Search

The spine is the most common skeletal site for metastatic disease and up to 10% of all patients with cancer develop spinal metastases during the course of their disease (Kakhki et al., Nucl Med Rev Cent East Eur 16(2):66–69, 2013; Zacharia et al., Indian J Surg Oncol 9(1):46–51, 2018; Laufer et al., Cancer Control 19(2):122–128, 2012). Most tumors spread to the spine via hematogenous venous circulation; however, local invasion from close proximity tumors is also observed. In concordance with relative bone mass, the thoracic spine is the most common site for spread, followed by the lumbosacral and cervical spine, respectively. With the aging population and robust development of systemic treatment options for various cancers, the prevalence of spine metastases is likely to increase over the coming years. While the vast majority are confined to the bony elements of the spine, those with epidural extension or intradural location often require treatment to preserve neurologic status and quality of life. As with systemic treatment options, various advances in multi-modality of treatment of these tumors have accelerated over the past 20 years and resulted in excellent local control rates for the majority of patients. Nonetheless, there continues to be a void in our understanding of genetic tropism for certain primary tumors to metastasize to the spine and what mutations portend a more favorable prognosis based on available treatment options, which is an active area of research. Currently, the focus of management involves timely diagnosis, close observation, and treatment when radiographic findings or clinical symptoms become burdensome.

The surgical treatment paradigm for treating metastatic disease to the spine continues to evolve as the long-term survival of patients with metastatic disease improves. There has been a significant advancement in radiation therapy and chemotherapy in the treatment of metastatic disease; however, surgery has evolved as a major treatment option for patients with spinal metastases. Surgical decompression is particularly useful in treating patients with high-grade ESCC (epidural spinal cord compression) and CEC (cauda equina compression), and instrumentation/stabilization is indicated for treating spinal instability. The use of NOMS (neurologic, oncologic, mechanical, systemic) framework provides a treatment algorithm that facilitates coordination between a multidisciplinary team to offer safe, reliable, and reproducible treatment for patients with metastatic spinal disease.

Endoscopic transsphenoidal pituitary surgery (ETPS) is rapidly replacing both the open transcranial as well as the transsphenoidal microscope-based techniques for resection of pituitary adenomas. This change has resulted from technological advances in lens and camera resolution, minimally invasive surgical instrumentation, and neuronavigation systems, leading to an improved field of view as well as more extensive approaches to skull-base lesions accessed through small portals. Angled endoscopes provide visualization of recesses inside the sella and direct visualization of the medial wall of the cavernous sinus, not accessible by the operating microscope. ETPS is also less invasive, with less postoperative pain, shorter hospitalization, and fewer postoperative complications than microscopic transsphenoidal surgery. The disadvantages include lack of depth perception, the need for an assistant or endoscope holder, and increased incidence of postoperative epistaxis. There is also a steep learning curve, requiring an average of 25–50 operations to learn the techniques necessary to operate using the endoscope. Despite this, experiences with ETPS have largely been positive, with benefits outweighing the costs. In this chapter, we look at the surgical outcomes of functional and nonfunctional pituitary adenomas, and further discuss complications associated with ETPS in general.

Basic neurosurgical procedures used to treat neurological conditions and emergencies include creating a burr hole, doing a craniotomy for access to the brain, laminectomy for access to the spinal cord, and placing a cerebral shunt. A burr hole is a small opening in the skull that is drilled to reach the dura mater. A craniotomy is a surgical procedure that requires removal of a piece of the skull to access the brain. Removal of the lamina of the spine (laminectomy) is done to gain access to the spinal cord. And finally, a cerebral shunt is used to transport fluids, most commonly cerebrospinal fluid (CSF), from the brain to another body cavity in order to decrease intracranial pressure (ICP). Steps involved in performing these basic neurosurgical procedures are described in this chapter.