Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy: description of technique and report of two cases

Efficacy and safety of en-bloc resection versus debulking for spinal tumor: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to consolidate the existing evidence regarding the comparison between en-bloc resection surgery and debulking surgery for spinal tumors, including both primary and metastatic tumors.

MATERIALS AND METHODS

The databases of PubMed, Embase, Cochrane database, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was carried out and included all studies that directly compared en-bloc resection surgery with debulking surgery for spinal tumors in patients through March 2024. The primary outcomes included recurrence rate, postoperative metastasis rate, mortality rate, overall survival (OS), recurrence-free survival (RFS), complication, and so on. The statistical analysis was conducted using Review Manager 5.3.

RESULTS

We systematically reviewed 868 articles and included 27 studies involving 1135 patients who underwent either en-bloc resection surgery (37.89%) or debulking surgery (62.11%). Our meta-analysis demonstrated significant advantages of en-bloc resection over debulking surgery. Specifically, the en-bloc resection group had a lower recurrence rate (OR = 0.19, 95%CI: 0.13-0.28, P < 0.00001), lower postoperative metastasis rate (P = 0.002), and lower mortality rate (P < 0.00001). Additionally, en-bloc resection could improve OS and RFS (HR = 0.45, 95%CI: 0.32-0.62, P < 0.00001 and HR = 0.37, 95%CI: 0.17-0.80, P = 0.01, respectively). However, en-bloc resection required longer operative times and was associated with a higher overall complication rate compared to debulking surgery (P = 0.0005 and P < 0.00001, respectively).

CONCLUSION

The current evidence indicates that en-bloc surgical resection can effectively control tumor recurrence and mortality, as well as improve RFS and OS for patients with spinal tumors. However, it is crucial not to overlook the potential risks of perioperative complications. Ultimately, these findings should undergo additional validation through multi-center, double-blind, and large-scale randomized controlled trials (RCTs).

PRISMA-the 100 most-cited articles on chondrosarcoma recurrence: A bibliometric analysis

BACKGROUND

Chondrosarcoma (CHS) is highly prone to recurrence and has become the most common malignant bone tumor in adults. The authors aim to identify and analyze the top 100 most-cited articles in this field, enabling researchers to quickly grasp the research focus and progress in the area of chondrosarcoma recurrence.

METHODS

A search in the Web of Science database yielded a total of 305 articles related to CHS recurrence between 2013 and 2022. Filtering was done based on the titles and abstracts of the articles in the list, and the top 100 most-cited articles were selected. The following information were analyzed using bibliometric methods: article title, first author, year of publication, journal of publication, total citations, country, institution, and keywords.

RESULTS

Among the selected 100 articles, the most frequently cited one has 224 citations. The most commonly appearing journals, institutions, and countries are as follows: "Clinical Orthopaedics Related Research" (5 times); Fudan University, University of Texas System, and Royal Orthopaedic Hospital (4 times each), with China and the USA cited the most (21 times each). The year 2018 is the most productive year (17 articles). About 97 first authors contributed one article each, and 3 had 2 articles each. Among all 229 keywords, the top 3 in frequency are CHS (20%), recurrence (4%), and surgery (3%). Twenty article topics are related to surgical treatment.

CONCLUSION

Research on CHS recurrence is citation-rich but focuses more on treatments than understanding mechanisms, indicating a need for deeper mechanistic exploration for treatment breakthroughs in the future.

En bloc resection of huge primary tumors with epidural involvement in the mobile spine using the "rotation-reversion" technique: Feasibility, safety, and clinical outcome of 11 cases

BACKGROUND

En bloc resection of spinal tumors provides better local control and survival outcomes than intralesional resection. Safe margins during en bloc resection of primary spinal tumors with epidural involvement are required for improved outcomes. The present study describes a "rotation-reversion" technique that has been used for en bloc resection of huge primary tumors in the mobile spine with epidural involvement and reported the clinical outcomes in these patients.

METHODS

All patients with primary spinal tumors who were treated with the rotation-reversion technique at our institution between 2015 and 2021 were evaluated retrospectively. Of the patients identified, those with both huge extraosseous soft-tissue masses and epidural involvement were selected for a case review. Clinical and radiological characteristics, pathologic findings, operative procedures, complications, and oncological and functional outcomes of these patients were reviewed.

RESULTS

Of the 86 patients identified with primary spinal tumors who underwent en bloc resection using the rotation-reversion technique between 2015 and 2021, 11 had huge extraosseous soft-tissue masses with epidural involvement in the mobile spine. The average maximum size of these 11 tumors was 8.1 × 7.5 × 9.7 cm. Median follow-up time was 28.1 months, mean operation time was 849.1 min (range 465-1,340 min), and mean blood loss was 6,972.7 ml (range 2,500-17,700 ml), with 10 (91%) of the 11 patients experiencing perioperative complications. The negative margin rate was 91%, with only one patient (9%) experiencing local recurrence. Ten patients were able to walk normally or with a crutch at the last follow-up, whereas one was completely paralyzed preoperatively.

CONCLUSION

The rotation-reversion technique is an effective procedure for the en bloc resection of huge primary spinal tumors, with the extension of invasion in selected patients including not only the vertebral body but also the pedicle and part of the posterior arch.

Radiolucent Carbon Fiber-Reinforced Implants for Treatment of Spinal Tumors-Clinical, Radiographic, and Dosimetric Considerations

The management of spine tumors is multimodal and personalized to each individual patient. Patients often require radiation therapy after surgical fixation. Although titanium implants are used most commonly, they produce significant artifact, leading to decreased confidence in target-volume coverage and normal tissue sparing. Carbon-based materials have been found to have minimal effects on dose perturbation in postoperative radiation therapy and have shown biostability and biocompatibility that are comparable to titanium implants. Using the PubMed and Web of Sciences databases, we conducted a systematic review of carbon-based screw and rod fixation systems in the treatment of spinal tumors. We reviewed clinical studies regarding safety of spine fixation with carbon fiber-reinforced (CFR) implants and biomechanical studies, as well as radiation and dosimetric studies. The radiolucency of CFR-polyether ether ketone implants has the potential to benefit patients with spine tumor. Clinical studies have shown no increase in complications with implementation of CFR-polyether ether ketone implants, and these devices seem to have sufficient stiffness and pullout strength. However, further trials are necessary to determine if there is a clinically significant impact on local tumor control.

Multi-level En Bloc Resection as a Preferred Salvage Therapy for Recurrent Thoracolumbar Chondrosarcoma: A Comparative Study With Piecemeal Resection

STUDY DESIGN

A retrospective analysis was performed.

OBJECTIVE

The aim of this study was to evaluate the feasibility and effectiveness of multilevel en bloc resection versus piecemeal resection for recurrent thoracolumbar chondrosarcoma (CHS).

SUMMARY OF BACKGROUND DATA

Multilevel en bloc resection for recurrent thoracolumbar CHS is rarely performed.

METHODS

Included in this retrospective study were 27 patients with recurrent thoracolumbar CHS who received either multilevel en bloc resection or piecemeal resection as a salvage revision procedure in our center between 2010 and 2018. Relevant data between the two methods were compared. Relapse-free survival (RFS) and overall survival (OS) were analyzed by log-rank analysis.

RESULTS

Our series comprised 16 males and 11 females with a mean age of 40.7 years. Multilevel en bloc resection was performed in 17 patients, and piecemeal resection in 10 patients. Of the 17 patients receiving multilevel en bloc resection, five patients experienced recurrence, of whom three died, whereas in the 10 patients receiving piecemeal resection, seven experienced recurrence and all of them died, showing a significant difference between the two groups (P = 0.04 for recurrence, P = 0.007 for death). Complications occurred more frequently in the patients receiving multilevel en bloc resection (P = 0.04), but RFS and OS were prolonged significantly in this group of patients as compared with piecemeal resection group (56.8 ± 9.7 vs. 17.2 ± 4.2, P = 0.016; 67.3 ± 8.4 vs. 21.4 ± 3.5, P = 0.002).

CONCLUSION

Multilevel en bloc resection as a salvage therapy for recurrent thoracolumbar CHS is technically challenging with high risk of complications, but it can significantly prolong RFS and OS of such patients as compared with piecemeal resection.

LEVEL OF EVIDENCE

4.

Recurrent lumbar-origin osteoblastoma treated with multiple surgery and carbon ion radiotherapy: a case report

BACKGROUND

Although osteoblastoma is an uncommon benign bone tumor, it sometimes behaves in a locally aggressive fashion. We herein report a case of recurrent lumbar spine osteoblastoma that was treated by repeated surgery and carbon ion radiotherapy.

CASE PRESENTATION

A 13-year-old Japanese girl presented with left side lumbar pain. Computed tomography and magnetic resonance imaging of the lumbar spine demonstrated a tumorous lesion in the left side pedicle of L4. Although gross total resection of the mass, including the nidus, was performed in the initial surgery, recurrence was observed repeatedly in the short term and the pathological diagnosis of all of the resected tumors was conventional osteoblastoma. We finally performed carbon ion radiotherapy after the patient's 3rd palliative operation, and achieved a good outcome. No further recurrence has been observed in 10 years of follow-up.

CONCLUSION

We performed carbon ion radiotherapy for a case of recurrent spinal osteoblastoma and achieved a good outcome without recurrence at 10 years after carbon ion radiotherapy treatment. To the best of our knowledge, this is the first case of osteoblastoma that was treated with carbon ion radiotherapy after multiple surgeries.

Single stage en bloc resection of a recurrent metastatic osteosarcoma of the pediatric lumbar spine through multiple exposures - a novel approach

To obtain a wide resection and safe margins in recurrent spine osteosarcoma, the surgical approach can include – posterior only, combined posterior and anterior, and combined posterior and anterior with a return to posterior in multiple stages. In our case, we used a novel approach of multiple extensile exposures circumferentially in a single stage with a single surgical prep. We present the case of a 9-year-old female with a history of metastatic osteosarcoma, who previously underwent an attempted en bloc resection with an L3 corpectomy and left below knee amputation. At 1 year follow-up, she developed a recurrent solitary spine lesion at the previous surgical resection site. An additional attempt at complete surgical resection was performed with a complex en bloc L2, L3, L4 corpectomy with removal of deep spinal implants and anterior and posterior spinal fusion with instrumentation and revision decompressive laminectomy. The patient had a good functional outcome without neurological deficits, except those resulting from resection of involved lumbar nerve roots. At last follow-up of 5 months, there was no local recurrence or distant metastasis. This approach for revision resection of recurrent spinal osteosarcoma can be performed successfully with clean margins in a safe manner.

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.

Treatment of Spinal Tumors in a High Volume Center has Direct Impact on Local Recurrence, Morbidity, and Mortality

OBJECTIVE OF THE STUDY

En bloc resections of spine tumors aim at locally controlling the disease for both improving the patient's quality of life as well as improving mortality. The purpose of this study was to compare the outcome between patients who were initially treated in a high volume specialized center, and patients who initially underwent either invasive diagnostic procedure or an initial surgical attempt to treat the disease in a different center.

MATERIALS AND METHODS

A retrospective study of 1681 patients affected by spine tumors-treated from 1990 to 2015 by the same team.

RESULTS

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. One hundred sixty-eight patients (77.8%) were solely treated in the institute and were considered noncontaminated cases (NCCs) and 48 (22.2%) were previously treated elsewhere and were considered contaminated cases (CCs). Median follow-up was 45 months (0-371).Thirty-three local recurrences (15.28%) were recorded. Fourteen patients (29.17%) from the CC and 19 (11.31%) from the NCC group.A total of 153 complications were observed in 100 out of 216 patients (46.2%). Sixty-four of these patients (30%) suffered 1 complication, while the rest had 2 or more. Twenty-eight (58%) of the CC group and 72 (42.85%) of the NCC group, had at least 1 complication.Sixty patients died as a result of the disease during the follow-up period. Twenty-one (43.75%) and 39 (23.21%) patients died in the CC and NCC cohorts, respectively.CC, surgical margins of the resected tumor-intralesional, marginal, and malignant tumors, were statistically significant independent risk factors for local recurrence of the tumor. Contamination, local recurrence, neoadjuvant radiotherapy, the number of level resected, and metastatic tumors compared with primary malignant tumor, were shown to be independent risk factors for patient's death.

CONCLUSIONS

It is apparent that there is a substantial added risk in performing either invasive diagnostic procedures or attempting a surgical resection of the tumor in a nonspecialized center. This risk includes both higher recurrences of the tumor as well as increased mortality. It is therefore reasonable to conclude that the whole treatment, from biopsy to resection, should be performed in the same center, and this center should be a high volume, specialized in treating these type of spine pathologies.The surgeon who treats the patient first has a great responsibility, as it is the first treatment that most affects prognosis. To reduce the chance of local recurrence, morbidity, and mortality, all invasive diagnosis and treatment, should be performed by an experienced team, as the consequences are dramatic.

Solitary vertebral metastasis of primary clear cell carcinoma of the liver: a case report and review of literature

Primary clear cell carcinoma of liver (PCCCL) is an uncommon variant of primary hepatocellular carcinoma. Though the literature describes a better prognosis in relation to the proportion of clear cells in the tumour when compared to the other variants, there is no general consensus in the management due to its rarity and unclear clinicopathological and prognostic factors. There is dearth of evidence with regard to the metastasizing nature of PCCCL and its management. In addition, the management of recurrent spinal tumours both primary and metastatic is not clear as the available evidence is mostly based on case reports. We describe an unusual presentation of PCCCL with solitary spinal metastasis and further complicated by tumour recurrence in a 71-year-old male. Such presentation has never been described before. He presented with low back pain and incomplete neurological deficits involving both lower limbs. On detailed evaluation, he was found to have a solitary metastasis at L3 vertebra secondary to PCCCL. He underwent radical excision of tumour and reconstruction for the solitary metastasis at L3 vertebral body and trans arterial chemo embolisation (TACE) for the hepatic lesion. Pt was asymptomatic until 9 months post operatively when he developed tumour recurrence at L3 vertebra. Patient subsequently underwent 2 stage palliative surgery followed by radiotherapy and chemotherapy. At his latest follow-up (1 year), the patient's overall general condition has improved with residual neurological deficits in the lower limb. PCCCL is a rare type of hepatocellular carcinoma which can present as "solitary metastasis" to the spine. Although the literature suggests a good prognosis for this histological type, this case did not have a good outcome. In addition to providing information for the management of similar cases in the future, this case report highlights that every patient has to be managed on a case-by-case basis.

The role of revision surgery and adjuvant therapy following subtotal resection of osteosarcoma of the spine: a systematic review with meta-analysis

OBJECTIVE Primary osteosarcoma of the spine is a rare osseous neoplasm. While previously reported retrospective studies have demonstrated that overall patient survival is impacted mostly by en bloc resection and chemotherapy, the continued management of residual disease remains to be elucidated. This systematic review was designed to address the role of revision surgery and multimodal adjuvant therapy in cases in which en bloc excision is not initially achieved. METHODS A systematic literature search spanning the years 1966 to 2015 was performed on PubMed, Medline, EMBASE, and Web of Science to identify reports describing outcomes of patients who underwent biopsy alone, neurological decompression, or intralesional resection for osteosarcoma of the spine. Studies were reviewed qualitatively, and the clinical course of individual patients was aggregated for quantitative meta-analysis. RESULTS A total of 16 studies were identified for inclusion in the systematic review, of which 8 case reports were summarized qualitatively. These studies strongly support the role of chemotherapy for overall survival and moderately support adjuvant radiation therapy for local control. The meta-analysis revealed a statistically significant benefit in overall survival for performing revision tumor debulking (p = 0.01) and also for chemotherapy at relapse (p < 0.01). Adjuvant radiation therapy was associated with longer survival, although this did not reach statistical significance (p = 0.06). CONCLUSIONS While the initial therapeutic goal in the management of osteosarcoma of the spine is neoadjuvant chemotherapy followed by en bloc marginal resection, this objective is not always achievable given anatomical constraints and other limitations at the time of initial clinical presentation. This systematic review supports the continued aggressive use of revision surgery and multimodal adjuvant therapy when possible to improve outcomes in patients who initially undergo subtotal debulking of osteosarcoma. A limitation of this systematic review is that lesions amenable to subsequent resection or tumors inherently more sensitive to adjuvants would exaggerate a therapeutic effect of these interventions when studied in a retrospective fashion.

En Bloc Resections in the Spine: The Experience of 220 Patients During 25 Years

BACKGROUND AND OBJECTIVE

En bloc resections aim at surgically removing a tumor in a single, intact piece. Approach must be planned for the complete removal of the tumor without violation of its margins. The shared knowledge of the morbidity, mortality, risk assessment for local disease recurrence, complications, and death, related to spine tumors excised en bloc could improve the treating physician's apprehension of the diseases and decision making process before, during, and after surgical treatment. The purpose of this study was to review and report the experience gained during 25 years in one of the world's biggest spine oncologic centers.

METHODS

A retrospective study of prospective collected data of 1681 patients affected by spine tumors, of whom 220 had en bloc resections performed.

RESULTS

Most tumors were primary-165 cases (43 benign and 122 malignant); metastases occurred in 55 patients. A total of 60 patients died from the disease and 33 local recurrences were recorded. A total of 153 complications were observed in 100 of 216 patients (46.2%); 64 of these patients (30%) suffered 1 complication, whereas the rest had 2 or more. All complications were categorized according to temporal distribution and severity. These were further divided into 7 groups according to the type of complication. There were 105 major and 48 minor complications. Seven patients (4.6%) died as a result of complications. There were 33 local recurrences (15.28%) recorded. Contaminated cases, surgical margins of the resected tumor-intralesional, marginal, and malignant tumors-were statistically significant independent risk factors for local recurrence of the tumor. Contamination, local recurrence, neoadjuvant radiotherapy, number of levels resected, and metastatic tumors compared with primary malignant tumor were shown to be independent risk factors for a patient's death.

CONCLUSIONS

Treatment of spinal aggressive benign and malignant bone tumors with en bloc resection is beneficial in terms of better local control and prognosis, although it is a highly demanding and risky procedure. Margins are the key point of this procedure, thus a careful preoperative oncologic and surgical staging is necessary to define the optimal surgical approach. The adverse event profile of these surgeries is high. Therefore, it should be performed by experienced and multidisciplinary teams in specialized high volume centers.

[Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]

OBJECTIVE

To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES).

METHODS

A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes.

RESULTS

A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance.

CONCLUSION

TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation.

Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team

PURPOSE

Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries.

METHODS

A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team.

RESULTS

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection.

CONCLUSION

The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.

Quantitative in vivo fusion assessment by (18)F-fluoride PET/CT following en bloc spondylectomy

PURPOSE

The purpose of this retrospective analyses was to evaluate the bone viability in the ventral column of the spine following large segmental defect reconstructions. Osseous integration of implants following spinal fusion procedures is an essential precondition to provide adequate mechanical strength to any applied forces and subsequently satisfying patient outcomes. Although CT scan is the non-invasive gold standard for fusion assessment, it lacks the ability to visualize bone viability and, therefore, discrepancy remains about sensitivity and specificity of CT as evaluation tool of spinal fusion.

METHODS

A novel modality, (18)F Fluoride PET/CT, specifically allows quantitative in vivo evaluation of metabolic activity of the osseous integration. Bone viability following large segmental reconstructions in patients after mono- and multi-level en bloc spondylectomies (EBS) was analyzed. Spinal fusion was assessed on plain radiographs and CT scans according to the FDA fusion criteria as well as (18)F PET/CT.

RESULTS

A total of eight patients underwent (18)F PET/CT were included (one 4-level-, one 3-level, two 2-level and four 1-level EBS). The average follow-up between EBS and radiographic studies was 24.8 months. On plain radiographs and CT scans, successful fusion was confirmed in all patients. However, (18)F PET/CT showed non-union in all cases. The metabolic bone activity within the cage was fourfold decreased compared to the reference vertebra, whereas the metabolic activity of the adjacent endplates was 1.6-fold increased compared to the reference vertebra.

CONCLUSION

This study suggests a discrepancy between fusion rates assessed by plain radiographs and CT scan compared to (18)F PET/CT.

Combined modified en bloc corpectomy with replacement of the aorta in curative interdisciplinary treatment of a large osteosarcoma infiltrating the aorta

PURPOSE

We report a case of a large three-level spinal osteosarcoma infiltrating the adjacent aorta. This is the first case in which a combined modified three-level en bloc corpectomy with resection and replacement of the adjacent aorta was successful as a part of interdisciplinary curative treatment.

METHODS

Case report.

RESULTS

The surgical procedure was performed as a two-step treatment. A heart lung machine (HLM) was not used, in order to avoid cerebral and spinal ischemia and to decrease the risk of hematogenous tumor metastases. Instead, a bypass from the left subclavian artery the distal descending aorta was used. We modified the en bloc corpectomy procedure, leaving a dorsal segment of the vertebral bodies to enable rapid surgery. The procedure was successful and the en bloc resection of the vertebral body with aortal resection could be achieved. Except for pallhypesthesia in the left dermatomes Th7-Th10, the patient does not have any postoperative neurologic deficits.

CONCLUSION

Combined corpectomy with aortic replacement should be considered as a reasonable option in the curative treatment of osteosarcoma with consideration of the immense surgical risks. The use of an HLM is not necessary, especially considering the inherent risk of hematogenous tumor metastases. Modified corpectomy leaving a dorsal vertebral body segment was considered a reasonable variation since tumor-free margins could still be expected.

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.

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.

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.

Four-rod stabilization of severely destabilized lumbar spine caused by metastatic tumor

We report a case of a 67-year-old female with severely destabilized lumbar spine caused by metastatic malignant tumor. The primary lesion was a thyroid follicular adenocarcinoma. Complete destruction of the L3, L4, and L5 vertebrae had resulted in severe instability, which left the patient with severe back pain and bed-ridden. Since the vertebrae were so severely damaged at 3 levels, 4 rods were used to stabilize the spine. Following stabilization, the pain was alleviated and the patient's quality of life improved. We introduce here the 4-rod technique to stabilize the spine over 3 vertebral levels following severe destruction by metastatic tumor.

Strategy in the surgical treatment of primary spinal tumors

Primary spine tumors are rare, accounting for only 4% of all tumors of the spine. A minority of the more common primary benign lesions will require surgical treatment, and most amenable malignant lesions will proceed to attempted resection. The rarity of malignant primary lesions has resulted in a paucity of historical data regarding optimal surgical and adjuvant treatment and, although we now derive benefit from standardized guidelines of overall care, management of each neoplasm often proceeds on a case-by-case basis, taking into account the individual characteristics of patient operability, tumor resectability, and biological potential. This article aims to provide an overview of diagnostic techniques, staging algorithms and the authors' experience of surgical treatment alternatives that have been employed in the care of selected benign and malignant lesions. Although broadly a review of contemporary management, it is hoped that the case illustrations given will serve as additional "arrows in the quiver" of the treating surgeon.

360-degree osteosynthesis via a posterolateral transpedicular approach in high-risk patients

PURPOSE

Patients requiring anterior-posterior thoracic spine stabilization and suffering from concomitant cardiopulmonary disease are at increased risk to develop procedure-related complications. In order to reduce cardiopulmonary complications, the efficacy of a posterolateral transpedicular approach for 360-degree fusion was investigated.

METHODS

Fourteen consecutive patients presenting with spinal cord compression from osteoporotic, metastatic and tuberculotic fractures were treated. Spinal cord decompression was achieved by laminectomy, facetectomy and corpectomy with subsequent posterior instrumented fusion using a screw-rod system.

RESULTS

The procedure was successfully performed in 14 high-risk patients. Preoperatively, all patients presented with thoracic and lower back pain and nine patients with a paraparesis (Frankel grade C). The implants were introduced monoportally or biportally. In all cases, neurological symptoms moderately improved.

CONCLUSION

The posterolateral transpedicular approach might be a safe, less-invasive and efficient alternative to anterior-posterior fusion. However, biomechanic efficacy and long-term outcome as compared to the transthoracic technique remains to be studied in a larger patient cohort.