Two-stage multilevel en bloc spondylectomy with resection and replacement of the aorta

En-bloc resection of a chordoma in L3 by a combined open posterior and less invasive retroperitoneal approach: technical description and case report

INTRODUCTION

To fulfill oncological criteria, extensive open anterior and posterior approaches are usually performed in the lumbar spine to obtain an appropriate en-bloc spondylectomy. It is commonly accepted that the price of a tumor-free margin includes such extensive incisions and soft-tissue damage, with consequent relevant blood loss and possible postoperative complications as delayed wound healing. In this article, a case of chordoma in L3 is presented, submitted to an oncologically appropriate en-bloc resection performed by an open posterior approach combined with a mini-retroperitoneal approach. The successful oncologic procedure was combined with a short and uneventful postoperative course.

MATERIALS AND METHODS

The authors present the surgical technique and the possible challenges of minimally invasive anterior oncologic surgery as a contribution to a limited literature.

RESULTS

Up to date, palliative care of single metastases has been the main setting in which anterior, minimally invasive surgery has been performed in the lumbar spine. The authors explained how, in selected cases, this approach can be performed in combination with an open posterior access for an oncologically appropriate treatment of a primary malignant tumor.

CONCLUSION

Anterior, minimally invasive surgery can have a role in selected patients with primary malignant tumors of the lumbar spine. The surgical team should have extensive training both in oncologic and minimally invasive surgery.

Interdisciplinary Surgical Treatments and Long-Term Outcomes of Lumbar Spinal Tumors With Retroperitoneal Involvements: A Retrospective Case Series Study

Purpose

Surgical treatments are technically challenging for lumbar spinal tumor (LST) with extensive retroperitoneal involvements. Our study aimed to report the experience and outcomes concerning interdisciplinary surgical collaborations in managing such LSTs.

Patients and Methods

Nine patients underwent interdisciplinary surgical treatments which were performed by specialists, namely, spinal, vascular, and urinary surgeries. Data on clinical characteristics were collected, and the Visual Analogue Scale (VAS) and the Japanese Orthopaedic Association Score (JOAS) were used in the evaluation before and after surgery. The postoperative complications and the long-term outcomes were reported as well.

Results

The interdisciplinary work included double J catheter indwelling (n = 9), nephrostomy (n = 5), replacement of the common iliac vein (n = 2), abdominal aorta repair (n = 3), and vital vessel repair (n = 8). The early-stage complications included complaints of moderate low back pain and slight implant shift (n = 1, 11.1%) and tardive ureterodialysis (n = 1, 11.1%). The 3- and 5-year disease-free survival rates were 76.2 ± 14.8 and 50.8 ± 23.0%, respectively, during the mean follow-up of 34.6 ± 17.9 months (range, 9.5–68.7). Besides this, more blood loss was associated with recurrent and metastatic tumor status (p = 0.043) and surgery time >5 h (p = 0.023). Remarkable pain relief and favorable quality of life were achieved based on the postoperative VAS (3.3 ± 0.9, p < 0.001) and JOAS (16.6 ± 0.5, p < 0.001).

Conclusions

The treatments of LSTs with wide-range retroperitoneal involvements require interdisciplinary surgical collaborations to lower the risks and improve the long-term outcomes. High-quality prospective cohort studies with large samples are warranted to establish general surgical protocols in managing LSTs with extensive retroperitoneal involvements.

Primary osseous chondrosarcoma in the lumbar spine: case report and literature review with analysis

Primary spinal chondrosarcoma (CS) is rare. Only a few previous case reports have included a detailed description of the surgical process used to treat the CS. In addition, a paucity of documentation exists comparing differences in the outcomes between the approaches in en bloc resection. Here, we present a case of CS in the lumbar (L) spine treated with two-stage (anterior and posterior approach) en bloc surgery and analyze the differences between one-stage and two-stage approaches in the treatment of primary lumbar CS. A 30-year-old male patient with an L3 vertebral body CS presented with back pain and lower limb weakness. Lumbar spine magnetic resonance imaging (MRI) showed an L3 vertebral body tumor with cord and root compression. Two-stage surgery comprising posterior total laminectomy and transpedicular screw fixation over L2–L4 in the first stage, with subsequent anterior corpectomy, cage implantation, and anterior lumbar interbody fusion was performed to achieve total tumor removal and stabilization. The patient’s symptoms improved postoperatively, with no recurrence as of the 2-year follow-up. The analysis of previous similar cases showed that two-stage surgery, compared with one-stage surgery, appears to be beneficial in lumbar spine multisegment disease, providing a lower recurrence rate.

Multi-Step Combined Upfront Surgery for Locally Advanced Paravertebral Sarcoma: A Case Report

Background: Paravertebral localization of primary undifferentiated pleomorphic sarcoma (UPS) with bone and vascular involvement is infrequent and challenging. Multi-step surgical procedure has been described as a feasible and effective option to achieve sustained local tumor control.

Methods: We report on a 62-year old man with paravertebral UPS infiltrating the aortic wall and the 9th thoracic vertebra who underwent a multi-step surgical procedure aimed at achieving oncologic radicality through a coordinated effort between thoracic, vascular and spinal surgeons. After balancing the risks and benefits of perioperative therapies, upfront surgery was performed including aortic resection with bypass grafting followed by a triple en bloc vertebrectomy with tumor excision. Mid-term follow-up (22 months) is then provided.

Results: The combined procedure achieved oncological radicality and no local recurrence in the mid-term. No major complications occurred.

Conclusions: Multi-step and multi-specialty surgery is a feasible and effective strategy to treat primary UPS in unfavorable localization. A strategic cooperation between surgeons and a multidisciplinary tumor board is required to define an optimal, personalized treatment strategy in sarcoma patients.

Function Preservation or Oncological Appropriateness in Spinal Bone Tumors?: A Case Series of Segmental Resection of the Spinal Canal Content (Spinal Amputation)

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To evaluate (1) if the segmental resection of the content of the spinal canal could provide an Enneking appropriate tumor-free margin for local control of primary bone tumors surrounding and invading the canal and (2) the safety profile of the segmental resection of the neurostructures.

SUMMARY OF BACKGROUND DATA

Treatment outcomes of primary malignant and benign aggressive bone tumors of the spine have been dramatically changed by the application of the musculoskeletal oncologic principles described by Enneking. However, the efficacy of spinal oncology surgery might be limited by unique features of spinal anatomy.

METHODS

Database search was conducted with the following inclusion criteria: en bloc resection, segmental inclusion of the spinal canal content in the surgical specimen, histologically proven diagnosis, minimum follow-up of 2 years. Exclusion criteria were piecemeal excision of the tumor (debulking) and diagnosis other than primary bone tumors (metastasis, or local extension of extraosseous tumors).

RESULTS

A consecutive cohort of eight patients (three men, five women) was available for review. Two patients died within 3 months from the surgery for systemic disease progression or sequelae of the surgery. En bloc resection with segmental spinal canal content inclusion was able to achieve local control of the disease in four out of remaining six cases (66.7%) at an average follow-up of 68.7 months (range 12-174 mo). Three patients in whom local control was achieved are free from disease at an average follow-up of 98.7 months (range 38-174), and one died for systemic disease progression (after 38 mo). Seven out of 8 patients (87.5%) experienced overall 16 complications.

CONCLUSION

En bloc resection including the spinal canal content (spinal amputation) to achieve a tumor-free margin might be considered to perform an Enneking appropriate treatment for motivated patients.

LEVEL OF EVIDENCE

4.

Revision surgery for tumors of the thoracic and lumbar spine: causes, prevention, and treatment strategy

INTRODUCTION

Revision surgery in spine tumor surgery can offer peculiar challenges given the severity of the majority of these lesions and the complexity of surgical procedures that are required.

MATERIALS AND METHODS AND RESULTS

Based on literature review and on personal experience, surgical site infection, cerebrospinal fluid leakage, tumor recurrence and hardware failures are some of the possible causes of surgical revision in this set of patients.

CONCLUSIONS

The aim of this study is to evaluate the most frequent complications that can lead to revision in spine tumor patients, to provide suggestions on how to prevent these events and to offer reasonable strategies to properly plan and perform a revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

Revision strategy and follow-up for implant failure in a case of combined anterior and posterior reconstruction after three-level en bloc vertebral body replacement and replacement of the aorta for chondrosarcoma of the thoracic spine

OBJECTIVE

In 2013, we reported a case of combined anterior and posterior reconstruction after three-level en bloc vertebral body replacement and replacement of the aorta for chondrosarcoma of the thoracic spine. Eight years after, we observed an implant failure and now report on revision strategy and 2-year follow-up (f/u) after revision.

METHODS

We report about the 2-year f/u of the same now 51-year-old gravedigger who needed to undergo revision surgery after implant failure. We did a combined anterior and posterior correction vertebral interbody fusion by (1) removal of broken screws in Th9 and L2, removal of broken titanium bars, correction of kyphosis, enhancement of the vertebral interbody fusion from Th8 to L4 using monoaxial titanium screws and cancellous bone transplantation and (2) removal of the broken plate and the loose cage, implantation of a novel expandable PEEK cage from Th11 to L1 and anterior stabilization from Th9/10 to L2/3, as well as autologous and allogeneic cancellous bone transplantation.

RESULTS

Two years after revision surgery, the patient presented fully reintegrated without any complains. No painkillers needed to be taken. Pain was reported with 2 out of 10 on the VAS.

CONCLUSION

Both procedures offer a good primary stabilization with excellent pain reduction and good return to life. Limited information on long-term survivors is known. Therefore, the theoretical advantage of a biological solution needs to be checked in the long-term f/u for consistency.

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.

En bloc spondylectomy for primary malignant fibrous histiocytoma of the thoracic spine with aortic involvement: case report

In this article, the authors describe a 48-year-old man who initially presented with progressively worsening back pain. Magnetic resonance imaging revealed a soft-tissue mass involving the T10-11 vertebral bodies with extension anteriorly into the aorta as well as epidural extension without spinal cord compression. A biopsy of the mass showed findings consistent with a malignant fibrous histiocytoma (MFH). A total en bloc spondylectomy with resection and reconstruction of the involved aorta using a vascular graft was performed. The patient received postoperative radiation therapy and is neurologically intact at 18 months postoperatively. To the authors' knowledge, this is the first reported case of a spinal MFH resection with aortic reconstruction.