Epidemiology and Demographics for Primary Vertebral Tumors

Outcomes After Definitive Surgery for Spinal and Sacral Chordoma in 101 Patients Over 20 Years

BACKGROUND AND OBJECTIVES

Spinal chordomas are primary bone tumors where surgery remains the primary treatment. However, their low incidence, lack of evidence, and late disease presentation make them challenging to manage. Here, we report the postoperative outcomes of a large cohort of patients after surgical resection, investigate predictors for overall survival (OS) and local recurrence-free survival (LRFS) times, and trend functional outcomes over multiple time periods.

METHODS

Retrospective review of all patients followed for spinal chordoma at a quaternary spinal oncology center from 2003 to 2023 was included. Data were collected regarding demographics, preoperative and perioperative management, and follow-up since initial definitive surgery. Primary outcomes were OS and LRFS, whereas secondary outcomes were functional deficits.

RESULTS

One hundred one patients had an average follow-up of 6.0 ± 4.2 years. At the time of census, 25/101 (24.8%) had experienced a recurrence and 10/101 (9.9%) had died. After surgery, patients experienced a significant decrease in pain over time, but rates of sensory deficits, weakness, and bowel/bladder dysfunction remained static. Tumors ≥100 cm3 (hazard ratio (HR) = 5.89, 95% CI 1.72-20.18, P = .005) and mobile spine chordomas (HR = 7.73, 95% CI 2.09-28.59, P = .002) are related to worse LRFS, whereas having neoadjuvant radiotherapy is associated with improved LRFS (HR = 0.09, 95% CI 0.01-0.88, P = .038). On the other hand, being age ≥65 years was associated with decreased OS (HR = 16.70, 95% CI 1.54-181.28, P = .021).

CONCLUSION

Surgeons must often weigh the pros and cons of en bloc resection and sacrificing important but affected native tissues. Our findings can provide a benchmark for counseling patients with spinal chordoma. Tumors ≥100 cm3 appear to have a 5.89-times higher risk of recurrence, mobile spine chordomas have a 7.73 times higher risk, and neoadjuvant radiotherapy confers an 11.1 times lower risk for local recurrence. Patients age ≥65 years at surgery have a 16.70 times higher risk of mortality than those <65 years.

Robotic assisted surgery for the treatment of spinal metastases: A case series

OBJECTIVE

Spinal metastases can significantly affect quality of life in patients with cancer and present complex neurosurgical challenges for surgeons. Surgery with instrumentation is often indicated to alleviate pain, preserve neurological function, and ensure mechanical stability. However, distortions in the bony anatomy due to oncological disease can decrease the accuracy of pedicle screw placement. Robotic-assisted surgery may offer an opportunity to increase screw accuracy and improve navigation of spinal lesions compared to conventional techniques. Therefore, we presented our institutional experience evaluating robotic-assisted surgical fixation for spinal metastases.

METHODS

Patients undergoing robotic-assisted surgery at a large tertiary care center between January 2019 - January 2023 for the treatment of spinal metastases were identified. Patient characteristics, including demographics, tumor pathology, surgical complications, and post-operative outcomes were extracted. The Gertzbein Robbins classification system (GRS) was used to assess pedicle screw placement accuracy in patients with post-operative computed tomography.

RESULTS

Twenty patients were identified, including 7 females (35 %), with an overall median age of 66 years (range: 39-80 years) and median BMI of 25 kg/m2 (range: 17-34 kg/m2). An average of four spinal levels were instrumented, with metastases located primarily in the thoracic (n=17, 85 %) spine. Common primary tumor types included prostate (n=4), lung (n=2), and plasma cell (n=2) cancers. Most pedicle screws (92 %) were classified as GRS A in patients with postoperative imaging. Post-operative complications were unrelated to the use of the robot, and included pulmonary embolism (n=1), deep vein thrombosis (n=2), and gastric symptoms (n=3). Three patients were readmitted at 30 days, with one reoperation due to tumor recurrence. Four patients were deceased within 6 months of surgery.

CONCLUSIONS

Despite the inherent high-risk nature of these surgeries, this study underscores the safety and efficacy of robotic-assisted surgery in the management of spinal metastases. Robots can be helpful in ensuring accuracy of pedicle screw placement in patients with metastatic disease.

Epidemiology of Surgically Treated Spinal Tumors: A Multicenter Surveillance Study of 9686 Patients from the German Spine Registry (DWG Register)

Tumors of the spine are challenging in terms of diagnoses and interdisciplinary treatment. This study was conducted to evaluate and characterize a large multicenter cohort of surgically treated spine tumor patients.Data of the German Spine Society (DWG) were used to characterize a cohort of all surgically treated spine tumor cases that were registered between 2017 and 2021. Subgroup analysis was performed for tumor entity, tumor localization, height of most severely affected segments, surgical treatment, and demographic parameters.In total, there were 9686 cases, of which 6747 were "malignant", 1942 were "primary benign", 180 were "tumor-like lesions", and 488 were "other" spinal tumors. Subgroups showed differences in number of affected segments as well as localization. There were further significant differences in surgical complication rates (p = 0.003), age (p < 0.001), morbidity (p < 0.001), and duration of surgery (p = 0.004).This is a representative study on spinal tumors from a large spine registry and allows for the epidemiological characterization of surgically treated tumor subgroups and quality control of registry data.

Is 3D-printed self-stabilizing endoprosthesis reconstruction without supplemental fixation following total sacrectomy a viable approach for sacral tumours?

PURPOSE

The spinopelvic reconstruction poses significant challenges following total sacrectomy in patients with malignant or aggressive benign bone tumours encompassing the entire sacrum. In this study, we aim to assess the functional outcomes and complications of an integrated 3D-printed sacral endoprostheses featuring a self-stabilizing design, eliminating the requirement for supplemental fixation.

METHODS

We retrospectively analyzed patients with sacral tumours who underwent total sacrectomy followed by reconstruction with 3D-printed self-stabilizing endoprosthesis. Clinically, we evaluated functional outcomes using the 1993 version of the musculoskeletal tumour society (MSTS-93) score. Perioperative and postoperative complications were also documented.

RESULTS

10 patients met final inclusion criteria. The median age was 49 years (range, 31-64 years). The median follow-up time was 26.5 months (range, 15-47 months). Median postoperative functional MSTS-93 was 22.5 (range, 13-25). The median operation time was 399.5 min (305-576 min), and the median intraoperative blood loss was and 3200 ml (2400-7800 ml). Complications include wound dehiscence in one patient, bowel, bladder, and sexual dysfunction in four patients, cerebrospinal fluid leak in one patient, and tumour recurrence in one patient. There were no mechanical complications related to the endoprosthesis at the last follow-up.

CONCLUSION

The utilization of 3D-printed self-stabilizing endoprosthesis proved to be a viable approach, yielding satisfactory short-term outcomes in patients undergoing total sacral reconstruction without supplemental fixation.

Surgical management of tumors of the cervical spine and craniovertebral junction involving the vertebral artery: A narrative review

BACKGROUND

The vertebral artery (VA) is in close proximity to bony structures, nerves and nerve sheaths of the cervical spine and craniovertebral junction (CVJ). These structures can be sources of tumors that are responsible for displacement, encasement and sometimes invasion of the VA. Removing these tumors while minimizing the risk of vascular injury requires thorough knowledge of the vascular anatomy, risk factors of vascular injury, the relationships of each tumor type with the VA, and the different surgical approaches and techniques that result in the best outcomes in terms of vascular control, tumoral exposure and resection.

OBJECTIVE

To present an overview of preoperative and anatomical considerations, differential diagnoses and various approaches to consider in cases of tumors in close relationship with the VA.

METHOD

A review of recent literature was conducted to examine the anatomy of the VA, the tumors most frequently affecting it, surgical approaches, and the necessary pre-operative preparations for ensuring safe and maximal tumor resection. This review aims to underscore the principles of treatment.

CONCLUSION

Tumors located at the CVJ and the cervical spine intimately involved with the VA, pose a surgical challenge and increase the risk of incomplete removal of the lesion. Detailed knowledge of the patient-specific anatomy and a targeted pre-operative work-up enable optimal planning of surgical approach and management of the VA, thereby reducing surgical risks and improving extent of resection.

Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review

Nontraumatic pathologic conditions of the craniovertebral junction encompass a range of conditions affecting the complex anatomy of this region without direct physical injury. These conditions include congenital syndromes that predispose individuals to ligamentous laxity, potentially leading to instability. Additionally, rare but noteworthy cases such as Grisel syndrome, a cause of pediatric torticollis, may arise without a traumatic trigger. Inflammatory diseases, including rheumatoid arthritis, ankylosing spondylitis, and crystal deposition, can lead to cervical instability and spinal cord compression. Infections at the upper cervical spine are dominated by tuberculosis, typically transmitted through hematologic or lymphatic routes with characteristic imaging findings. On the other hand, purulent bacterial infections in this area are rare. Furthermore, although tumors involving the structures of the craniovertebral junction are infrequent, they can lead to significant complications, albeit less frequently through cord compression and more commonly via pathologic fractures or subluxation. The craniocervical junction is a complex anatomic region comprising ligaments, bones, joints, and muscles that support the head's weight and enable its wide range of motion. Accurate recognition and understanding of the complex anatomy and the various nontraumatic pathologic conditions at the craniovertebral junction are pivotal for initiating timely and appropriate treatment strategies. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Understanding a mass in the paraspinal region: an anatomical approach

The paraspinal region encompasses all tissues around the spine. The regional anatomy is complex and includes the paraspinal muscles, spinal nerves, sympathetic chains, Batson's venous plexus and a rich arterial network. A wide variety of pathologies can occur in the paraspinal region, originating either from paraspinal soft tissues or the vertebral column. The most common paraspinal benign neoplasms include lipomas, fibroblastic tumours and benign peripheral nerve sheath tumours. Tumour-like masses such as haematomas, extramedullary haematopoiesis or abscesses should be considered in patients with suggestive medical histories. Malignant neoplasms are less frequent than benign processes and include liposarcomas and undifferentiated sarcomas. Secondary and primary spinal tumours may present as midline expansile soft tissue masses invading the adjacent paraspinal region. Knowledge of the anatomy of the paraspinal region is of major importance since it allows understanding of the complex locoregional tumour spread that can occur via many adipose corridors, haematogenous pathways and direct contact. Paraspinal tumours can extend into other anatomical regions, such as the retroperitoneum, pleura, posterior mediastinum, intercostal space or extradural neural axis compartment. Imaging plays a crucial role in formulating a hypothesis regarding the aetiology of the mass and tumour staging, which informs preoperative planning. Understanding the complex relationship between the different elements and the imaging features of common paraspinal masses is fundamental to achieving a correct diagnosis and adequate patient management. This review gives an overview of the anatomy of the paraspinal region and describes imaging features of the main tumours and tumour-like lesions that occur in the region.

Applications of Carbon Fiber Instrumentation in Spinal Oncology: Recent Innovations in Spinal Instrumentation and 2-Dimensional Illustrative Operative Video

BACKGROUND

The management of spinal oncology necessitates a multimodal approach, with surgical intervention, radiation-based therapy, and postoperative advanced imaging. These systems must work well together to provide optimal patient outcomes. Traditional metallic spinal implants produce image artifacts and lead to radiation dose attenuation, which inhibit both disease monitoring and disease treatment, respectively.

OBJECTIVE

To demonstrate the feasibility of an improved biomaterial implant that provides structural stability, while also allowing for disease monitoring and treatment in spinal oncology patients.

METHODS

From February 2021 to September 2021, 3 patients with spinal oncologic deformity requiring resection and posterior spinal stabilization underwent fixation with polyether ether ketone-carbon fiber implants at a single academic institution.

RESULTS

Patient ages ranged from 23 to 74 years (mean: 44.7 years). All patients underwent posterior spinal fixation using standard approaches. They each received polyether ether ketone-carbon fiber pedicle screw and rod implants, placed in standard fashion. There were no dural tears, postoperative wound infections, or other complications related to their treatment. Postoperative surveillance revealed gross total resection of the targeted tumor on postoperative radiographic imaging.

CONCLUSION

Polyether ether ketone-carbon fiber implants are a safe and effective option for the treatment of thoracolumbar posterior spinal pathology. The utilization of this novel type of instrumentation in posterior spinal approaches may provide benefit to patients with spinal tumors over existing forms of posterior spinal instrumentation.

In Vertebral Hemangiomas with Neurological Deficit, Is a Less Extensive Approach Adequate

STUDY DESIGN

This was a retrospective study.

PURPOSE

To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate.

OVERVIEW OF LITERATURE

AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients.

METHODS

Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein-Boriani-Biagini classifications and Spinal Instability Neoplastic Score. At followup, neurological and radiological evaluations were performed.

RESULTS

Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14-72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11- L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24-96 months).

CONCLUSIONS

In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.

Medium to long term follow-up of survival and quality of life in patients with primary tumors of the cervical spine: Experience From a large single center

Objectives

To evaluate the survival and medium to long term health-related quality of life (HRQoL) of patients with primary cervical spinal tumors in a cross-sectional study and to identify any significant associations with demographic or clinical characteristics.

Methods

Patients diagnosed with primary cervical spinal tumors were retrospectively enrolled and their clinical, radiologic, and follow-up data (specifically the EQ-5D questionnaire) were collected. Univariate and multivariate Cox time-dependent regression analyses were performed to examine the significance of certain variables on overall survival. Univariate and multivariate logistic regression analyses were conducted to identify variables significant for overall HRQoL and each dimension of the EQ-5D.

Results

A total of 341 patients were enrolled in the study with a mean follow-up of 70 months. The diagnosis was benign in 246 cases, malignant in 84, and unconfirmed in 11. The 5-year overall survival rate was 86% and the 10-year overall survival rate was 65%. Multivariate analysis suggested that surgical treatment (P = 0.002, hazard ratio [HR] = 0.431, 95% CI. [0.254, 0.729]), benign and malignant tumors [P < 0.001, HR = 2.788, 95% CI. (1.721, 4.516)], tumor and surrounding normal tissue boundary [P = 0.010, HR = 1.950, 95% CI. (1.171, 3.249)], and spinal instability [P = 0.031, HR = 1.731, 95% CI. (1.051, 2.851)] still had significant effects on survival.

Conclusions

In this cross-sectional study, we evaluated the survival period and medium and long-term health-related quality of life of patients with primary tumors of the cervical spine, and analyzed the significant related factors of tumor clinical characteristics. Surgery, myelopathy, malignancy, spinal pain relieved by lying down or supine position, and tumor infiltration on MRI were significant predictors for overall survival. Enneking stage and age were significant predictors for HRQoL.

Augmented Reality Neuronavigation for En Bloc Resection of Spinal Column Lesions

BACKGROUND

Primary tumors involving the spine are relatively rare but represent surgically challenging procedures with high patient morbidity. En bloc resection of these tumors necessitates large exposures, wide tumor margins, and poses risks to functionally relevant anatomical structures. Augmented reality neuronavigation (ARNV) represents a paradigm shift in neuronavigation, allowing on-demand visualization of 3D navigation data in real-time directly in line with the operative field.

METHODS

Here, we describe the first application of ARNV to perform distal sacrococcygectomies for the en bloc removal of sacral and retrorectal lesions involving the coccyx in 2 patients, as well as a thoracic 9-11 laminectomy with costotransversectomy for en bloc removal of a schwannoma in a third patient.

RESULTS

In our experience, ARNV allowed our teams to minimize the length of the incision, reduce the extent of bony resection, and enhanced visualization of critical adjacent anatomy. All tumors were resected en bloc, and the patients recovered well postoperatively, with no known complications. Pathologic analysis confirmed the en bloc removal of these lesions with negative margins.

CONCLUSIONS

We conclude that ARNV is an effective strategy for the precise, en bloc removal of spinal lesions including both sacrococcygeal tumors involving the retrorectal space and thoracic schwannomas.

A Case Report of a Sacral Giant Cell Tumor Treated With Block Resection and Lumbo-Pelvic Fixation

Giant cell tumors (GCT) are benign but locally aggressive neoplasms composed of osteoclast-like giant cells and fusiform to ovoid mononuclear stromal cells. GCT generally comprise 5-10% of all benign bone tumors; they appear most frequently between the second and third decades of life. These tumors are also distributed throughout the vertebral column. Approximately half of all spinal GTCs develop in the sacrum. Many cases remain clinically silent and are discovered incidentally during the study of minor trauma. Symptomatic tumors often mimic other common spinal pathologies. Imaging studies ideal for diagnosis are CT and MRI. The techniques used in the treatment of giant cell tumors are curettage or intralesional surgery, block resection, radiotherapy, and chemotherapy. Herein, we report on a 23-year-old female patient diagnosed with a tumoral mass in the anterior part of the sacrum, suggestive of GCT. The lesion was completely excised in two consecutive surgeries, and lumbopelvic fixation was performed with favorable immediate postoperative results. Careful surgical planning with a multi-disciplinary approach leading to block resection still remains the most viable option for the treatment of vertebral GCT.

Holistic Approach to the Diagnosis and Treatment of Patients with Tumor Metastases to the Spine

The treatment of neoplastic spine metastases requires multi-faceted assessment and an interdisciplinary approach to patients. The metastases do not show specific symptoms but are often the first confirmation of the presence of a primary tumor in a patient. The diagnostic process includes imaging and invasive procedures, e.g., biopsy. It is essential to qualify the patient for an appropriate treatment using dedicated scales. Decompression of the spinal cord is a critical issue to save or restore neurological function in a patient with spine metastases. Surgical treatment ought to meet three criteria: release spinal cord and nerve roots, restore the spine’s anatomical relations, and ensure the internal stabilization of the spine. A good result from surgical treatment enables the continuation of radiotherapy, chemotherapy, hormone therapy, and targeted molecular therapy. Stereotactic radiosurgery and stereotactic body radiotherapy are more effective ways of treating spine metastases than conventional external beam radiotherapy. They allow higher doses of radiation, concentrated precisely at the tumor site. Our review summarizes the established and emerging concepts in the treatment of spine metastases. A holistic approach to the patient enables the selection of the appropriate therapy.

PROFILE OF PATIENTS WITH SPINE TUMOR OPERATED IN A SOUTH AMERICAN REFERENCE SERVICE. EPIDEMIOLOGICAL STUDY

ABSTRACT Objective: The objective was to conduct an analytical epidemiological study to understand the profile, treatment, and outcome of patients with spinal tumors in a Brazilian Quaternary Hospital of the SUS. Methods: A retrospective cohort analysis of data from the last five years was performed. It was described qualitative characteristics evaluated by absolute and relative frequencies and quantitative characteristics by sintetized measures. Associations between characteristics were verified using chi-square tests or exact tests. Results: 92 patients met the eligibility criteria. The mean age was 56.1 years (±14.7), with 48 men (52.2%) and 44 women (47.8%). The types of tumors organized in the three proposed groups had 19 multiple myelomas (20.7%), 62 metastases (67.3%), and 11 other tumors (12%). The neurological status measured through the ASIA score was A: 5.4%, B: 22.8%, C: 26.1%, D: 35.9%, E: 9.8%. Karnofsky was prevalent in the 50-70 range with 65.2%. The total hospitalization period had a mean of 22.8±18 days, preoperatively 11.9±9.2 days, and postoperatively 10.9±14 days. Karnofsky presented lower values according to the worst ASIA (p < 0.001). A total of 12 patients (13%) died during hospitalization. The total and postoperative length of stay was longer in patients who died (p = 0.002 and p < 0.001). Conclusions: This study provides epidemiological data that allow an understanding of the profile of patients with spinal tumors in the Brazilian Public Health System. The severity of the patients is higher when compared to most of the series cases in the literature. The patients with longer hospitalization stay died. Level of evidence IV; Case series.

Nerve preservation during partial sacrectomy by two-stage anterior and posterior approach: illustrative case

BACKGROUND

Preserving the neurological function of sacral nerves during total or partial sacrectomy is challenging.

OBSERVATIONS

The authors describe a case of an osseous desmoplastic fibroma of the sacrum in a 51-year-old woman. The patient attended the authors’ institution with loss of muscle strength and sensitivity impairment in both legs, gait instability, bowel constipation, urinary incontinence, and weight loss. Preoperative magnetic resonance imaging and positron emission tomography/computed tomography showed intrapelvic and posterior extension of the tumor but sparing of S1 and the sacroiliac and lumbosacral joints. After a multidisciplinary discussion of the case, a staged anterior–posterior approach to the sacrum was chosen. The abdominal approach allowed full mobilization of the uterus, ovaries, bladder, and colon and protection of iliac vessels. After tumor resection, a synthetic surgical mesh was placed over the sacrum to minimize soft tissue defects. Then, the posterior stage allowed the authors to perform a bicortical osteotomy, achieving wide tumor excision with minimal nerve root injury. Spinopelvic fixation was not necessary, because both sacroiliac and lumbosacral joints remained intact. A few days after the surgery, the patient restarted ambulation and recovered sphincter control.

LESSONS

Multidisciplinary planning and a staged abdominal and posterior approach for partial sacrectomy were fundamental to preserve neurological function in this case.

Aggressive L3 vertebral hemangioma coexisting with adult thoracolumbar scoliosis: Case report

Vertebral hemangiomas are benign vascular tumors that are commonly asymptomatic. A low percentage might become aggressive; however, they are not known to be associated with scoliosis. We present a case of a third lumbar vertebral lesion coexisting with a moderate thoracolumbar scoliosis. The patient's initial presentation was back pain with bilateral lower limb radiculopathy and neurogenic claudication. Diagnosis was established using CT and MRI, which showed classical findings of an aggressive vertebral hemangioma. The patient underwent Partial hemangioma excision and scoliosis correction, with satisfactory outcome at 1 year follow up.

Hemangioma of the Lumbar Spine Involving the Spinous Process: A Rare Case Report and Review of the Literature

Hemangiomas of the spine are usually benign and asymptomatic. They can cause devastating complications such as pathological fractures of the spine and neurological disability. This report documents an atypical location of a hemangioma in a lumbar spinous process, in combination with a spondylolisthesis at the same level, which makes it even more uncommon. Surgery can be effective and safe and can significantly improve patient outcomes. Moreover, prior embolization can prevent acute hemorrhage in addition to providing careful diagnosis and evaluation.

Epidemiology of spinal cord and column tumors

The spine is a frequent location for metastatic disease. As local control of primary tumor pathology continues to improve, survival rates improve and, by extension, the opportunity for metastasis increases. Breast, lung, and prostate cancer are the leading contributors to spinal metastases. Spinal metastases can manifest as bone pain, pathologic fractures, spinal instability, nerve root compression, and, in its most severe form, spinal cord compression. The global extent of disease, the spinal burden, neurologic status, and life expectancy help to categorize patients as to their candidacy for treatment options. Efficient identification and workup of those with spinal metastases will expedite the treatment cascade and improve quality of life.

Epidemiological characteristics of 1385 primary sacral tumors in one institution in China

Background

Sacral tumors and tumor-like lesions are a rare group of lesions that can affect children and adults of all ages. Little is known about clinical characteristics of age, gender, histologic type, and anatomic site in China.

Methods

A total of 1385 patients with sacral tumors and tumor-like lesions, which had the clinical record at our bone tumor center from January 2000 to November 2018 were analyzed. The metastatic cancers were not included in the present study.

Results

A total of 51.7% (716 cases) were malignant and 48.3% (669 cases) were benign tumors or tumor-like lesions. Of malignant tumors, chordoma was the most common malignant tumor (316 cases, 22.8% of all tumors), followed by chondrosarcoma, myeloma, and other histologic types. The most common histological type of benign tumors was a giant cell tumor accounting for 14.8% (205 cases) of all tumors, followed by neurofibroma, schwannoma, and other types. The most common age group affected by malignant bone tumors was the 51- to 60-year-old group, followed by the 41- to 50-year-old group. The most commonly affected age group for benign tumors and tumor-like lesions was the 31- to 50-year-old group, followed by the 21- to 30-year old group. Furthermore, the following histologic types had gender predilection. Chordoma, chondrosarcoma, myeloma, and osteosarcoma affected more frequently males than females. Malignant peripheral nerve sheath tumor, lymphoma, giant cell tumor, neurofibroma, tuberculosis, teratoma, and epidermoid cyst more frequently affected females than males.

Conclusions

The large cohort of sacral tumors and tumor-like lesions in our database may reveal their clinical characteristics of age, gender, histologic type, and anatomic site in China and features of sacral tumors and tumor-like lesions are fairly distinct from the mobile spine and extremities.

Surgical Management of Multiple Myeloma With Symptomatic Involvement of the Spine

INTRODUCTION

Multiple myeloma (MM) is the most frequent primary malignancy of the spine. We aimed to investigate the clinical presentation, surgical indications and outcomes, complications, survival, and its influencing factors in surgically treated MM patients with symptomatic involvement of the spine (SIS).

METHODS

Retrospective analysis of prospectively collected data. Out of 350 MM patients treated at our institution over a period of 12 years (2006-2018), we identified 24 patients who were surgically treated for SIS. We collected data on demographics, clinical presentation, comorbidities, surgical indications, and outcomes and investigated the factors predisposing to postoperative complications and survival.

RESULTS

The median follow-up duration was 85 months; median overall survival (OS) was 50 months. Clinical presentation at admission included pain (88%), sensory and/or motor deficit (67%), and bowel/bladder dysfunction (25%). Symptomatic pathological fractures were seen in 33%. Predominant surgical indications were rapid neurological deterioration with or without spinal cord compression (SCC), followed by mechanical instability. The majority of our patients benefited from surgery in terms of pain reduction in the short term as well as in the long term. There were 21% patients with surgical-related complications (<3 months). Surgical site infections occurred in 17%, without any obvious factors predisposing to infective complications. Neurological deterioration during hospital stay, especially in the presence of motor deficit and/or bowel/bladder dysfunction, significantly reduced OS.

CONCLUSIONS

Sudden-onset neurological deterioration was the predominant factor leading to surgery. We achieved good short- and long-term pain reduction. Surgery is a valuable option for MM patients with SIS who present with rapid neurological deterioration with or without SCC and/or mechanical instability.

Strategy for the Practice of Spine Oncological Surgery During the Covid-19 Pandemic

STUDY DESIGN

Case series.

OBJECTIVE

For each of the most frequent clinical scenarios, the authors reached a consensus on how should be timing and indications be optimized to reduce risk while maintaining the expected outcomes under the Covid-19 pandemics.

SUMMARY OF BACKGROUND DATA

The organization of health care has been changed by the Covid-19 pandemic with a direct impact on Spine Oncology Surgery. Emergency surgery is still a priority, but in case of spinal tumors it should be better defined which conditions require emergency treatment.

METHODS

An expert panel with general spine surgeons, oncological spine surgeons, and radiation oncologists was formed to analyze the most frequent scenarios in spinal musculoskeletal oncology during Covid-19 pandemics.

RESULTS

Spine metastases can be found incidentally during follow-up or can clinically occur by increasing pain, pathologic fracture, and/or neurological symptoms. Primary spine tumors are much more rare and very rarely present with acute onset. The first step is to suspect this rare condition, to avoid to treat a primary tumor as it were a metastasis. Most complex surgery, like en bloc resection, associated with high morbidity and mortality rate for the treatment of low grade malignancy like chordoma or chondrosarcomas, if intensive care unit availability is reduced, can be best delayed some weeks, as not impacting on prognosis, due to the slow growth rate of these conditions. The currently accepted protocols for Ewing sarcoma (ES) and osteogenic sarcoma must be performed for local and systemic disease control. For ES, after the first courses of chemotherapy, radiotherapy can be selected instead of surgery, during Covid-19, to the end of the full course of chemotherapy. In immunocompromised patients, (treated by chemotherapy), it is necessary to avoid contact with affected or exposed people.

CONCLUSION

Even more than during normal times, a multidisciplinary approach is mandatory to share the decision to modify a treatment strategy.

LEVEL OF EVIDENCE

5.

Overview of the management of primary tumors of the spine

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide a narrative review for diagnosis and management of Primary spine tumors.

METHODS

A detailed review of literature was done to identify relevant and well cited manuscripts to construct this narrative review.

RESULTS

Primary tumors of the spine are rare with some racial differences reported. There are numerous adjuvant technologies and developments that influence the way we currently manage these tumors. Collimated radiation allows for heavy dosage to be delivered and have been reported to give good local control both as an adjuvant and neoadjuvant setting. These have made surgical decision making even more intricate needing a multicentric approach. Dedicated care has been shown to significantly improve health quality of life measures and survival.

CONCLUSION

While, it is beyond the scope of this paper to discuss all primary tumors subtypes individually, this review highlights the developments and approach to primary spine tumors.

[An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction]

Objective

To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness.

Methods

The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C _{0, 1}, 3 cases of C ₂, 1 case of C _{1, 2}, 1 case of C _{2, 3}, and 1 case of C _0-2. Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation.

Results

The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 ( t=7.638, P=0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score ( t=1.549, P=0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases.

Conclusion

Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.

Bone up on spinal osseous lesions: a case review series

Spinal osseous neoplasms are frequently encountered and can be challenging when present as solitary lesions. Familiarity with the range of benign and malignant spinal pathology can help the radiologist formulate a comprehensive differential diagnosis. This article focuses on the spectrum of extradural spinal tumors, accounting for the majority of primary spinal tumors, by comparing the epidemiology, pathophysiology, clinical presentation, and characteristic imaging appearance of these lesions. The discussion includes the commonly encountered benign lesions, such as vertebral venous vascular malformation and enostosis, as well as malignant lesions including metastases and lymphoma. The article also includes other less-encountered primary spinal tumors such as plasmacytoma, osteoid osteoma, osteoblastoma, giant cell tumor, eosinophilic granuloma, chordoma, chondrosarcoma, osteosarcoma, Ewing’s sarcoma, and angiosarcoma. Familiarity with the characteristic imaging features can help the radiologist reach an accurate diagnosis and obviate the need for unnecessary invasive procedures such as biopsy and surgery.

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.

Vertebral hemangiomas: Diagnosis and management. A single center experience

OBJECTIVE

Vertebral hemangiomas (VH) are common benign lesions involving the spine. Owing to the multiplicity of treatments, the management of VH has not always been consistent. In this retrospective review of a single center experience, indications and options available for the treatment of VH are outlined.

PATIENTS AND METHODS

This is a retrospective review of 71 cases of VH managed at our institution between 2005 and 2019. Sixty of these cases were managed non-operatively, with 11 cases undergoing operative intervention. Of the 11 cases that underwent surgery, there were 2 cervical cases and 9 in the thoracic spine. Ten cases were symptomatic, and 1 incidental. Three patients presented with localized pain, and the remaining 7 had neurological deficit. Decompression with maximal resection of the hemangioma was undertaken in 10 cases, and vertebroplasty in 1.

RESULTS

Of the 60 patients who were managed non-operatively, 13 patients had presented with back/neck pain, with the remaining 47 patients being asymptomatic and diagnosed incidentally. Among the 13 symptomatic patients, all were offered surgical intervention for pain management, but given lack of severity of symptoms, all had opted for conservative approaches of pain control. In the 11 patients who underwent surgery, the preoperative diagnosis of VH was accurate in all but 1 case. There were 2 cervical cases treated with corpectomy. One patient was treated with vertebroplasty, and the remaining 8 with decompression. Radiation was used in 2 cases. Of the 10 patients undergoing decompression, 7 patients had improvement of the neurologic deficit, with resolution of pain in the remaining 3. None of our cases demonstrated deterioration.

CONCLUSION

VH are often discovered incidentally during evaluation of spinal pain. Except in rare cases, the diagnosis of VH is made correctly from the radiographic and MRI studies. Observation for the asymptomatic lesion is appropriate. For VH presenting with deficit or intractable pain, decompressive surgery is recommended. Radiation is appropriate in cases of recurrent VH.

Do routine blood test results help in the diagnosis of spine tumors? A retrospective study of the significance of pretreatment neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios from 503 spine tumor patients

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are not fully evaluated for the diagnosis of musculoskeletal tumors, especially spine tumors. The objective of our study was to assess the feasibility of NLR and PLR as indicators for pretreatment diagnosis of spine tumors.Patients who underwent surgical treatment in our hospital for spine tumors were retrospectively analyzed. Blood test results (neutrophil, lymphocyte, and platelet counts) and final pathological results from surgery or biopsy specimen were collected. Spine tumors were divided into 4 groups. Diagnostic values of NLR and PLR were analyzed using the area under the receiver operating characteristic (ROC) curve (AUC).There were 503 patients included. The average age of all patients was 46.3 years. Age, NLR, and PLR were significantly different between benign and malignant tumors groups (P < .05), and ROC analysis showed that the AUC was 0.704 and 0.637 for NLR and PLR. Age, location, NLR, and PLR were significantly different between primary and nonprimary tumor groups (P < .05), and ROC analysis showed that the AUC was 0.713 and 0.647 for NLR and PLR. Age, location, NLR, and PLR were significantly different between primary benign and primary malignant tumor groups (P < .05), and ROC analysis showed that the AUC was 0.624 and 0.577 for NLR and PLR.Pretreatment NLR and PLR had clinical significance in the identification and pretreatment diagnosis of spine tumors. Additionally, NLR and PLR were significantly different between benign and malignant tumors, primary and nonprimary tumors, and primary benign and primary malignant tumors.

Chondrosarcoma of the Osseous Spine Treated by Surgery With or Without Radiotherapy: A Propensity Score Matched and Grade/Stage-stratified Study

STUDY DESIGN

This was a longitudinal cohort study.

OBJECTIVE

The main objective of this study was to investigate the outcomes of surgery with or without radiotherapy during treatment of patients with chondrosarcoma of the osseous spine.

SUMMARY OF BACKGROUND DATA

Chondrosarcoma is a primary spinal malignant tumor; chemotherapy and radiotherapy (RT) are generally unsuccessful, and thus, the main treatment of choice is complete en bloc resection. However, even with complete resection, these patients still have a significant rate of recurrence, morbidity, and mortality. Although there have been reports that the addition of RT to surgery may lead to increased survival and better cancer control, the evidence of the efficacy of RT remains controversial.

MATERIALS AND METHODS

Patients diagnosed with chondrosarcoma who are then treated by surgery alone or surgery+RT were identified and extracted from the SEER (Surveillance, Epidemiology, and End Results) database (1973-2013). Propensity score matched (PSM) analysis was performed to balance patient characteristics between surgery alone and surgery+RT groups. Patients with a different grade and stage were stratified and analyzed.

RESULTS

A total of 778 patients with chondrosarcoma of the osseous spine treated by surgery alone or surgery+RT were extracted from the SEER database. Before PSM, the unadjusted Kaplan-Meier curve and bivariable Cox proportional hazard regression models showed that the surgery alone group had higher chondrosarcoma cancer-specific survival and overall survival than the surgery+RT group (both P<0.001), while the difference was attenuated after PSM. Stratified analysis found that RT was worse for low-grade chondrosarcoma patients and had a better trend for high-grade chondrosarcoma patients.

CONCLUSIONS

The results of our present study suggest that low-grade chondrosarcoma of the osseous spine is resistant to RT, while high-grade chondrosarcoma patients had a better trend with RT.

LEVEL OF EVIDENCE

Level III.

Spondylolisthesis and tumors: a treatment algorithm

BACKGROUND

Pars defect and spondylolisthesis are frequent conditions, while bone tumors-particularly the primaries-are rare. The contemporary occurrence can delay the diagnosis of the tumor, if symptoms are considered related to spondylolisthesis, or can make reconstruction more demanding. To our knowledge, only two case reports of this contemporary occurrence have been published in the literature. Being such rare, guidelines on surgical treatment have not been proposed yet.

MATERIALS AND METHODS

A retrospective review of patients treated for spine bone tumors by the senior author from 1990 to 2017 was performed to find cases of contemporary occurrence of spondylolisthesis and/or pars defect and spine bone tumors. General health data, radiological imaging, histological tumor diagnosis, treatment, and follow-up were analyzed and discussed.

RESULTS

Among the 1870 patients treated for spinal tumors between 1990 and 2017 by the senior author, 14 cases of association between tumors and spondylolysis/spondylolisthesis were observed. The cohort includes five males (35.7%) and nine females (64.3%), aged 14-72. Mean age of patients at surgery time was 47.

CONCLUSIONS

Interactions between spondylolisthesis and bone tumors of the spine are episodic. These two conditions rarely occur in the same patient. No treatment strategy has been described until now. The target of this paper is to propose an algorithm to surgically treat patients with concomitant bone tumor and spondylolisthesis. This classification identifies a treatment-oriented algorithm based on two major categories: type A, bone tumor arising on the same vertebra or to an adjacent level; type B, bone tumor arising at least one unit far from the spondylolisthesis. This algorithm can help the surgeon facing this rare combination of diseases in the appropriate preoperative planning. These slides can be retrieved under Electronic Supplementary Material.

Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence

One of the major determinants of surgical candidacy in patients with symptomatic spinal metastases is the ability of the patient to tolerate the procedure-associated morbidity. In other pathologies, minimally invasive (MIS) procedures have been suggested to have lower intra-operative morbidity while providing similar outcomes. We conducted a systematic review of the PubMed library searching for articles that directly compared the operative and post-operative outcomes of patients treated for symptomatic spinal metastases. Inclusion criteria were articles reporting two or more cases of patients >18 years old treated with MIS or open approaches for spinal metastases. Studies reporting results in spinal metastases patients that could not be disentangled from other pathologies were excluded. Our search returned 1,568 articles, of which 9 articles met the criteria for inclusion. All articles were level III evidence. Patients treated with MIS approaches tended to have lower intraoperative blood loss, shorter operative times, shorter inpatient stays, and fewer complications relative to patients undergoing surgeries with conventional approaches. Patients in the MIS and open groups had similar pain improvement, neurological improvement, and functional outcomes. Recent advances in MIS techniques may reduce surgical morbidity while providing similar symptomatic improvement in patients treated for spinal metastases. As a result, MIS techniques may expand the pool of patients with spinal metastases who are candidates for operative management.

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.

A Simple Bone Cyst in Cervical Vertebrae of an Adolescent Patient

Introduction

Spinal simple bone cysts, also known as solitary cysts, are extremely unusual benign primary bone tumors with few cases reported in the literature.

Case Presentation

Incidental Magnetic Resonance Imaging (MRI) finding of a C2 Simple bone cyst in a 13-year-old female patient is reported. Complementary studies suggested the benign nature of the lesion. Patient underwent cervical curettage followed by tumor excision. A lateral submandibular approach to the upper cervical spine was used and careful bone resection was possible with a radiofrequency assisted burr and no instrumentation or fixation was required. The stability of the defect was ensured by filling it with bone allograft and by prescribing a postsurgical plastic cervical collar to maintain neck immobilization. Histological examination supported the diagnosis of simple bone cyst. At 6–12-month follow-up the patient presented no recurrence or symptomatology.

Conclusions

Solitary bone cysts are infrequent entities in the cervical vertebrae and preservation of spine stability without instrumentation to avoid neurological complications is often challenging. In this case, the proximity of the cyst to the right vertebral artery and the risk of injury were high; however the surgical approach used was successful and no recurrence or instability was evidenced on postoperative MRI.

Epidemiological characteristics of primary spinal osseous tumors in Eastern China

BACKGROUND

Primary spinal osseous tumors are rare, yet they represent a difficult treatment paradigm because of the complexities of tumor resection and significant resistance to chemotherapy and radiation therapy. The geographic distribution of primary spinal osseous tumors throughout the world appears to be quite variable, with a very low incidence reported in Asian countries.

METHODS

Data on 1209 cases of primary spinal osseous malignant and benign tumor cases diagnosed during the 20-year period of 1995 through 2015 in eastern China were analyzed.

RESULTS

In 780 cases (64.5%), the lesion was benign and in 429 (35.5%) was malignant. The commonest primary malignant tumors were chordoma (9.8% of all cases) followed by plasma cell myeloma (8.5% of all cases). The most common benign tumor was hemangioma (28.1% of all cases) followed by giant cell tumor of bone (15.7% of all cases) and osteoblastoma (4.4% of all cases). The benign tumors affected men in 33.8% of cases and women in 30.7% of cases, the malignant tumors affected men in 23.7% of cases and women in 11.8%. The mean age (mean ± SD) in the benign group was 34.7 ± 19.8 years and in the malignant group was 47.4 ± 16.5 years. Related symptoms were pain (54.4%), radiculopathy (12.9%), cord compression (9.2%), mass (5.7%), pathological fracture (4.7%), deformity (2.1%), and weight loss (1.9%). The anatomical locations included almost every vertebra of the spine. The thoracic spine (38.1%) was the most common location of the tumors, followed by the cervical spine (27.4%) and lumbar spine (18.4%).

CONCLUSIONS

Compared with other similar series reported in the literature from the other countries, our results obtained in a developing country were different in some degree. This large series of primary spinal osseous tumors may reflect fairly well their real incidence and provide a sufficiently detailed perspective on epidemiologic studies of primary spinal osseous tumors in eastern China.

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.

Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis

OBJECTIVE

The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors.

METHODS

Data from adult patients who underwent surgery for spinal tumors (2011–2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

RESULTS

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12–23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8–20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4–5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4–19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14–25 days), and sepsis (2.9%) at 13 days (IQR 7–21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3–5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3–9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5–26 days).

CONCLUSIONS

In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.

What's new in vertebral cementoplasty?

Vertebral cementoplasty is a well-known mini-invasive treatment to obtain pain relief in patients affected by vertebral porotic fractures, primary or secondary spine lesions and spine trauma through intrametameric cement injection. Two major categories of treatment are included within the term vertebral cementoplasty: the first is vertebroplasty in which a simple cement injection in the vertebral body is performed; the second is assisted technique in which a device is positioned inside the metamer before the cement injection to restore vertebral height and allow a better cement distribution, reducing the kyphotic deformity of the spine, trying to obtain an almost normal spine biomechanics. We will describe the most advanced techniques and indications of vertebral cementoplasty, having recently expanded the field of applications to not only patients with porotic fractures but also spine tumours and trauma.

Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up

OBJECT

Atlantoaxial tumors account for a substantial proportion of primary bone tumors in children. Before resection, surgeons must consider the complex regional anatomy, the potential for neurological compromise, craniocervical instability, and the question of tumor resectability in a growing spine. Using current technology, the authors analyzed surgical cases in this light and present outcomes and treatment recommendations after long-term patient follow-up.

METHODS

The authors reviewed clinical records for 23 children whose primary atlantoaxial bone tumors were treated from 1996 through 2010.

RESULTS

Pathological lesions among the 23 patients were 4 aneurysmal bone cysts, 2 osteochondromas, 5 chordomas, 4 osteoblastomas, 3 fibrous dysplasias, 4 eosinophilic granulomas, and 1 Ewing's sarcoma. Clinical presentation consisted of neck pain (n = 23), headaches and occipital pain (n = 16), myelopathy (n = 8), and torticollis (n = 4). Selective angiography and coil embolization were undertaken for all patients with aneurysmal bone cysts and osteoblastomas, 2 patients with chordomas, 1 patient with fibrous dysplasia, and 1 patient with Ewing's sarcoma. Primary embolization treatment of radiation-induced aneurysmal bone cyst of the atlas showed complete reossification. Results of CT-guided needle biopsy were diagnostic for 1 patient with eosinophilic granuloma and 1 with Ewing's sarcoma. Needle biopsies performed before referral were associated with extreme blood loss for 1 patient and misdiagnosis for 2 patients. Surgery involved lateral extrapharyngeal, transoral, posterior, and posterolateral approaches with vertebral artery rerouting. Complete resection was possible for 9 patients (2 with osteochondroma, 3 with fibrous dysplasia, 2 with chordoma, and 2 with osteoblastoma). Decompression and internal fusion were performed for 3 patients with aneurysmal bone cysts. Of the 23 patients, 7 underwent dorsal fusion and 4 underwent ventral fusion of the axis body. Chemotherapy was necessary for the patients with eosinophilic granuloma with multifocal disease and for the patient with Ewing's sarcoma. There was no morbidity, and there were no deaths. All patients with benign lesions were free of disease at the time of the follow-up visit (mean ± SD follow-up 8.8 ± 1.1 years; range 2-18 years). Chordomas received proton or LINAC irradiation, and as of 4-15 years of follow-up, no recurrence has been noted.

CONCLUSIONS

Because most atlantoaxial tumors in children are benign, an intralesional procedure could suffice. Vascular control and staged resection are critical. Ventral transoral fusion or lateral extrapharyngeal fusion has been successful. Resection with ventral fusion and reconstruction are essential for vertebral body collapse. Management of eosinophilic granulomas must be individualized and might require diagnosis through needle biopsy.

Percutaneous computed tomography fluoroscopy–guided conformal ultrasonic ablation of vertebral tumors in a rabbit tumor model

Object

Radiofrequency ablation (RFA) has proven to be effective for treatment of malignant and benign tumors in numerous anatomical sites outside the spine. The major challenge of using RFA for spinal tumors is difficulty protecting the spinal cord and nerves from damage. However, conforming ultrasound energy to match the exact anatomy of the tumor may provide successful ablation in such sensitive locations. In a rabbit model of vertebral body tumor, the authors have successfully ablated tumors using an acoustic ablator placed percutaneously via computed tomography fluoroscopic (CTF) guidance.

Methods

Using CTF guidance, 12 adult male New Zealand White rabbits were injected with VX2 carcinoma cells in the lowest lumbar vertebral body. At 21 days, a bone biopsy needle was placed into the geographical center of the lesion, down which an acoustic ablator was inserted. Three multisensor thermocouple arrays were placed around the lesion to provide measurement of tissue temperature during ablation, at thermal doses ranging from 100 to 1,000,000 TEM (thermal equivalent minutes at 43°C), and tumor volumes were given a tumoricidal dose of acoustic energy. Animals were monitored for 24 hours and then sacrificed. Pathological specimens were obtained to determine the extent of tumor death and surrounding tissue damage. Measured temperature distributions were used to reconstruct volumetric doses of energy delivered to tumor tissue, and such data were correlated with pathological findings.

Results

All rabbits were successfully implanted with VX2 cells, leading to a grossly apparent spinal and paraspinal tissue mass. The CTF guidance provided accurate placement of the acoustic ablator in all tumors, as corroborated through gross and microscopic histology. Significant tumor death was noted in all specimens without collateral damage to nearby nerve tissue. Tissue destruction just beyond the margin of the tumor was noted in some but not all specimens. No neurological deficits occurred in response to ablation. Reconstruction of measured temperature data allowed accurate assessment of volumetric dose delivered to tissues.

Conclusions

Using a rabbit intravertebral tumor model, the authors have successfully delivered tumoricidal doses of acoustic energy via a therapeutic ultrasound ablation probe placed percutaneously with CTF guidance. The authors have thus established the first technical and preclinical feasibility study of controlled ultrasound ablation of spinal tumors in vivo.