Neurosurgery notes/Spine/Spinal tumours/Spinal metastatic tumours/Metastatic spinal tumours cord compression (MSCC)- Bony spinal metastasis/NOMS

NOMS

View Details
logo
Parent item
Metastatic spinal tumours cord compression (MSCC)- Bony spinal metastasis
Sub-item
Spine Instability Neoplastic Score (SINS)
  • General
    • Scoring systems are helpful but they are not the bottom line
    • Prognosis and stability of spine are crucial
    • A truly multidisciplinary approach is required. Every patient is different.
    • Beware of writing patients off
      • The elderly
      • Those with comorbidities
      • The prognosis
  • NOMS framework: Neurologic, Oncologic, Mechanical, Systemic Laufer 2013
750 Table 3. Current NOMS decision framework Treatment of Spinal Metastatic Tumors Neurologic Oncologic Low-grade ESCC + no myelopathy Radiosensitive High-grade ESCC ± myelopathy Radiosensitive Radioresistant Radioresistant Radiosensitive Radiosensitive Radioresistant Radioresistant Radioresistant Radioresistant Mechanical Stable Unstable Stable Unstable Stable Unstable Stable Stable Unstable Unstable Systemic Able to tolerate surgery Unable to tolerate surgery Able to tolerate surgery Unable to tolerate surgery Decision cEBRT Stabilization followed by cEBRT SRS Stabilization followed by SRS cEBRT Stabilization followed by cEBRT Decompression/stabilization followed by SRS cEBRT Decompression/stabilization followed by SRS Stabilization followed by cEBRT Low-grade ESCC is defined as grade O or 1 on Spine Oncology Study Group scoring system [5]. High-grade ESCC is defined as grade 2 or 3 on the ESCC scale [5]. Stabilization options include percutaneous cement augmentation, percutaneous pedicle screw instrumentation, and open instrumentation. For patients with significant systemic comorbidities that affect the ability to tolerate open surgery, stabilization may be limited to cement augmentation and/or percutaneous screw augmentation. Abbreviations: cEBRT, conventional external beam radiation; ESCC, epidural spinal cord compression; NOMS, neurologic, oncologic, mechanical, and systemic; SRS, stereotactic radiosurgery. O o o o O u Low-grade ESCC No myelopathy High-grade ESCC +/- myelopathy Radiosensitive Radioresistant/ previously radiated Stable Unstable Able to tolerate surgery Unable to tolerate surgery Radiation cEBRT SRS Separation surgery Stabilization Figure 6. Schematic depiction of the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework. Abbreviations: cEBRT, conventional external beam radiation; SRS, stereotactic radiosurgery.
750 Table 3. Current NOMS decision framework Treatment of Spinal Metastatic Tumors Neurologic Oncologic Low-grade ESCC + no myelopathy Radiosensitive High-grade ESCC ± myelopathy Radiosensitive Radioresistant Radioresistant Radiosensitive Radiosensitive Radioresistant Radioresistant Radioresistant Radioresistant Mechanical Stable Unstable Stable Unstable Stable Unstable Stable Stable Unstable Unstable Systemic Able to tolerate surgery Unable to tolerate surgery Able to tolerate surgery Unable to tolerate surgery Decision cEBRT Stabilization followed by cEBRT SRS Stabilization followed by SRS cEBRT Stabilization followed by cEBRT Decompression/stabilization followed by SRS cEBRT Decompression/stabilization followed by SRS Stabilization followed by cEBRT Low-grade ESCC is defined as grade O or 1 on Spine Oncology Study Group scoring system [5]. High-grade ESCC is defined as grade 2 or 3 on the ESCC scale [5]. Stabilization options include percutaneous cement augmentation, percutaneous pedicle screw instrumentation, and open instrumentation. For patients with significant systemic comorbidities that affect the ability to tolerate open surgery, stabilization may be limited to cement augmentation and/or percutaneous screw augmentation. Abbreviations: cEBRT, conventional external beam radiation; ESCC, epidural spinal cord compression; NOMS, neurologic, oncologic, mechanical, and systemic; SRS, stereotactic radiosurgery. O o o o O u Low-grade ESCC No myelopathy High-grade ESCC +/- myelopathy Radiosensitive Radioresistant/ previously radiated Stable Unstable Able to tolerate surgery Unable to tolerate surgery Radiation cEBRT SRS Separation surgery Stabilization Figure 6. Schematic depiction of the neurologic, oncologic, mechanical, and systemic (NOMS) decision framework. Abbreviations: cEBRT, conventional external beam radiation; SRS, stereotactic radiosurgery.
  • Neurological (Bilsky 2010 J Neurosurgery spine)
    • Mainly a radiological assessment.
      • Will take into account presence of myelopathy
    • ESCC (Epidural spinal cord compression scale):
        • MRI-T2 sq used at most compressed site
            • Grade
            Sub grade
            Risk
            0
            Bone only
            Low grade
            1a
            1b
            1c
            Epidural invasion without thecal deformation
            Thecal deformation without touching cord
            Touching cord without cord compression
            Low grade
            2
            Cord compression with CSF
            High grade
            3
            Cord compression without CSF
            High grade
        • Low grade: no need decompression
        • High grade: need decompression
  • Oncological:
    • Tumors are considered to be radiosensitive or radioresistant based on their response to cEBRT (not SRS)
    • Now slightly out of date as SRS can make renal cell cancer more radiosensitive
    • For NSCLC: EGFR mutations even more sensitive
    • Mnemonic My Silly Rabbit Tries New Carrots Loudly
      • Study
      Lymphoma, seminoma, myeloma
      Breast
      Prostate
      Sarcoma
      Melanoma
      Gastrointestinal
      NSCLC
      Renal
      Gilbert et al.
      F
      F
      U
      U
      U
      U
      U
      U
      Maranzano et al.
      F
      F
      F
      U
      U
      U
      U
      U
      Rades et al.
      F
      I
      I
      U
      U
      I
      U
      I
      Rades et al.
      F
      F
      F
      U
      U
      U
      U
      U
      Katagiri et al.
      F
      F
      F
      U
      U
      U
      U
      U
      Maranzano et al.
      F
      F
      F
      U
      U
      U
      U
      U
      Rades et al.
      F
      I
      I
      U
      U
      I
      U
      I
      • Radioresistant:
        • melanoma
        • sarcoma
        • renal cell Ca
        • thyroid
        • NSCL
      • Radiosensitive:
        • multiple myeloma
        • Lymphoma
        • germ cell tumor
        • breast Ca
        • prostate Ca
      • Chemoresistant:
        • gastric Ca
        • bladder Ca
        • Squamous cell Ca
      • Chemosensitive:
        • teratoma
        • choriocarcinomaimage.jpg
       
    • Conventional External beam radiotherapy (cEBRT)
      • delivered in one or two radiation beams without precise conformal techniques.
      • significantly limited by the spinal cord within the radiation field.
    • SRS
      • which delivers high doses of tightly focused radiation, relies on IGRT (image-guided radiation therapy) platforms and can be administered as a single fraction or in 3–5 fractions using a hypofractionated schedule
      • For radioresistant tumours
      • Solid tumours with radioresistant histologies generally require SRS to achieve durable local control, whereas radiosensitive solid tumours may be treated with cEBRT or SRS.
    • literature supports the use of cEBRT even when there is evidence of high grade ESCC from radiosensitive tumours due to the ability of cEBRT to cause mitotic cell death within the tumour and subsequent spinal cord decompression
    • See radiotherapy
  • Systemic
    • Ambulatory patients with radiosensitive tumours have the best prognosis
      • Likely to remain mobile
    • Bhanot 2022: Survival after surgery for spinal metastases: a population-based study
      • After surgery, median survival is 8 months
      • Worst prognosis: UGI, melanoma, lung
      • Best prognosis: Breast, Thyroid, Myeloma
    • Patient's ability to tolerate the proposed intervention based on the extent of systemic comorbidities and tumour burden
    • No scoring system for this because
      • Multiple reviews have shown that physicians frequently tend to overestimate the expected survival time;
      • Always-evolving armamentarium of anticancer pharmacotherapy continuously alters survival expectations.
    • Individualised discussion with the patient's oncologist.
      • Because surgery for patients with spinal metastases serves a palliative purpose, we concentrate on whether the patients would have an opportunity to adequately recover from the indicated surgery and/or radiation in order to continue systemic therapy.
      • Generally, as long as reasonable pharmacotherapy is available for the postoperative period to attempt systemic tumor control and systemic progression does not appear to be rapid enough to prevent postoperative recovery, the patient will be considered for surgery.