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Management of vertebral metastases in the cervico-occipital junction
Manejo de las metástasis vertebrales en la charnela cervicooccipital
R. González-Díaza,b, R.M. Egea-Gámeza,b,
Corresponding author
rosamaria.egea@salud.madrid.org

Corresponding author.
, F.J. Ortega-Garcíaa, A. González-Menocalc, M. Galán-Ollerosb
a Unidad de Columna, Hospital Nuestra Señora del Rosario, Madrid, Spain
b Servicio de Cirugía Ortopédica y Traumatología, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
c Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
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given the peculiar anatomy of the area and the neurovascular structures that may be affected&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In order to carry out a correct treatment of these patients&#44; the following must be taken into account&#58; the intraspinal extension&#44; which will determine the possibility of oncological resection&#59; the neurological and general status of the patient&#44; as well as the histology of the initial tumour&#44; differentiating between aggressive tumours that are difficult to control oncologically&#44; such as pancreatic or gastric cancer&#44; from tumours with better long-term control and less aggressiveness&#44; such as breast cancer&#46; The appearance of spinal cord compression conditions the patient&#39;s quality of life&#44; so that&#44; regardless of the prognostic assessment scales used&#44; surgery may be indicated&#46; It is not uncommon for a patient to present with a neurological lesion with a metastasis and a tumour of unknown origin&#44; which further complicates decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The origin of the metastasis is of paramount importance&#46; In fact&#44; tumours such as lymphoma&#44; myeloma or plasmacytoma will respond very well to treatment by radiotherapy&#44; which will reduce tumour size&#44; improve neurological damage&#44; if applicable&#44; and allow surgery&#44; if indicated&#44; in cases of instability of the affected region&#46; The vascularisation of the tumour must also be taken into account&#44; since renal&#44; thyroid&#44; or hepatocellular carcinomas are highly vascularised and the possibility of embolisation of these should be considered beforehand&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">The clinical presentation of tumours located in the cervico-occipital hinge is usually very discreet&#44; progressing very slowly&#46; This leads to delayed diagnosis which tends to be given when these tumours are larger&#46; The most common clinical presentation is cervical pain and occipital neuralgia&#44; as well as suboccipital and retroauricular headaches&#46; Pain with rotation is present in up to 90&#37; of cases when occipito-cervical involvement is present&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> The presence of myelopathy&#44; however&#44; is rare&#44; being present in 0&#8211;22&#37; of cases&#44; due to the fact that the spinal canal is highly spacious in this region&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnosis by imaging</span><p id="par0025" class="elsevierStylePara elsevierViewall">The first test to be performed is a plain X-ray to check for correct alignment of the cervical spine&#46; In half of the cases no pathological findings will be found&#44; and in others it may show lytic or sclerotic areas&#44; as well as alterations in alignment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The CT scan and its reconstructions will serve to define the lytic lesion&#59; the coronal&#44; sagittal and axial planes will be assessed to analyse the degree of bone destruction&#44; as well as the involvement of elements that may alter the stability of the cervico-occipital hinge &#40;condyles&#41;&#46; CT is also essential for correct preoperative planning&#44; to plan the resection areas and their relationship with the structures to be preserved&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">If vascular involvement is suspected&#44; or in cases where the tumour is close to vascular structures&#44; CT angiography or MRI angiography is recommended&#44; where the relationship with the vertebral and carotid arteries will be verified&#44; facilitating safer surgery&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnostic test par excellence in this type of tumour is magnetic resonance imaging &#40;MRI&#41;&#44; and by means of the different sequences&#44; a probable diagnosis of its nature can be made&#44; as well as a greater analysis of the state of the surrounding soft tissues&#44; such as the ligaments&#46; A complete extension study is also necessary&#44; since factors such as the presence of visceral metastases and bone metastases in other locations influence the decision-making process for the management of these patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Management&#58; radiation versus surgery</span><p id="par0045" class="elsevierStylePara elsevierViewall">Spinal metastases management varies constantly due to advances in the different types of adjuvant treatment&#44; and better general control of the disease&#46; In general&#44; surgery is indicated in patients with over 6&#8211;12 months life expectancy &#40;its indication in survival below 3 months is more controversial&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> in addition to spines with instability or with progressive neurological symptoms&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Bilsky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> recommend non-surgical treatment in patients with correct alignment and&#47;or minimal subluxation&#44; regardless of histology and tumour radio-sensitivity&#46; Surgery would be indicated in cases with instability criteria&#44; including&#58; atlanto-axial displacement<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#44; unilateral condylar destruction of 70&#37;&#44; bilateral condylar destruction<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; angulation<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#176; with displacement of &#62;3&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; or with persistent pain despite radiotherapy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In cases where conservative treatment is the treatment of choice&#44; we must bear in mind that radiotherapy has better results in prostate and breast metastases&#44; and worse in renal and pulmonary metastases&#44; and that similar results are obtained with a single dose &#40;8<span class="elsevierStyleHsp" style=""></span>Gy&#41; and with fractionated doses of radiation&#44; considering in certain cases the possibility of stereotactic radiosurgery&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Adjuvant hormonal chemotherapy will play a role in hormone-sensitive tumours &#40;breast&#44; thyroid and small cell lung carcinomas&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Multidisciplinary management between oncologists&#44; pathologists&#44; radiologists&#44; radiotherapists&#44; anaesthesiologists and surgeons is essential to reach the best decision for each patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Evaluation and instability scales</span><p id="par0070" class="elsevierStylePara elsevierViewall">There are a multitude of prognostic rating scales&#44; most notably the Baue&#39;s&#44; Tokuhashi&#39;s and Tomita&#39;s scales&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The modified Bauer scale<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#44;8</span></a> gives 1 point for each of the following prognostic factors&#58; &#40;1&#41; absence of internal organ metastases&#59; &#40;2&#41; solitary skeletal metastasis&#59; &#40;3&#41; absence of lung cancer&#59; and &#40;4&#41; primary breast&#44; kidney&#44; lymphoma or multiple myeloma&#46; The total points are classified into three prognostic groups&#44; with median overall survival of 4&#46;8 &#40;score between 0 and 1&#41;&#44; 18&#46;2 &#40;score of 2&#41; and 28&#46;4 &#40;score of 3 and 4&#41; months each&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The Tokuhashi classification system<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> takes into account the patient&#39;s general condition&#44; the original tumour&#44; the presence of visceral and bone metastases and neurological involvement and a fairly reliable assessment has been established for most tumours &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The Tomita system<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> assesses the original tumour&#44; differentiating between slow&#44; moderate or rapid-growing tumours&#44; the number of visceral and bone metastases&#44; proposing a treatment plan according to the calculated survival for each case &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Against this backdrop we can reach a decision and an assessment of the prognosis of our patients&#44; but there are other key issues&#44; such as neurological compression&#44; vertebral instability and general patient status&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">It is widely established that&#44; in the face of neurological compression&#44; surgical treatment is indicated in most cases&#44; mainly to improve the patient&#39;s quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">11</span></a> In this regard&#44; the NOMS algorithm by Bilsky and Smith<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a> helps to assess spinal cord compression&#44; and analyses neurological status &#40;N&#41;&#44; oncological status &#40;O&#41;&#44; mechanical instability &#40;M&#41; and systemic disease &#40;S&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The general status of the patient should be considered&#44; as suggested by the treatment algorithm proposed by the Boriani group&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The scale most currently used to assess spinal stability is the Spine Instability Neoplastic Score &#40;SINS&#41;&#44; developed by the Spine Oncology Study Group<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">14&#44;15</span></a> and globally accepted&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a> with 96&#37; sensitivity and 80&#37; specificity&#46; It assesses 6 aspects&#58; location&#59; presence of pain&#59; radiological alignment&#59; involvement of posterior elements&#59; degrees of vertebral body collapse and tumour morphology &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Indications for surgery</span><p id="par0110" class="elsevierStylePara elsevierViewall">Tokuhashi classification scale is useful for surgical indication decision&#46; Criteria for instability and indication for surgical stabilisation are established when there is a subluxation fracture<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#44; unilateral condylar destruction of 70&#37; or bilateral condylar destruction<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37; &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">17&#44;18</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Once the surgical indication has been made&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">19&#44;20</span></a> the approach to be used must be chosen&#46; The most common approach is a posterior approach&#44; which allows access to the posterior elements of the occipito-cervical junction&#46; The variability of the vertebral artery<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> must be taken into account&#44; and therefore a CT angiography or MRI angiography should be performed prior to any intervention&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition to the posterior approach&#44; there is the transoral approach&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22&#44;23</span></a> indicated for irreducible anterior compression&#44; which allows access from the clivus to the body of C3 and the possibility of fixation with a plate&#46; The posterolateral approach&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> also exists and this allows access to the anterior and lateral areas of the occipito-cervical junction&#46; It is particularly suitable when there is a highly vascularised lesion&#44; but if fixation is required&#44; bilateral exposure will be necessary&#46; These anterior or antero-lateral approaches sometimes require the assistance of maxillofacial surgeons or otorhinolaryngologists&#44; as a thin layer of pharyngeal tissue may remain over the operated area&#44; requiring local rotational flaps or vascularised free flaps to cover it&#46; It is important to note that postoperatively&#44; after a transoral&#47;transmandibular approach&#44; delayed orotracheal extubation&#44; feeding tubes and monitoring of diet and swallowing may be required&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding which instrumentation to use&#44; screws<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> are recommended over wires&#44; as they achieve better pain relief&#44; correction of alignment and a higher fusion rate&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> Kato et al&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> concluded that the use of Luque sublaminar instrumentation in upper cervical spine metastases provided significant stability for pain relief&#44; even in late-stage disease&#44; as long as the patient&#39;s general condition allows such surgical intervention&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">We can conclude that metastases of the occipito-cervical junction are rare lesions that initially produce few clinical symptoms&#46; As these lesions increase in size&#44; they may cause pain and&#47;or instability&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Surgical treatment will be considered in those patients with a life expectancy of 6&#8211;12 months or more&#46; In those with a survival of 3 months or less&#44; the indication is controversial&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The main indication for surgery is when there is persistent pain&#44; neurological deficit or instability criteria&#58; atlanto-axial displacement<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm&#59; unilateral condylar destruction of 70&#37;&#59; bilateral condylar destruction<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50&#37;&#59; angulation<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>11&#176; with displacement of &#62;3&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; requiring in these cases a complete radiological study due to the characteristic anatomy and proximity to important vascular structures &#40;vertebral and carotid arteries&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Level of evidence</span><p id="par0145" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">iv</span>&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study did not receive any grants or funding&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Occipito-cervical metastases correspond to 0&#46;5&#37; of spinal metastases&#46; The management of these lesions is complex and involves multiple radiological studies&#44; such as simple radiology&#44; computed tomography &#40;CT&#41;&#44; magnetic resonance imaging &#40;MRI&#41;&#46; Is vascular involvement is suspected&#44; tests to assess vascular permeability are also recommended &#40;angioCT&#41;&#46; This type of lesion&#44; due to its complex location&#44; may require different types of approaches&#44; commonly it will be the posterior approach&#44; but sometimes anterior or antero-lateral approaches will be needed assisted by maxillofacial surgeons or otorhinolaryngologists for correct excision of the tumour&#46; Pain with head turning can guide us to the diagnosis in an unstable spine&#46; Magnetic resonance is the test of choice to diagnose and study these lesions&#46; The presence of instability or progressive neurological symptoms is an indication for surgery&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las met&#225;stasis a nivel occipitocervical corresponden solo al 0&#44;5&#37; de las met&#225;stasis del raquis&#46; El manejo de estas lesiones es complejo y conlleva m&#250;ltiples estudios radiol&#243;gicos&#44; tales como la radiolog&#237;a simple&#44; la tomograf&#237;a computarizada &#40;TC&#41; o la resonancia magn&#233;tica &#40;RM&#41;&#46; Ante la sospecha de afectaci&#243;n vascular tambi&#233;n ser&#225; recomendable la realizaci&#243;n de pruebas que valoren la permeabilidad vascular &#40;angio-TC&#44; angio-RM&#41;&#46; Este tipo de lesiones&#44; debido a su compleja localizaci&#243;n&#44; puede precisar distintos tipos de v&#237;as de abordaje&#59; com&#250;nmente ser&#225; el abordaje posterior&#44; pero en ocasiones se necesitar&#225;n abordajes anteriores o anterolaterales asistidos por cirujanos maxilofaciales u otorrinolaring&#243;logos para una correcta ex&#233;resis de la tumoraci&#243;n&#46; El dolor con los giros puede orientarnos al diagn&#243;stico en una columna inestable&#46; La RM es la prueba de elecci&#243;n para diagnosticar y estudiar estas lesiones&#46; La presencia de inestabilidad o de cl&#237;nica neurol&#243;gica progresiva es indicaci&#243;n de cirug&#237;a&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Good &#40;80&#8211;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of extra-vertebral bone metastases</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Greater than or equal to 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Number of metastases in vertebral body</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Greater than or equal to 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Metastases in main internal organs</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non resectable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Resectables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No metastases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary cancer site</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lung&#44; osteosarcoma&#44; stomach&#44; bladder&#44; oesophagus&#44; pancreas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liver&#44; spleen&#44; primary tumour unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kidney&#44; uterus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rectum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Thyroids&#44; prostate&#44; breast&#44; carcinoid tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Spinal cord lesion&#47;myelopathy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Complete &#40;Frankel A&#44; B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Incomplete &#40;Frankel C&#44; D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None &#40;Frankel E&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3480378.png"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SINS component&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Location</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Transverse &#40;occipito-C2&#44; C7-T2&#44; T11-L1&#44; L5-S1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Movable spine &#40;C3&#8211;C7&#44; L2&#8211;L4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Semi-rigid &#40;T3&#8211;T10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rigid &#40;S2&#8211;S5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pain</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Occasional non mechanical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Painless tumour&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Bone tumour</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lytic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mixed &#40;lytic&#47;blastic&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Blastic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Radiographic vertebral alignment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Subluxation&#47;translation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>De novo deformity &#40;kyphosis&#47;scoliosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal alignment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vertebral body collapse</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No collapse with &#62;50&#37; of body affected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None of the above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Involvement of posterolateral</span><span class="elsevierStyleItalic">elements</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>None of the above&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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                    0 => array:2 [
                      "titulo" => "Metastatic disease of the cervical spine&#46; A review"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46;G&#46; Jenis"
                            1 => "E&#46;J&#46; Dunn"
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                    0 => array:2 [
                      "doi" => "10.1097/00003086-199902000-00010"
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop Relat Res"
                        "fecha" => "1999"
                        "volumen" => "359"
                        "paginaInicial" => "89"
                        "paginaFinal" => "103"
                      ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Metastases to the craniovertebral junction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;D&#46; Moulding"
                            1 => "M&#46;H&#46; Bilsky"
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                    0 => array:2 [
                      "doi" => "10.1227/01.NEU.0000365829.97078.B2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurosurgery"
                        "fecha" => "2010"
                        "volumen" => "66"
                        "numero" => "Suppl&#46;"
                        "paginaInicial" => "113"
                        "paginaFinal" => "118"
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                      "titulo" => "Surgical management of metastatic spine disease"
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                          "etal" => false
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                            0 => "R&#46;J&#46; Petteys"
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                    0 => array:2 [
                      "doi" => "10.1053/j.semss.2009.03.004"
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                        "tituloSerie" => "Semin Spine Surg"
                        "fecha" => "2009"
                        "volumen" => "21"
                        "paginaInicial" => "86"
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                0 => array:2 [
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                      "titulo" => "Metastatic disease of the cervical spine"
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                            0 => "A&#46;R&#46; Poynton"
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                            2 => "F&#46;P&#46; Girardi"
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                            4 => "F&#46;P&#46; Cammisa Jr&#46;"
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                        "titulo" => "Cancer in the spine&#58; comprehensive care"
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                0 => array:2 [
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                      "titulo" => "Diagnosis and management of a metastatic tumor in the atlantoaxial spine"
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                            3 => "V&#46; Prabhu"
                            4 => "P&#46;J&#46; Boland"
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                    0 => array:2 [
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                        "tituloSerie" => "Spine &#40;Phila Pa 1976&#41;"
                        "fecha" => "2002"
                        "volumen" => "27"
                        "paginaInicial" => "1062"
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                        "link" => array:1 [
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                  "contribucion" => array:1 [
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                      "titulo" => "Tratamiento de las met&#225;stasis de la columna cervical"
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                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Saadat"
                            1 => "J&#46;H&#46; Schwab"
                            2 => "F&#46; Hornicek"
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                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "editores" => "R&#46;Gonz&#225;lez Diaz, H&#46;Koller"
                        "titulo" => "Cirugia de la columna cervical"
                        "paginaInicial" => "177"
                        "edicion" => "primera edici&#243;n"
                        "serieFecha" => "2015"
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              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Survival after surgery for spinal and extremity metastases&#46; Prognostication in 241 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;C&#46; Bauer"
                            1 => "R&#46; Wedin"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3109/17453679508995508"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Orthop Scand"
                        "fecha" => "1995"
                        "volumen" => "66"
                        "paginaInicial" => "143"
                        "paginaFinal" => "146"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7740944"
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                  "contribucion" => array:1 [
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                      "titulo" => "Survival analysis of 254 patients after manifestation of spinal metastases&#58; evaluation of seven preoperative scoring systems"
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "G&#46; Hofmann"
                            3 => "H&#46; Clar"
                            4 => "M&#46; Kapitan"
                            5 => "A&#46; Berghold"
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                    0 => array:2 [
                      "doi" => "10.1097/BRS.0b013e3182011f84"
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                        "tituloSerie" => "Spine &#40;Phila Pa 1976&#41;"
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Article information
ISSN: 18884415
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos