Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation

The Evolution of Minimally Invasive Spine Tumor Resection and Stabilization: From K-Wires to Navigated One-Step Screws

Minimization of the surgical approaches to spinal extradural metastases resection and stabilization was advocated by the 2012 Oncological Guidelines for Spinal Metastases Management. Minimally invasive approaches to spine oncology surgery (MISS) are continually advancing. This paper will describe the evolution of minimally invasive surgical techniques for the resection of metastatic spinal lesions and stabilization in a single institute. A retrospective analysis of patients who underwent minimally invasive extradural spinal metastases resection during the years 2013-2019 by a single surgeon was performed. Medical records, imaging studies, operative reports, rates of screw misplacement, operative time and estimated blood loss were reviewed. Detailed description of the surgical technique is provided. Of 138 patients operated for extradural spinal tumors during the study years, 19 patients were treated in a minimally invasive approach and met the inclusion criteria for this study. The mortality rate was significantly improved over the years with accordance of improve selection criteria to better prognosis patients. The surgical technique has evolved over the study years from fluoroscopy to intraoperative 3D imaging and navigation guidance and from k-wire screw insertion technique to one-step screws. Minimally invasive spinal tumor surgery is an evolving technique. The adoption of assistive devices such as intraoperative 3D imaging and one-step screw insertion systems was safe and efficient. Oncologic patients may particularly benefit from the minimization of surgical decompression and fusion in light of the frailty of this population and the mitigated postoperative outcomes associated with MIS oncological procedures.

Complete Endoscopic Resection of an Osteoid Osteoma in the Body of a Thoracic Vertebra: A Case Report

CASE

A 29-year-old man presented nontraumatic diffuse thoracic pain. Magnetic resonance imaging of the spine showed a cortical lesion with peripheral hyperintensity, a central sclerotic hypointense nidus, and surrounding paraspinal inflammatory changes at the T3 vertebral body. Clinical and radiologic findings were consistent with an osteoid osteoma. The patient successfully underwent an endoscopic partial corpectomy and mass resection. At the 6-month follow-up, radiographs showed complete tumor resolution.

CONCLUSION

Endoscopic resection is an adequate and minimally invasive technique for the complete resection of osteoid osteomas.

Less invasive O-arm navigation-guided excision of thoracic extraosseous intraforaminal osteoblastoma: A case report

Background:

Gross-total excision of spinal osteoblastomas remains challenging as they are typically found in close proximity to major neural and/or vascular structures. Here, we found that O-arm navigation allowed for safe/effective excision of a spinal osteoblastoma in a 29-year-old male.

Case Description:

A 29-year-old male presented neurologically intact with mid back pain of 8 months’ duration and 2 months of the left-sided chest wall discomfort. X-rays showed a sclerotic left D12 pedicle, while the MRI revealed an extradural lesion in extending into the left D11-12 neural foramen (i.e., hypointense on both T1- and T2-weighted images). The CT scan suggested a “floating” foraminal radiolucent lesion with surrounding vertebral body/posterior elements sclerosis and dense peripheral rim enhancement. These findings were diagnostic for an osteoblastoma. Utilizing O-arm navigation, the nidus and full extent of the lesion were excised (i.e., utilizing intralesional curettage). Two year’s postoperatively, there was no MR evidence of tumor recurrence.

Conclusion:

O-arm navigation provided accurate intraoperative localization to safely and fully excise a left D11– D12 spinal osteoblastoma.

Severe contracture in the lower extremity resulting from an osteoid osteoma of the lumbar spine in close proximity to neural elements in an adolescent: a case report

CASE

We report a rare case of a right-sided L4-5 facet osteoid osteoma in a 11-year-old female who presented with lower extremity pain, contractures, and gait disturbance in the setting of failed radiofrequency ablation. After open excision and single-level posterolateral fusion with instrumentation, her symptoms resolved and her spinopelvic parameters normalized.

CONCLUSIONS

This case highlights the contracture that may occur as a result of neurogenic pain from an osteoid osteoma in close proximity to neural structures.

Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series

BACKGROUND

Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches.

OBSERVATIONS

Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness.

LESSONS

In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.

Evaluation of an Ultrasound-Based Navigation System for Spine Neurosurgery: A Porcine Cadaver Study

BACKGROUND

With the growing incidence of patients receiving surgical treatment for spinal metastatic tumours, there is a need for developing cost-efficient and radiation-free alternatives for spinal interventions. In this paper, we evaluate the capabilities and limitations of an image-guided neurosurgery (IGNS) system that uses intraoperative ultrasound (iUS) imaging for guidance.

METHODS

Using a lumbosacral section of a porcine cadaver, we explored the impact of CT image resolution, ultrasound depth and ultrasound frequency on system accuracy, robustness and effectiveness. Preoperative CT images with an isotropic resolution of , and were acquired. During surgery, vertebrae L1 to L6 were exposed. For each vertebra, five iUS scans were acquired using two depth parameters (5 cm and 7 cm) and two frequencies (6 MHz and 12 MHz). A total of 120 acquisition trials were evaluated. Ultrasound-based registration performance is compared to the standard alignment procedure using intraoperative CT. We report target registration error (TRE) and computation time. In addition, the scans' trajectories were analyzed to identify vertebral regions that provide the most relevant features for the alignment.

RESULTS

For all acquisitions, the median TRE ranged from 1.42 mm to 1.58 mm and the overall computation time was 9.04 s ± 1.58 s. Fourteen out of 120 iUS acquisitions (11.66%) yielded a level-to-level mismatch (and these are included in the accuracy measurements reported). No significant effect on accuracy was found with CT resolution (F (2,10) = 1.70, p = 0.232), depth (F (1,5) = 0.22, p= 0.659) nor frequency (F (1,5) = 1.02, p = 0.359). While misalignment increases linearly with the distance from the imaged vertebra, accuracy was satisfactory for directly adjacent levels. A significant relationship was found between iUS scan coverage of laminae and articular processes, and accuracy.

CONCLUSION

Intraoperative ultrasound can be used for spine surgery neuronavigation. We demonstrated that the IGNS system yield acceptable accuracy and high efficiency compared to the standard CT-based navigation procedure. The flexibility of the iUS acquisitions can have repercussions on the system performance, which are not fully identified. Further investigation is needed to understand the relationship between iUS acquisition and alignment performance.

Video-assisted thoracoscopic image-guided spine surgery: evolution of 19 years of experience, from endoscopy to fully integrated 3D navigation

OBJECTIVE

The purpose of this study was to describe the evolution of thoracoscopic spine surgery from basic endoscopic procedures using fluoroscopy and anatomical localization through developmental iterations to the current technology use in which endoscopy and image-guided surgery are merged with intraoperative CT scanning.

METHODS

The authors provided detailed explanations of their thoracoscopic spine surgery techniques, beginning with their early-generation endoscopy with fluoroscopic localization, which was followed with point surface matching techniques and early image guidance. The authors supplanted this with the modern era of image guidance, thoracoscopic spine surgery, and seamless integration that has reached its current level of refinement.

RESULTS

A retrospective review of single-institution thoracoscopic procedures performed by the senior author over the course of 19 years yielded a total of 160 patients, including 73 women and 87 men. The mean patient age was 55 years, and the range included patients 16-94 years of age. There were no patients with worsened neurological function. One hundred sixteen patients underwent surgery for thoracic disc herniation, 18 for underlying neoplasms with spinal cord compression, 14 for osteomyelitis and discitis, 12 for thoracic deformity with neurological changes, and 8 for traumatic etiologies.

CONCLUSIONS

More than 19 years of experience has revealed the benefits of integrating thoracoscopic spine surgery with intraoperative CT scanning and image-guided surgery, including direct decompression without manipulation of neural elements, superior 3D spatial orientation, and localization of complex spinal anatomy. With the exponential growth of machine learning, robotics, artificial intelligence, and advances in imaging techniques and endoscopic imaging, there may be further refinements of this technique on the horizon.

Minimally Invasive Surgery Strategies: Changing the Treatment of Spine Tumors

Innovation in surgical technique and contemporary spinal instrumentation paired with intraoperative navigation/imaging concepts allows for safer and less-invasive surgical approaches. The combination of stereotactic body radiotherapy, contemporary surgical adjuncts, and less-invasive techniques serves to minimize blood loss, soft tissue injury, and length of hospital stay without compromising surgical efficacy, potentially enabling patients to begin adjuvant treatment sooner.

T1 Vertebra Pedicular Osteoid Osteoma: Minimally Invasive Surgical Resection Aided by New Integrated Navigation to 3D Imaging Device

We hereby describe a minimally invasive resection of a T1 pedicular osteoid osteoma next to the vertebral canal. The patient had an 18-month report of painful radiculopathy. We performed the surgery under 3D imaging guidance using navigation with an all-in-one device. Full procedure irradiation was 1.17 mSv for a 181-picture acquisition. Complete operative time incision to closure was 58 minutes. Despite sparing the vertebral stability without any fixation, the tumor resection was well-margined, thanks to the focused guidance. After surgery, the patient had complete relief of his symptoms at the 6-month follow-up. 3D imaging system coupled to navigation made the procedure safe without consuming time. The single Surgivisio® device allows comfortable 3D minimally invasive spine navigation surgery with the ergonomics of a C-arm.

Motion preservation surgery: excision of juxta C5-C6 intervertebral disc osteoid osteoma using 3D C-arm based navigation: technical report

INTRODUCTION

Precise targeted excision of the C5-C6 osteoid osteoma with placement of reference array on clavicle with minimal disturbance of anatomy and motion.

METHODS

A 20-year-old male presented with an osteoid osteoma in the superior end plate of the C6 vertebra abutting the spinal canal causing intractable pain. The authors curetted the nidus using a 3D C-arm-based intraoperative scan integrated with an optical navigation system through a minimal access anterior cervical exposure. The patient reference array was affixed to the left clavicle using a threaded pin.

RESULTS

The postoperative CT-scan revealed complete excision. Follow-up MRI and CT after 12 months revealed C5-C6 intervertebral disc to be intact without evidence of any tumor recurrence. VAS for neck pain improved from 8/10 to 2/10 immediately postoperatively and 0/10 at 1 year follow-up with no limitation of cervical movement. A motion segment was preserved with this technique.

CONCLUSIONS

Navigation allowed safe curettage of the nidus with minimal disturbance to the anatomy and motion. The site of attachment of patient reference array on clavicle can be recommended as stable, meeting all the criteria for optimal accuracy and stability.

Surgical resection of osteoid osteoma and osteoblastoma of the spine

Intraoperative radiographic guidance has traditionally been utilized in orthopedic surgery through 2-D navigation with the C-arm and recently with 3-D navigation with the O-arm. The aim of this study was to describe the outcome of surgical treatment of spinal osteoblastoma and osteoid osteoma with the utilization of the O-arm and conventional C-arm guidance. This is a retrospective cohort study of patients with spinal osteoid osteoma and or osteoblastoma who were treated at our institution between 2002 and 2011. Seventeen patients were examined in this study including seven with spinal osteoblastoma and 10 with spinal osteoid osteoma. The mean age of the patients at surgery was 11.5±3.9 years. The O-arm was used in seven patients and the C-arm in 10 patients. The C-arm failed to identify the tumor in one case and needed transport to perform a computed tomographic-scan. The length of surgery was shorter when the O-arm was used, especially in the osteoblastoma group. Thirteen patients were pain free at the last follow-up visit and two patients developed recurrence. Radiographs at the last follow-up did not show signs of vertebral instability following tumor resection. Safe and effective localization of spine tumors and confirmation of tumor removal during surgery was achieved by intraoperative radiographic guidance specifically with the O-arm 3-D navigation system.

LEVEL OF EVIDENCE

III.

Anterior Impingement Syndrome of the Ankle Caused by Osteoid Osteoma in the Talar Neck Treated with Arthroscopy and 3D C-Arm-Based Imaging

Osteoid osteoma in periarticular lesions tends to have an unusual presentation that likely leads to a delayed or missed diagnosis compared with a typical osteoid osteoma in the metaphysis or diaphysis of the long bone. In cases that are unresponsive to conservative treatment, surgical interventions including en bloc resection, computed tomography-guided percutaneous treatment, and arthroscopic resection have been performed; however, these methods frequently result in inadequate tumor resection and recurrence. Here we present a case of a 16-year-old girl with osteoid osteoma in the talar neck presenting as anterior impingement syndrome due to marked synovitis in the ankle joint which was successfully treated without complications by arthroscopic synovectomy and tumor resection followed by intraoperative 3D C-arm-based imaging confirming complete tumor lesion removal. Her pain was relieved immediately after the surgery, and there was no recurrence at 12 months of follow-up. This is the first case report of the surgical treatment of the osteoid osteoma in the talar neck with the combination methods of arthroscopy and 3D C-arm-based imaging.

Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis

OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14-87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62-865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5-7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1-36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

"Advances in the surgical management of bone tumors"

Bone tumor surgery is extremely challenging, particularly when tumors are located in tightly confined anatomical areas and abutting critical organs and neurovascular structures. Tumor resection requires good cutting accuracy to ensure safety, to achieve negative margins, and to preserve critical structures when possible. The purpose of this paper was to review the literature on the surgical advances for bone tumor surgery published within the last year. The majority of literature identified focused on computer-assisted surgical approaches. There is increasing evidence that 3D navigation plays an important role in the resection of bone tumors. Reconstruction materials that encourage healing and prevent infections are also in development. Optimal care includes execution of a well-developed pre-operative plan using a multidisciplinary approach led by the orthopaedic oncologist.

[Factors affecting the outcome of surgical management for extramedullary spinal cord tumors: a multicenter study]

Extramedullary spinal cord tumors (ESCTs) are relatively rare neoplasms requiring surgical treatment. This paper presents a study of outcomes in patients with ESCTs treated at Irkutsk region hospitals with different facilities.

AIM

To identify factors affecting the outcome of surgical treatment of ESCTs.

MATERIAL AND METHODS

The disease stage before surgery was evaluated according to the I.Ya. Razdol'skiy and McCormick classifications. Features and extension of the approach, the extent of blood loss, surgery duration, and the equipment used were analyzed. Treatment outcomes were assessed according to the MacNub and McCormick neurological outcome scales.

RESULTS

ESCTs were removed totally in 84 (95%) patients and subtotally in 4 (5%). Tumor recurrence was detected in 8 patients. No deaths were observed. No correlation was found between the treatment outcome, according to the McCormick scale, and factors such as gender, tumor location, histological type, tumor grade, disease duration, and type of a surgical approach and the equipment used. Factors having medium and high correlations with the disease outcome are a neurological disease phase and an initial neurological deficit: sensory deficit, r=0.32; motor deficit, r=0.33; pelvic disturbances, r=0.35; McCormick grade before surgery, r=0.74; disease phase r=0.41 (p<0.05).

CONCLUSION

The disease phase is the most significant factor affecting the outcome of surgical treatment in patients with ESCTs. Despite this, important aspects of surgical treatment of ESCT include the approach that is adequate to the tumor size and localization, as well as combination of different surgical techniques.

Posterior internal fixation plus vertebral bone implantation under navigational aid for thoracolumbar fracture treatment

The aim of this study was to investigate the method of posterior thoracolumbar vertebral pedicle screw reduction and fixation combined with vertebral bone implantation via the affected vertebral body under navigational aid for the treatment of thoracolumbar fractures. The efficacy of the procedure was also measured. Between June 2005 and March 2011, posterior thoracolumbar vertebral pedicle screw reduction and fixation plus artificial bone implantation via the affected vertebral pedicle under navigational aid was used to treat 30 patients with thoracolumbar fractures, including 18 males and 12 females, ranging in age from 21 to 57 years. Compared with the values prior to surgery, intraspinal occupation, vertebral height ratio and Cobb angle at the follow-up were significantly improved. At the long-term follow-up, the postoperative Cobb angle loss was <1° and the anterior vertebral body height loss was <2 mm. Posterior thoracolumbar vertebral pedicle screw reduction and fixation combined with vertebral bone implantation via the affected vertebral body under navigational aid may increase the accuracy and safety of surgery, and it is an ideal method of internal implantation. Bone implantation via the affected vertebral body may increase vertebral stability.