Postradiative stenosis of the spinal canal: features of the clinic, diagnosis and treatment (clinical case)

Postradiation epidural fibrosis is one of the rare complications of cancer treatment in patients receiving radiation therapy, leads to a mosaic clinical picture, including manifestations of polyneuropathy, caudogenic intermittent lameness syndrome and can significantly affect the quality of life of patients. Depending on the type of cancer, the volume of the affected tissues and the level of damage to the spine, radiation fibrosis syndrome is characterized by a diverse clinical picture. The main clinical manifestations of post-radiation fibrosis of the spinal canal at the level of the lumbar spine are pain, numbness, paresthesia in the lower extremities. A thorough history and physical examination, combined with the use of neuroimaging data, help establish an accurate diagnosis and select an effective treatment. When studying the problem of post-radiation fibrosis, it is extremely difficult to predict the time, risk group and specificity of characteristic symptoms, given the development of pathology in elderly and senile patients, against the background of existing degenerative changes in the spine. However, there is a close relationship with dosage, anatomical impact, nature of damage and clinical symptoms. Conservative methods of treating post-radiation fibrosis with spinal canal stenosis include the use of analgesic, antiinflammatory therapy. With a prolonged course of pain syndrome, insufficient effectiveness of conservative treatment, local blockades or epidural injections are carried out. In the absence of the effect of conservative treatment, indications for surgical intervention arise.

1. Megan Brooks WHO: Global Cancer Burden Rising Amid Striking Inequities – Medscape – February 01, 2024. https://www.medscape.com/viewarticle/global-cancer-burden-rising-amid-striking-inequities-2024a10002an?form=fpf

2. Karri J, Lachman L, Hanania A, Marathe A, Singh M, Zacharias N, Orhurhu V, Gulati A, Abd-Elsayed A. Radiotherapy-specific chronic pain syndromes in the cancer population: an evidencebased narrative review. Adv Ther. 2021;38:1425–46. https://doi.org/10.1007/s12325-021-01640-x

3. Di Francesco T, Khanna A, Stubblefield MD. Clinical evaluation and management of cancer survivors with radiation fibrosis syndrome. Semin. Oncol. Nurs. 2020;36:150982

4. Yarnold J, Brotons M-CV. Pathogenetic mechanisms in radiation fibrosis. Radiother Oncol. 2010;97:149–61. https://doi.org/10.1016/j.radonc.2010.09.002

5. Kline-Quiroz, C., Fricke, B. Molecular and Biologic Targets for Radiation Fibrosis: Implications for Rehabilitation. Curr Phys Med Rehabil Rep. 2021;9:127–135. https://doi.org/10.1007/s40141-021-00321-8

6. Borrelli MR, Shen AH, Lee GK, Momeni A, Longaker MT, Wan DC. Radiation-induced skin fibrosis: pathogenesis, current treatment options, and emerging therapeutics. Ann Plast Surg. 2019;83:S59–64. https://doi.org/10.1097/SAP.0000000000002098

7. Jones N, Stubblefield MD. Evaluation and management of radiation-induced plexopathies. Current Physical Medicine and Rehabilitation Reports. 2022;10:345–54. https://doi.org/10.1007/s40141-022-00374-3

8. Stubblefield MD. Clinical evaluation and management of radiation fibrosis syndrome. Phys Med Rehabil. Clin. N. Am. 2017;28:89–100. https://doi.org/10.1016/j.pmr.2016.08.003

9. Borrelli MR, Diaz Deleon NM, Adem S, et al. Fat grafting rescues radiation-induced joint contracture. Stem Cells. 2020;38:382–9. https://doi.org/10.1002/stem.3115

10. Abbas DB, Lavin CV, Fahy EJ, Griffin M, Guardino NJ, Nazerali RS, Nguyen DH, Momeni A, Longaker MT, Wan DC. Fat grafts augmented with vitamin E improve volume retention and radiation-induced fibrosis. Aesthet Surg J. 2022;42:946–55. https://doi.org/10.1093/asj/sjac066

11. Yokogawa N, Murakami H, Demura S, Kato S, Yoshioka K, Yamamoto M, Iseki S, Tsuchiya H. Effects of Radiation on Spinal Dura Mater and Surround-ing Tissue in Mice. PLoS One. 2015 Jul 27;10(7):e0133806. https://doi.org/10.1371/journal.pone.0133806. PMID: 26214850; PMCID: PMC4516356.

12. Loewen I, Jeffery CC, Rieger J, Constantinescu G. Prehabilitation in head and neck cancer patients: a literature review. J Otolaryngol Head Neck Surg. 2021;50:2.

13. Chang EI, Rose MI, Rossi K, Elkwood AI. Microneurosurgical treatment options in peripheral nerve compression syndromes after chemotherapy and radiation treatment. J Surg Oncol. 2018;118:793–9. https://doi.org/10.1002/jso.25254

14. Fischer AA. Tissue compliance meter for objective, quantitative documentation of soft tissue consistency and pathology. Arch Phys Med Rehabil. 1987;68:122–5.

15. Stubblefield MD. Neuromuscular complications of radiation therapy. Muscle & nerve. 2017;56(6):1031–40.

16. Yarikov A.V., Smirnov I.I., Perlmutter O.A., Fraerman A.P., Kalinkin A.A., Sosnin A.G., Khomchenkov M.V. Stenosis of the vertebral canal of the lumbar spine // Journal of Clinical Practice. 2020;11(3):50–60. (In Russ.) https://doi.org/10.17816/clinpract34032

17. Ramia P, Bodgi L, Mahmoud D, Mohammad MA, Youssef B, Kopek N, Al-Shamsi H, Dagher M, Abu-Gheida I. Radiationinduced fibrosis in patients with head and neck cancer: a review of pathogenesis and clinical outcomes. Clin Med Insights Oncol.Ф 2022;16:11795549211036898. https://doi.org/10.1177/11795549211036898

18. Azzam P, Mroueh M, Francis M, Abou Daher A, Zeidan YH. Radiation-induced neuropathies in head and neck cancer: prevention and treatment modalities. Ecancermedicalscience. 2020;14(8). https://doi.org/10.3332/ecancer.2020.1133

19. Nepon H, Safran T, Reece EM, Murphy AM, Vorstenbosch J,Davison PG. Radiation-induced tissue damage: clinical consequences and current treatment options. Semin Plast Surg. 2021;35:181–8.

20. Nogueira RMP, Vital FMR, Bernabe DG, de Carvalho MB. Interventions for radiation-induced fibrosis in patients with breast cancer: systematic review and meta-analyses. Adv Radiat Oncol. 2022;7:100912. https://doi.org/10.1055/s-0041-1731464