skeletal systems.  Rofo. 1992;  156 (2) 182-188
• 11 Gellad F E, Sadato N, Numaguchi Y, Levine A M. Vascular metastatic lesions of the spine: preoperative embolization.  Radiology. 1990;  176 (3) 683-686
• 12 Tralhão J G, Kayal S, Dagher I, Sanhueza M, Vons C, Franco D. Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients.  Hepatogastroenterology. 2007;  54 (76) 1200-1206
• 13 Heran M K, Smith A D, Legiehn G M. Spinal injection procedures: a review of concepts, controversies, and complications.  Radiol Clin North Am. 2008;  46 (3) 487-514, v–vi
• 14 Nambu K, Kawahara N, Kobayashi T, Murakami H, Ueda Y, Tomita K. Interruption of the bilateral segmental arteries at several levels: influence on vertebral blood flow.  Spine (Phila Pa 1976). 2004;  29 (14) 1530-1534
• 15 Kawahara N, Tomita K, Murakami H et al.. Effect of preoperative embolization of bilateral segmental arteries at multiple (up to three) levels on intraoperative blood loss in total en bloc spondylectomy. In: Proceedings of the North American Spine Society Annual Meeting. Toronto, Canada: The Spine Journal; 2008: 67S-68S
• 16 Schirmer C M, Malek A M, Kwan E S, Hoit D A, Weller S J. Preoperative embolization of hypervascular spinal metastases using percutaneous direct injection with n-butyl cyanoacrylate: technical case report.  Neurosurgery. 2006;  59 E431-432 author reply E431-432
• 17 Liebig T, Henkes H, Kirsch M, Piotin M, Jans P, Kühne D. Preoperative devascularization of a circumferential osteogenic metastasis to the upper cervical spine by direct percutaneous needle puncture: a technical note.  Neuroradiology. 2005;  47 (9) 674-679
• 18 Basile A, Rand T, Lomoschitz F et al.. Trisacryl gelatin microspheres versus polyvinyl alcohol particles in the preoperative embolization of bone neoplasms.  Cardiovasc Intervent Radiol. 2004;  27 (5) 495-502
• 19 Sun S, Lang E V. Bone metastases from renal cell carcinoma: preoperative embolization.  J Vasc Interv Radiol. 1998;  9 (2) 263-269
• 20 Berkefeld J, Scale D, Kirchner J, Heinrich T, Kollath J. Hypervascular spinal tumors: influence of the embolization technique on perioperative hemorrhage.  AJNR Am J Neuroradiol. 1999;  20 (5) 757-763
• 21 Barton P P, Waneck R E, Karnel F J, Ritschl P, Kramer J, Lechner G L. Embolization of bone metastases.  J Vasc Interv Radiol. 1996;  7 (1) 81-88