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This diagnostic and treatment guide outlines a practical, clinical approach to the geriatric patient with lumbar spine pain. There is considerable academic debate on much of this, and it is omitted here to avoid confusion. However, I emphasize that this conceptualization is only one approach to what can frequently be a vexing problem, and does not imply that differences are incorrect.
Our experiences with more than 2000 bone scintigrams in 803 tumour patients underline the high ranking of skeletal scintigraphy in oncology. Among our patients--who, as a matter of fact, represented a selected material--the rate of false negative scintigraphs was less than 1%. The incidence mentioned in literature is between 1 and 3% (6, 11, 38, 41). By balanced and differentiated assessment of bone scintigrams and analogous x-ray films (plain radiographs, spot-film radiographs, if necessary x-ray tomograms), taking into consideration storage anomalies in respect of localization, form and storage intensity, false-positive results can be reduced to a minimum; as a matter of fact, we believe that in oncology patients the quota of false-positive results can be reduced to less than 3%. In tumour patients, the question as to whether there are any bone metastases, can be correctly answered with a probability of about 96% by means of skeletal scintigraphic imaging and the analogous x-ray film as a complementary examination. The bone scintigram is excellently suited for effecting malignoma staging. It is, in fact, superior to all other methods. Skeletal scintigraphic imaging enables the identification of metastases earlier than any other method. It is the most sensitive primary search method which can be utilized for on-target application of x-ray diagnostic methods. Both solitary and multiple osseous metastases can be accurately localized by scintigraphy. The early identification of skeletal metastases in skeletal regions with endangered stability, is particularly important, since an impending spontaneous fracture can be prevented by osteosynthesis or local radiation therapy. Changes in the growth of metastases under radiation and/or chemotherapy can be reliably observed by scintigraphic follow-ups, and can be assessed to determine whether there is a continued growth or a remission. If scintigram and x-ray film are employed side by side--a procedure which is imperative during first examination and later with specific courses of the disease, the low grade specificity of scintigraphy is largely compensated by the x-ray method.
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Seven patients with chordoma who were treated in the Universitätsklinik für Nuklearmedizin und Radiotherapie, Zürich, since 1950 are presented. In all the cases, high-dose irradiation resulted in symptom-free survival of many years duration. Five years after the first treatment, all the patients are alive, after ten years about 50% of the patients are alive. Our own experiences as well as the already published cases show that radiotherapy has an important role in the management of chordoma.
Spinal computed tomography has considerably enhanced differential diagnostic safety in the course of the past two years. It has disclosed new possibilities of indication in the diagnosis of the vertebral column. With the expected improvement in apparatus technology, computed tomography will increasingly replace invasive examination methods. Detailed knowledge of clinical data, classification of the neurological findings, and localisation of the height--as far as possible--are the necessary prerequisites of successful diagnosis. If they are absent, it is recommended to perform myelography followed by secondary CT-myelography. If these preliminary conditions are observed, spinal CT can make outstanding contributions to the diagnosis of slipped disk, of the constricted vertebral canal, as well as tumours, malformations and posttraumatic conditions, postoperative changes and inflammatory processes.
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The radiological appearance of chondrosarcoma, especially in their less common skeletal sites, is described. Variations in the radiographic manifestations are mentioned and the difficulties of differential diagnosis, especially in the long bones, ribs and hands, are stressed.
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A 76 year old man, presenting with symptoms of general malaise alone, had a marrow biopsy which showed and undifferentiated carcinoma. A subsequent autopsy revealed a multi-nodular pleural mesothelioma, which was not seen radiologically, presumably because of the small size of the nodule. There were bilateral adrenal metastases and diffuse bony metastases involving the marrow. An occupational contact with asbestos was retrospectively confirmed. It is rare that a pleural mesothelioma does not exhibit thoracic signs and very uncommon that bony metastases should give the diagnosis in such a tumour.
Careful preoperative planning is of great importance for successful surgical treatment of soft-tissue sarcomas. All means available should be used for determining as exactly as possible the location and extension of the tumor. Based on the observation that malignant soft-tissue tumors usually respect preformed fibrous barriers until a late stage, special surgical techniques have been devised. Some muscles in the body are dispensable and can be removed without significant loss of function. For assessing the prognosis after surgical treatment of soft-tissue sarcomas, a nonparametric multivariate analysis and a long follow-up period are essential. Seven cases of total spondylectomy (removal of one or several entire vertebrae), three cases of extended hemipelvectomy (parts of the adjacent spine included in the specimen), and one case of lumbosacral amputation (hemicorporectomy) are briefly reviewed with recent follow-up data.
The authors surveyed 31 surgical and radiotherapy series comprising over 2300 patients with spinal metastases to determine the influence of factors such as tumor biology and topography, pretreatment neurological status, the presence of a myelographic block, the progression rate of symptoms, and the general medical condition of the patient on both the functional prognosis and the choice of treatment. Both life expectancy and the functional results after therapy are mainly dependent on tumor biology, which in turn determines radiosensitivity. The remaining factors seem to have only complementary predictive power. Because radiotherapy has been found to be as effective as operation plus radiotherapy in the management of the majority of patients with spinal metastases, it is very important to improve the selection of surgical candidates (less than 42% of the total cases) to prevent unnecessary surgery-related morbidity and mortality. Factors considered important in the selection of therapy are the location of the tumor within the spinal canal, the neurological status at the time of treatment, and the systemic condition of the patient.
This article addresses the subject of available technology and techniques of neuroimaging of the spine. It also reviews broad areas of neuropathology such as congenital anomalies, degenerative joint disease, the postoperative spine, disorders of the spinal cord, neoplasia, trauma, and infection. A general approach to the radiographic diagnosis of spinal disorders is covered.
280 patients presenting osteophilic tumors were evaluated by conventional tomography of the cervical spine. Metastasis were found in 120 cases among which 70% had no symptoms. Axis was first concerned and sometimes lesions could not be detected on plain radiographs. Authors insist on the need of a systematic cervical spine tomographic study in patients with osteophilic tumors.
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