Total en bloc spondylectomy for spinal tumors: surgical techniques and related basic background

Delayed-Onset Paraplegia Due to Spinal Cord Infarction After Repeated Tumor Excision Surgeries of the Thoracic Spine

Tumor excision surgeries of the spine present a distinct challenge regarding the maintenance of spinal cord blood supply because they often require preoperative embolization of segmental arteries, ligation of the corresponding nerve roots, and circumferential exposure of the dural sac. The authors present a case of delayed-onset spinal cord infarction after repeated tumor excision surgeries of the thoracic spine. A 49-year-old man had undergone a left nephrectomy for renal cell carcinoma, 2 pulmonary metastasectomies, and excision of a left sixth rib metastasis before referral to the authors' institution. He had a recurrence of the bone metastasis involving the left fourth and fifth ribs and T5 vertebra. He underwent 3 tumor excision surgeries, including spondylectomy of T5 and T7, for the repeated tumor recurrences involving the thoracic spine. These surgeries required preoperative embolization of 9 segmental arteries at 6 consecutive levels and ligation of 6 nerve roots at 3 consecutive levels. Thirty hours after the third surgery, the neurologic deficit worsened. The postoperative paraplegia was diagnosed as delayed-onset spinal cord infarction via magnetic resonance imaging. This is the first case report describing delayed-onset paraplegia due to spinal cord ischemia caused by embolization of segmental arteries and ligation of nerve roots in multi-spinal levels for spine tumor surgeries. In spine tumor surgery, embolization of bilateral segmental arteries at 4 or more consecutive levels and/or ligation of bilateral nerve roots pose a risk for ischemic spinal cord disease. [Orthopedics. 2019; 42(1):e131-e134.].

Metastasis Affecting Craniocervical Junction: Current Concepts and an Update on Surgical Management

STUDY DESIGN

Literature review.

OBJECTIVES

Metastatic disease affecting the craniovertebral junction (CVJ) only accounts for 0.5% of all spine metastases. The management of these disease processes is complex, which involves multimodality radiological studies and various surgical approaches. We aimed to review the available evidence and summarize the findings in this review.

METHODS

The authors conducted search of PubMed and Google Scholar with the following search terms: metastasis, craniovertebral junction (CVJ), occipitocervical, approaches, stability, and radiotherapy. Articles were reviewed by the authors and determined for inclusion based on relevance and level of evidence.

RESULTS

The majority of relevant research reviewed composed of literature reviews of particular aspects regarding metastatic disease affecting the craniovertebral junction, including diagnosis, surgical approach, and radiotherapy.

CONCLUSIONS

Prompt evaluation of rotational neck pain with or without occipital neuralgia may reveal early metastatic disease within a stable CVJ. Magnetic resonance imaging appears to be the gold standard imaging modality in detecting this pathology, with nuclear bone scan playing a role in distinguishing benign and malignant processes. Unfortunately, no level 1 evidence exists for use of either radiotherapy or surgery in these cases; however, from the available literature, spinal instability and evidence of progressive neurology are relative indications for operative intervention.

Total en bloc spondylectomy for primary tumors of the lumbar spine

This was a retrospective clinical study.This study aimed to evaluate our institution's experience with total en bloc spondylectomy (TES) in patients treated for primary lumbar spine tumors and investigate postoperative clinical outcomes.TES is a widely accepted by spinal and musculoskeletal surgical oncologists and results in favorable health-related quality of life outcomes. However, this procedure still imposes major risks and complications.The cases of TES performed for primary lumbar spine tumors between 1993 and 2015 were retrospectively analyzed. Primary outcome measures were the rates of perioperative complications and reoperation for instrumentation failure.We enrolled 30 patients (13 men and 17 women; median age and follow-up, 38 years and 87 months, respectively). Three, 7, and 5 cases involved previous radiotherapy, intralesional resection, and chemotherapy, respectively. The most common tumor was giant cell tumor (14 cases) followed by osteosarcoma (4 cases) and plasmacytoma (3 cases). The median estimated blood loss was 1450 mL, and the median operative time was 11 hours. At least 1 perioperative complication occurred in 26 patients (86.7%), with the most common being postoperative muscle weakness (24 patients, 80.0%) followed by surgical site infection and postoperative cerebrospinal fluid leakage (7 patients, respectively; 23.3% each). Revision surgery for instrumentation failure was required in 6 patients (20.0%) at a median of 33 months after the index TES. Four patients experienced local tumor recurrence (13.3%), and their 10-year disease-free rate was 75.0%.TES is a feasible and effective procedure for primary lumbar spine tumors, but the risks of perioperative complications and late instrumentation failure should be acknowledged. Surgical oncologic outcomes were good, especially in patients who underwent TES as their first surgical treatment. Therefore, being familiar with the indications for TES and the surgical technique is important.

Chordoma of the mobile spine and sacrum: clinical management and prognosis

Background

Chordomas are rare malignant tumors of the spinal column often afflicting the upper cervical spine and sacrum. There are few large single center series on chordomas due to its rarity. The purpose of this study is to report a single center's experience with the operative and non-operative management of chordomas.

Methods

We evaluated our institution's pathology database from 1994 to 2016 to identify patients diagnosed with chordomas. Inclusion criteria were chordomas of the mobile spine and sacrum. Exclusion criteria were chordomas of the clivus and resection performed at another institution. We collected patient demographics as well as the type of resection performed, intra-operative complications, wound complications and recurrence/prognosis.

Results

We identified 18 patients diagnosed with chordomas at our institution, and 12 met our inclusion criteria. There were four females and eight males with an average age of 64 [32-87] years. All patients were Caucasian and 10 of the 12 had surgery. Of the two patients with sacral chordomas that did not have surgery, one received chemotherapy and the other did not elect for any treatment. One is alive 161 months following diagnosis and the second died 96 months following diagnosis. Five of the lesions were in the mobile spine (one cervical, two thoracic, two lumbar) and seven were in the sacrum. Six patients underwent an en bloc resection [two via total en bloc spondylectomy (TES)]. Average length of follow up is 60 [3-161] months and eight of 12 patients are alive at latest follow up. Intraoperative complications included cardiac arrest, pleural tear, and excessive blood loss (8 L). Two patients, with sacral chordomas, had wound complications. Recurrence occurred in one patient with piecemeal resection and one patient with incomplete resection had post-operative metastatic lesions to the liver and lung.

Conclusions

We found less recurrence in patients managed with an en bloc resection as opposed to piece meal or intralesional resections. Sacral chordoma patients had higher wound complication rates as compared to chordomas of the mobile spine. The long life expectancy of non-surgically managed patients underscores the indolent nature of chordomas.

Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach

BACKGROUND

Total en bloc spondylectomy (TES) significantly decreases the rate of local recurrence and provides long-term survival in patients with malignant tumor of the spine. This procedure can be performed through a posterior-only approach. However, TES for lower lumbar spine through a posterior-only approach is technically challenging.

METHODS

We retrospectively reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES in a posterior-only approach from June 2012 to December 2015. This series included 5 female and 4 male patients, with a mean age of 54.1 years. Endpoints included length of surgery, estimated blood loss, visual analogue scale for pain, instrumentation failure, perioperative complications, local control rate, and overall survival.

RESULTS

All patients underwent TES and circumferential reconstruction of the involved level. Average operative time and estimated blood loss were 282 minutes and 2421 mL, respectively. The mean follow-up time was 41.2 months. We encountered nerve roots stretches in all patients during the surgeries. Three patients experienced acute lower-extremity neurologic dysfunction, but the symptoms were significantly alleviated in 4 weeks postoperatively and fully resolved within 6 months. Five patients showed no evidence of disease at the latest follow-up. Three patients died of metastasis and systemic failure. One patient developed new metastases and was alive with disease. Titanium mesh cage subsidence was observed in 3 patients, but no implant failures or related clinical symptoms were found.

CONCLUSIONS

TES for the fourth lumbar spine in a posterior-only approach is feasible. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.

Single-stage multi-level construct design incorporating ribs and chest wall reconstruction after en bloc resection of spinal tumour

PURPOSE

Multi-level reconstruction incorporating the chest wall and ribs is technically demanding after multi-segmental total en bloc spondylectomy (TES) of thoracic spinal tumours. Few surgical techniques are reported for effective reconstruction. A novel and straightforward technical reconstruction through posterior-lateral approach was presented to solve the extensive chest wall defect and prevent occurrences of severe respiratory dysfunctions after performing TES. The preliminary outcomes of surgery were reviewed.

METHODS

Multi-level TES was performed for five patients with primary or recurrent thoracic spinal malignancies through posterior-lateral approach. The involved ribs and chest wall were removed to achieve tumour-free margin. Then titanium mesh with allograft bone and pedicle screw-rod system were adopted for the circumferential spinal reconstruction routinely. Titanium rods were modified accordingly to attach to the screw-rod system proximally, and the distal end of rods was dynamically inserted into the ribs.

RESULTS

The mean surgery time was 6.7 hours (range 5-8), with the average blood loss of 3260 ml (range 2300-4500). No severe neurological complications were reported while three patients had complaints of slight numbness of chest skin (no. 1, 3, and 5). No severe respiratory complications occurred during peri-operative period. No implant failure and no local recurrence or distant metastases were observed with an average follow-up of 12.5 months.

CONCLUSIONS

The single-stage reconstructions incorporating spine and chest wall are straightforward and easy to perform. The preliminary outcomes of co-reconstructions are promising and favourable. More studies and longer follow-up are required to validate this technique.

Posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty for metastatic involvement of the axis

Background

Metastases to the upper cervical spine were rarely reported in the literature. However, metastases to this area may cause spinal instability and cord compression, which in turn can result in respiratory failure and neurological dysfunction. The present study investigated the efficacy and safety of posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty for this disease.

Methods

This was a retrospective study that included 10 patients with metastatic involvement of the axis from March 2002 to May 2014. All cases presented with occipitocervical pain: 5 patients with compressive myelopathy and 6 patients with radiculopathy. Japanese Orthopedic Association (JOA) scores and Visual Analogue Scale (VAS) were used to evaluate the improvement of neurological function and pain intensity, respectively.

Results

All patients underwent posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty. The VAS scores and JOA scores both improved postoperatively, from 8.2 ± 0.4 to 2.3 ± 0.2 and from 10.1 ± 2.2 to 14.2 ± 2.9, respectively. Additionally, the improvement rate of JOA was 52.4 ± 1.8%. The mean overall survival was 12.8 months. The median survival time was 7 months. The 6-month and 12-month survival rates were 70% and 40%, respectively. The mean duration of operation was 182 min and blood loss was 450 mL. The mean volume of bone cement injected was 4.0 mL. The cement extravasation was observed in only 1 patient without clinical symptoms. One patient developed tumour recurrence and died 1 month later.

Conclusions

Posterior decompression and occipitocervical fixation followed by intraoperative vertebroplasty was a safe and valuable palliative method with relatively less invasion to treat metastatic involvement of the axis.

En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series

OBJECTIVES

The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines.

METHODS

This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015.

RESULTS

A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively.

CONCLUSION

This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

Risk factors of instrumentation failure after multilevel total en bloc spondylectomy

INTRODUCTION

Multilevel total en bloc spondylectomy (TES) is required to secure oncologically adequate resection margins. However, no useful information has been reported for spinal reconstruction after multilevel TES. Therefore, this study set out to assess the clinical and radiological outcomes of spinal reconstruction after multilevel TES.

METHODS

Forty-eight patients treated with multilevel TES at our institute were included in the analysis. Reconstruction was achieved with posterior pedicle screw fixation and an anterior titanium mesh cage filled with iliac autograft in all cases. Spinal shortening was performed to increase spinal stability from the reconstruction. Instrumentation failure and radiological findings were evaluated with radiography and computerized tomography (CT).

RESULTS

After excluding one patient whose general condition was deteriorating, radiological evaluations of 47 patients were performed over a period of more than a year. The follow-up time was 17 to 120 months (mean: 70.2 months). Instrumentation failure occurred in one patient (5.9%) after thoracic multilevel TES, in 4 patients (25.0%) after thoracolumbar multilevel TES, and in 3 patients (42.9%) after lumbar multilevel TES. No instrumentation failure was observed in cervicothoracic cases. Cage subsidence (>2 mm) occurred in 30 patients (63.8%). In 22 of them, subsidence appeared on the CT one month after surgery. The risk factors of instrumentation failure included a multilevel TES below the thoracolumbar level and a long span of vertebral resection. There was no instrumentation failure in any of the 11 "disc-to-disc cutting" cases.

CONCLUSIONS

This study identified the risk factors of instrumentation failure after multilevel TES. There is a high risk of instrumentation failure in cases of long vertebral resection below the thoracolumbar level. On the other hand, our reconstruction method can be successful for multilevel TES above the thoracic level.

Classification and scoring systems for metastatic spine tumors: a literature review

Introduction

Accurate evaluation of metastasis and life prognosis is essential for selecting a suitable therapeutic strategy for metastatic spine tumors owing to limitations in treatment options. For this purpose, various classification, evaluation, and scoring systems have been developed.

Methods

Classification, evaluation, and scoring systems for metastatic spine tumors reported to date were identified by performing a literature search on PubMed. We reviewed the most cited classifications and scorings before 2009, and all classifications and scorings reported after 2010 from the search results.

Results

Six classifications and 23 scorings were reviewed. The classification/evaluation methods are divided into 1) anatomical classification/evaluation methods, 2) evaluation methods for neurological symptoms/instability, and 3) scoring systems for predicting life expectancy. The first 2 were useful for the planning and evaluation of surgical indications. Scoring systems for life prognosis also permitted rough prediction of the outcomes and were useful for the selection of a suitable treatment. However, variation of the patient background, diversity of adopted prognostic factors, and the absence of scoring systems that could predict the outcome with an accuracy of 90% or higher introduced some limitations.

Conclusion

The identified classification, evaluation, and scoring systems have been generally useful for treatment strategies. However, we emphasize the necessity of multidisciplinary development and revision of classification and evaluation methods to adapt to the prolongation of survival associated with increased diversity and improvement of treatment options.

Modified En Bloc Spondylectomy for Tumors of the Thoracic and Lumbar Spine: Surgical Technique and Outcomes

BACKGROUND

Total en bloc spondylectomy (TES) for the treatment of spinal tumors decreases local recurrence and improves survival compared with intralesional resection. TES approaches vary in both the number of stages to complete the procedure and instruments with which osteotomies are performed.

METHODS

We describe a 2-stage technique that employs the use of threadwire saws. We performed a retrospective review of cases of primary tumors and solitary metastases involving the thoracic or lumbar spine treated with use of our modified technique at our institution between 2010 and 2016, identifying eligible patients by searching for specific phrases in operative reports found in our oncologic database. Clinical notes, operative notes, imaging reports, and pathology reports were reviewed for all patients.

RESULTS

Thirty-three patients underwent our modified technique, in which we pass a threadwire saw between the vertebral body and the thecal sac. The most common tumor type was chordoma (64%), and tumors were most commonly located in the lumbar spine (61%). There were no intraoperative injuries to the spinal cord or great vessels. One patient experienced a dural tear secondary to the passage of a saw. Seventeen (52%) of the patients had perioperative complications, with 1 death. Seven (22%) of the patients had complications occurring within 90 days after discharge, and 8 (25%) had complications occurring >90 days after discharge. Instrumentation failure was observed in 8 cases (25%). Negative margins were obtained in 94% of the cases. Local recurrence was observed in 2 cases (6%). The majority of patients had normal motor function at the time of the most recent follow-up.

CONCLUSIONS

Our modified en bloc spondylectomy represents an effective technique for the resection of spinal tumors in selected patients, allowing for visualization of vessels anterior to the spine and the avoidance of spinal cord injury.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

En Bloc Resection of Primary Malignant Bone Tumor in the Cervical Spine Based on 3-Dimensional Printing Technology

OBJECTIVE

To investigate the feasibility and safety of en bloc resection of cervical primary malignant bone tumors by a combined anterior and posterior approach based on a three-dimensional (3-D) printing model.

METHODS

Five patients with primary malignant bone tumors of the cervical spine underwent en bloc resection via a one-stage combined anteroposterior approach in our hospital from March 2013 to June 2014. They comprised three men and two women of mean age 47.2 years (range, 26-67 years). Three of the tumors were chondrosarcomas and two chordomas. Preoperative 3-D printing models were created by 3-D printing technology. Sagittal en bloc resections were planned based on these models and successfully performed. A 360° reconstruction was performed by spinal instrumentation in all cases. Surgical margins, perioperative complications, local control rate and survival rate were assessed.

RESULTS

All patients underwent en bloc excision via a combined posterior and anterior approach in one stage. Mean operative time and estimated blood loss were 465 minutes and 1290 mL, respectively. Mean follow-up was 21 months. Wide surgical margins were achieved in two patients and marginal resection in three; these three patients underwent postoperative adjuvant radiation therapy. One vertebral artery was ligated and sacrificed in each of three patients. Nerve root involved by tumor was sacrificed in three patients with preoperative upper extremity weakness. One patient (Case 3) had significant transient radiculopathy with paresis postoperatively. Another (Case 4) with C 4 and C 5 chordoma had respiratory difficulties and pneumonia after surgery postoperatively. He recovered completely after 2 weeks' management with a tracheotomy tube and antibiotics in the intensive care unit. No cerebrovascular complications and wound infection were observed. No local recurrence or instrumentation failure were detected during follow-up.

CONCLUSION

Though technically challenging, it is feasible and safe to perform en bloc resection of cervical primary bone tumors. This is the most effective means of managing cervical spine tumors. Preoperative 3-D printing modelling enables better anatomical understanding of the relationship between the tumor and cervical spine and can assist in planning the surgical procedure.

Management Strategy of Osteoblastomas Localized in the Occipitocervical Junction

OBJECTIVE

The aim of this article was to analyze extracted patient data from the literature and highlight the best treatment options and survival outcomes for osteoblastomas in the occipitocervical region.

METHODS

A systematic literature search method was used to select articles containing information about the demographic features, tumor location, treatment characteristics, adjuvant therapies, and follow-up time.

RESULTS

From 25 articles, 31 cases of osteoblastoma in the occipitocervical junction were selected for analysis. Average patient age was 17 years (range, 5-57 years); there were 21 male (67%) and 10 female (33%) patients. All patients had cervical pain as the presenting symptom. Other symptoms included torticollis (0.13%) and sensory or motor neurologic deficits (0.16%). The average follow-up time was 41 months, and the local recurrence rate was 0.125%. Recommendations of each article are categorized and discussed in detail.

CONCLUSIONS

Osteoblastoma is a rare entity in the occipitocervical region, so treatment experiences are limited and mostly based on case reports. To determine the best treatment for these lesions, osteoblastomas should be staged using the Enneking staging system; different methods may be recommended for different stages, and the feasibility of fusion depends on the remaining amount of bony structures and joints. Additional adjuvant therapies may be recommended only in special cases.

Electrophysiological monitoring during preoperative angiography to guide decisions regarding permanent occlusion of major radicular arteries in patients undergoing total en bloc spondylectomy

OBJECTIVE

Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion.

METHODS

This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented.

RESULTS

Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization.

CONCLUSIONS

Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.

One-stage surgical treatment for thoracic and lumbar Spinal tuberculosis by transpedicular fixation, debridement, and combined interbody and posterior fusion via a posterior-only approach

This study examined the clinical outcomes of one-stage surgical treatment for patients with spinal tuberculosis via a posterior-only approach. Twenty-four patients with thoracic or lumbar spinal tuberculosis whose lesions were confined to adjacent segments were admitted to our hospital and treated. The American Spinal Injury Association (ASIA) impairment scale was used to assess the neurological function. All patients were treated with one-stage surgical treatment via a posterior-only approach. The clinical efficacy was evaluated by the Japanese Orthopaedic Association (JOA) scores and oswestry disability index (ODI) of nerve function. Patients were evaluated preoperatively and postoperatively by measurement of spinal deformity using Cobb angle and radiological examination. All the patients were followed up for 13 to 27 months. They had significantly postoperative improvement in JOA score, ODI and ASIA classification scores. The kyphotic angles were significantly corrected and maintained at the final follow-up. Bone fusion was achieved within 4-12 months. It was concluded that one-stage surgical treatment via a posterior-only approach is effective and feasible for the treatment of spinal tuberculosis.

The impact of complete surgical resection of spinal metastases on the survival of patients with thyroid cancer

Spinal metastases (SMs) from thyroid cancers significantly reduce the quality of life by causing pain and neurological deficits and increase mortality. Complete surgical resection of isolated thyroid SMs is a promising treatment option; however, the postoperative outcome is unknown. This study aimed to compare the postoperative courses of patients undergoing complete resection of thyroid SMs with those of patients undergoing incomplete resection, with a minimum 4‐year follow‐up. We performed a retrospective analysis of 32 patients who underwent tumor excision surgery for thyroid SMs at our medical center during a 28‐year period. Twenty patients underwent complete excision, and 12 underwent incomplete excision. Survival was defined as the time from the first spinal surgery to death or last follow‐up. Kaplan–Meier analysis with the long‐rank test was used to compare the overall survival rates between the groups. For all patients, the overall 5‐ and 10‐year survival rates were 71% and 31%, respectively. The median overall survival time was 6.4 years. The patients undergoing complete excision survived longer than those undergoing incomplete excision (5‐year survival: 84% vs. 50%; 10‐year survival: 52% vs. 8%; P < 0.01). Only one patient undergoing complete excision experienced local tumor recurrence in the operated spine, whereas all long‐term survivors (>18 months after surgery) in the incomplete excision group experienced local tumor recurrence and a consequent deterioration in performance status. Complete surgical resection of thyroid SMs, if achievable, has the potential not only to maintain performance status, but also to prolong survival.

Invasiveness Reduction of Recent Total En Bloc Spondylectomy: Assessment of the Learning Curve

STUDY DESIGN

Case-control study.

PURPOSE

To evaluate the surgical magnitude and learning curve of "second-generation" total en bloc spondylectomy (TES).

OVERVIEW OF LITERATURE

In June 2010, we developed second-generation TES combined with tumor-induced cryoimmunology, which does not require autograft harvesting.

METHODS

TES was performed in 63 patients between June 2010 and September 2013. Three groups of patients were evaluated: 20 undergoing surgery in the first year of development of second-generation TES (group I), 20 in the second year (group II), and 23 in the third year (group III). Patient backgrounds showed no remarkable differences. Operating time, intraoperative blood loss, blood transfusion, and postoperative C-reactive protein and creatine phosphokinase were compared among the groups.

RESULTS

Mean±standard deviation operating time was 486±130 minutes in group I, 441±85 minutes in group II, and 396±75 minutes in group III. The time was significantly shorter in group III than in group I (p<0.05). Intraoperative blood loss was 901±646 mL in group I, 433±177 mL in group II, and 411±167 mL in group III. Blood loss was significantly lower in groups II and III than in group I (p<0.01). Transfusion was not required in 20 of 23 patients in group III, and mean C-reactive protein levels on postoperative day 3 were significantly lower in this group than in group I (6.12 mg/L vs. 10.07 mg/L; p<0.05). Postoperative creatine phosphokinase levels did not differ among the groups.

CONCLUSIONS

TES is associated with a significant learning curve. Thus, second-generation TES can no longer be considered highly invasive.

Fixed-Angle, Posteriorly Connected Anterior Cage Reconstruction Improves Stiffness and Decreases Cancellous Subsidence in a Spondylectomy Model

STUDY DESIGN

An idealized biomechanical model.

OBJECTIVE

The aim of this study was to evaluate the biomechanical properties of a construct designed to minimize intervertebral cage subsidence and maximize stiffness.

SUMMARY OF BACKGROUND DATA

Reconstruction after vertebral resection typically involves posterior segmental fixation and anterior interbody support. However, poor bone density, adjuvant radiation, or the oncologic need for endplate resection make interbody device subsidence and resultant instrumentation failure a significant concern.

METHODS

An idealized thoracolumbar spondylectomy reconstruction model was constructed using titanium segmental instrumentation and Delrin plastic. In vivo mechanical stress was simulated on a custom multi-axis spine simulator. Rigid body position in space was measured using an optical motion-capture system. Cancellous subsidence was modeled using a 1 cm thick wafer of number 3 closed-cell Sawbones foam at one endplate. Ten foam specimens were tested in a control state consisting of posterior segmental fixation with a free interbody cage. Ten additional foam specimens were tested in the test state, with the Delrin interbody cage "connected" to the posterior rods using two additional pedicle screws placed into the cage. Foam indentation was quantified using a precision digital surface-mapping device, and subsidence volume calculated using geometric integration.

RESULTS

The control group exhibited significantly greater foam indentation after cycling, with a mean subsidence volume of 1906 mm [95% confidence interval (95% CI) 1810-2001] than the connected cage group subsidence volume of 977 mm (95% CI 928-1026 mm; P < 0.001]. Construct stiffness was greater in the connected cage group (3.1 Nm/degree, 95% CI 3.1-3.2) than in the control group (2.3 Nm/degree, 95% CI 2.2-2.4; P < 0.001).

CONCLUSION

In an idealized spondylectomy model, connecting the anterior column cage to the posterior instrumentation using additional pedicle screws results in a construct that is nearly 40% stiffer and exhibits 50% less cancellous subsidence compared with a traditional unconnected cage.

LEVEL OF EVIDENCE

N/A.

Successful treatment of advanced malignant fibrous histiocytoma of the right forearm with apatinib: a case report

Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma in late adult life. Unfortunately, advanced MFH has a poor prognosis due to a lack of effective drugs. We present here a case of advanced MFH with partial response to apatinib, a new potent oral small-molecule tyrosine kinase inhibitor targeting the intracellular domain of vascular endothelial growth factor receptor 2 (VEGFR-2). To the best of our knowledge, this is the first case report using apatinib for MFH. Quantitative polymerase chain reaction analysis revealed high expression of VEGFR-2 mRNA, suggesting that apatinib leads to clinical response by inhibiting VEGFR-2 tyrosine kinase activity and the crucial role of VEGFR-2 for MFH. Apatinib could be a new option for the treatment of MFH. Further studies are needed to optimize the treatment.

En Bloc Resection and Reconstruction Using a Frozen Tumor-Bearing Bone for Metastases of the Spine and Cranium from Retroperitoneal Paraganglioma

BACKGROUND

Paragangliomas are neuroendocrine tumors that originate from autonomic nervous system-associated paraganglia and are rare tumors accounting for only 0.3% of all neoplasms. Malignant paragangliomas frequently spread to the skeleton. The authors present a case of malignant paraganglioma with bone metastases to the spine and cranium, as well as excellent local control achieved with en bloc tumor resection and reconstruction using frozen tumor-bearing bone for the sites of the metastases.

CASE

The patient was a 61-year-old woman who underwent retroperitoneal paraganglioma resection 12 years previously. Nine years after the primary surgery, she began to experience back pain. Magnetic resonance imaging revealed an isolated metastasis in T6, and the following evaluation detected another metastasis in the left temporal bone. We performed curative surgeries for the metastases, including total en bloc spondylectomy of T6, partial craniectomy for the cranial metastasis, and spinal and cranial reconstruction using frozen tumor-bearing bone for the sites of the metastases. At the 24-month follow-up examination, bone fusion was achieved between the frozen bone and the adjacent healthy bone in the spine and cranium. At 36 months postoperatively, an asymptomatic metastatic lesion was found in the pelvis. Nevertheless, no local recurrences at the surgical sites were detected. Her quality of life and performance in activities of daily living were well preserved. To the author's knowledge, this is the first report to present a case of cranioplasty achieved using a liquid nitrogen frozen, tumor-bearing autologous bone flap in a single-stage operation.

Postoperative Cerebrospinal Fluid Leakage Associated With Total En Bloc Spondylectomy

Cerebrospinal fluid (CSF) leakage is a serious postoperative complication associated with total en bloc spondylectomy. The authors examined the risk factors for CSF leakage after this procedure. A total of 72 patients underwent total en bloc spondylectomy at the authors' institution between May 2010 and April 2013. Postoperative CSF leakage was observed in 17 of the 72 patients (23.6%). The results of univariate analysis suggested that age 54 years or older, preoperative surgical site irradiation, resection of 3 or more vertebral bodies, and dural injury were significant risk factors for postoperative CSF leakage after total en bloc spondylectomy. Multivariate analysis showed that preoperative surgical site irradiation was the only significant risk factor for postoperative CSF leakage (adjusted odds ratio, 5.22; 95% confidence interval, 1.03-26.45, P=.046). The authors also assessed the course of treatment for postoperative CSF leakage in each patient. Of 17 patients with postoperative CSF leakage, 13 recovered without further complications, but 4 required reoperation (2 for wound dehiscence, 1 for surgical site infection, and 1 for severe intracranial hypotension). All 4 patients who required reoperation had a history of surgical site irradiation. Thus, this study suggests that careful consideration should be given to postoperative CSF leakage in patients with a history of surgical site irradiation. These findings may contribute to the management of postoperative CSF leakage associated with total en bloc spondylectomy and supplement the information given to the patient in the process of obtaining informed consent.

A biomechanical comparison of 360° stabilizations for corpectomy and total spondylectomy: a cadaveric study in the thoracolumbar spine

Background

To date, there has been no adequate biomechanical model that would allow a quantitative comparison in terms of stability/stiffness between a corpectomy with the posterior column preserved and a total spondylectomy with the posterior column sacrificed. The objective of this study was to perform a biomechanical comparison of 360° stabilizations for corpectomy and total spondylectomy, using the human thoracolumbar spine.

Methods

Five human cadaveric thoracolumbar spines (T8-L2) were tested according to the following loading protocol: axial compression, flexion, extension, lateral bending to the right and left, and axial rotation to the right and left. This loading protocol was applied three times. Each specimen was tested intact, after corpectomy, and after total spondylectomy. The relative stiffness of each motion segment was determined for each test.

Results

There was no significant difference in stiffness after reconstruction of total spondylectomy versus corpectomy in our thoracolumbar model. Our construct consisted of an anterior cage and four-level pedicle screw instrumentation (two above and two below) and provided similar stiffness in both models. Despite the additional bone resection in a total spondylectomy versus corpectomy, the constructs did not differ biomechanically. Additionally, there was no significant difference in stiffness between the intact specimen and either reconstruction model.

Conclusions

A classic corpectomy, which leaves the posterior column intact, is no better in terms of stability/stiffness than a total spondylectomy carried out using a shorter cage, followed by compression using posterior instrumentation.

Advances in the clinical research of the minimally invasive treatment for the posterior edge of vertebral-body defects by spinal metastases

Spinal metastasis is one of the commonly observed complications in the advanced stages of cancer patients, and is a serious threat to human life and health. Malignant tumor invasion usually leads to defects in the posterior margins of the vertebral body, which caused significant cancer pains to patients and increased the risk of surgery. Currently, minimally invasive treatments of vertebral defects caused by spinal metastases include percutaneous vertebroplasty (PVP) combined with radiofrequency ablation and PVP combined with ¹²⁵I seed implantation. These minimally invasive techniques have particular superiority to control pain in patients with spinal metastases, improve nerve function, reduce the incidence of fractures and surgical risk, and improve the quality of life. The present study reviewed the progress in clinical research on vertebral defects caused by spinal metastases, and the mechanisms and minimally invasive treatment.

Surgical treatment for spinal tuberculosis with bilateral paraspinal abscess or bilateral psoas abscess: one-stage surgery

STUDY DESIGN

This was a prospective study on the clinical outcomes of single-stage surgery for thoracic and lumbar spine tuberculosis patients with bilateral paraspinal or bilateral psoas abscesses.

OBJECTIVE

The aim of this study was to investigate the feasibility of, indications for, and clinical effects of single-stage posterior surgery for the treatment of thoracic and lumbar spinal tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

SUMMARY OF BACKGROUND DATA

An increasing number of articles have been published on the use of single-stage surgery for spinal tuberculosis; however, none of these articles have discussed the use of such surgery in patients with bilateral abscesses.

METHODS

Between January 2003 and January 2011, 41 patients with thoracic and lumbar spinal tuberculosis and bilateral paraspinal or bilateral psoas abscesses were treated with single-stage posterior surgery. All of the patients were treated preoperatively with 1-2 weeks of antituberculosis drugs. All patients were managed postoperatively with standard courses of chemotherapy with triple or quadruple antituberculosis drugs. The clinical symptoms, complications, and laboratory and image indicators were recorded.

RESULTS

There were no local recurrences except in one L3-L4 tuberculosis patient. Two patients presented with extraspinal tuberculosis in the third year. There were no incision complications. Bone fusion was observed 6 months after the operation. The erythrocyte sedimentation rate was normal at 3 weeks-3 months postoperatively. There were no internal fixation failures. The internal fixations in 6 young patients were removed after the spinal tuberculosis was cured.

CONCLUSIONS

Single-stage posterior surgery with instrumentation results in less operative trauma and can be a suitable alternative for treating thoracic and lumbar tuberculosis with bilateral paraspinal or bilateral psoas abscesses.

Multilevel en bloc spondylectomy for tumors of the thoracic and lumbar spine is challenging but rewarding

BACKGROUND

Over the years, en bloc spondylectomy has proven its efficacy in controlling spinal tumors and improving survival rates. However, there are few reports of large series that critically evaluate the results of multilevel en bloc spondylectomies for spinal neoplasms.

QUESTIONS/PURPOSES

Using data from a large spine tumor center, we answered the following questions: (1) Does multilevel total en bloc spondylectomy result in acceptable function, survival rates, and local control in spinal neoplasms? (2) Is reconstruction after this procedure feasible? (3) What complications are associated with this procedure? (4) is it possible to achieve adequate surgical margins with this procedure?

METHODS

We retrospectively investigated 38 patients undergoing multilevel total en bloc spondylectomy by a single surgeon (AL) from 1994 to 2011. Indications for this procedure were primary spinal sarcomas, solitary metastases, and aggressive primary benign tumors involving multiple segments of the thoracic or lumbar spine. Patients had to be medically fit and have no visceral metastases. Analysis was by chart and radiographic review. Margin quality was classified into intralesional, marginal, and wide. Radiographs, MR images, and CT scans were studied for local recurrence. Graft healing and instrumentation failures at subsequent followup were assessed. Complications were divided into major or minor and further classified as intraoperative and early and late postoperative. We evaluated the oncologic status using cumulative disease-specific and metastases-free survival analysis. Minimum followup was 24 months (mean, 39 months; range, 24-124 months).

RESULTS

Of the 38 patients, 34 (89%) were alive and walking without support at final followup. Thirty-one (81%) had no evidence of disease. Two patients died postoperatively and another two died of systemic disease (without local recurrence). Only three patients (8%) had a local recurrence. There were 14 major complications and 22 minor complications in 25 patients (65%). Only one patient required revision of implants secondary to mechanical failure. Two cases of cage subsidence were noted but had no clinical significance. Wide margins were achieved in nine patients (23%), marginal in 25 (66%), and intralesional in four (11%).

CONCLUSIONS

In patients with multisegmental spinal tumors, oncologic resections were achieved by multilevel en bloc spondylectomy and led to an acceptable survival rate with reasonable local control. Multilevel en bloc surgery was associated with a high complication rate; however, most patients recovered from their complications. Although the surgical procedure is challenging, our encouraging mid-term results clearly favor and validate this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Management of metastatic cervical spine tumors

The skeletal system is the third most common site of metastases after the lung and liver. Within the skeletal system, the vertebral column is the most common site of metastases, and 8% to 15% of vertebral metastases are in the cervical spine, consisting, anatomically and biomechanically, of the occipitocervical junction, subaxial spine, and cervicothoracic junction. The vertebral body is more commonly affected than the posterior elements. Nonsurgical management techniques include radiation therapy (stereotactic and conventional), bracing, and chemotherapy. Surgical techniques include percutaneous methods, such as vertebroplasty, and palliative methods, such as decompression and stabilization. Surgical approach depends on the location of the tumor and the goals of the surgery. Appropriate patient selection can lead to successful surgical outcomes by restoring spinal stability and improving quality of life.

Surgical site infection after total en bloc spondylectomy: risk factors and the preventive new technology

BACKGROUND CONTEXT

Surgical site infection (SSI) associated with instruments remains a serious and common complication in patients who undergo total en bloc spondylectomy (TES). It is very important that the risk factors for SSI are known to prevent it.

PURPOSE

The purpose of the study was to identify independent risk factors for SSI after TES and evaluate the positive effect of iodine-supported spinal instruments in the prevention of SSI after TES.

STUDY DESIGN

This is a retrospective clinical study.

PATIENT SAMPLE

One hundred twenty-five patients who underwent TES for vertebral tumor were evaluated.

OUTCOME MEASURES

Incidence rate of SSI, risk factors for SSI after TES, and safety of iodine-supported spinal instruments were the outcome measures.

METHODS

Risk factors for SSI were analyzed using logistic regression. In recent 69 patients with iodine-supported spinal instruments, the thyroid hormone levels in the blood were examined to confirm if iodine from the implant influenced thyroid function. Postoperative radiological evaluations were performed regularly.

RESULTS

The rate of SSI was 6.4% (8/125 patients). By multivariate logistic regression, combined anterior and posterior approach and nonuse of iodine-supported spinal instruments were associated with an increased risk of SSI. The rate of SSI without iodine-supported spinal instruments was 12.5%, whereas the rate with iodine-supported spinal instruments was 1.4%. This difference was statistically significant. There were no detected abnormalities of thyroid gland function with the use of iodine-supported instruments. Among the 69 patients with iodine-supported spinal instruments, 2 patients required additional surgery because of instrument failure. However, there were no obvious involvements with the use of iodine-supported spinal instruments.

CONCLUSIONS

This study identified combined anterior and posterior approach and nonuse of iodine-supported spinal instruments to be independent risk factors for SSI after TES. Iodine-supported spinal instrument was extremely effective for prevention of SSI in patients with compromised status, and it had no detection of cytotoxic or adverse effects on the patients.

Patient-reported outcome and quality of life after total en bloc spondylectomy for a primary spinal tumour

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour.

Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs.

The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery.

Cite this article: Bone Joint J 2014;96-B:1693–8.

Fusion following lateral mass reconstruction in the cervical spine

OBJECT

Recently, aggressive surgical techniques and a push toward en bloc resections of certain tumors have resulted in a need for creative spinal column reconstruction. Iatrogenic instability following these resections requires a thoughtful approach to adequately transfer load-bearing forces from the skull and upper cervical spine to the subaxial spine.

METHODS

The authors present a series of 7 cases in which lateral mass reconstruction with a cage or fibular strut graft was used to provide load-bearing support, including 1 case of bilateral cage placement.

RESULTS

The authors discuss the surgical nuances of en bloc resection of high cervical tumors and explain their technique for lateral mass cage placement. Additionally, they provide their rationale for the use of these constructs throughout the craniocervical junction and subaxial spine.

CONCLUSIONS

Lateral mass reconstruction provides a potential alternative or adjuvant method of restoring the load-bearing capabilities of the cervical spine.

L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature

Study Design Case report and review of the literature.

Objective We present the case of a two-level lumbar spondylectomy at L4 and L5 for en bloc resection of a giant cell tumor (GCT) and lumbopelvic reconstruction.

Methods A 58-year-old woman presented with a 7-month history of progressive intractable back and leg pain secondary to a biopsy-proven Enneking stage III GCT of the L4 and L5 vertebrae. The patient underwent a successful L4–L5 spondylectomy and lumbopelvic reconstruction using a combined posterior and anterior approach over two operative stages.

Results Postoperative complications included a deep wound infection and a cerebrospinal fluid leak; however, following surgical debridement and long-term antibiotic treatment, the patient was neurologically intact with minimal pain and there was no evidence of tumor recurrence or instrumentation failure at more than 2 years of follow-up.

Conclusion Spondylectomy that achieves en bloc resection is a viable and effective treatment option that can be curative for Enneking stage III GCTs involving the lower lumbar spine. The lumbosacral junction represents a challenging anatomic location for spinal reconstruction after spondylectomy with unique technical considerations.

Motor function of the upper-extremity after transection of the second thoracic nerve root during total en bloc spondylectomy

BACKGROUND

In total en bloc spondylectomy (TES) of upper thoracic spine including the second thoracic (T2) vertebra, T2 nerve roots are usually transected. In this study, we examined the association between transection of the T2 nerve roots and upper-extremity motor function in patients with upper thoracic TES.

METHODS

We assessed 16 patients who underwent upper thoracic TES with bilateral transection of the T2 nerve roots. Patients were divided into three groups: 3 patients without any processing of T1 and upper nerve roots (T2 group), 7 with extensive dissection of T1 nerve roots (T1-2 group), and 6 with extensive dissection of T1 and upper nerve roots (C-T2 group). Postoperative upper-extremity motor function was compared between the groups.

RESULTS

Postoperative deterioration of upper-extremity motor function was observed in 9 of the 16 patients (56.3%). Three of the 7 patients in the T1-2 group and all 6 patients in the C-T2 group showed deterioration of upper-extremity motor function, but there was no deterioration in the T2 group. In the T1-2 group, 3 patients showed mild deterioration that did not affect their activities of daily living and they achieved complete recovery at the latest follow-up examination. In contrast, severe dysfunction occurred frequently in the C-T2 group, without recovery at the latest follow-up.

CONCLUSIONS

The transection of the T2 nerve roots alone did not result in upper-extremity motor dysfunction; rather, the dysfunction is caused by the extensive dissection of the T1 and upper nerve roots. Therefore, transection of the T2 nerve roots in upper thoracic TES seems to be an acceptable procedure with satisfactory outcomes.

Recurrent adamantinoma in the thoracolumbar spine successfully treated by three-level total en bloc spondylectomy by a single posterior approach

PURPOSE

Adamantinoma is a low-grade primary malignant bone tumour with slow growth and local recurrence. Its occurrence in the spine is extremely rare, particularly with multilevel involvement. This paper wants to present the first case involving a patient with recurrent thoracolumbar spinal adamantinoma, who underwent a successful three-level spondylectomy for en bloc resection.

METHODS

A 24-year-old man with osteolytic masses of T11 and T12 vertebral bodies was performed curettage by a posterior approach in 2008. The pathology report showed the excised neoplasm was a rare adamantinoma. This patient underwent a tumorectomy again because of its local recurrence nearly 3 years later. In 2012, it was unfortunately revealed that the excised tumour had relapsed and had spread to the L1 vertebral body. Due to its repeated recurrence and aggressive lesion, total en bloc spondylectomy (TES) for this malignant tumour was thought to be the best option for preventing repeated recurrence and possible cure. TES for T11-L1 thoracolumbar spine was performed and spinal reconstruction was completed with instrumentation and a titanium mesh cage through a one-stage single posterior approach.

RESULTS

After three-level TES, neurological deficits of the patient demonstrated good recovery and no evidence of adamantinoma recurrence or deformity was found at 2-year follow-up.

CONCLUSIONS

This is the first case involving multilevel thoracolumbar spinal adamantinoma with repeated recurrence to be successfully treated by three-level TES by a single posterior approach.

Systemic antitumor immune response following reconstruction using frozen autografts for total en bloc spondylectomy

BACKGROUND CONTEXT

Total en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor, such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs a patient's survival. In cryosurgery, antitumor immunity is activated after percutaneous cryoablation of tumors. We applied this tumor-induced cryoimmunology to TES surgery and developed a "second-generation TES" that brings about TES enhancing antitumor immunity to prolong a patient's survival.

PURPOSE

To present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery.

STUDY DESIGN

This is a retrospective review of prospectively collected data.

PATIENT SAMPLE

The sample consisted of 65 consecutive patients who underwent second-generation TES.

OUTCOME MEASURES

Interferon gamma (IFN-γ) and interleukin-12 (IL-12) before surgery and at both 1 and 3 months after surgery was used to assess the immunity-enhancing effect.

METHODS

In second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In the most recent 33 of the 65 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla at the end of the TES surgery. In 60 of 65 cases, measurement of IFN-γ and IL-12 was performed.

RESULTS

IFN-γ increased after surgery in 45 (75%) of 60 cases. The mean IFN-γ relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (284%±596% and 275%±354%: p<.05). IL-12 increased after surgery in 44 (73.3%) of 60 cases. The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared with before surgery, were significantly higher (277%±385% and 486%±1032%: p>.05 and p<.01) at 3 months. At final follow-up, 13 of the 65 patients died due to progression of metastases (mean 12.6 months after TES), 15 remained free from disease, and 36 patients were alive with disease.

CONCLUSIONS

The second-generation TES using frozen tumor-bearing autograft inside a cage affords three benefits: (1) no pain at the bone harvest site, (2) shortening of operation time, and (3) decrease of blood loss. Moreover, our results show that second-generation TES provides not only a local radical cure but also a systemic immunological enhancement.

Scoring system for prediction of metastatic spine tumor prognosis

Assessing the prognosis before treatment for metastatic spine tumor is extremely important in therapy selection. Therefore, we review some prognostic scoring systems and their outcomes. Articles with combinations of two keywords among “metastatic spine tumor” and “prognosis”, “score”, “scoring system”, “predicting”, or “life expectancy” were searched for in PubMed. As a result, 236 articles were extracted. Those referring to representative scoring systems about predicting the survival of patients with metastatic spine tumors were used. The significance and limits of these scoring systems, and the future perspectives were described. Tokuhashi score, Tomita score, Baur score, Linden score, Rades score, and Katagiri score were introduced. They are all scoring systems prepared by combining factors that affect prognosis. The primary site of cancer and visceral metastasis were common factors in all of these scoring systems. Other factors selected to influence the prognosis varied. They were useful to roughly predict the survival period, such as, “more than one year or not” or “more than six months or not”. In particular, they were utilized for decision-making about operative indications and avoidance of excessive medical treatment. Because the function depended on the survival period in the patients with metastatic spine tumor, it was also utilized in assessing functional prognosis. However, no scoring system had more than 90% consistency between the predicted and actual survival periods. Future perspectives should adopt more oncological viewpoints with adjustment of the process of treatment for metastatic spine tumor.

Perioperative complications of total en bloc spondylectomy: adverse effects of preoperative irradiation

Background

Total en bloc spondylectomy (TES) is associated with a high complication rate because it is technically demanding and involves patients compromised by cancer. Specifically, perioperative complications are more likely to occur in patients receiving preoperative irradiation. We examined the perioperative complications associated with TES in patients receiving preoperative irradiation.

Methods

Seventy-seven patients underwent TES between May 2010 and April 2013. We performed a retrospective review of prospectively collected data for 50 patients with metastatic tumors of the thoracic spine, excluding patients with primary spinal tumors, lumbar spinal metastasis, and combined anterior and posterior approach TES. Patients were divided into 2 groups: those with preoperative irradiation (RT-TES group, 18 patients) and those without preoperative irradiation (TES group, 32 patients). The following perioperative complications, occurring within 2 months of surgery, were compared between the groups: intraoperative dural injuries, epidural hematomas, deep surgical-site infections, postoperative cerebrospinal fluid leakage, wound dehiscence, pleural effusions, and neurological deficits.

Results

Significant differences in patient characteristics were not observed between the RT-TES and TES groups. Perioperative TES complications occurred in 20/50 patients (40.0%). The complication rate in the RT-TES group was 77.8% (14 out of 18), threefold higher than the 18.8% (6 out of 32) in the TES group (P<0.01). The incidence of complications, including intraoperative dural injuries, postoperative cerebrospinal fluid leakage, wound dehiscence, and pleural effusions, was significantly higher in the RT-TES group (P<0.01).

Conclusion

The perioperative complication rate associated with TES for spinal metastasis was significantly higher among patients receiving preoperative irradiation than among those not receiving preoperative irradiation.

Four- and five- level en bloc spondylectomy for malignant spinal tumors

STUDY DESIGN

Retrospective study.

OBJECTIVE

To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors.

SUMMARY OF BACKGROUND DATA

EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity.

METHODS

We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease.

RESULTS

Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up.

CONCLUSION

Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it.

LEVEL OF EVIDENCE

4.

Clinical outcome of spinal reconstruction after total en bloc spondylectomy at 3 or more levels

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

To assess the clinical and radiological outcome of spinal reconstruction after total en bloc spondylectomy (TES) at 3 or more levels.

SUMMARY OF BACKGROUND DATA

There have been few reports of multilevel spondylectomy for spinal tumor. This is the first case series on the clinical outcome for reconstructions after 3 or more levels of TES.

METHODS

Twenty-six patients treated by 3 or more levels of TES at Kanazawa University Hospital were included in this analysis. Reconstruction was performed with pedicle screw fixation and a titanium mesh cage filled with autograft in all cases. To increase spinal stability in reconstruction, spinal shortening was performed. Instrument failure and radiological findings were evaluated using radiograph and computed tomographical scan with multiplanar reconstructions. The length of spinal shortening was also measured.

RESULTS

Excluding 4 patients with deteriorating general condition, radiological evaluation was performed for more than 1 year in 22 patients. All 22 patients had no evidence of local recurrence at the surgical site of the spine during the follow-up period. Cage subsidence was seen in 11 patients (50%). Eight of the 11 patients showed the appearance of subsidence 1 month after the surgery. There was one instrument failure that required revision surgery 8 months after TES surgery. One other patient showed bone resorption on the contact surfaces of the cage at 24 months after the surgery. The mean length of the resection vertebrae was 84.6 mm (52-124 mm), while the length of the shortening was 10.4 mm (3-22 mm).

CONCLUSION

No local recurrence was observed after TES at 3 or more levels. Cage subsidence was a common phenomenon (50%) and already observed 1 month after surgery in 8 of the 11 cases. Spinal shortening has the potential to provide good stability for multilevel TES.

LEVEL OF EVIDENCE

4.

Patient and family satisfaction with en bloc total resection as a treatment for solitary spinal metastasis

Many studies have evaluated patient satisfaction surgeries for primary cancers. No studies have evaluated patient satisfaction in metastasectomies. The authors examined patient and family satisfaction with en bloc total resection of solitary spinal metastases and evaluated the factors that correlated with dissatisfaction. From 1998 to 2010, total en bloc spondylectomy (TES) was performed in 110 patients with solitary spinal metastases at the authors' institution. Questionnaires were sent by mail to 110 patients and their families in January 2012. Questionnaire included a subjective assessment of the results of surgery and the following questions: (1) Would you have the surgery again if you were returned to your presurgery status? and (2) Do you feel that you are a patient without cancer? To identify factors for dissatisfaction with the outcomes of TES, univariate and multivariate analyses were performed. Questionnaires were successfully delivered to 104 patients and their families. Responses were collected from 47 patients and 61 family members. Forty-five patients were very satisfied or satisfied with the outcomes of TES, and the other 2 were neutral. Fifty-four family members were very satisfied or satisfied, 5 were neutral, and 2 were dissatisfied. Forty-five patients indicated they would have the surgeries again. Thirteen patients indicated that they felt like patients without cancer. In multivariate analysis, patient death less than 2 years postoperatively and major postoperative complications were associated significantly with dissatisfaction.

More than 10-year follow-up after total en bloc spondylectomy for spinal tumors

BACKGROUND

There are many reports of en bloc resection for spinal tumors. However, no studies have evaluated the clinical outcomes with follow-up exceeding 10 years after surgery.

METHODS

We reviewed 82 patients who had undergone total en bloc spondylectomy (TES) before January 2002 and identified 29 (19 with primary tumors and 10 with metastatic tumors) who had survived for more than 10 years after surgery. We evaluated the clinical outcomes including patient-based outcomes using questionnaire. The questionnaire included subjective assessment of the results of TES and SF-36.

RESULTS

Overall, 33 % of patients with metastases from kidney cancer and 25 % of those with metastases from thyroid cancer survived for more than 10 years after TES for solitary spinal metastases. Four patients with metastatic tumors had no evidence of disease at the time of survey. There were no tumor recurrences in any of the 23 patients who underwent TES as the primary surgery. No revision surgeries have been required as a result of instrumentation failure in any of the 29 patients. About 90 % of the patients were satisfied or very satisfied with the results of TES. The SF-36 results demonstrated that the both physical and mental health of patients with primary tumors was equivalent to those of healthy individuals, and the mental health of patients with metastatic tumors was almost similar to them.

CONCLUSIONS

This study showed the long-term clinical outcomes after TES to be favorable. TES played an important role in the treatment strategy for spinal tumors including metastases.

Reconstruction using a frozen tumor-bearing vertebra in total en bloc spondylectomy can enhance antitumor immunity

PURPOSE

Distant metastases from thyroid carcinoma are successfully cured if they take up radioiodine ((131)I), are of small size, and located in the lungs. Bone metastases have the worst prognosis because (131)I therapy and external beam radiotherapy are less effective. Our propose here is to report a patient with solitary spinal metastasis and multiple lung metastases from thyroid carcinoma, whose spinal metastasis was treated by total en bloc spondylectomy (TES) enhancing antitumor immunity using frozen tumor-bearing bone for spinal reconstruction.

METHODS

The patient was a 37-year-old male who had solitary spinal metastasis at T4 and multiple lung metastases from thyroid carcinoma. (131)I therapy for the multiple lung metastases resulted in no effect because the apparent (131)I uptake was observed only in T4 metastasis. We performed a TES of T4 with cryotreatment. After en bloc excision of T4, the excised tumor-bearing vertebra was frozen by liquid nitrogen. In spinal reconstruction, the frozen vertebra was used in a mesh cage inserted into the anterior defect.

RESULTS

After surgery, the thyroglobulin level decreased without any other adjuvant therapy and the serum levels of INF-γ and IL-12 increased. This indicates antitumor immunity was activated. Then, (131)I therapy became effective to the lung metastases causing the tumors to decrease in size and number. Three years after surgery, progression in the lung metastases, other metastasis, and local recurrence have not been observed.

CONCLUSIONS

TES with cryotreatment as presented is a novel surgery which can enhance antitumor immunity against other visible or non-visible metastases.

Novel reconstruction technique using a frozen tumor-bearing vertebra from a total en bloc sponydylectomy for spinal tumors

This article describes a novel reconstruction technique using frozen tumor-bearing vertebrae in total en bloc spondylectomy for spinal tumors. Instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from the total en bloc spondylectomy are frozen in liquid nitrogen and used as grafted bone for spinal reconstruction. A retrospective review of 56 patients was undertaken. As a result of this review, it was determined that this technique has the benefits of no pain at the bone harvest site, shortened operative time, decreased blood loss, and an additional antitumor immune response.

Increase of IL-12 following reconstruction for total en bloc spondylectomy using frozen autografts treated with liquid nitrogen

Background

Total en bloc spondylectomy (TES) is a surgery designed to achieve complete resection of a malignant spinal tumor such as spinal metastasis. Although this procedure decreases the rate of local recurrence, it is questionable whether local control prolongs patient’s survival. We developed a “second-generation TES” that brings about TES enhancing antitumor immunity to prolong patient’s survival. Our purpose is to present a second-generation TES applied tumor-induced cryoimmunology and assess the immunity-enhancing effect after implementing this surgery.

Methods

We performed a retrospective review of prospectively collected data in second-generation TES as carried out in 56 cases. In second-generation TES, instead of harvesting autograft from the ilium or fibula, the resected lamina and vertebral body from TES are frozen using liquid nitrogen and used as grafted bone for spinal reconstruction. In recent 26 of the 56 cases, in addition to the TES procedure, a small amount of the tumor tissue from the resected tumor-bearing vertebra was also placed into liquid nitrogen. This small amount of tumor tissue was then implanted subcutaneously on one side of the axilla. In 52 of 56 cases, measurement of interleukin 12 (IL-12) was performed before surgery and at both 1 and 3 months after surgery.

Results

IL-12 increased after TES surgery in 38 of 52 cases (73.1%). The mean IL-12 relative concentrations at both 1 and 3 months after surgery, as compared to before surgery, were significantly higher (121±89 and 149±111%: P<0.05 and P<0.01).

Conclusions

Our results show that second-generation TES may provide not only a local radical cure but also a systemic immunological enhancement. Further prolonged survival in patients with a malignant spinal tumor is promising by second-generation TES.

Posterior vertebral column resection for correction of rigid spinal deformity curves greater than 100°

OBJECT

The surgical treatment of severe and rigid spinal deformities poses difficulties and dangers. In this article, the authors summarize their surgical techniques and evaluate patient outcomes after performing posterior vertebral column resection (PVCR) for the correction of spinal deformities with curves greater than 100°, and investigate the crucial points to ensure neurological safety during this challenging procedure.

METHODS

The authors retrospectively reviewed their experience with 28 patients with extremely severe (Cobb angles in the coronal or sagittal plane > 100°) and rigid thoracic or thoracolumbar spine deformities who underwent PVCR. The average patient age was 20.2 years and all patients underwent a minimum follow-up of 24 months (range 24-60 months). Patients were divided into groups according to their morphological classification as follows: kyphosis alone (Group A, 6 patients with a mean Cobb angle of 109.0° [range 105°-120°]); kyphoscoliosis with coronal plane curves notably greater than sagittal plane curves (Group B, 14 patients with mean scoliotic curves of 116.6° [range 102°-170°] and kyphotic curves of 77.7° [range 42°-160°]); and kyphoscoliosis with sagittal curves notably greater than coronal plane curves (Group C, 8 patients with a mean coronal curve of 85.4° [range 65°-110°] and a mean sagittal curve of 117.6° [range 102°-155°]).

RESULTS

A total of 36 vertebrae were removed in 28 patients who had a severe rigid spinal deformity, and the mean fusion extent was 13.3 vertebrae (range 7-17 vertebrae). The mean operating time was 620 minutes (range 320-920 minutes) with an average operative blood loss of 6,680 ml (range 3,000-24,000 ml). The overall final correction rate of scoliosis was 59.0%, and average postoperative kyphotic Cobb angles ranged from 30.4° to 95.9°. In Group A the mean preoperative sagittal angle of 109.0° was corrected to a mean postoperative angle of 32.0°. In the Group B kyphoscoliotic patients, the correction rate in the coronal plane was 58.6%; the Cobb angle in the sagittal plane was corrected from a mean of 77.7° preoperatively to 25.1° postoperatively; in Group C, the correction rate in the coronal plane was 58.5%, and the mean sagittal angle was reduced from a mean of 117.6° preoperatively to 39.0°. Of the 28 patients who underwent PVCR, 46 complications were observed in 18 patients intra- and postoperatively. There were 5 neurological complications including 1 case of late-onset paralysis and 4 cases of thoracic nerve root pain, all of which resolved during the early follow-up period. Nonneurological complications occurred more often in kyphoscoliotic patients (41 complications). The mean follow-up of all patients was 33.7 months (range 24-60 months).

CONCLUSIONS

Posterior vertebral column resection was effective in correcting severe rigid spinal deformity, although the procedure was technically demanding, exhaustingly lengthy, and was associated with a variety of complications. The PVCR technique created a space for spinal correction and spinal cord tension adjustment and the correction could be performed under direct inspection and by palpation of the tension in the spinal cord through the space. Therefore, in terms of the spinal cord, the deformity correction process involved in the PVCR procedure is relatively safe.

Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach

PURPOSE

The objectives of this study were to describe our surgical management with a modified total en bloc spondylectomy (TES) and to evaluate the clinical effects in patients with thoracolumbar tumors.

METHODS

Sixteen consecutive patients with thoracolumbar neoplasms underwent a modified TES via single posterior approach followed by dorsoventral reconstruction from December 2008 to July 2011. Details of the modified technique were described and the patients' clinical information was retrospectively reviewed and analyzed.

RESULTS

Significant improvements in neurological function were achieved in most of the patients. Local pain or radicular leg pain was relieved postoperatively. The mean operation time was 7.2 h, with an average blood loss of 2,300 ml. No major complications, instrumentation failure or local recurrence was found at the final follow-up. Five patients died of the disease during mean 14-month (3.0-23) follow-up.

CONCLUSIONS

The modified TES with a single posterior approach is feasible, safe and effective for thoracolumbar spine tumors.

The role of embolization for hemangiomas

We retrospectively studied 31 patients with painful bone (15 patients) and soft-tissue (16 patients) hemangiomas treated with 39 embolizations using N-2-butyl cyanoacrylate from 2003 to 2010. The mean tumor size before embolization was 6 cm for bone and 7 cm for soft-tissue hemangiomas. The technique of embolization was the same for bone and soft-tissue lesions. Preoperative embolization was done in six patients, while the remaining patients had embolization as only treatment. The mean follow-up was 47 months (11-89 months). The clinical and imaging effect of treatment was evaluated at follow-up with a pain score scale, tumor size, and ossification. In four patients, embolization was not feasible because of the inability to catheterize and low blood flow of the feeding vessels. Nine patients with bone and 10 with soft-tissue hemangiomas experienced complete pain relief. Four patients with bone and four with soft-tissue hemangiomas experienced recurrence of pain and were treated with repeat embolization. Re-recurrences were not observed in any of the patients with soft-tissue hemangiomas until the period of this study. Ossification and tumor size reduction were higher for bone hemangiomas. Embolization-related complications were more common for soft-tissue hemangiomas.