Neurology & Neurosurgery Advances

NewYork-Presbyterian

Advances in Neurology & Neurosurgery

A Multidimensional Treatment Approach to Spinal Tumors

NewYork-Presbyterian Hospital is among the most advanced centers in the nation for the diagnosis and treatment of both primary and metastatic tumors of the spine. The brain and spine tumor programs of Weill Cornell Medicine and Columbia University integrate multiple disciplines to provide comprehensive evaluation and treatment strategies that include minimally invasive surgery, stereotactic radiosurgery, and percutaneous therapies.

While surgery remains the cornerstone of treatment for pain, instability, and improved neurological function, our international renowned neurosurgeons, who are members of Och Spine at NewYork-Presbyterian Hospital, offer the latest treatment options to provide patients with spinal tumors better outcomes and a prolonged quality of life.

The Tumor Board

NewYork-Presbyterian’s comprehensive and multidisciplinary approach to the diagnosis and treatment of patients is augmented through tumor boards at both Weill Cornell and Columbia. Comprised of neuro-oncologists, surgeons, general oncologists, radiation oncologists, neurologists, radiologists, and endovascular interventionalists, the tumor boards recommend a concerted approach to evaluation and the development of individualized treatment plans thereby optimizing each patient’s plan of care.

Through multidisciplinary tumor boards, our patients are not just evaluated and treated by a single specialist, but they also benefit from the breadth, depth, and experience of all that NewYork-Presbyterian Hospital has to offer.

Detecting Tumors Sooner and Smaller

Columbia and Weill Cornell neurosurgeons are renowned in the microsurgical management of spinal tumors, including benign tumors located both inside and outside of the spinal cord. Indeed, Columbia neurosurgeon Paul C. McCormick, MD, MPH, served as lead author in the development of a classification system for the clinical evaluation and correlation of risk with respect to surgery of spinal cord tumors. The McCormick Classification System, which remains in use today, grades the clinical severity of spinal cord tumors.

The improved sensitivity, specificity, and availability of imaging has allowed physicians to diagnose tumors at a much earlier stage and have also lessened the risk of surgery. The more precise imaging, including MRI, also enables physicians to visualize very small tumors that are clearly incidental in nature in patients who are not symptomatic. Small intradural extramedullary tumors are followed over time, rather than surgically removed, which carries a risk of neurological deficit from opening the spinal cord.

Navigating Surgery

Our neurosurgeons have advanced training and expertise in spinal oncology and complex reconstructive surgery for spinal deformity.

Accomplished in both minimally invasive and open complex spine surgery for spinal cord and spinal column pathologies, they apply a multidisciplinary team approach to evaluate, treat, and manage the patient both surgically and nonsurgically.

image of Cervical spine meningioma

Cervical spine meningioma

The mainstay of treatment for many of the metastatic diseases involves chemotherapy and radiation therapy and not necessarily surgery, which often is not used to cure the disease but to remove the focal pressure off the spinal cord. Medical oncologist, radiation oncologists, neuroradiologists, and specialists in pain management and rehabilitation medicine come together to implement a treatment plan for patients with metastatic disease, the most common condition in the spine oncology world.

Prior to a surgical procedure, our neurosurgeons may incorporate endovascular techniques to reduce blood flow to spinal tumors, which maximizes the safety and effectiveness of surgery. During surgery, our neurosurgeons use advanced neuronavigation tools and intraoperative neuromonitoring in real time, including high intensity transcranial stimulation to monitor motor function particularly in upper cervical tumors.

Robotic surgery is the newest iteration of navigation-based systems to facilitate accurate instrumentation placement in complex spine surgeries. In published reports, robotic spine surgery in high volume academic centers has been found to have both time- and cost-saving benefits due to improved screw accuracy, avoidance of revisions, and reduction in infection and hospital admission days as a result of being able to perform procedures without open surgery.

The type of tumor dictates how much of the tumor the surgeon would need to resect. In the case of metastatic tumors, especially where there is extensive tumor infiltration of the spinal column, they might need only to remove the part of the tumor that is compressing on the spinal cord and causing neurological dysfunction.

Pain control and palliation are of utmost importance with spinal oncology specifically related to metastatic disease. Because many of these conditions are not curable, the surgeon’s goal is to provide the best quality of life for patients with excellent pain control using surgery and non-surgical interventions, such as systemic therapy and radiation oncology with the assistance of the palliative pain service.

In addition to managing metastatic spine disease, our neurosurgeons treat a significant portion of benign intramedullary tumors, which involve the spinal cord itself or the area just outside of the spinal cord. These tumors are challenging to treat, as they are difficult to resect technically, requiring microsurgical skills. However, in some instances, patients can receive a total cure after surgical resection.

Augmented Reality

A particularly exciting development in spine surgery is the application of augmented reality (AR). While the technology has been used in surgery of the brain, our neurosurgeons are now incorporating augmented reality for localization and minimally invasive resection of tumors.

image of an S1-2 intradural schwannoma

Example of an S1-2 intradural schwannoma resected through a minimally invasive approach using a tubular retractor with augmented reality. Even prior to durotomy, the outline of the tumor is denoted by the blue line. Once the durotomy is made, tumor resection is guided by internal debulking working toward the borders visualized through augemented reality. After excision, the remaining space can be explored using the blue AR outline as a perimeter to inspect for confirmation of gross total resection. (Global Spine Journal, 2020, Vol. 10)
Click here to view a larger image.

Augmented reality involves overlaying virtual bony structures and preplanned screw
trajectories, differentiating neural tissue and bony landmarks by color to identify the optimal trajectory to reach the pathology. Through the use of tubular retractors, AR enables the surgeon to perform maneuvers in the resection of intradural tumors with more confidence. AR applications are expected to be extended to intramedullary spinal cord tumors.

Applying Stereotactic Radiosurgery

Stereotactic radiosurgery procedures not only shrink tumors, but also help to alleviate symptoms of spine tumors, such as pain or weakness. Patients often will have surgery first to safely remove as much of the tumor as possible while protecting the spinal cord, and then undergo radiosurgery to target remaining visible tumor or microscopic tumor cells that may be left behind after the surgery.

Occasionally, when tumors are found early and are not encroaching upon the spinal cord or the spinal nerves, stereotactic radiosurgery helps to manage definitively the tumor and inhibit its further growth, as well as to manage pain. Unlike older forms of radiation for spinal tumors, stereotactic radiosurgery is very focused and can limit radiation to just the area involved with the tumor, minimizing radiation to normal surrounding tissues, such as the spinal cord, spinal nerves, and nearby organs.

Delivering Percutaneous Treatments

Interventional neuroradiologists provide percutaneous treatments that specifically target the spinal tumor or spinal metastasis in terms of pain or tumor control. Patients with tumors anywhere in the spine that cause significant pain and/or pathologic vertebral compression fractures can benefit from vertebral augmentation. Vertebroplasty, in which a cement mixture is inserted into the fractured bone to restore bone integrity, and kyphoplasty, in which a balloon is inserted into the fractured bone to create a space and then filled with cement, provide stabilization and pain relief.

image of a Pathological fracture in the spine

Pathological fracture caused by vertebral body tumor

Fluoroscopic-guided thermal radiofrequency ablation affords the potential to control nonresectable tumors and manage pain. Ablation, which also includes cryoablation and microwave ablation, treats at least part of the tumor and offers tumor control. This minimally invasive percutaneous procedure involves the placement of a needle through a very small incision in the back and into the tumor in the spine with little trauma to the patient. Often kyphoplasty and ablation can be performed together in a single session for patients with very painful metastasis that is causing a fracture in the spine.

Employing Spinal Intra-arterial Chemotherapy

When standard treatments, such as radiation and systemic chemotherapy, have failed, spinal intra-arterial chemotherapy (SIAC), a unique therapeutic treatment developed at Weill Cornell, can be offered to a subgroup of patients who suffer from progressive or recurrent epidural disease and remain at risk for neurological compromise.

Dedicated Spine Care from Two Ivy League Schools

As the dedicated spine center, NewYork-Presbyterian Och Spine brings together world-class Columbia and Weill Cornell physicians, including spine surgeons — both orthopedic surgeons and neurosurgeons — physiatrists (rehabilitation medicine physicians), neurologists, physical therapists and pain management specialists. We treat patients of all ages for every type of spine issue — from everyday back pain to the most complex spinal deformities and spinal tumors.

Reference Article

Hussain I, Cosar M, Kirnaz S, Schmidt FA, Wipplinger C, Wong T, Härtl R. Evolving navigation, robotics, and augmented reality in minimally invasive spine surgery. Global Spine Journal. 2020 Apr;10(2 Suppl):22S-33S.