Ms H is a 56-year-old interventional radiology technician living alone in a 2-story house. In 1986, she developed breast cancer, initially treated by left mastectomy followed by chemotherapy and chest wall radiotherapy. In 1990, she developed bony metastases. Bisphosphonates were initiated and a left rib resection performed; after a salpingo-oophorectomy, she had regression of a left hip metastasis. In 2000, a T7 vertebral metastasis was treated with 44 Gy to the T6 to T8 vertebral area. In 2004, a recurrent lesion required T7 vertebral corpectomy with structural rib autograft and a T4 to T10 instrumented fusion. Capecitabine was begun and continued through November 2006, when she developed thoracic pain and progressive difficulty walking. The T7 vertebral tumor now involved the T6 to T7 ventral epidural space with significant cord impingement. The posterior spinal fixation had loosened, and she had progressive deformity of her spine. Ms H's original surgeon, Dr L, recommended surgery by Dr O followed by stereotactic radiosurgery (1500 centigrays in 5 fractions during 5 days) at a university hospital 400 miles from her home. Ms H agreed.
On admission, she had difficulty with her gait and with urinary retention and had episodes of overflow urinary incontinence. Her midthoracic pain was incapacitating despite a transdermal fentanyl patch and oral rescue opioids. She was largely confined to bed but ambulated to the bathroom holding onto walls and using a walker.
On physical examination, Ms H was distraught. She had a left mastectomy scar and postradiation chest wall changes. She walked with an ataxic gait and had increased tone in the lower limbs bilaterally. The results of her motor examination were remarkable for 4 out of 5 strength in the left extensor hallucis longus, in the tibialis anterior, and bilaterally in her iliopsoas muscles. Sensation was decreased in the left first toe web, and there was loss of proprioception bilaterally. Knee and ankle jerks were hyperactive and symmetrical; there were 3 beats of clonus bilaterally, with a positive Babinski sign on the left foot.
After administration of preoperative medications, including 4 mg of dexamethasone orally twice a day; 20 mg of famotidine orally once a day; 50 μg/h of fentanyl through a transdermal patch that was changed every 3 days; and 4 mg of hydromorphone orally every 4 hours as needed for pain, she underwent revision posterior surgery with laminectomies of the T6 through T8 vertebrae and excision of tumor from the dorsal aspect of the spine followed by instrumented spinal fusion from the T3 to L2 vertebrae. Five days later, she underwent corpectomies of the T6 to T8 vertebrae with resection of the epidural tumor and anterior column reconstruction from the T5 to T9 vertebrae using a cage, rods, and structural rib.
Eight days after the anterior surgery, Ms H was transferred to a rehabilitation facility, where she stayed for 3 weeks. Five months later, she required ...