Operative treatment of thoraco-lumbar metastases, using methylmetacrylate and Kempf's rods for vertebral replacement and stabilization. Report of 15 cases

Results and complications of vertebrectomy with posterior approach after 2-year follow-up

<sec><title>OBJECTIVE:</title><p> To describe the surgical technique for vertebrectomy by posterior single approach in the thoracic and thoracolumbar spine with circumferential reconstruction and arthrodesis, and evaluate retrospectively the results and complications after 2 years of follow-up in patients undergoing this technique.</p></sec><sec><title>METHODS:</title><p> Retrospective analysis of medical records and imaging studies of 12 patients with vertebrectomy indication for various pathologies, undergoing this surgical technique.</p></sec><sec><title>RESULTS:</title><p> Eight (66.67%) patients were male and four patients (33.33%) were females aged 13-66 years (mean 40 years). There were nine patients with involvement of the thoracic spine and three of the lumbar, and one patient with two consecutive vertebrae affected. All patients had improved or remained with the neurological condition. Surgical complications were two cases of hemothorax, two cases of loosening of the screws, one of them requiring surgical revision, and a case of material failure and pseudarthrosis.</p></sec><sec><title>CONCLUSION:</title><p> Vertebrectomy by posterior approach in thoracolumbar spine with circumferential reconstruction and fusion can be performed safely for a variety of indications.</p></sec>

Complication Avoidance in Vertebral Column Spine Tumors

The role of surgery for metastatic spine disease is palliative with the goals of achieving excellent neurologic and functional status, spinal stability, pain relief, and local tumor control. Although patients with metastatic spine tumors often have numerous medical and oncologic issues, careful perioperative planning and surgical techniques can help limit complications and help improve patient outcomes significantly.

Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors

OBJECT

Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach-related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure. To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome.

METHODS

Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, preoperative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups.

CONCLUSIONS

Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases

STUDY DESIGN

Retrospective review of prospectively maintained institutional spine database.

OBJECTIVES

To assess the pain, neurologic, and functional outcome of patients with metastatic spinal cord compression using a posterolateral transpedicular approach with circumferential fusion.

SUMMARY OF BACKGROUND DATA

Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and spinal fusion. For patients whose concurrent illness or previous surgery makes an anterior approach difficult, a posterior transpedicular approach was used to resect the involved vertebral bodies, posterior elements, and epidural tumor. This approach provides exposure sufficient to decompress and instrument the anterior and posterior columns.

METHODS

During the past 15 months, 25 patients were operated on using a posterolateral transpedicular approach. The primary indications for surgery were back pain (15 patients) and neurologic progression (10 patients). All patients had vertebral body disease, and 21 patients had high-grade spinal cord compression from epidural disease as assessed by magnetic resonance imaging. Seven patients underwent preoperative embolization for vascular tumors. In each patient, the anterior column was reconstructed with polymethyl methacrylate and Steinmann pins and the posterior column with long segmental fixation.

RESULTS

All patients achieved immediate stability. Pain relief was significant in all 23 patients who had had moderate or severe pain. Neurologic symptoms were stable or improved in 23 patients. One patient with an acutely evolving myelopathy was immediately worse after surgery, and one patient had a delayed neurologic worsening, progressing to paraplegia.

CONCLUSIONS

The posterolateral transpedicular approach provides a wide surgical exposure to decompress and instrument the anterior and posterior spine. This technique avoids the morbidity associated with anterior approaches and provides immediate stability. Vascular tumors may be removed safely after embolization. Patients can be mobilized early after surgery.

Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis

The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple columns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resection of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid surgeons in selecting the optimum approach for individual patients.

Surgical treatment of extradural spinal cord compression due to metastatic tumours

The authors present a group of 23 patients with extradural spinal metastases who had undergone surgical treatment with different approaches, with reference to the anatomical site of the tumours. They report the results and discuss the criteria of the different surgical technical choices.