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

Sagittal en bloc resection of thoracolumbar tumours: a report of thirty one cases

PURPOSE

To develop a novel classification of sagittal en bloc resection (SEBR) based on anatomical locations for thoracolumbar spine tumors and assess the clinical outcomes of this surgical procedure.

METHODS

31 patients with thoracolumbar tumours treated with SEBR were enrolled in this study. The individualized surgical strategy was adopted based on our surgical classification. Demographics, perioperative outcomes, complications and postoperative outcomes were assessed.

RESULTS

Based on our surgical classifications, patients were divided into four types. All bony resection margins were negative, wide resection was achieved in 25 patients, marginal resection in four, and intralesional resection in two. 18 patients underwent anterior reconstruction. Complications were encountered in five patients, and instrumentation failure occurred in one patient. The median follow-up was 24 (range, 6-72) months and recurrence was found in only one patient.

CONCLUSION

SEBR is a safe and effective surgical procedure for patients with thoracolumbar spinal tumours in specific anatomical locations. The proposed surgical classification covers all SEBR types and is easy to apply, it may assist surgical decision-making in patients with spinal tumours.

Perioperative complications of en bloc resection and anterior column reconstruction for thoracic and lumbar spinal tumors

PURPOSE

To evaluate the perioperative clinical outcomes of en bloc resection and anterior column reconstruction for thoracolumbar spinal tumors.

METHODS

This study conducted a retrospective analysis of prospective data collection of 86 consecutive patients, including 40 males and 46 females, with an average age of 39 years (ranged from 10 to 71 years). There were 35 cases of a malignant primary tumor,42 cases of an aggressive benign tumor, and nine cases of metastases. The main lesions were located in 65 cases of thoracic spine, 17 cases of lumbar spine, and 4 cases of thoracolumbar spine. Tumors involved one level in 45 patients, two levels in 12 patients, three levels in 21 patients, four levels in five patients, five levels in two patients, and six levels in one patient.

RESULTS

According to the Weinstein-Boriani-Biagini surgical staging system, all patients achieved en bloc resections, including 74 cases of total en bloc spondylectomy and 12 cases of sagittal resections. The mean surgical time was 559 min (210-1208 min), and the mean total blood loss was 1528 ml (260-5500 ml). A total of 122 complications were observed in 62(72.1%) patients, of which 18(20.9%) patients had 25 major complications and one patient (1.2%) died of complications. The combined approach (P = 0.002), total blood loss (P = 0.003), staged surgery (P = 0.004), previous surgical history (P = 0.045), the number of involved vertebrae (P = 0.021) and lumbar location (P = 0.012) were statistically significant risk factors for major complication. When all above risk factors were incorporated in multivariate analysis, only the combined approach (P = 0.052) still remained significant.

CONCLUSIONS

En bloc resection and anterior column reconstruction is accompanied by a high incidence of complications, especially when a combined approach is necessary.

Two-step osteotomy/discectomy through cannulated screw (TOCS) technique for en bloc resection of spine tumor: surgical technique and preliminary results

PURPOSE

We have developed a novel technique for osteotomy/discectomy during en bloc resection of spine tumors named two-step osteotomy/discectomy through cannulated screw (TOCS). This study aims at describing the procedure of TOCS technique and assessing its efficiency and safety.

METHODS

We retrospectively reviewed fourteen patients who underwent en bloc resection for spine tumors using TOCS technique in our center between August 2018 and September 2022. The technique was based on a specially designed "slotted" cannulated screw which was a cannulated screw with a longitudinal slot to provide the accessibility of T-saw. During osteotomy/discectomy, the "slotted" cannulated screw was inserted obliquely along the plane between the dura and the posterior wall of spine in light of the planned osteotomy/discectomy plane under routine fluoroscopic imaging guidance. The T-saw was introduced through the screw, and the osteotomy/discectomy was performed sequentially in two steps under the guidance of the screw by turning the slot away and toward the dura. The intra-/perioperative complication, neurological function (determined by Frankel grading), surgical margin (determined by a pathologist using AJCC R system), follow-up details were documented.

RESULTS

The mean duration of surgery was 599.3 (360-890) min with a mean volume of intra-operative hemorrhage of 2021.4 (800-5000) mL. The intra-/perioperative complications were found in four patients (28.6%). R0 and R1 resections were achieved in nine and five patients, respectively. There was no R2 resection. After a mean follow-up period of 30.6 (10-67) months, all patients were alive except one patient died ten months after surgery due to unrelated cause. No recurrence and implant failure were found. Thirteen patients (92.9%) exhibited completely normal neurological function same as their preoperative neurological status.

CONCLUSION

Using TOCS technique can facilitate a precise, complete and safe osteotomy/discectomy procedure during en bloc resection for spine tumor without the aid of intra-operative navigation.

Does Preoperative Bilsky Score Predict Outcome Following Surgical Resection of Primary Tumors of the Spine?

OBJECTIVE

In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0-1 versus 2-3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes.

METHODS

A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0-1 versus 2-3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS).

RESULTS

Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0-1 and 19 (50.0%) Bilsky 2-3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2-3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002).

CONCLUSIONS

Bilsky 2-3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes.

Comparison of clinical efficacy of 3D-printed artificial vertebral body and conventional titanium mesh cage in spinal reconstruction after total en bloc spondylectomy for spinal tumors: a systematic review and meta-analysis

Propose

This meta-analysis aimed to determine whether 3D-printed artificial vertebral bodies (AVBs) have superior clinical efficacy compared to conventional titanium mesh cages (TMCs) for spinal reconstruction after total en bloc spondylectomy (TES) for spinal tumors.

Methods

Electronic databases, including PubMed, OVID, ScienceDirect, Embase, CINAHL, Web of Science, Cochrane Library, WANFANG, and CNKI, were searched to identify clinical trials investigating 3D-printed AVB versus conventional TMC from inception to August 2023. Data on the operation time, intraoperative blood loss, preoperative and postoperative visual analogue scale (VAS) scores, preoperative and postoperative Frankel classification of spinal cord injury, vertebral body subsidence, and early complications were collected from eligible studies for a meta-analysis. Data were analyzed using Review Manager 5.4 and Stata 14.0.

Results

Nine studies assessing 374 patients were included. The results revealed significant differences between the 3D-printed AVB and conventional TMC groups with regard to operation time (P = 0.04), intraoperative blood loss (P = 0.004), postoperative VAS score (P = 0.02), vertebral body subsidence (P < 0.0001), and early complications (P = 0.02). Conversely, the remaining preoperative VAS score and Frankel classifications (pre-and postoperative) did not differ significantly between the groups.

Conclusion

The 3D-printed AVB in spinal reconstruction after TES for spinal tumors has the advantages of a short operative time, little intraoperative blood loss, weak postoperative pain, low occurrence of vertebral body subsidence and early complications, and a significant curative effect. This could provide a strong basis for physicians to make clinical decisions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023441521, identifier CRD42023441521.

Customized 3-dimensional-printed Vertebral Implants for Spinal Reconstruction After Tumor Resection: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To examine the outcomes of customized 3-dimensional (3D) printed implants for spinal reconstruction after tumor resection.

SUMMARY OF BACKGROUND DATA

Various techniques exist for spinal reconstruction after tumor resection. Currently, there is no consensus regarding the utility of customized 3D-printed implants for spinal reconstruction after tumor resection.

MATERIALS AND METHODS

A systematic review was registered with PROSPERO and performed according to "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines. All level I-V evidence studies reporting the use of 3D-printed implants for spinal reconstruction after tumor resection were included.

RESULTS

Eleven studies (65 patients; mean age, 40.9 ± 18.1 y) were included. Eleven patients (16.9%) underwent intralesional resections with positive margins and 54 patients (83.1%) underwent en bloc spondylectomy with negative margins. All patients underwent vertebral reconstruction with 3D-printed titanium implants. Tumor involvement was in the cervical spine in 21 patients (32.3%), thoracic spine in 29 patients (44.6%), thoracolumbar junction in 2 patients (3.1%), and lumbar spine in 13 patients (20.0%). Ten studies with 62 patients reported perioperative outcomes radiologic/oncologic status at final follow-up. At the mean final follow-up of 18.5 ± 9.8 months, 47 patients (75.8%) had no evidence of disease, 9 patients (14.5%) were alive with recurrence, and 6 patients (9.7%) had died of disease. One patient who underwent C3-C5 en bloc spondylectomy had an asymptomatic subsidence of 2.7 mm at the final follow-up. Twenty patients that underwent thoracic and/or lumbar reconstruction had a mean subsidence of 3.8 ± 4.7 mm at the final follow-up; however, only 1 patient had a symptomatic subsidence that required revision surgery. Eleven patients (17.7%) had one or more major complications.

CONCLUSION

There is some evidence to suggest that using customized 3D-printed titanium or titanium alloy implants is an effective technique for spinal reconstruction after tumor resection. There is a high incidence of asymptomatic subsidence and major complications that are similar to other methods of reconstruction.

LEVEL OF EVIDENCE

Level V, systematic review of level I-V studies.

The Role of En Bloc Resection in the Modern Era for Primary Spine Tumors

STUDY DESIGN

A literature review.

OBJECTIVE

The aim of this review is to provide an overview of benign and malignant primary spine tumors and a balanced analysis of the benefits and limitations of (and alternatives to) surgical treatment with en bloc resection.

SUMMARY OF BACKGROUND DATA

Primary spine tumors are rare but have the potential to cause severe morbidity, either from the disease itself or as a result of treatment. The prognosis, goals, and treatment options vary significantly with the specific disease entity. Appropriate initial management is critical; inappropriate surgery before definitive treatment can lead to recurrence and may render the patient incurable, as salvage options are often inferior.

METHODS

We performed a comprehensive search of the PubMed database for articles relevant to primary spine neoplasms and en bloc spine surgery. Institutional review board approval was not needed.

RESULTS

Although Enneking-appropriate en bloc surgery can be highly morbid, it often provides the greatest chance for local control and/or patient survival. However, there is growing data to support modern radiotherapy as a feasible and less morbid approach to certain primary neoplasms that historically were considered radioresistant.

CONCLUSIONS

Choosing the optimal approach to primary spine tumors is complex. A comprehensive and up-to-date assessment of the evidence is required to guide patient care and to balance the often-competing goals of prolonging life and preserving quality of life.

Surgical outcomes and risk factors for surgical complications after en bloc resection following reconstruction with 3D-printed artificial vertebral body for thoracolumbar tumors

BACKGROUND

The outcomes of patients with tumors of the thoracolumbar spine treated with en bloc resection (EBR) using three-dimensional (3D)-printed endoprostheses are underreported.

METHODS

We retrospectively evaluated patients with thoracolumbar tumors who underwent surgery at our institution. Logistic regression analysis was performed to identify the potential risk factors for surgical complications. Nomograms to predict complications were constructed and validated.

RESULTS

A total of 53 patients with spinal tumors underwent EBR at our hospital; of these, 2 were lost to follow-up, 45 underwent total en bloc spondylectomy, and 6 were treated with sagittal en bloc spondylectomy. The anterior reconstruction materials included a customized 3D-printed artificial vertebral body (AVB) in 10 cases and an off-the-shelf 3D-printed AVB in 41 cases, and prosthesis mismatch occurred in 2 patients reconstructed with the off-the-shelf 3D-printed AVB. The median follow-up period was 21 months (range, 7-57 months). Three patients experienced local recurrence, and 5 patients died at the final follow-up. A total of 50 perioperative complications were encountered in 29 patients, including 25 major and 25 minor complications. Instrumentation failure occurred in 1 patient, and no prosthesis subsidence was observed. Using a combined surgical approach was a dependent predictor of overall complications, while Karnofsky performance status score, lumbar spine lesion, and intraoperative blood loss ≥ 2000 mL were predictors of major complications. Nomograms for the overall and major complications were constructed using these factors, with C-indices of 0.850 and 0.891, respectively.

CONCLUSIONS

EBR is essential for the management of thoracolumbar tumors; however, EBR has a steep learning curve and a high complication rate. A 3D-printed AVB is an effective and feasible reconstruction option for patients treated with EBR.

Delay of Surgery for Spinal Metastasis due to the COVID-19 Outbreak Affected Patient Outcomes

OBJECTIVE

The present study is to analyze the effects of the coronavirus disease 2019 (COVID 2019) outbreak and the subsequent lockdown on the outcomes of spinal metastasis patients.

METHODS

The study was a retrospective analysis of data from a prospective cohort study. All patients underwent surgical intervention for spinal metastases between January 2019 and December 2021 and had at least 3 months of postoperative follow-up. The primary outcome was overall mortality during the 4 different stages (pre-COVID-19 era, COVID-19 pandemic except in Taiwan, national lockdown, lifting of the lockdown). The secondary outcomes were the oncological severity scores, medical/surgical accessibility, and patient functional outcome during the 4 periods as well as survival/mortality.

RESULTS

A total of 233 patients were included. The overall mortality rate was 41.20%. During the Taiwan lockdown, more patients received palliative surgery than other surgical methods, and no total en bloc spondylectomy was performed. The time from surgeon visit to operation was approximately doubled after the COVID-19 outbreak in Taiwan (75.97, 86.63, 168.79, and 166.91 hours in the 4 periods, respectively). The estimated survival probability was highest after the national lockdown was lifted and lowest during the lockdown. In the multivariate analysis, increased risk of mortality was observed with delay of surgery, with emergency surgery having a higher risk with delays above 33 hours, urgent surgery (below 59 and above 111 hours), and elective surgery (above 332 hours).

CONCLUSION

The COVID-19 pandemic and related policies have altered daily clinical practice and negatively impacted the survival of patients with spinal metastases.

[Translated article] Vertebral metastases. En bloc treatment

En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilisation techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimise outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.

Vertebral metastases. En bloc treatment

En bloc resection of vertebral metastases has been the subject of study in medical literature due to its impact on patients' quality of life and effectiveness in local disease control. This bibliographic analysis examines the findings and perspectives of published studies concerning en bloc resection of oligometastases in the spine. The technique, which involves the complete removal of the tumour along with a portion of the surrounding bone, has been shown to improve local tumour control, reduce recurrence, and potentially prolong patient survival compared to conventional decompression and stabilization techniques. However, en bloc resection also presents risks and complications, such as surgical morbidity and extended recovery time. Appropriate patient selection, preoperative planning, and a multidisciplinary approach are essential to optimize outcomes. As new techniques and advances in adjuvant treatment develop, en bloc resection of oligometastases in the spine remains an area of interest in oncological research.

A Systematic Review of Perioperative Complications in en Bloc Resection for Spinal Tumors

STUDY DESIGN

Systematic review.

OBJECTIVE

En bloc resection is a major, invasive surgical procedure designed to completely resect a vertebral tumor with a sufficient margin. It is technically demanding and potentially poses risks of perioperative complications. In this systematic review, we investigated the incidence of complications after en bloc resection for spinal tumors.

METHODS

We screened PubMed and Embase databases for relevant English publications, from 1980 to 2020, using the following terms: spine OR spinal AND en bloc AND tumor. Using a standard PRISMA template, after the initial screening, full-text articles of interest were evaluated.

RESULTS

Thirty-six studies with 961 patients were included. The overall mean age of patients was 49.6 years, and the mean follow-up time was 33.5 months. There were 560 complications, and an overall complication rate of 58.3% (560/961). The 5 most frequent complications were neurological damage (12.7%), hardware failure (12.1%), dural tear and cerebrospinal fluid leakage (10.6%), wound-related complications (7.6%) and vascular injury and bleeding (7.3%). The complication-related revision rate was 10.7% (103/961). The average incidence of complication-related death was 1.2% (12/961).

CONCLUSIONS

En bloc resection is a surgical procedure that is very invasive and technically challenging, and the possible risks of perioperative complications should not be neglected. The overall complication rate is high. However, complication-related death was rare. The advantages of surgery should be weighed against the serious perioperative morbidity associated with this technique.

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

Background

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

Methods

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

Results

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

Conclusion

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

Biomechanical comparison of different prosthetic reconstructions in total en bloc spondylectomy: a finite element study

Objective

To analyse and compare the biomechanical differences between 3D-printed prostheses, titanium mesh cages and poorly matched titanium mesh cages in total en bloc spondylectomy (TES).

Methods

The finite element model of T10-L2 for healthy adults was modified to make three models after T12 total spondylectomy. These models were a 3D-printed prosthesis, titanium mesh cage and prosthesis-endplate mismatched titanium mesh cage for reconstruction. The range of motion (ROM), stress distribution of the endplate and internal fixation system of three models in flexion and extension, lateral bending and axial rotation were simulated and analysed by ABAQUS.

Result

In flexion, due to the support of the anterior prosthesis, the fixation system showed the maximum fixation strength. The fixation strength of the 3D-printed prosthesis model was 26.73 N·m /°, that of the TMC support model was 27.20 N·m /°, and that of the poorly matched TMC model was 24.16 N·m /°. In flexion, the L1 upper endplate stress of the poorly matched TMC model was 35.5% and 49.6% higher than that of the TMC and 3D-printed prosthesis, respectively. It was 17% and 28.1% higher in extension, 39.3% and 42.5% higher in lateral bending, and 82.9% and 91.2% higher in axial rotation, respectively. The lower endplate of T11 showed a similar trend, but the magnitude of the stress change was reduced. In the stress analysis of the 3D-printed prosthesis and TMC, it was found that the maximum stress was in flexion and axial rotation, followed by left and right bending, and the least stress was in extension. However, the mismatched TMC withstood the maximum von Mises stress of 418.7 MPa (almost twice as much as the buckling state) in rotation, 3 times and 5.83 times in extension, and 1.29 and 2.85 times in lateral bending, respectively.

Conclusion

Different prostheses with good endplate matching after total spondylectomy can obtain effective postoperative stable support, and the reduction in contact area caused by mismatch will affect the biomechanical properties and increase the probability of internal fixation failure.

Complications and Risk Factors in En Bloc Resection of Spinal Tumors: A Retrospective Analysis on 298 Patients Treated in a Single Institution

En bloc resection consists in the surgical removal of a vertebral tumor in a single piece with a sufficient margin, to improve survival and reduce recurrence rate. This procedure is technically demanding and correlates with a high complication rate. The purpose of this study is to investigate the risk factors for complications in en bloc resection and evaluate if benefits overcome the risks in term of overall survival. We retrospectively analyzed prospectively collected data of patients treated with en bloc resection between 1980 and 2021. Complications were classified according to SAVES-V2. Overall Survival was estimated using Kaplan-Meier method. A total of 149 patients out of 298 (50%) suffered from at least one complication. Moreover, 220 adverse events were collected (67 intraoperative, 82 early post-operative, 71 late post-operative), 54% of these were classified as grade 3 (in a severity scale from 1 to 6). Ten years overall survival was 67% (95% CI 59-74). The occurrence of relapses was associated to an increased risk of mortality with OR 3.4 (95% CI 2.1-5.5), while complications did not affect the overall survival. Despite a high complication rate, en bloc resection allows for a better control of disease and should be performed in selected patients by specialized surgeons.

Intralesional Marginal Resection for Osteoblastoma in the Mobile Spine: Experience From a Single Center

Osteoblastoma (OB) is a benign bone tumor with aggressive behavior and a tendency for local recurrence. The appropriate surgical strategy for spinal OB remains unclear. This retrospective study aimed to verify the clinical efficacy and safety of intralesional marginal resection of OB in the mobile spine. We enrolled 50 consecutive patients with spinal OB between January 2009 and December 2019. The tumors were staged based on the Enneking system, with 21 and 29 lesions being determined as stage 2 (St.2) and stage 3 (St.3), respectively. Among them, 42 patients underwent intralesional marginal resection, five underwent extensive curettage, and three underwent en bloc resection successfully since their lesions were limited to the posterior element in a single vertebra. We analyzed clinical characteristics, perioperative and follow-up images, surgical details, and follow-up data. Within a median follow-up duration of 50 (range: 24–160) months, six (12.0%) patients had local recurrence. The recurrence rates among patients who underwent intralesional marginal resection, curettage, en bloc resection were 7.1%(3/42), 60.0%(3/5), and 0%(0/3), respectively. The recurrence rate of intralesional marginal resection of St.3 lesions was slightly higher than that of St.2 lesions (7.7%[2/26] vs. 6.3%[1/16]). There were 16(38.1%), 3(60.0%), and 0 patients with surgical complications among those who underwent intralesional marginal resection, curettage, and en bloc resection, respectively. Local recurrence was observed in five (5/14, 35.7%) patients who had vertebral artery extension and in none who did not have vertebral artery extension (p = 0.02). Our findings suggest that intralesional marginal resection could be an appropriate treatment choice for patients with spinal OB, both St.2 and St.3 lesions, with an acceptable local recurrence rate and a low risk of complications. Vertebral artery extension could be a strong risk factor for local recurrence in patients with spinal OB.

Complications in spinal tumor surgery (review of literature)

Combined anterior and posterior approaches are required in spinal tumor surgery and considered highly invasive. Anatomical and physiological features of the surgical intervention area should be taken into consideration as well. Thus, these criteria reflect the severity of intraoperative complications during the surgical treatment of spinal tumors. The authors reviewed the scientific literature on the frequency and nature of complications in surgical interventions for spinal tumors.The most significant risk factors for intraoperative complications have been considered, the main of which are: the proximity of the location of the main vessels and viscera, the development of postoperative liquorrhea, as well as surgical site infection. Based on the studied information, we presented the methods of prevention and surgical tactics options in complications.

Vessel-Plasty Using Bone-Filling Mesh Container for Treatment of Malignant Severe Compression Fractures in Cervical Vertebrae

Objective

To evaluate the feasibility, safety, and efficacy of vessel-plasty using bone-filling mesh container (BFMC) for malignant severe compression fractures of cervical vertebra.

Methods

This study prospectively recruited fifteen consecutive patients (eight men, seven women; mean age, 57.4 years) with severe malignant compression fractures of cervical vertebrae for vessel-plasty. Procedure duration, incidence of cement leakage and other complications, pain relief and improvement of neck function were analyzed. Pain was assessed using a visual analog scale (VAS) and function by the neck disability index (NDI), with scores recorded before the procedure and at 3 days and 1, 3, 6 and 12 months after the procedure.

Results

A total of 16 vertebrae were treated. All vertebrae had destruction of bone in more than one place as well as broken bone walls. Mean procedure duration was 42.9±13.6 minutes. Bone cement leakage occurred in two vertebrae without any symptoms. No procedure-related complications occurred. Mean VAS and NDI declined from 7.1 ± 1.4 and 63.6 ± 16.3, respectively, before the procedure to 3.5 ± 1.1 and 37.4 ± 11.0, respectively, at three days after the procedure (P < 0.01). CT images at three months after the procedure confirmed that there were no cases of refractures at the treated or adjacent levels, recurrence of vertebral collapse and mobilization of bone cement block.

Conclusion

Vessel-plasty using BFMC appears to be effective and safe for malignant severe compression fractures in cervical vertebrae. It is effective in stabilizing vertebral body, relieving pain.

Hybrid Therapy (Surgery and Radiosurgery) for the Treatment of Renal Cell Carcinoma Spinal Metastases

BACKGROUND

The management of spinal metastatic renal cell carcinoma (mRCC) is controversial regarding extent of resection and radiation dosing.

OBJECTIVE

To determine outcomes in patients treated with hybrid therapy (separation surgery plus adjuvant stereotactic body radiation therapy [SBRT]) for mRCC.

METHODS

A retrospective study of a prospectively collected cohort of patients undergoing hybrid therapy for mRCC between 2003 and 2017 was performed. SBRT was delivered as high-dose single-fraction, high-dose hypofractionated, or low-dose hypofractionated. Extent of disease, clinical and operative outcomes, and complications data were collected, and associations with overall survival (OS) and progression-free survival were determined.

RESULTS

Ninety patients with mRCC with high-grade epidural spinal cord compression (ESCC grades 2 and 3) were treated. Metastases were widespread, oligometastatic, and solitary in 56%, 33%, and 11% of patients, respectively. SBRT delivered was high-dose single-fraction, high-dose hypofractionated, and low-dose hypofractionated in 24%, 56%, and 20% of patients, respectively. The 1-yr cumulative incidence of major complications was 3.4% (95% confidence interval [CI]: 0.0%-7.2%). The median follow-up was 14.2 mo for the entire cohort and 38.3 mo for survivors. The 1-yr cumulative incidence of progression was 4.6% (95% CI: 0.2%-9.0%), which translates to a local control rate of 95.4% (95% CI: 91.0%-99.8%) 1 yr after surgery. The median OS for the cohort was 14.8 mo.

CONCLUSION

These data support the use of hybrid therapy as a safe and effective strategy for the treatment of renal cell spine metastases.

Comparison of Surgical Outcomes Between Separation Surgery and Piecemeal Spondylectomy for Spinal Metastasis: A Retrospective Analysis

Objective: This study aimed to compare the outcomes between piecemeal spondylectomy and separation surgery for patients with spinal metastasis.

Summary of Background Data: Piecemeal spondylectomy and separation surgery are two widely-used treatment options for spinal metastasis. However, no studies have compared the surgical outcomes between both treatment modalities.

Methods: Patients with spinal metastasis who underwent piecemeal spondylectomy or separation surgery between August 2017 and April 2020 at our spine center were recruited. Demographic, preoperative, perioperative, and follow-up data were collected and analyzed. Kaplan–Meier analysis and the log-rank test were used to analyze overall survival (OS) and progression-free survival (PFS) in patients with spinal metastasis.

Results: Overall, 26 patients were treated with piecemeal spondylectomy, and 29 underwent separation surgery with postoperative stereotactic radiosurgery. Both groups showed significant postoperative improvements in neurological status. The piecemeal spondylectomy group had significantly more blood loss (1784.62 ± 833.64 vs. 1165.52 ± 307.38 ml) and required longer operative time (4.76 ± 0.93 vs. 3.73 ± 1.15 h) than the separation surgery group. No significant difference in OS was found between the groups (P = 0.064); however, patients in the separation surgery group experienced less local recurrence than those in the piecemeal spondylectomy group (P = 0.0014). Notably, significant differences were detected in the development of complications between the groups (P = 0.029).

Conclusion: Separation surgery led to less blood loss and reduced complications and had shorter operation time than piecemeal spondylectomy. Although no significant differences were found in OS between the groups, separation surgery was associated with better PFS compared with piecemeal spondylectomy. These findings suggest that separation surgery has some advantages over piecemeal spondylectomy for patients with spinal metastatic disease.

Histological examination of a retrieved custom-made 3D-printed titanium vertebra : Do the fine details obtained by additive manufacturing really promote osteointegration?

PURPOSE

In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma.

METHODS

Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure.

RESULTS

The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization.

CONCLUSION

The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.

The Early Results of Vertebral Pathological Compression Fracture of Extra- nodal Lymphoma with HIV-positive Patients Treated by Percutaneous Kyphoplasty

BACKGROUND

Vertebral pathological compression fracture involving extra-nodal lymphoma impacts negatively on the quality of life of HIV-positive patients. The choice of a safe and effective approach to palliative care in this condition remains a challenge.

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of percutaneous kyphoplasty (PKP) in the treatment of vertebral pathological compression fracture of extra-nodal lymphoma in HIV-positive patients.

METHODS

A retrospective analysis, from January 2016 to August 2019, was performed on 7 HIVpositive patients, 3 males and 4 females, with extra-nodal lymphoma with a vertebral pathological compression fracture. The patients were treated using percutaneous kyphoplasty in our hospital. Preoperative assessment of the patients was conducted regarding their hematological profile, biochemical indicators, liver and kidney function, blood coagulation function, CD4+T lymphocyte count and viral load. Subsequently, the patients were placed on highly active antiretroviral therapy (HAART) and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) regimen. Besides, antibiotics, nutritional support and immune-modulating drugs were also administered, rationally. Postoperatively, the height of the anterior edge of the injured vertebrae, Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) values were evaluated. Patients were also monitored for any complications related to the operation.

RESULTS

The average CD4+T cell count for the patients was 164 (range 114 ~247 / ul), while the viral load was 26,269 (range 5,765 ~82,321 copies/ul). All patients received nutritional and immune support and registered significant improvements in the levels of ALB and Hb (P<0.05). In all cases, the operation was uneventful with neither cement leakage nor toxic reactions observed. Similarly, no opportunistic infections, other complications or deaths were reported. The height of the anterior vertebral body and the ODI score of the injured vertebrae were significantly improved immediately after surgery (P<0.05). Compared to the preoperative VAS (7.71±1.11), postoperative values were significantly reduced immediately after surgery (3.85±0.90) and at 2 weeks, 1 month and 6 months post-surgery: 2.71±0.76, 3.29±1.11, and 4.00±0.82, respectively (P<0.01).

CONCLUSION

Supported with appropriate perioperative treatment measures, PKP is safe and effective in the treatment of pathological vertebral compression fracture due to extra-nodal lymphoma in HIV-positive patients.

Surgical Metastasectomy in the Spine: A Review Article

BACKGROUND

The use of surgical metastasectomy (SM) has increased across cancer types in recent decades despite the increasing efficacy of modern systemic treatment modalities. Symptomatic spinal metastases severely compromise patients' performance status. However, as spinal SM is a complex surgery with potentially significant complications, it is not considered the treatment of choice.

METHODS

We reviewed the articles on SM in several primary cancers with different types of metastatic lesions and extracted the data from relevant articles to provide a comprehensive review including the surgical techniques, indications, reported outcomes, and future prospects of SM in spinal metastases.

RESULTS

Total en bloc spondylectomy (TES) is a method of spinal SM associated with a lower risk of tumor recurrence and complications. Intralesional transpedicular osteotomy using a fine threadwire saw allows prevention of spinal cord and nerve root injuries. Spinal SM is considered suitable for patients with controlled primary disease having no evidence of disseminated extraspinal metastases, a completely resectable solitary lesion in the spine, and adequate cardiopulmonary reserve to tolerate the surgery. Metastatic lesions from kidney and thyroid cancers have been reported as the best candidates for spinal SM. Although data about spinal SM are limited, the reported outcomes are favorable with acceptable local recurrence rates in long-term follow-up.

CONCLUSION

In patients with isolated resectable spinal metastases, complete SM including TES is a useful option as it can improve function and survival. However, appropriate patient selection and surgical feasibility remain the most important aspects of management.

IMPLICATIONS FOR PRACTICE

Surgical metastasectomy for spinal metastases may be a potentially curative treatment option with a low risk of local recurrence and lead to prolonged long-term survival if appropriate patients are selected and if the surgery is carried out by experienced surgeons in high-volume centers.

En bloc resection and reconstruction of a huge chondrosarcoma involving multilevel upper thoracic spine and chest wall: case report

Background

En bloc resection of malignant tumors involving upper thoracic spine is technically difficult. We surgically treated a patient with grade 2 chondrosarcoma involving T1–5, left upper thoracic cavity, and chest wall.

Case presentation

A 37 years old, male patient was referred to our hospital for a huge lump involved left shoulder and chest wall. In order to achieve satisfied surgical margins, anterior approach, posterior approach, and lateral approach were carried out sequentially. After en bloc tumor resection, the upper thoracic spine was reconstructed with a 3D-printed modular vertebral prosthesis, and the huge chest wall defect was repaired by a methyl methacrylate layer between 2 pieces of polypropylene mesh. Postoperatively, the patient suffered from pneumonia and neurological deterioration which fully recovered eventfully. At 24 months after operation, the vertebral prosthesis and internal fixation were intact; there was no tumor local recurrence, and the patient was alive with stable pulmonary metastases.

Conclusion

This case report describes resection of a huge chondrosarcoma involving not only multilevel upper thoracic spine, but also entire left upper thoracic cavity and chest wall. Although with complications, en bloc tumor resection with combined surgical approach and effective reconstructions could improve oncologic and functional prognosis in carefully selected spinal tumor patients.

Preliminary Results of a 3D-Printed Modular Vertebral Prosthesis for Anterior Column Reconstruction after Multilevel Thoracolumbar Total En Bloc Spondylectomy

OBJECTIVE

To evaluate preliminary results of a 3D-printed modular prosthesis for spinal reconstruction after multilevel thoracolumbar total en bloc spondylectomy (TES).

METHODS

Patients with thoracolumbar spinal tumors treated surgically between January 2016 and April 2019 were included in this retrospective study. A total of 17 male and 10 female patients with a mean age of 42 (range, 15-72) years comprised the sample. The pathological diagnoses included six chondrosarcomas (one of them was mesenchymal chondrosarcoma), six giant cell tumors, three malignant peripheral nerve sheath tumors, two osteosarcomas, two undifferentiated high-grade pleomorphic sarcomas (UPS), two solitary fibrous tumors, one Ewing's sarcoma, one liposarcoma, and four metastatic tumors. Tumors involved 2 levels in 14 patients, 3 levels in seven patients, 4 levels in four patients, 5 levels in one patient, and 6 levels in one patient. A 3D-printed modular prosthesis was used for anterior column reconstruction after TES. All analyses were performed using SPSS version 18.0 (SPSS, Inc., Chicago, IL). Descriptive statistics were used to analyze the demographic data and clinical outcomes. Data forms included mean, standard deviation and range.

RESULTS

Under general anesthesia, all patients received TES with an average operative time of 639 (range, 210-1650) min, and the mean blood loss during operation was 4.1 (range, 0.8-13.3) L. Twenty-two patients have been transferred to ICU for a mean time of 3.2 (range, 0-6) d. All patients had follow-up procedures except for one, who died of perioperative complications. Mean time of follow-up was 22 (range, 12-41) months. Local recurrence (19.2%) occurred in two patients with intralesional margin and three patients with marginal margin, respectively. At the end of follow-up, three patients died of disease, eight patients were alive with disease, and 15 patients had no evidence of disease. Average lengths of resected vertebrae and modular prostheses were 71.4 ± 26.5 mm (range, 40-142 mm) and 68.4 ± 23.9 mm (range, 40-132 mm), respectively. In 26 patients with minimum follow-up of more than 1 year, no evidence of internal fixation failure or dislocation of vertebral prosthesis was found. Asymptomatic prosthetic subsidence into adjacent vertebral bodies occurred in 10 patients with a mean length of 1.8 ± 1.0 mm (range, 1-4 mm). The subsidence was seen at proximal end in two patients, distal end in four patients, and both ends in four patients. Eighteen major complications and 14 minor complications were found in 15 patients. All patients fully recovered at 3 or 6 months after operation. At the latest follow-up, in 23 alive patients, 19 can walk independently and two can achieve outdoor activities by walking aid.

CONCLUSION

For spinal reconstruction after multilevel thoracolumbar TES, 3D-printed modular vertebral prosthesis is suitable for different length of anterior column reconstruction with less mechanical complications, and can provide a stable environment to maintain or rehabilitate patients' neurological function in short-term follow-up.

The use of autologous free vascularized fibula grafts in reconstruction of the mobile spine following tumor resection: surgical technique and outcomes

OBJECTIVE

Reconstruction of the mobile spine following total en bloc spondylectomy (TES) of one or multiple vertebral bodies in patients with malignant spinal tumors is a challenging procedure with high failure rates. A common reason for reconstructive failure is nonunion, which becomes more problematic when using local radiation therapy. Radiotherapy is an integral part of the management of primary malignant osseous tumors in the spine. Vascularized grafts may help prevent nonunion in the radiotherapy setting. The authors have utilized free vascularized fibular grafts (FVFGs) for reconstruction of the spine following TES. The purpose of this article is to describe the surgical technique for vascularized reconstruction of defects after TES. Additionally, the outcomes of consecutive cases treated with this technique are reported.

METHODS

Thirty-nine patients were treated at the authors' tertiary care institution for malignant tumors in the mobile spine using FVFG following TES between 2010 and 2018. Postoperative union, reoperations, complications, neurological outcome, and survival were reported. The median follow-up duration was 50 months (range 14-109 months).

RESULTS

The cohort consisted of 26 males (67%), and the median age was 58 years. Chordoma was the most prevalent tumor (67%), and the lumbar spine was most affected (46%). Complete union was seen in 26 patients (76%), the overall complication rate was 54%, and implant failure was the most common complication, with 13 patients (33%) affected. In 18 patients (46%), one or more reoperations were needed, and the fixation was surgically revised 15 times (42% of reoperations) in 10 patients (26%). A reconstruction below the L1 vertebra had a higher proportion of implant failure (67%; 8 of 12 patients) compared with higher resections (21%; 5 of 24 patients) (p = 0.011). Graft length, number of resected vertebrae, and docking the FVFG on the endplate or cancellous bone was not associated with union or implant failure on univariate analysis.

CONCLUSIONS

The FVFG is an effective reconstruction technique, particularly in the cervicothoracic spine. However, high implant failure rates in the lumbar spine have been seen, which occurred even in cases in which the graft completely healed. Methods to increase the weight-bearing capacity of the graft in the lumbar spine should be considered in these reconstructions. Overall, the rates of failure and revision surgery for FVFG compare with previous reports on reconstruction after TES.

Should Denosumab or Radical Surgery Be Recommended for a Spinal Giant Cell Tumour in a Fertile Female?

Giant cell tumour (GCT) of the spine is a benign aggressive tumour with high recurrence rates. Patients can be asymptomatic due to the slow growth rate and present with localized pain or neurological dysfunction. Current management strategies include intralesional curettage, total en-bloc resection (TER) and denosumab therapy. Treatment strategies can be particularly challenging in women of childbearing age who wish to conceive, as the risks of tumour recurrence need to be balanced against the fetal complications associated with adjuvant denosumab therapy. This case report discusses the management options and controversies for women of childbearing age with GCT of the thoracic spine. Clinicians need to be aware of the complications associated with TER and denosumab treatment when managing GCTs of the spine in young females.

Evaluation of the Metastatic Spine Disease Multidisciplinary Working Group Algorithms as Part of a Multidisciplinary Spine Tumor Conference

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The Metastatic Spine Disease Multidisciplinary Working Group Algorithms are evidence and expert opinion-based strategies for utilizing radiation therapy, interventional radiology procedures, and surgery to treat 5 types of spine metastases: asymptomatic spinal metastases, uncomplicated spinal metastases, stable vertebral compression fractures (VCF), unstable VCF, and metastatic epidural spinal cord compression (MESCC). Evaluation of this set of algorithms in a clinical setting is lacking. The authors aimed to identify rate of treatment adherence to the Working Group Algorithms and, subsequently, update these algorithms based on actual patient management decisions made at a single-institution, multidisciplinary, spine tumor conference.

METHODS

Patients with metastatic spine disease from primary non-hematologic malignancies discussed at an institutional spine tumor conference from 2013 to 2016 were evaluated. Rates of Working Group Algorithms adherence were calculated for each type of metastasis. Based on the reasons for algorithm nonadherence, and patient outcomes in such cases, updated Working Group Algorithms recommendations were proposed.

RESULTS

In total, 154 eligible patients with 171 spine metastases were evaluated. Rates of algorithm adherence were as follows: asymptomatic (67%), uncomplicated (73%), stable VCF (20%), unstable VCF (32%), and MESCC (41%). The most common deviation from the Working Group Algorithms was surgery for MESCC despite poor prognostic factors, but this treatment strategy was supported based on median survival surpassing 6 months in these patients.

CONCLUSIONS

Adherence to the Working Group Algorithm was lowest for MESCC and VCF patients, but many nonadherent treatments were supported by patient survival outcomes. We proposed updates to the Working Group Algorithm based on these findings.

Prognostic factors for spinal chordomas and chondrosarcomas treated with postoperative pencil-beam scanning proton therapy: a large, single-institution experience

OBJECTIVE

The aim of this paper was to evaluate the prognostic factors in surgical and adjuvant care for spinal chordomas and chondrosarcomas after surgery followed by high-dose pencil-beam scanning proton therapy (PBS-PT).

METHODS

From 1997 to 2016, 155 patients (61 female patients; median age 55 years) with spinal (cervical, n = 61; thoracic, n = 29; lumbar, n = 13; sacral, n = 46; pelvic, n = 6) classic chordomas (n = 116) and chondrosarcomas (n = 39; most were low grade) were treated with maximal safe resection followed by PBS-PT (median dose prescribed: 74 Gy [relative biological effectiveness], range 48.6-77 Gy). The majority of patients (n = 153, 98.7%) had undergone at least 1 resection prior to PBS-PT (median 1, range 0-5; biopsy only, n = 2). Fewer than half (45.1%) of the surgeries were rated as gross-total resections (GTRs) prior to PBS-PT. Surgical stabilization (SS) was present in 39% of all patients (n = 60). Ninety-one patients (59%) presented with macroscopic tumor at the start of PBS-PT. The median follow-up duration was 64.7 months (range 12.2-204.8 months).

RESULTS

The 5-year local tumor control, disease-free survival (DFS), and overall survival were 64.9% (95% CI 56.3%-73.5%), 59.4% (95% CI 50.6%-68.2%), and 77.9% (95% CI 70.6%-85.2%), respectively. In total, 63 patients (40.6%) experienced failure during the follow-up period: local only in 32 (20.6%), distal only in 7 (4.5%), local + distal in 19 (12.3%), surgical pathway failure (SPF) only in 2 (1.3%), local + SPF in 2 (1.3%), and distal + SPF in 1 (< 1%). Univariate analysis identified gross residual disease, the presence of SS, and treatment era prior to 2008 as highly significant for worse outcome, with all 3 remaining significant on multivariate analysis. The type of surgery (GTR or subtotal resection/biopsy) and whether GTR was achieved by en bloc or curettage did not show a significant prognostic effect. Surgical complications prior to PBS-PT were present in 42.5% of all surgically treated patients and were seen more commonly in patients with multiple surgical interventions (p = 0.005) and those operated on with the intent of en bloc resection (p = 0.006).

CONCLUSIONS

The extent of resection and metallic stabilization substantially influenced clinical outcomes for patients with spinal chordoma or chondrosarcoma despite high-dose adjuvant PBS-PT. Optimal upfront surgical management of these tumors continues to include GTR, as possible, with prompt adjuvant proton therapy.

The Neurology-Stability-Epidural compression assessment: A new score to establish the need for surgery in spinal metastases

OBJECTIVE

The aim of this study was to translate new evidence about management of spinal metastases in a practical and reliable score for surgeons, radiation oncologists and oncologists, able to establish the need for surgery regardless the available technology and settings.

PATIENTS AND METHODS

Three main items were identified and graded: Neurological status (0-5 points), Stability of the spine according to the Spinal Instability Neoplastic Score (SINS) Score (0-5 points), and Epidural compression according to the Epidural Spinal Cord Compression (ESCC) scale (0-3 points). Patients were considered suitable for surgery with ASA score < 4 and ECOG score <3. A retrospective clinical validation of the NSE score was made on 145 patients that underwent surgical or non surgical treatment.

RESULTS

Agreement between the undertaken treatment and the score (88.3% of patients), resulted in a strong association with improvement or preservation of clinical status (neurological functions and mechanical pain) (p < 0.001) at 3 and 6 months. In the non-agreement group no association was recorded at the 3 and 6 months follow-up (p 0.486 and 0.343 for neurological functions, 0.063 and 0.858 for mechanical pain).

CONCLUSION

Functional outcomes of the study group showed that the proposed NSE score could represent a practical and reliable tool to establish the need for surgery. Agreement between the score and the performed treatments resulted in better clinical outcomes, when compared with patients without agreement. Further validation is needed with a larger number of patients and to assess reproducibility among surgeons, radiation oncologists, and oncologists.

Patient Characteristics Following Surgery for Spinal Metastases: A Multicenter Retrospective Study

Objectives

To summarize the epidemiological characteristics of patients following surgery for spinal metastases retrospectively and make a univariate analysis to identify independent variables that could affect the operation decision making.

Methods

This was a multicenter retrospective review of patients with spinal metastasis who were treated with surgery from 1 January 2007 to 31 July 2019. Basic clinical data were analyzed retrospectively by univariate analysis to identify independent variables that could affect the decision of operation modalities, including gender, age, spinal metastatic site, Frankel score, Karnofsky performance score (KPS), spinal instability neoplastic score (SINS), visual analogue scale (VAS), Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, primary tumor, extraspinal metastasis, visceral metastasis, and bone lesion (osteolytic, osteoblastic or mixed).

Results

A total of 580 patients including 332 males and 248 females were enrolled in the study with an average age of 58.26 years old (range, 13–86 years old). The most common spinal metastatic level was the thoracic vertebra (190 [32.76%]), followed by the lumbar vertebra (146 [25.17%]), cervical vertebra (47 [8.10%]), and sacral vertebra (35 [6.03%]). Metastases involving more than two sites of the cervical, thoracic, lumbar, and sacral vertebrae arose in 162 (27.93%) patients. For primary tumor, there were 198 (34.14%) cases of lung cancer, 41 (7.07%) cases of kidney cancer, 39 (6.72%) cases of breast cancer, 38 (6.55%) cases of gastrointestinal cancer, 35 (6.03%) cases of lymphoma and myeloma, 25 (4.31%) cases of prostate cancer, 24 (4.14%) cases of liver cancer, 23 (3.97%) cases of mesenchymal tissue sarcoma, 20 (3.45%) cases of thyroid cancer, and 84 (14.48%) cases were tumor with unknown origin. Sixty‐three (10.86%) patients received minimally invasive surgery, 460 (79.31%) patients received palliative surgery, and the remaining 57 (9.83%) received tumor resection. According to the univariate analysis, the KPS score, SINS score, VAS score, Tokuhashi score, urinary and fecal incontinence, spinal pathological fracture, and bone lesion (osteolytic, osteoblastic or mixed) were independent and favorable factors affecting the surgery modalities.

Conclusions

Surgical treatment for spinal metastases was mainly to relieve pain, rebuild spinal stability, improve nerve function, control local tumors, and improve the quality of life of patients. For middle‐aged and elderly patients with good general conditions, severe pain, spinal pathological fracture, spine instability and without urinary and fecal incontinence, early surgical treatment should be actively carried out.

Stent screw-assisted internal fixation (SAIF): clinical report of a novel approach to stabilizing and internally fixating vertebrae destroyed by malignancy

OBJECTIVE

Severe lytic cancerous lesions of the spine are associated with significant morbidity and treatment challenges. Stabilization and restoration of the axial load capability of the vertebral body (VB) are important to prevent or arrest vertebral collapse. Percutaneous stent screw-assisted internal fixation (SAIF), which anchors a VB stent/cement complex with pedicular screws to the posterior vertebral elements, is a minimally invasive, image-guided, 360° internal fixation technique that can be utilized in this patient cohort. The purpose of this study was to assess the feasibility, safety, and stabilization efficacy of VB reconstruction via the SAIF technique in a cohort of patients with extensive lytic vertebral lesions, who were considered to have an unstable or potentially unstable spine according to the Spinal Instability Neoplastic Score (SINS).

METHODS

This study was a retrospective assessment of a prospectively maintained database of a consecutive series of patients with neoplastic extensive extracompartmental osteolysis (Tomita type 4-6) of the VB treated with the SAIF technique. VB reconstruction was assessed on postprocedure plain radiographs and CT by two independent raters. Technical and clinical complications were recorded. Clinical and imaging follow-ups were assessed.

RESULTS

Thirty-five patients with extensive osteolytic metastatic lesions of the VB underwent 36 SAIF procedures. SAIF was performed as a stand-alone procedure in 31/36 cases and was associated with posterior surgical fixation in 5/36 (4/5 with decompressive laminectomy). In 1 case an epidural cement leak required surgical decompression. VB reconstruction was categorized as satisfactory (excellent or good rating) by the two raters in 34/36 cases (94.5%) with an interrater reliability of 94.4% (Cohen's kappa of 0.8). Follow-up, ranging from 1 to 30 months, was available for 30/36 levels. Long-term follow-up (6-30 months, mean 11.5 months) was available for 16/36 levels. Stability during follow-up was noted in 29/30 cases.

CONCLUSIONS

SAIF provides 360° nonfusion internal fixation that stabilizes the VB in patients with extensive lytic lesions that would otherwise be challenging to treat.

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

INTRODUCTION

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

MATERIALS AND METHODS AND RESULTS

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

CONCLUSIONS

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

Surgical Strategies for Chordoma

Chordomas are rare tumors of the axial skeleton whose slow growth belies a relentless tumor with a propensity for recurrence and late metastasis. Local control remains an issue with chordoma in spite of aggressive operative management. High local failure rates have led to the exploration of alternative methods of treatment. Radiation continues to gain acceptance as an adjuvant to surgery and, in some cases, as a standalone treatment. However, the use of radiation remains controversial, and operative management remains the standard of care in spite of relatively high morbidity.

Composite peek/carbon fiber pre-shaped rods and sublaminar bands for posterior stabilization of cervico-thoracic junction: A novel technique

The combination of surgery plus radiotherapy is a valid treatment option when en bloc resection with wide margins is not feasible. The aim of this paper is to show a novel technique for fixation of cervico-thoracic junction with carbon fiber reinforced peek pre-shaped rods with sublaminar bands in order to guarantee cervical spine stability and particle therapy efficacy. A 42 years-old man with a Sclerosing Epithelioid Fibrosarcoma (SEF) arising from C7, involving the right latero-cervical region from C5 to the apex of the right lung, underwent an en bloc resection with a double approach (anterior plus posterior). Fixation of cervical spine was achieved with composite PEEK/carbon fiber rods connected to C4 and T2 laminae with sublaminar bands. After surgery, the patient received 9 cycles of chemotherapy (cisplatin, etoposide and adriamycin) and proton therapy. At 2 years follow-up, no local recurrence was detected with implant stability demonstrating no mechanical failure. The main issues related to this case were: planning en bloc resection able to achieve an Enneking appropriate margin; incorporate in the decision making process the functional loss related to the sacrifice of neurological structures infiltrated by the tumor; establish a therapeutic strategy that included, in addition to surgery, adjuvant chemotherapy and radiotherapy for improving local and systemic control; stabilize with implants that do not interfere with accelerated particle radiotherapy.

Percutaneous Interventional Management of Spinal Metastasis

Spinal metastasis is usually associated with debilitating pain and results in deteriorating life quality. The role of percutaneous management of spinal metastasis has evolved from a diagnostic role to a significant part of therapeutic options in conjunction with conventional management techniques, including radiotherapy and open surgical options. Percutaneous vertebral augmentation (PVA) showed substantial pain reduction, vertebral stabilization, and improvement of quality of life. Minimally invasive local ablative procedures (MILAPs) demonstrated significant pain reduction, local tumor burden control, and improvement of quality of life. Though combined PVA and MILAP's synergistic role in pain reduction may need additional investigation, considering different actions on spine metastasis patients, combining both techniques might beneficial to selected patients. The role of percutaneous management will likely expand since its role in improving patient's quality of life with very minimal procedure-related risk and in conjunction with future technological advancement.

Clinical effectiveness of Enneking appropriate versus Enneking inappropriate procedure in patients with primary osteosarcoma of the spine: a systematic review with meta-analysis

PURPOSE

Primary osteosarcoma of the spine is a rare osseous tumour. En bloc resection, in contrast to intralesional resection, is the only procedure able to provide Enneking appropriate (EA) margins, which has improved local control and survival of patients with primary osteosarcoma of the spine. The objective of this study is to compare the risk of local recurrence, metastases development and survival in patients with primary osteosarcoma of the spine submitted to Enneking appropriate (EA) and Enneking inappropriate (EI) procedures.

METHODS

A systematic search was performed on EBSCO, PubMed and Web of Science, between 1966 and 2018, to identify studies evaluating patients submitted to resection of primary osteosarcoma of the spine. Two reviewers independently assessed all reports. The outcomes were local recurrence, metastases development and survival at 12, 24 and 60 months.

RESULTS

Five studies (108 patients) were included for systematic review. These studies support the conclusion that EA procedure has a lower local recurrence rate (RR 0.33, 95% CI 0.17-0.66), a lower metastases development rate (RR 0.39, 95% CI 0.17-0.89) and a higher survival rate at 24 months (RR 1.78, 95% CI 1.24-2.55) and 60 months (RR 1.97, 95% CI 1.14-3.42) of follow-up; however, at 12 months, there is a non-significant difference.

CONCLUSIONS

EA procedure increases the ratio of remission and survival after 24 months of follow-up. Multidisciplinary oncologic groups should weigh the morbidity of an en bloc resection, knowing that in the first year the probability of survival is the same for EA and EI procedures. These slides can be retrieved under Electronic Supplementary Material.

Spinal metastasis: diagnosis, management and follow-up

Spine metastatic disease is an increasingly common occurrence in cancer patients due to improved patient survival. Close proximity of the bony spinal column to the spinal cord limits many conventional treatments for metastatic disease. In the past decade, we have witnessed dramatic advancements in therapies, with improvements in surgical techniques and recent adoption of spine stereotactic radiotherapy techniques leading to improved patient outcomes. Multidisciplinary approaches to patient evaluation, treatment and follow-up are essential. Imaging plays an ever increasing role in disease detection, pre-treatment planning and assessment of patient outcomes. It is important for the radiologist to be familiar with imaging algorithms, best practices for surgery and/or radiotherapy and imaging findings in the post-treatment period that may indicate disease recurrence. In this review, we present a multidisciplinary discussion of spine metastases, with specific focus on pre-treatment imaging, planning, current treatment approaches, and post-treatment assessment.

Total en bloc resection of primary and metastatic spine tumors

Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "en bloc" offers a more aggressive modality over more conservative resection techniques. En bloc resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of en bloc resection, as well as specific indications and considerations when employing this operative technique.

Mini-open Lateral En Bloc Corpectomy: Cadaveric Feasibility and Early Clinical Experience

BACKGROUND

Open approaches to the thoracolumbar spine for en bloc vertebral body tumor resection are associated with significant surgical morbidity. Less invasive surgical techniques may reduce complications.

OBJECTIVE

To present our experience with a staged posterior midline and mini-open anterolateral extracoelomic approach to en bloc corpectomy for vertebral body tumor resection in cadaver specimens and patients.

MATERIALS AND METHODS

The feasibility and safety of the staged posterior midline and mini-open anterolateral extracoelomic approach were evaluated in 3 cadaveric specimens. The procedure was performed at 3 levels (L1-L3) in each cadaver specimen (9 levels) and then in 1 clinical case. The cadaveric neurovascular structures were evaluated for tissue injury, whereas the operative experience, patient complications, and early surgical and clinical outcomes were reviewed.

RESULTS

The approach allowed for en bloc corpectomy without any injury to the cadaveric neurovascular structures. The procedure was reproducible in the clinical setting, which showed favorable clinical and radiographic patient outcomes.

CONCLUSIONS

Early clinical experience suggests the staged posterior midline and mini-open anterolateral extracoelomic approach is feasible and safe for en bloc tumor resection compared with open techniques with related morbidity. Long-term studies are needed to understand the strengths and limitations of this technique.

Prognostic Factors for Patients With Undifferentiated High Grade Pleomorphic Sarcoma of the Spine

STUDY DESIGN

Retrospective survival analysis of 44 undifferentiated high grade pleomorphic sarcoma (UPS) of the spine.

OBJECTIVE

To identify factors related to overall survival (OS) and help decision making in the treatment of undifferentiated high grade pleomorphic sarcoma of the spine.

SUMMARY OF BACKGROUND DATA

UPS is an aggressive malignant tumor rarely originating from the spine. Due to its scarcity, only a few studies had been reported to describe the clinical features, treatments, and outcomes of sporadic cases, devoid of evaluation on prognostic factors.

METHODS

Enrolled in this survival analysis were 44 patients who underwent surgery and adjuvant therapies from January 1999 to December 2015. Kaplan-Meier methods were applied to estimate the overall survival. A multivariate Cox algorithm was applied to recognize factors independently associated with overall survival.

RESULTS

Multivariate analysis suggested that age greater than or equal to 55 years (hazard ratio [HR], 3.923, P < 0.001), Eastern Cooperative Oncology Group (ECOG) score four (HR, 4.656, P < 0.001), and subtotal resection or piecemeal total resection (HR, 4.375, P < 0.001) were independently associated with poor overall survival.

CONCLUSION

We identified independent prognostic factors of UPS of the spine. Subtotal resection or piecemeal total resection, age more than or equal to 55 years and ECOG score four are factors adversely affecting overall survival of patients with UPS of the spine.

LEVEL OF EVIDENCE

4.

Surgical Approach to Bone Metastases

PURPOSE OF REVIEW

The purpose of this review was to examine the recent changes in the surgical treatment of bone metastases and how the treatment paradigm has shifted with the improvement of adjuvant therapies. How surgery fits into the local and systemic treatment was reviewed for bone metastases in different areas.

RECENT FINDINGS

The more common use of targeted chemotherapies and focused high-dose radiation have altered the treatment paradigm of bone metastases. Overall changes in the surgical treatment of bone metastases have been driven by an increased multidisciplinary approach to metastatic cancer and the awareness that one type of surgery does not work for all patients. The individual patient treatment goals dictate the surgical procedures used to achieve these goals. Advancements in adjuvant therapy-like radiation and more targeted chemotherapies have allowed for less invasive surgical approaches and therefore faster recoveries and reduced surgical morbidity for patients.

An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report

Spinal metastases are becoming increasingly common because patients with metastatic disease are living longer. The close proximity of the spinal cord to the vertebral column limits many conventional therapeutic options that can otherwise be used to treat cancer. In response to this problem, an innovative multidisciplinary approach has been developed for the management of spinal metastases, leveraging the capabilities of image-guided stereotactic radiosurgery, separation surgery, vertebroplasty, and minimally invasive local ablative approaches. In this Review, we discuss the variables that should be considered during the management of these patients and review the role of each discipline and their respective management options to provide optimal care. This work is synthesised into a practical algorithm to aid clinicians in the management of patients with spinal metastasis.