Revision Noes from Orthobullets
MSCC
While this patient does have metastatic breast cancer and will likely eventually succumb to her
disease, she has a life-expectancy of greater than one year (see below), is in intractable pain,
and has a progressing neurologic deficit. Therefore surgical treatment is indicated. Because her
compression is anterior, a thoracic corpectomy, instrumented spinal fusion, and postoperative
radiotherapy is indicated.
A scoring system by Tokuhashi et al has been shown to be a valuable method to predict life
expectancy. In this revised system, scores are given according to the table shown in illustration
A. Total scores of 0 to 8, 9 to 11, and 12 to 15 predict a life expectancy of less than 6 months, 6
months or more, and 1 year or more, respectively. This patient is in good general condition (2
points), has no extraspinal bone mets (2 points), has an isolated spinal lesion (2 points), has no
mets to internal organs (2 points), has breast cancer (5 points), and has a mild incomplete palsy
(1 point). Therefore using the system by Tokuhashi et al, her total score is 14 points, and she has
a life expectancy greater than 1 year.
Klimo et al emphasize that decompressive laminectomy alone carries all the risks associated
with an invasive procedure and offers the patient little benefit unless it is used to remove disease
isolated to the posterior elements.
Patchell in a landmark randomized clinical trial showed that direct decompressive surgery plus
postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with
spinal cord compression caused by metastatic cancer.
Schmidt et al review the epidemiology and treatment of metastatic cancer to the spine, and point
out that spinal cord compression may develop in 5% to 10% of cancer patients.
Advanced chemotherapy likely will not help as she has already failed multiagent chemo.
Because the lesion is primarily anterior, a posterior decompression is not adequate and would
remove any remaining intrinsic stability in her spine. While radiation therapy would eliminate
some of her pain, it would not address the spinal compression, and is inferior to surgery plus
postoperative radiotherapy. Finally, palliative care is always a consideration, but should be
reserved for patients who desire that treatment or have a life expectancy of less than six months.
Osteomyleitis
The presence of an abscess in the setting of acute hematogenous osteomyelitis (AHO) is an
indication for biopsy, culture, and open debridement. Appropriate treatment of osteomyelitis
should lead to a rapid decline in the CRP, which peaks two days post-operatively, then begins to
decline and normalizes within a week. Imaging studies will take much longer to show resolution
of bone infection.
Unkila-Kallio et al performed a study to compare the clinical value of the erythrocyte
sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count in
diagnosis and follow-up of acute hematogenous osteomyelitis in children. They found that CRP
increased and especially decreased significantly faster than ESR, reflecting the effectiveness of
the therapy given and predicting recovery more sensitively than ESR or WBC count.
Dormans et al reviewed acute hematogenous osteomyelitis (AHO) and subacute osteomyelitis,
including Brodie's abscess, subacute epiphyseal osteomyelitis, and chronic recurrent multifocal
osteomyelitis. They recommended various imaging modalities and ultimately biopsy to clarify the
diagnosis. The goals of treatment were defined as (1) identification of the organism, (2) proper
antibiotic selection, (3) adequate delivery of antibiotics and (4) arrest of tissue destruction.
Shoulder Anatomy
The suprascapular notch is proximal to the point where the suprascapular nerve innervates both
the supraspinatus and the infraspinatus, therefore compression would cause weakness of both.
Compression at the spinoglenoid notch will affect only the infraspinatus as the suprascapular
nerve has already innervated the supraspinatus by this point. The teres minor and deltoid are
both innervated by the axillary nerve. The axillary nerve passes through the quadrangular space
and compression here could result in denervation of the posterior deltoid. Spinoglenoid notch
cysts are classically seen in volleyball players and associated with SLAP tears.
Martin et al review the outcomes of 24 overhead athletes who underwent arthroscopic
debridement of labral tears. Results were good to excellent in 21 of the 24 patients when there
was no gross instability or Bankart lesion present.
Meister et al review the evaluation and treatment of the throwing athlete. Rotator cuff weakness,
labral tears and paralabral cysts are discussed. Treatment is based on the pathoanatomy of the
throwing shoulder, and most athletes will achieve successful rehabilitation with nonoperative
care.
Illustration A demonstrates the anatomy of the suprascapular nerve and its sites of compression.