Metastatic bone disease (MBD) is a devastating and debilitating disease that occurs in approximately 400,000 individuals per year within the US. The pelvis and sacrum are common sites of advances osteolysis and pathologic fractures. Current mainstays of care for non-acetabular pelvic MBD are radiation therapy and pain management. Despite these treatments, pain and dysfunction caused by the pelvic ring instability can persist.
Open surgical interventions to address pathologic fractures and large periacetabular defects are associated with significant morbidity and prolonged recovery. The goal of a percutaneous screw fixation of the pelvis is to offer a minimally invasive procedure that provides mechanical stability of pathologic pelvic ring fractures. It also offers an effective palliative option for patients who have exhausted the standard of care.
Patients who have MBD often develop pathologic fractures of the pelvis and pelvic ring due to secondary metastatic lesions. These lesions ‘eat’ away at the bone and weaken it, this can result in debilitating pain and limited mobility as the pelvic ring provides a vast amount of support during standing and basic everyday movements.
The procedure uses 3D reconstruction imaging, and an augmented reality needle assisted guidance system combined with specialized techniques. An intraoperative cone beam CT is performed, allowing specific custom screw trajectories to be planned based upon patients’ pathology. The augmented reality integrates these planned screw trajectories with intraoperative fluoroscopy. Any residual tumor is ablated, and bone cement is injected to maintain position of the screws.
This procedure has demonstrated a significant improvement in patients pain and function. Not only does it improve the pain and function, but it also tends to have a short length of stay within the hospital before patients can discharge home. Conversely, with the traditional open surgical interventions, many patients experience an extended hospital stay and some may never be able to leave. Additionally, the percutaneous screw fixation provides patients an obtainable palliative care option. Many MBD patients are considered terminal, bedridden and dependent on caregivers. This bring up an important concept of what ought we to do? I believe it is important to provide these patients an opportunity for pain relief, comfort and independence for something even as simple as showering on their own. We ought to partake in acts of beneficence to improve the patients’ quality of life and promote their well-being no matter the length of time they will benefit from the care.
Lee, L., Schutz, M., Myhre, S. L., Tasse, J., Blank, A. T., Brown, A., & Lerman, D. M. (2023). Minimally invasive
management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization. Journal of Surgical Oncology, 128(2), 359–366. https://doi.org/10.1002/JSO.27284
Hi Makena!
ReplyDeleteThank you for the post, I can see your excitement in the process of the percutaneous screw fixation in the writing. I wonder what average age MBD usually arises in a patients as well as if this is a genetically inherited disease? Since this is a metastatic bone disease I assume its origins are cancerous? I would also be curious to know if the patient would experience issues with calcium levels considering this is a bone disease. As we know calcium is needed for muscle contractions, myocardial activity and bone health. Therefore hypercalcemia could cardiac issues such as widened QRS complexes and can lead to bradycardia, heart blocks, or arrhythmias (Sadiq et al., 2024). Overall this sounds highly uncomfortable and I agree, focus on treatments to insure an abundance of pain management.
Sadiq, N. M., Anastasopoulou, C., Patel, G., et al. (2024). Hypercalcemia. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430714/