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Other than a couple of very select ones. So the principles are what's key here rather than focusing on individual tumors. It's not like primary bone tumors where you need to learn, you know, the onion skin of Ewings and all of that kind of stuff. You don't see those same classic appearances in the spine. But what you should focus on really is the differentials and, and the management for the different groups as well. So um in terms of asking people questions, I know it's not, not, not the dumb thing now to pick people out at random. So, um what I'm going to do is I'm going to pause and I'm gonna hope that people will step in and answer questions as I ask them because I also can't see the chat. So I don't, I assume there's no hands up or stuff. So if you want to answer a question, just don't mute yourself, same thing with questions. Just please do interrupt at the time because it um often a lot of questions are better sort of when they're applicable to the thing rather than in retrospect. So, um so please just, but in whenever you like. Um so it's not going to be news to you that tumors are metastatic, almost all of the time. Primary bone tumors make up a very small percentage of all bone tumors. And uh even more so in the spine and spine tumors are, you know, the vast majority of the time going to be metastatic and the vast majority of the time they're going to be one of the key five. So, um prostate and breast kidney, lung and thyroid and then you've obviously got the myelomas and lymphomas, um which I guess you could kind of consider as primary bone tumors because they originate in the bone marrow, but um but not treated in the same way. Um Now they all have their characteristics. So you'll, you'll know that prostate tends to have a blastic sort of more mixed blastic appearance. Breast can be quite li um kidney is very vascular. Lung is also lytic and thyroid can also be very vascular. Um One thing I did want to touch on with, with this is um really what we, what we should be doing is uh and what you should be saying in the exam especially, but um is you should really be doing full examinations of anyone you see with a tumor. So it's not just about the orthopedic examination, it's not just doing a quick spine exam and a neuro exam and the rest of it. And then relying on the imaging to tell you um really for, for good medical practice but also for um making sure you image the right parts of people. Um a thorough examination is key. So what you, well, who wants to jump in here and tell me what kind of things? I mean, there are some keys on the screen. Really? But what kind of things are you looking for on examination? Uh Hi, Iggy here. All right. So for uh for a man. So I, I would ask for, well, so in general, in the history, I will look for any red flags or any um preceding symptoms or such as night sweats and uh systemic features. Yep. That's in general uh asking the patient if they've had significant history or past medical history or family history of uh cancer. Yep. Uh in my work up um is uh in my blood test especially, I would do basic bloods first including CRP ESR and a bone profile. Ok. And uh on top of that, I would uh do a uh cancer profile for specific to the patients. So prostate do a PSA for females. I will do ca 125 and ca 19 9. Yeah. Um And of course, with the chaperone, I will examine the patient uh first looking for um uh so for female patients looking for any breast lumps, um uh for male patients asking them if they've had any testicular tumors or any uh prostate problems or any urinary symptoms, uh any recent skin lesions that can suggest myeloma or lymphoma. Um and that will be my screening before any imaging investigation. Yeah. So the only other things you could ask about would be hematuria, which might be an indication for either pros prostate or, or renal cell carcinomas. Um It's worth having a feel in all of the key lymph lymph zones. So, you know, inguinal lymph nodes, supraclavicular, et cetera to just see whether there's any lymphadenopathy, which would obviously be lymphoma, but um local spread from wherever as well. So, supraclavicular being lung, all of the posterior and anterior chains, chains in the neck for thyroid and then the axillary lymph node for breasts as well. So palpating for lymphadenopathy, asking about weight loss, all of those constitutional symptoms that you get taught as a medical student and gradually stop asking as you get as you get older. But they're taught for a reason, they're important and they're key too often rely on um on imaging. And the thing is um so in your bloods, you could also do thyroid function if you were thinking about that. I almost certain, not many people do that. Um But having a palpation of the thyroid and feeling whether there's a goiter. Um Number one is a good thing to do. Number two, the patients feel like you're giving them a good sort of thorough mot. Um And number three is actually quite a lot of your imaging. So if you think about a CT chest pelvis, unless you've got a huge retrosternal goiter that's probably not going to be picked up. Um likewise on an MRI of the C so an MRI CT of the C spine, um If that's um to the spine, you'll often notice that they um they cut out a lot of the anterior soft tissue. So it's very easy to miss imaging the thyroid. And that could be, you know, something that, that we know spreads to the bone, but we often don't image or examine. So I think those kind of things are really going to be sort of things that I would expect people to be saying in the exam, but also things to know. So um when I see, so I'll be honest with you often by the time I see a tumor patient, unless it's an incidental finding, um they've already had imaging. But um but in the acute setting say they come in with, you know, off their legs and the legs aren't working and we don't have a diagnosis, then it's all about the examination. And I think it's something especially with telemedicine that medicine is moving away from and a skill that's ever becoming lost. But I think it really can give us some really key findings. So I'd encourage you all to when you're seeing possible tumor patients to just take a step back and think about look, what examination can I do to try to narrow this down so that I'm at least targeting my investigations and likewise with the prostate, I think, um, as you all know, and I saw in the chat something about pr, so presumably Mr Cook was talking about that, but, um, you're going to be doing apr on the vast majority of anyone you're suspecting having metastatic cord compression. So why not feel the prostate while you're in there if it, obviously it's one. so, um these are the kind of things that I'd expect people to be sort of just coming out with all of the time. And I think it should be routine. I know it is, but I think it should be routine that everyone should get a fairly thorough examination of most of the key areas. Um And, and that does include breast. Um So, um a lot of the time we don't examine breasts in women because it's a sensitive exam. But um but you can rest assured that the women out there are well aware that breast cancer is the most common female cancer. And so, um they will, they're kind of will be expecting it. So if you don't do it, that sort of reduces their confidence in your examination as well. So I think um a a full examination not shying away from, from that is a really important thing and something that I would strongly encourage. Um So as I said, primary tumors are rare, um there's a bimodal distribution. So you've got the teenagers and then the sort of mid thirties, but in reality, you can, um you can get them in any, any age group depending on what tumor you're talking about. Um So really what you talking about is anyone with an isolated lesion without a known primary, you have to assume that therefore, if you can't find somewhere that it's spread from, that it could be a primary bone tumor. And the um the reason why that is really is because the management is so vastly different and the outcomes are so vastly different that um that it's really important to know. So what is, so what, what do people think is the differences in the management? So why is it, why do we harp on about primary bone tumors so much because they're so rare? Why do we spend so much time talking about them? What's so special about their management? Why do I why do primary bone tumors matter? Come on, come on over the. So, you know, there's different prognosis. So you can have a better prognosis if you can do a resection of a primary bone tumor um than malignant. And actually the majority of the time malignant can be managed um with stabilization and radiotherapy rather than needing a reception um to treat the cancer. Uh Yeah. So basically, um you're right then. So number one, if it's isolated to one bone and you can resect it, then potentially that could be a curative resection, if there's no metastatic disease, which presumably there isn't. If you can't find a primary. Number two, the treatment can be very different. So some bone tumors can be very radiosensitive. Um some can be highly malignant to metastasize early. So they need very early input. So being on a normal bog standard cancer pathway isn't good enough. And of course, we're talking about the people that the age group that they occur in as well. So young people getting tumors means their recurrence rate is going to be high simply because they've got more years over which it can recur does that make sense? So if the younger you are, the longer you're going to live, the more chance of you having a recurrence, um because you've got longer to live and therefore there's more chance of it happening and the principles of spine, primary bone tumors remain pretty much vastly the same as all other um primary bone tumors. So um what are those principles? This should roll off anyone's tongue? Really? So you see something that you think is a primary bone tumor, what do you do? So you want to get um local distance staging. So for this spinal spinal tumors, you want to get an MRI of the whole spine and a CT chest abdo pelvis to look for any metastatic spread if you want any referral to a tertiary bone tumor center, um for their further ongoing management, which would usually be along the lines of uh biopsying the lesion um following an MDT discussion with the radiology images um in conjunction with the surgeons and the radiologist performing the um biopsies that be image usually image guided biopsy. OK. And what are the, what are the Sorry Ben, I know you're talking and um but what, what are the principles of the biopsy? Um So it's so usually image guided done through uh an extensive extensile approach that will usually be used as part of the surgical approach for resection. If that's uh appropriate um done in the center, that's going to be performing any further surgery on that patient uh is gonna try and reduce any uh spread of the tumor. So, immaculate hemostasis entering only through one for the other primary brain tumors entering through one compartment. But in the spine as suppose entering through that same approach and uh tattooing or marking your biopsy trac. So it can be resected um as part of any further surgery or treated with any radiotherapy as needed. Um Perfect. Yeah. So, um yeah, broadly broadly. That's right. So, um it should be done in conjunction with the surgeon that's going to be able to do it. You should mark the tract, immaculate hemostasis, try not to cross um compartments. Um So the most direct route possible and um ideally away from neurovascular structures. Um so the eu can excise said tract. Um So, uh all of those are, you know, they're just the basic principles that should sort of roll off the tongue really. Um And, and the same applies to the spine really. So, um, and, and what that really means is for, for various reasons, you're gonna try to get a as, as direct a root to the tumor as possible through as little other tissues as possible and try to keep away from the nerves because you can't resect those. But, but obviously, most of the spine is surrounded by some quite beefy other structures that you can't resect either. So, um it's just a case of uh planning your margins um and planning your approach. Um So, yeah, good, thanks, Ben. Um It would be wrong of me to do a talk about buying tumors without talking about intradural tumors. Now, I'm not gonna painfully drag out all different types of intradural tumors and we are not neurosurgeons. Um So I don't expect you to necessarily be able to reel them off quite yet, but I think it's really important that you understand the concept with this drawing um on the, on the right half of the screen here. Um because I think you'll hear in MDT S if you go to them, these concepts are intramedullary, intradural, extramedullary, and extradural. So, the important thing about these is to understand really what it means. So an intramedullary tumor means it's within the spinal cord itself. So the tumor is within the cord and the reason that's important is number one, because it's more likely to be a different set of tumors compared to those tumors that are outside the cord. And number two, because the resection becomes more tricky, more dangerous and has some more wide reaching consequences in terms of the neurology. Um So, and of course, you're looking for a neurosurgeon to do this. So anything in ural really, you're looking for a neurosurgeon but definitely intramedullary. Um So the the way to see this really is the best way to find it is to look at, start by looking at your MRI scan in a normal region of the spinal cord and gradually scan down, look at where the tumor's originating, where it's starting. Look at where the try to get a mind in your mind where the Jura is where the edge of the cord is and try to work out somewhere in amongst this whole black, sort of different shades of gray, exactly where the tumor starts and finishes. And if you can't distinguish it from the cord, then almost certainly it's going to be intramedullary and intramedullary tumors most commonly would be astrocytoma, ependymoma, paraganglion, schwannoma, but you can get intramedullary metastases as well. The um and things called drop metastases, which will be on the nerve root of the corner two. So, um just because it's intradural doesn't mean it can't be a me a metastatic disease. Ok. So the second thing is intradural extramedullary. Ok. So it's inside the Jura, but it's outside the chord. OK. So these can be quite tricky to distinguish from the intramedullary tumors because inside the Jura but outside the cord, um quite often look very similar. Um But what you have to do is you have to trace the Jura con continue follow the outline and see whether the tumors within or without. And that sounds easy, but it's a lot more difficult than you think. Um these um these are so as you can imagine, slightly easier to pick out because you're not opening up the entire spinal cord but still come with quite high um uh high um complication rates. But as you can imagine with it being intradural and with CS F flowing all around them, as opposed to intramedullary, the intradural extramedullary tumors have quite high recurrence rates and quite high intradural metastatic rates because the CSF is floating around potentially with all of these cancer cells within it. Ok. So intradural extramedullary tumors have a high intradural. Um yeah, intradural metastatic rate. OK? Because of the fact that CS they're bathed in CSF, which is circulating around the whole of the central nervous system all of the time. So the risk of metastasis is quite high for those. Ok. Um But things, so meningioma is obviously a benign tumor, but then there are things like leiomyosarcoma, um glioma and of course, metastatic disease as well. Ok. Um And the lists on the on the left ear is is in order of sort of likelihood if you see what I mean. Ok. And then extradural tumors. So these are outside of the dura. So they can be originating from the bone and pushing within the canal. They can be um originating from a nerve root. Um They can just be originating from nothing. Um They can just be isolated soft tissue within the canal. Um And these are by far the most common. OK. And this is the kind of thing that in Norwich, we will see and um is a spine surgeon rather than neurosurgeon specific tumor. Ok. So metastatic disease, vast majority of these. OK. So if you see an extra dual tumor, it's more, more likely to be metastatic than anything else. And that should be top of your differential unless there's a good reason why not. OK, then you've got things like chordoma, hemangioma. Um So hemangioma I'll, I'll stop on those in a minute because you'll see loads of those tons and tons on MRI scans. If you do a spine jump and the vast majority of them, we don't get excited about. Most of them aren't expand. So they do change the bony architecture, but most of them are benign and need nothing to, if you have multiple hemangioma malta, there are some hereditary conditions that that can cause that. And if you have multiple hemangiomata, which I believe is more than six, then you have a higher incidence of them undergoing um malignant transformation. And the reason for that is it's just a numbers game and the more of them there are, the more likely you are to have mutation within them, but also you're more likely to have underlying genetic abnormality, which is the cause of them. Ok. You can get aggressive hemangioma which expand the bone and can cause um number lysis of the bone. But number two compression of uh of the neural structures as well. The trouble with that is um they can be quite vascular and taking them out is difficult other things. So, lymphoma, myeloma and ependymoma are um extradural tumors. So there's your differential lists for the three things you don't, I guess you could learn them. Um But it's more important that you understand what these terms mean, I think and have just one or two for each one. Does that make sense? So, when this is more to general tumors rather than primaries now? Ok. So always, always, always have infection on your differential list because infection can mimic lots of things. Um especially TB uh and uh it is not uncommon for um for infection to mimic it. Now, Mr Crawford, who some of you I've worked with had a saying that I think it's quite, quite a good saying. Good, dis, bad, bad dis good. Um So if you have a um a well preserved intervertebral disc with um with changes in the vertebral body around that disc, but not encroaching upon the disc, then that's bad because that could be tumor. Ok. But if the disc is involved, then it's more likely to be infection. And that's, that's a spondylitis itis, that's good because that's easily treatable. And that's where he's getting to with that. So, I guess you could use that as a, as a little rule to pin your hat on. Um, but TB is quite a good mimicker. So TB will affect the vertebral bodies and of course, there are tumors that will, if they get big enough, they'll encroach into the disc space as well. But it's a good little, a good little rule to remember. Um Then you've got to gather your information. OK. So consider infection, gather your information and we've already been through this but staging CT bloods full examination, vitally important, can't stress that enough other things. So involve the MDT get oncology involved early. And um I say this for the exam but also for life as well. The oncologists are well used to dealing with a whole bunch of the other things that we're just not very good at in orthopedics. And by that, I mean, the other support the pastor risk care, the involving the million nurses access to other services. So and explanations about pathways and they have really good access to some excellent services. And I would encourage you to involve the oncologist early. I do know that in some hospitals, oncology are reluctant to get involved until you prove it's not hematological malignancy. Um, but in reality, that's relatively straightforward by doing some blood tests and if the bloods are normal, then it's unlikely to be hematological. And you can involve the oncologist in knowledge, we're really lucky. We have a very good oncology team, but I would encourage you to get oncology input early, but that's not to say you shouldn't speak to the patients. Ok. So, um, there is nothing, so I do a lot of tumor um uh a a lot of tumor work and I there's nothing more frustrating than a patient who uh doesn't know why they're there and doesn't understand the diagnosis. Now, I'm not saying that that's always the doctor's fault. Sometimes things don't sink in, that's fine. But you should, you shouldn't rely on the oncologist to break your bad news for you. That's something that you need to work on and support the patient and their family and we all know how to break bad news and almost all of us are not that used to it. Um So I think that's something that I would say is a really key thing for your ongoing management during your on calls and things is most patients will appreciate honesty. Ok. So just be honest with the patients. Um What you, what you really don't want is for the first time they hear, hear the word cancer to be. Hello, my name's doctor. So and so I'm the oncology doctor and they didn't know that they had cancer, but an oncologist is coming to see them that doesn't go down very well at all. Ok. Um Obviously you need a full neurological examination in looking for spinal cord compression. Um would, so in terms of spinal cord compression, does anyone wanna go through? Uh what kind of things you're looking for in terms of MSCC? So what, what, what on your examination would lead you to think that this patient might have spinal cord compression, upper motor neuron signs. So, brisk reflexes, um uh a general kind of uh lower limb or upper limb weakness as well. Uh And for your uh upgoing planters, um things like that. Yeah. So exactly. So upper upper motor neuron signs, um weakness, uh pretty much anything you like really? Um you don't always get upper moor neuron signs if it's very acute compression sometimes. So upper motor neurone signs do take a little while to um to develop. Um And of course, I'm sure you could all draw me the tracks of the spinal cord. Um and explain to me why some tumors encroaching on one part of the cord would affect certain things and some of the others and dorsal columns versus spinal thalamic, et cetera, et cetera. Um But I obviously won't ask you to do that on here. Um So steroids, this can be a little bit controversial. So um there's one thing that's not at all controversial. Steroids and trauma have no place. Ok. There is no place for steroids and trauma. Um There's very good evidence to say that it makes no difference to the um to the outcome and it can be detrimental. Um But in MS CC steroids do help. Ok. And I'm sure Mr Steele and anyone else who's on the call can think of several examples where they've given steroids to a patient and they've had a improvement in their neurology. Um Now the way steroids work is up for a little bit of debate and you can all go away and read it many, many papers about it. But the way I like to think of it is so, number one steroids clearly will have some kind of anti-inflammatory effect. That's kind of their point. But what they also do is they reduce the edema of the spinal cord itself. Ok. So, um those two things, so the, the reduction of edema and the um change in the inflammatory mediators just buys you some time. Ok. So it's not necessarily gonna um cure all of your problems, but it does buy you some a little bit of time. Um which is obviously a vital thing to get everything, all the rest of those things done. Um uh You sh so honest answer is um the, the textbook answer is that you shouldn't give them in people in whom you're suspecting lymphoma. Um I don't think it really hides a diagnosis of lymphoma. And indeed, when I speak to our hematology and oncology colleagues, um they agree. Um but what it can do is it can change some of the tumor markers, which does affect their ability to be able to um plan the treatment. So, ideally not a lymphoma and that should definitely be your official answer. Um But I think almost everyone you speak to would say, look, if steroids are going to make the difference between a patient having significant neurological deficits or not, then you know, why not give them a try. Ok. So that is recommendation that's coming from our oncologists at the moment. So, steroids for everyone, ideally not in those with lymphoma unless you absolutely have to. But for those of them SCC with advancing neurology, steroids are definitely a good thing. OK? And then the final principle is really that you need tissue. Ok. So you need a biopsy, ok. Um But I would encourage you um when you're thinking about this to think about um getting the staging scan before planning biopsies. Ok? Because there might well be somewhere that's much easier to get tissue from than inside someone's body. Ok. So it might be that they've got a sternal lesion or a clavicular lesion or a lymph node up in their neck or um or uh even liver lesions, to be honest, they're easier to and safer to biopsy than spine lesions. So, um if you can uh find an alternative lesion um then it is by far better to biopsy, the easiest ones rather than going straight for the spine. Um, because of course, biopsying the spine. Number one takes it is painful. Most people would need a general anesthetic unless it's soft tissue around the spine. Um, and number two comes a significant risk. So, um, look for the primary, but tissue diagnosis is still important because in today's world, with the many, many different oncological therapies, knowing the different receptors and stains that um each tissue responds to is really important for outcome. So, um let's just go back on actually. So in terms of, in terms of surgery, um how do you, so who, who's got in, who in their mind thinks they kind of uh understand um why we might consider operating on someone uh with metastatic spinal cord compression or, or why we don't operate on some people. I'm hoping at least Ben would know this. But so, hi, it's Luke. So I think there are various factors that will affect your decision. So there are nice guidelines suggesting. So, firstly, with relation to prognosis. So if somebody has a prognosis of less than three months, then on balance, they're probably not gonna benefit from surgery just due to the time it takes to recover from that surgery. Um So I'm just going to stop you there for a second. Luke. I know I'm interrupting and I'll let you carry on. What do you think about that three months. Like, what, what do you think about that? Three months? I think, I think three months is a long time to be bedbound and deteriorate if you, if you are going to live for three months. But at the same time, I think it's, it's, I think those recommendations are there because spinal surgery is not a benign thing and it takes a long time to recover from that. And therefore, I think if, if you have only got a limited, I guess you have to pick a number. Let me ask the question, I'm gonna ask. So you could ask that question in a couple of ways, isn't it? So, yeah, it is a long time to be in pain. And you can think of some of the procedures as palliative procedures kind of like a neck of femur fracture, you know, and if the neck of femur fracture had three months, actually, I think we probably would operate. Exactly. So you can think about it that way in terms of, you know, even if they are going to live three months, at least I can make that three months more comfortable. And there are definitely people who subscribe to that. Ok. What about the, how long does it take to recover from, you know, this cut, it say we're gonna do you know, a long posterior fusion or something? How long do you reckon it takes for them to recover properly from the um, I would, I would imagine a couple of weeks to a month, at least before I would imagine they could sit up in a chair perhaps, or maybe that would even be difficult. So, mobile is not the same. So it takes a good, you know, 2 to 3 weeks for the wound to heal. Then you've got sort of loads of pain while the muscles healing. I would. So I say even my elective patients, I say, look, the first sort of two months are going to be pretty miserable. And, you know, you, it will be 6 to 8 weeks and still you even start to turn the corner and then you'll start to get better. So at three months, really, they, they're only, you know, a little way through their recovery, it could take up to a year to recover from spine surgery. So, um, so actually, I think three months is fairly, fairly low compared to the decision making that a lot of people would be using. So I know it's guidance, but actually I would say that quite a lot of surgeons that I've worked with would actually use more like six months as their cut off, to be honest, ok, because by the time you operate on someone, it's going to take, you know, it's going to take at least 2 to 3 months for them to recover, which means what's the point of doing? Because you spend all their life recovering from surgery instead of, you know, not recovering from surgery, but I, I completely agree with the counterargument as well. So, these are interesting ethical debates that tumor surgeons have all the time. How long it's long, what about palliative surgery and in the world where everyone's monitoring everything you do with outcome scores and death rates and complication rates. Because obviously the people who are going to live three months are going to be a, a threes, probably, maybe even fours. Their wound breakdown rate is going to be higher. They're going to have poor metabolic status. Um I think that's probably moving people away from doing spine surgery in a world where um where people are ever monitoring what we do anyway, carry on. So, so yeah, surgery for um I guess one consideration is how prognosis and how long they um another consideration is the type of tumor. So um hematological tumors, for example, might be very chemo sensitive. So I think myeloma is a good example. So I think you can treat myeloma quite effectively with chemotherapy. And therefore it doesn't really make sense to go in and do a big surgical resection and stabilization if actually it's all going to shrink away with chemotherapy. So if there's alternative treatments and I think there are differences in terms of radio sensitivity as well with certain tumors. So what what happens to the hole that's left by a tumor that shrinks? Um I had a, I had a chat with one of the oncologists recently or hematologist recently about this and he was telling me that myeloma takes about six months to a year to fill in. So it does, it does, it does Reuss but it does so slowly. Um, so you do have this sort of transient period of vulnerability of the, of the nerves of, of the spinal column, um, which you do have to be aware of. Um, but, uh, but, but it will reo so you just have to get through that stage, I guess. Ok. Um uh Yeah, so yeah, and then radiosensitive as well. Those are the same uh on the same line, I forget which ones are actually more radiosensitive. But I think lung is not that radiosensitive and breast is. But so just to take that into account. Um yeah, so um Tom Ros who is one of the oncologists who everyone has a lot of respect for. I think he's one of the vice president of the Oncology Society or something. He says all, all tumors are radiosensitive. You just need to give them enough radiation, fair enough just whether it's survivable. Ok. Yeah. So, so I guess, but that, that might also influence it also. So the prognosis, I suppose. No, no, it goes back to prognosis. So the the type of tumor um de depends on their prognosis as well. So for example, I think breast is now is quite survivable um for quite a long time. So, you just have to consider um how long the patient's gonna? Well, we've talked about prognosis as well. Um ok. Uh Yeah, I can't, can't think of anything. I think also you can sometimes surg a surgical indication to go in and improve margins for then subsequent radiotherapy. So if, if a tumor is right, abutting and a neur a nervous structure, for example, if you can um surgically clear that margin a little bit, then that can sometimes allow radiotherapy whether that is palliative radiotherapy or not to then um to be, to be possible whereas it might not be before if you haven't. So we call that separation surgery. So separating the tumor from the neurological structure, separation surgery. OK. And that's a really sort of ever increasing thing with the increasing accuracy of multi beam stereotactic radiotherapy, which we now can offer in knowledge, but also with things like the um the gamma knife and all of those new radiotherapy things which can have super high focused um radiotherapy which has sort of um really targeted um drop off points. So you get maximum radiation dose within the tumor and you can really, um they ask for margins of about 2 to 3 millimeters. OK. So they can plan their radiotherapy about that accuracy. OK. Um And so why? So basically every tissue in the body has a radio radiotherapy tolerance. OK. So you can give it this amount of radiation before it starts to become troublesome. And the spinal cord is one of those as well. It's obviously very sensitive. So they can give the spinal cord a certain dose of radiation. But that's usually what limits how much they can give the a particular area. So from the scatter and the further away you can get your tumor from that, the higher they can concentrate the radiotherapy within that tumor fair enough. And one thing I didn't, so I know we were talking about indications, but on the flip side, kind of contraindications as well. So from a um surgical planning and just a fixation point of view. So when you get the MRI spine, if they are riddled and you've got no. So firstly, that would have a prognosis implication. But secondly, it means that you've got no, you can, yeah, you can resect the troublesome level. But if you've gone, if, if they're riddled and they've got no fixation points or um above or below, then it just technically is very challenging or impossible. Yeah. So you got to have something to fix. Yeah. Ok, great. Thanks le that's really good. Actually, you covered some really valid points there. Um So I always think about things risk versus benefits because I think that it's the way I like to explain things to patients, but you can explain it, you can think about it however you like, but this is, I just like to try to put it across this way. So what are the benefits of the surgery. So, um it improves the stability, ok, which can improve that pain quite significantly. Um So the first question is, is this tumor destabilizing the spine if it is? Um and the definition of stability by Punjabi wife, I'm sure you will know. Um but I I if the spine is unstable and causing mechanical instability, pain and that's an indication for surgery in its own, right? In my. Ok. Um Pain control and nursing. We talked about the palliation decompression. So, separation surgery and, and obviously stopping the neuro the neurological deterioration. Um and sometimes you can have a curative resection. So, um does anyone know and you might not need to? But does anyone know uh which there are two metastatic may? Yeah, two metastatic tumors, maybe three. that if you have a legal metastatic disease. So, one isolated me metastases to the bone that excising the primary plus that one metas one met is considered curative. Does anyone know that? Which, which three I throw in renal as one? But yeah, so renal is actually easy, easy one. I think I have a feeling that general surgeons take out a liver met. So, uh something that goes to the liver. Could it be bowel? I don't know, something like a no. So bowel doesn't go to the, I mean, it can go to the spine but it doesn't go that often. Um So the thyroid you um um but that's becoming more um controversial. Ok. And breast. Ok. So if you've got one isolated breast lesion, um because the, because the um the cure rates for breast cancer are so good, people are now starting to consider um a legal metastatic breast disease, a curative resection as well. But yes, renal being the most common sort of and best answer. That's still the best one. Ok. Um So the benefits of surgery, stability and pain control, decompressing the neurological structures, which is either for neuroprotection or separation surgery and possible curative resection. Ok. Um But the questions you need to ask yourself are quite rightly, will the patient live to see the benefits or are the benefits worth, you know, achieving? Are they going to be long lived enough? Um But one thing you didn't mention Luke, which I think is key and I'll show you a good example of this later is surgery will delay other therapy. Ok. Especially radiotherapy, you can't start radiotherapy to a lesion whilst the wound is healing, which means you're delaying them at least 2 to 3 weeks. Um And in some tumors that 2 to 3 weeks delay can be a big thing. Now, there's one center in um in that, well, there are a couple of tumor centers that are starting to do same day radiotherapy. So they do radiotherapy. Um but they try to keep the beams away from where the incision's going to be on the day. Um, irradiate the tumor and then they take the tumor out. Um, and then some POSTOP radiotherapy as well. Um, but, um, in the vast majority of people, um, once you've had radiotherapy, especially to the area, the risk of wound breakdown is high. Um, unfortunately, I have, um, a patient who is a, um, sort of a living example of that. Um, the risk of wound breakdown is high and that can be catastrophic. So, um, the question is, is what I'm gonna do that's worth the wait. OK. Is it worth delaying their other therapy for? Ok. And of course, don't forget to ask the patient what they want. And the only reason, the only way they can know what they want is if you explain it to them. So that would be an important thing. And that's going to have to be MDT because you're not going to know all of the other management strategies that are available. You're not going to know how successful they are. You're not going to know the impact of delays. So all of these things need to be discussed. And the last thing a patient needs is you, is, is, is mixed messages. OK. OK. So if you don't know the answer by far, best to tell them, you don't know the answer than it is to um, give them information that is then contradicted because I absolutely hate them. Um So how do you decide if it's stable? Well, you should all know about spinal stability by now. Um So, number one, do they have instability symptoms? So, um by that, I mean, mechanical pain. So pain that is worse when sitting, laying and mo sit, sitting, standing and moving and better when laying down, I pain when gravity when they're using their spine, if they do that suggests mechanical instability. Ok. Um And that is probably one of the mo the more key things that you can elicit from a patient. Um is when is it painful? What makes it worse? And is it better laying down? If it, if the pain is there all the time is even when they lay down, then it's probably not instability, pain, it's bone pain from the tumor. Um And then you can use the Mr rnct. So if you've obviously you've got a huge lytic lesion with key structural elements in the spine missing, that's more likely to be unstable. And you can use the three column theory, you can use the two column three as long as you've got a theory to work it out for unless you want to be a spine surgeon, I don't think it really matters. There are some um scores as well. Um That so that you can use spine surgery. I know you don't have to learn scores, but if you have a quick read around them, so then you might find that they just give you a bit of a, most scores are based on a sort of fairly sensible structure. You can get a bit of a structure as to whether how other people are thinking about it. And it's quite a good, I find scores themselves quite useless, but I find the way that people have conceptualized them and the, and the characterization quite useful if you see what I mean. So working out an individual score, I don't really, my personal view is I can hardly ever remember them. But, but the principles behind why that score is saying what it says is the thing you need to learn. OK. I'm gonna put this out there because um everyone, you know, will talk about unblocked resections and all of this kind of stuff and primary tumors. Um So the reason this is important is because um there's a few things. So the first is think of the spine like a clock face. OK? And um the spinous process being 12 o'clock, OK? Split it up into 12 segments. If a tumor encompasses um basically, if a tumor encompasses more segments than you can use to get the spinal cord out, OK, then you can't take the tumor out. OK, without sacrificing the spinal cord, which is in theory, something you can do. All right. But um in terms of principles, is it unblock resectable? If it encircles the spinal cord by more than two thirds, then it's unlikely that you're going to be able to get that tumor out past the spinal cord without damaging set spinal cord and therefore, it is not unblock resectable. You're going to have to split the tumor in half. Ok. Um Are the margins. So are the bits of the margins of resection that you're going to take out? Are they um far enough away from other important structures that you can safely take them out? Bearing in mind that you've got some fairly major vascular structures sitting just in front of the spine. OK. So if they are encompassing the vascu, so say, for instance, you've got a tumor that's so encroaching into the aorta or encircling um a major vessel, then clearly that's not gonna be resectable and you're gonna have to think again. All right. Um So the, the best tumors for resection are, are tumors that are isolated to one section of the spine that you can easily remove without compromising the spinal cord, ideally contained within the bone because that's going to be a much better prognosis. And these diagrams really just show you different ways you can take tumors out. Does that make sense? So, um what you essentially do is you um detach. So say, for instance, we're talking about this middle one here. I don't know if everyone can see my point here. But if you look at that middle diagram, you make a cut along the posterior lamina, you make a cut along the pedicle. And then what you can generally do is you can rotate up following this big blue. All right, you can rotate the tumor around the spinal cord, um by cutting through the disc space above and below. And you can rotate that tumor around and out through a sort of posterolateral approach, um, and remove the entire tumor without breaching any fascial planes. Ok. Um, some of the other tumors don't lend themselves to that. So the ones that you can't rotate posteriorly, you have to go anteriorly, which means you are breaching fascial planes, you're going in different, different organ cavities. So that's something to be aware of. But you don't really need to know exactly how to do each on block resection. You just need to understand um that it sort of the, the principles which are the same as all the other bone principles if you think about them logically, just for a second. OK. Um So just because I mentioned it, I'll talk about it, you can sacrifice the spinal cord. OK? Um And in young sarcoma patients, that is a discussion that is sometimes had. OK. So especially for low tumors, so low thoracic tumors or things, um you c you can sacrifice the spinal cord. So if it encompasses the spinal cord, um you can say to the patient, look, I can't take this out without damaging your spinal cord in, in a whole piece. If I, if I breach the tumor capsule, your prognosis decreases significantly at five years. Therefore, we can take it out by sacrificing your spinal cord, which will mean you're in a wheelchair, you lose your bladder, bowel function, et cetera, et cetera, but you'll be alive. Um, and you have a better prognosis and that is a really difficult place to be. Um, and often, um, then, then it becomes a lifestyle choice, doesn't it? So, would you rather live longer but in a wheelchair or would you have a reduced prognosis but be fully functional? And that is a big question that is very patient specific. So, um but it just so you know that that's a theoretical thing you can do as well. OK. So I've ra it on long enough and I've got 10 minutes left. So um I've got some cases. So and, and again, I'm not going to pick on anyone, but I want someone to talk me through this imaging sequence, please. Anyone. Hello? Hello. Um I think my microphone is not working but I'm using that. It's working, it's working. Um So the, it's a um ct of uh in the plane um as well as MRI scan of the uh of the uh Thoracolumbar region T two and T one on the um on the right side, as well as the axial of the spine showing a um isolated lesion to the L is isolated lesion to the L3 with um disruption of the Nplate and um sparing of the uh called a coin um in this patient, my workup in a 42 year old would include uh excluding trauma and metastases as well as a primary uh tumor, um, as well as starting with uh blood test history and examination. Um And uh at this stage, I expect that with that CT I would have a CT chest abdo pelvis as well and a whole spine. MRI. Ok. So, uh I'll, I'll talk to you through it quickly. So this is, um, she's, so she's 42. She, um, had another tiny, um, lesion on her lung. Can't remember which side. Um, her symptoms are loads and loads of back pain. So she was moving, how she got some back pain. Um, the, she went to see her GP GP said, well, you've been moving house and living, lifting heavy boxes. It's not unsurprising and I don't think that's unreasonable. Um, so she went away with some painkillers and, um, it didn't go away. So she went back and they said, well, you know, it, I think this was about four or five weeks later and they, they said, well, it's only four or five weeks. So it often will settle down, give her another set of painkillers. Um, and then she goes back a couple of weeks later and sees someone else who says, ok, well, we'll get you a, a, um, an MRI scan. Um, so she has the MRI scan and from that, this all happens. So, um, we don't have a obvious primary at this stage, the rest of the CT looks pretty normal. Um, she got a small lesion in her lung, but they don't think that's the primary, they think it looks more like a metastatic tumor. Ok. In this situation, um, if I'm suspecting metastasis, uh back pain with, um, is there any neurology? Sorry, I forgot to neurological. You wouldn't expect it to be based on this. I, no. So, neurologically intact, uh I would have an MD involvement with regards to um an MC PA and MC co to be able to have an MD approach in radio on hematology. Um given my blood panels has come back, I will al also need to suspect hematological conditions. Um But the, you stated that it's not, it's probably me metastases then um a biopsy is uh important in this situation and she's 42 and I want to know if definitely it's metastases from a primary or a primary lung, uh primary um spinal tumor, which is unlikely given the MRI findings. Ok. So um nothing you said there was wrong, it's, but it's not quite the same as what I did. Um So um she's already got one. She's already got metastatic disease. So, whether this is a primary or not, she is no longer curable. Yeah. Does that make sense? So, even if this is a normal bone tumor and she is no longer curable? Ok. So, um what we elected to do was to biopsy and fix her um because she was getting such bad instability pain. By this point, you can see she's got huge, horrible, it's a bit grainy there, but she's got huge, horrible licence here. Um And by this stage she's in absolute agony, unable to stand kind of pain. Um So we decided to biopsy and fix her, um expecting this to be metastatic disease or a primary that's already metastatic. I did. So I know the tumor guys in Birmingham and they thought that was a fairly sensible idea because it, you know, she wouldn't be a candidate for an old block even if it, because she's got metastatic disease anyway. So we did and we biopsied it and it was um breast cancer. Ok. So, um rather sadly, um so she did really well. She was super grateful she got back on her feet. She did super well. Um And her pain all settled down. Um and she healed up nicely. And then about six weeks after my surgery, she got admitted with sepsis and ended up having appendicitis, completely unrelated to anything, just got bloody unlucky and had appendicitis. Um So while she was recovering from that, there were more delays. And um so it was about three or four months, maybe five by the time she got over that and got well enough to have her chemo radiotherapy. So they did another staging scan and it showed this. So what we see for the interest of time because there are a couple more cases. So for the interest of time, what we see is a complete lysis of this L3 lesion. We've got a little spot here and we've got a couple of potential spots here. We repeated her MRI scan, which showed sort of obviously confirmed. So the differential would of course be metastatic disease. But she's just, don't forget she's just had sepsis. Yeah, she's just been septic. She had a perforated appendix. This could easily be infection. Ok. So, um that's another thing to rule out. So we did the MRI it showed it was a tumor. She had multiple other tumors. She's got now a few more spots in her lung. So clearly, we're losing the, the control of the disease battle. Ok. So a decision now needs to be made about whether to w what to do about this. She's completely unaware of this. This is an incidental finding on a staging ct. What do you think we should do? Iggy? Um have the discussion with the patient to see what, what does she want. Um So that's exactly what I wanted you to say because um you could say, look, this looks horrible, it looks awful. Um Let's fix it and, and that wouldn't be wrong, but she's already getting spreading metastatic disease and this is causing her absolutely no trouble. So obviously I talk to the whole thing in the MDT, et cetera, et cetera. This is her MRI. Sorry. And this is her x-ray. Um So obviously I talked to her through the whole MDT and we, I had some really long conversations with her and we decided that delaying her chemotherapy longer was going to be more detrimental to her than anything else even though she's got, so if you can see my arrow, even though she's got this retrolisthesis here, you can see the facet stone line up. She's completely asymptomatic. So, what I did is I put her in a collar and I watched it really closely, but we let her start her chemotherapy. Um, and they did a bit of radiotherapy to it. So this is a year down the line. And what we can see is that that doesn't look normal, but the position is maintained and um she is re ossifying. You can see. Yeah. So if we compare that to this x-ray over here, you can see, you can barely see that bone. She's re ossifying there. So actually, we got away with it. That turned out to be the right decision, but you can't just obviously make your decision and leave them. You have to watch them every week. So really unlucky lady. Um, but uh I, I think we, we got, we got away with it. It was a difficult decision, but that was her choice as much as ours. But talking to the patient is key because her and her husband really felt like any more delays would be the wrong thing to do so. Thank you, Iggy. That was a good one. So this is another one. I'm just going to quickly talk you through these because I think they're quite illustrative. So th this lady is in a whole ton of pain. This is a slightly different scan though, isn't it? Yeah. So she doesn't have a legal metastatic disease. She's got a spot here, spot here, spot here, two levels involved, some more spots down here. So she's got more multilevel spine, metastatic disease. Again, it's another lady. She's in her fifties. She's got a degenerative scoliosis. There's some instability, you can see the collapse here on the x-ray giving her a sort of scoliosis. MRI shows um you know, the T ones and twos, she's got a little bit of potential neurological compression up here. But um mostly that's tumor encroachment. Um So we elected to fix this lady um with some cement augmentation. She did really well. Um She had some radiotherapy. Um And sadly, she lived about, I think a year and then passed away. Um This was a supposed, so I won't dwell on this too much. Um This is just a um a fracture. Ok. Um But what it does, what it happened to show was this lesion within the spinal cord here. So this is quite subtle. Ok. So this is called signal change. OK. Um which is from the fracture on tumor, but it also showed this slightly unusual intrinsic cord lesion here, which turned out to be an intramedullary tumor within a spinal cord injury, which was very, very unlucky. And of course, they left it alone because um the, you know, the prognosis from the tumor from the injury was also bad. Ok. Um this is uh so again, another initiative case that would have been good to talk through, but this is a guy with lung cancer. He's a different cattle fish. So he's 76. He's got lung cancer which has a worse prognosis. He's got significant. So he's got significant lysis around the cervicothoracic junction, which is giving him a really, you know, quite bad Gius. Um and he's got metastatic cord compression, he's becoming myelopathic and going off his legs. But his prognosis is such that and the size of the surgery is such. So to reconstruct this level, you'd have to do an OCTO of IIC fusion, probably even that's going to fail because you've got such a wide area of lysis here that um we elected not to operate on this gentleman so that it was just a demonstration that you don't operate on everyone. And this one here is um spot diagnosis. Uh Anyone know what this is? Some of you might have even seen him to be honest, but 15 year old male, lots of pain in the neck, osteo osteoma. Yeah. So, osteoid osteoma, you can see it here. So down on this axial image at the bottom. You can see the nidus. Yeah. And it's in the, sorry, it's classic, isn't it? It's in the posterior elements. It's 15. It, it's in the, um, it is, you can see the nidus which is separate you and on the stairs you can see this huge inflammatory reaction which is from the pros prostaglandin release, which is what gives them all that pain. Um, so treatment, radio frequency of Ibuprofen. Ok. So, yeah, a anti-inflammatories definitely OK. They can be self remitting anyway. Um So a an anti-inflammatory made all of this pain hugely better. It didn't make it go away, but it was hugely better but not tolerable enough. And him and his mom pushed for, for something to be done. The problem with this is the ab so trying to ablate this cause don't forget ablation is heating it up here so close to the cord that that's gonna be really trickier. Um So we spoke to our radiology guys about whether they'd be willing to ablate it and they said no. So we sent him to the tumor center who said yes, they would, they ablated it and it didn't work because they didn't, they couldn't get close enough. Um So they kind of partially ablated it and didn't make his symptoms any better. So he uh went back to the tumor center for a resection in the end. Um So, uh So yeah, OK. Osteoid osteoma, common night pain, posterior elements can be a cause of painful scoliosis as well. Um, anti-inflammatories, uh, very good exam for the question. Does anyone have any, um, any questions about anything tumor related? That was great Tom. Well done. Thank you.