Tactics of Surgical Treatment in Myelogenic Lesions of the Spine and Spinal Cord

R.S. Dzhindzhikhadze, O.N. Dreval1, V.A. Lazarev1, S.T. Vetrile2, I.N. Shevelev2, E.R. Musaev4, A.K. Valiev4, A.V. Gorozhanin3, A.N. Borzunov3

( 1Faculty of Neurosurgery of the Russian Academy of Postgraduate Education;
2 Botkin Municipal Clinical Hospital;
2 Priorov Central Research Institute of Traumatology and Orthopedics;
3 Burdenko Research Institute of Neurosurgery;
4 Blokhin Russian Oncologic Center, Moskow)

Spinal lesions in multiple myeloma (MM) are regarded as one of the most severe complications on the one hand and a neoplastic process, compressing the spinal cord, on the other. Today the main purpose of surgical treatment is decompression of neural structures, arresting of pain syndrome and spine stabilization.

The research goal has been elaborating indications for neurosurgical interventions in complex treatment of cases with lesions of the spine and spinal cord, caused by MM.

Material and Methods. The present series includes 72 cases with multiple and solitary lesions of the spine and spinal cord, watched in MM. Operations were performed in 62 of them (September 1986 -May 2006). Irradiation and polychemotherapy were used in the rest 10 cases with spinal myelogenic lesions.

Open interventions were made in 53 (85.4%) out of 62 (100%) cases. Percutaneous vertebroplasty was performed in 6 (14.5%) patients. The operated cases were divided into three groups in compliance with an operation type. Group I (decompressive interventions) included 15 (21.1%) patients, operated with a posteromedian approach without subsequent stabilization. Group II (decompressive-stabilizing interventions) consisted of 38 (61.5%) cases, subjected to tumor removal and decompression of neural structures with subsequent stabilization. Group III (percutaneous vertebroplasty) was represented by 9 cases. Pain syndrome reduction was estimated on the basis of the visual-analog scale. Frankel and Karnofski scales were used for assessment of a neurological status and a functional result of treatment respectively.

Outcomes. Postoperative complications were present in 12 (19.3%) cases. Aggravation of neurological symptoms was watched in 7 (11.3%) cases. Its manifestations were moderate paresis of extremities and pelvic disorders (4 cases) and more marked radicular pain (3 cases). Persistent postoperative neurological deficiency was observed in 3 patients. There were 5 (8%) cases, who developed infection in a postoperative wound; 3 (4.8%) patients died within a month after operation.

Conclusions. Compression of the spinal cord and/or its roots, watched in solitary or multiple myeloma, is an indication for starting local irradiation and chemotherapy. An absolute indication for surgery is inefficient radio- and chemotherapy, resulting in progressive worsening of neurological functions and persistent pain syndrome. An optimum method is decompression with subsequent stabilization of an affected segment. Persistent pain syndrome and a risk of a pathologic fracture are main indications for percutaneous vertebroplasty.