Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of...
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Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of Neurosurgery Nelson Endowed Chair Center for Advanced Neurosurgery, University of Louisville
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Transcript of Modern Treatment of Spinal metastases Maxwell Boakye, MD MPH FACS FAANS Associate Professor of...
Modern Treatment of Spinal metastases
Maxwell Boakye MD MPH FACS FAANSAssociate Professor of Neurosurgery
Nelson Endowed ChairCenter for Advanced Neurosurgery University of
Louisville
My Background
bull Neurosurgeonbull Residency 2002bull Fellowships-complex spine-Emory and Spine
Oncology-Sloan Kettering-2003bull Stanford-2003-2010-worked with cyberknifebull Special interest in spine tumors and spine
radiosurgery
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
My Background
bull Neurosurgeonbull Residency 2002bull Fellowships-complex spine-Emory and Spine
Oncology-Sloan Kettering-2003bull Stanford-2003-2010-worked with cyberknifebull Special interest in spine tumors and spine
radiosurgery
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Goals
bull Epidemiologybull Presentationbull Imagingbull Role of Surgery bull Emerging Treatment paradigms bull Decision making and Frameworksbull Memorial Sloan Kettering NOMS criteriabull Cases
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Epidemiology
bull 20000 new cases of metastatic epidural cord compression each year
bull 10 of cancer patients will develop spinal metastatic
bull About 70 of all cancer deaths occur in elderly patients aged over 65
bull Postmortem studies metastases present in 90 of patients with systemic cancer
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Epidemiology
bull Number of elderly patients dying from cancer will double by 2030
bull By age 2050 the number of newly diagnosed patients aged 85 will quadruple
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Signs and symptoms
bull Myelopathy-Motor Sensory BowelBladderndash Usually from epidural cord compression
bull Painndash Biologic
bull nocturnalearly morning-resolves during day-usually from tumor infiltration Steroid responsive
ndash Mechanical-movement relatedndash Radicular-usually epidural disease in foramen
bull Other Symptoms eg LOC or AMS from brain
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Imaging
bull X-raysbull CTbull MRIbull PET
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Imaging findings
bull Imagingndash Epidural disease onlyndash Vertebral disease onlyndash Vertebral disease with epiduralndash Cord compressionndash Mechanical instabilityndash Pathological fracturesndash Single level Multiple level Distant metastases
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Treatment options
bull Surgerybull Radiation therapybull Radiosurgerybull Chemotherapy
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Main surgical approaches
bull Anterior Transthoracic Retroperitonealbull Posterior Laminectomybull Posterior transpedicular
costotransversectomy approach
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Epidural Compression Surgery is superior to radiation
Patchell et al Lancet Vol 366 643-648 2005
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Patchell study
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Surgery vs radiation-Patchell
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Surgery improves quality of life outcomes
Quan et Al Eur Spine Journal 2011 Jun 26
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Surgical complications
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Price of surgery High Morbidity and mortality
bull Mortality-5-6bull Complication rates-20-40
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Emerging Treatment Patterns
bull Vertebral augmentationndash Vertebroplastyndash Kyphoplasty
bull Radiosurgerybull Combined kyphoplasty and radiosurgery
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
KYPHOPLASTY
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
KYPHOPLASTY
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
CAFEacute TRIAL
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
CAFEacute trial
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Berenson et Al Lancet Oncology 2011 Mar12(3)225-35
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
CYBERKNIFE RADIOSURGERY
bull The CyberKnifereg a robotic manipulator to move a compact linear accelerator with six degrees of freedom
bull Real-Time Image Guidance Throughout the Treatment
bull Dynamic Motion Trackingbull Allows for accuracy and conformalitybull Louisville is getting one
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Other radiosurgery systems
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Concept of Separation surgery
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Separation surgery
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
DECISION MAKING
bull Who should be operated onbull Frameworks for prognosisbull Algorithms and Decision aids
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Tokuhashi score
1048707ge9bullExcisionbullSurvival gt 12 months
1048707le5bullPalliativebullSurvival lt 3 months
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Decision Making-NOMS criteria
bull Neurologicbull Oncologicbull Mechanicalbull Systemic
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
NOMS criteria
bull Neurologic-myelopathy degree of epidural cord compression
bull Oncologic- radiosensitivity of tumorbull Mechanical instability-movement related painbull Systemic disease and medical comorbidities
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Neurologic-Classification of Epidural compression
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Neurologic-Classification of epidural compression
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Oncologic-Radiosensitivity
bull ndashMyeloma amp Lymphoma most radiosensitivebull ndashProstate Breast Lung and Colon moderatelybull ndashThyroid Kidney Melanoma not
radiosensitive
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Mechanical Instability
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Systemic factors
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
SINS score
bull Ranges 0-18bull 0-6 Stablebull 7-12 indeterminate possibly impending
instabilitybull 13-18-Instabilitybull Surgical consultation is recommended for SINS
score gt 7bull Fisher CG Spine Vol 35(22) 1221-1229 2010
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Oncologic factors-Impact of Comorbidities
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Oncologic and Systemic factors-survival
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
Predictors of Survival
VAriable Hazard ratio 95 CI P-value
Age 1001 099-102 090
Ambulatory status
2355 152-366 00001
Cervical mets 107 069-165 076
Comorbidity 296 134-651 0007Epidural compression
120 069-209 052
Pathologic fracture 141 095-208 008
Radiosensitivity 256 167-391 lt00001Radiotherapy 098 067-143 091
Urinary incontinence
116 078-171 047
Visceral mets 109 075-157 065
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
NOMS decision framework
Bilsky M Hematol Oncol Clin N Am 20 (2006) 1307ndash1317
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
- Modern Treatment of Spinal metastases
- My Background
- Goals
- Epidemiology
- Epidemiology (2)
- Signs and symptoms
- Imaging
- Imaging findings
- Treatment options
- Main surgical approaches
- Slide 11
- Epidural Compression Surgery is superior to radiation
- Patchell study
- Surgery vs radiation-Patchell
- Surgery improves quality of life outcomes
- Surgical complications
- Price of surgery High Morbidity and mortality
- Slide 18
- Emerging Treatment Patterns
- KYPHOPLASTY
- KYPHOPLASTY (2)
- CAFEacute TRIAL
- CAFEacute trial
- Slide 24
- CYBERKNIFE RADIOSURGERY
- Slide 26
- Slide 27
- Other radiosurgery systems
- Slide 29
- Slide 30
- Concept of Separation surgery
- Separation surgery
- Slide 33
- Slide 34
- DECISION MAKING
- Tokuhashi score
- Decision Making-NOMS criteria
- NOMS criteria
- Neurologic-Classification of Epidural compression
- Neurologic-Classification of epidural compression
- Oncologic-Radiosensitivity
- Mechanical Instability
- Slide 43
- Systemic factors
- SINS score
- Oncologic factors-Impact of Comorbidities
- Oncologic and Systemic factors-survival
- Slide 48
- Slide 49
- Predictors of Survival
- NOMS decision framework
- Slide 52
- Slide 53
- Slide 54
- Slide 55
- Slide 56
- Slide 57
- Slide 58
- Slide 59
-
