A Novel Technique for Total En bloc Spondylectomy of the Fifth Lumbar Tumor Through Posterior-Only Approach

Modified Standard Total en bloc Spondylectomy for Solitary Thoracic or Lumbar Spinal Metastasis: A 1-Stage Posterior Approach Under Direct Visualization

BACKGROUND

Solitary spinal metastasis (SM) is one of the indications for total en bloc spondylectomy (TES). Conventional TES carries the risk of damage to the great vessels anterior to the vertebral column, mainly because of a lack of visualization of the anterior structures. In this study, we devised a modified standard TES technique to achieve direct visualization in a 1-stage posterior approach.

METHODS

Included in this study were patients ≥18 years old with solitary thoracic or lumbar SM who underwent the modified standard TES at our institution between January 2017 and October 2022. Patient data were retrospectively sourced from medical records, and patients had a minimum of 3 months of postoperative follow-up.

RESULTS

This study involved 71 East Asian patients (median age, 57 years; 34 males), comprising 38 patients with thoracic SM and 33 with lumbar SM. Lung cancer was the most common tumor histology. Fourteen patients (19.7%) experienced intraoperative complications; pleural rupture was the predominant complication, and there were no cases of injury to the spinal cord or great vessels. The median operative time was 305 minutes (range, 203 to 660 minutes). The median intraoperative blood loss was 1,000 mL (range, 400 to 4,000 mL). The median perioperative blood transfusion was 4 units (range, 0 to 12 units), and the median hospitalization duration was 17 days (range, 14 to 29 days). Additionally, 27 patients (38.0%) had acute (perioperative) complications. Seven patients were lost to follow-up. Significant clinical improvement was achieved 3 months postoperatively. Postoperative early and late complications were observed in 5 patients. Of the 64 patients with completed follow-up, 47 (73.4%) had negative surgical margins, and none received postoperative radiation therapy. Revision surgery for local tumor recurrence was performed in 4.7% of patients. The median follow-up was 31.5 months (range, 3 to 81 months).

CONCLUSIONS

Our modified standard TES was demonstrated to be a safe and effective surgical technique for solitary thoracolumbar SM.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An improved total en bloc spondylectomy for L5 vertebral giant cell tumor through a single-stage posterior approach

PURPOSE

Although total en bloc spondylectomy (TES) is strongly recommended for spinal giant cell tumor (GCT), it is extremely difficult to excise a L5 neoplasm intactly through the single-stage posterior approach. Given the risk of neurological and vascular injury, intralesional curettage (IC) is usually recommended for the treatment of L5 GCT. In this study, we presented our experience with the use of an improved TES to treat L5 GCT through the single-stage posterior approach.

METHODS

This study included 20 patients with L5 GCT who received surgical treatment in our department between September 2010 and April 2021. Of them, seven patients received improved TES without iliac osteotomy, and the other 13 patients received IC (n = 8), sagittal en bloc resection (n = 1), TES with iliac osteotomy (n = 3), and TES with radicotomy (n = 1) as control.

RESULTS

The mean operative time was 331.43 ± 92.95 min for improved TES group and 365.77 ± 85.17 min for the control group (p = 0.415), with the mean blood loss of 1142.86 ± 340.87 ml vs. 1969.23 ± 563.30 ml (p = 0.002). Postoperative treatment included bisphosphonates in nine patients and denosumab in 12 patients including one patient who changed from bisphosphonates to denosumab. Three patients who received IC experienced local recurrence, and no relapse was observed in improved TES group.

CONCLUSION

Single-stage posterior TES for L5 GCT was previously considered impossible. In this study, we presented our experience with the use of an improved surgical technique for L5 TES through the single-stage posterior approach, which has proved to be superior to the conventional procedures in terms of blood loss control and complication and recurrence rates.

LEVEL OF EVIDENCE

IV.

Modified Total en Bloc Spondylectomy with Self-Made Intervertebral Hook Blade in Spinal Tumors: A Retrospective Study

OBJECTIVE

Total en bloc spondylectomy (TES) is an important surgical treatment for spinal tumors that can achieve en bloc resection of the affected vertebral body by using the T-saw. However, the conventional TES process and the surgical instruments currently in use have some inconveniences, which may lead to longer operative times and a higher incidence of complications. To address these obstacles, we developed a modified TES technique using a homemade intervertebral hook blade. The objectives of this study were to describe our modified total en bloc spondylectomy (TES) using a homemade intervertebral hook blade and to assess its clinical effects in patients with spinal tumors.

METHODS

Twenty-three consecutive patients with spinal tumors were included from September 2018 to November 2021. Eleven patients underwent a modified TES using an intervertebral hook blade, and 12 patients underwent a conventional TES using a wire saw. Details of the modified technique for TES were depicted, and the intraoperative blood loss, operative time, and improvement in pain symptom and neurological function measured by visual analog score (VAS) and American Spinal Injury Association (ASIA) score of all patients was reviewed and analyzed. Nonparametric analysis of covariates (ANCOVA) was performed to compare the clinical outcomes between patients treated with modified TES and conventional TES.

RESULTS

The modified TES significantly reduced operative time (F = 7.935, p = 0.010) and achieved favorable improvement of neurological function (F = 0.570, p = 0.459) and relief of pain (F = 3.196, p = 0.088) compared with the conventional TES group. The mean intraoperative blood loss in the modified TES group (2381.82 ml) was lower than that in the conventional TES group (3558.33 ml), although the difference was not statistically significant (F = 0.677, p = 0.420).

CONCLUSIONS

Modified TES using the intervertebral hook blade can effectively reduce the operation time and intraoperative bleeding, and meanwhile ensure the improvement of neurological function and relief of pain symptoms, suggesting that this modified technique is feasible, safe, and effective for spinal tumors.

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.

Total en bloc spondylectomy for the L5 metastasis of a carcinoid tumor: illustrative case

BACKGROUND

Total en bloc spondylectomy (TES) was designed to achieve oncological complete tumor resection in a vertebral compartment. Because of the special anatomy of the lumbosacral junction, TES procedure at the L5 level is a challenge, and it has been explained in few reports in the literature. Performing TES in the lower lumbar region, as normal, is accomplished by using a combined approach.

OBSERVATIONS

The authors presented the case of a 20-year-old man with an isolated spinal metastasis at the L5 level of carcinoid tumor of jejunum, limited to the vertebral body. Due to good long-term prognosis, after multidisciplinary evaluation the authors decided to treat the patient with TES through a combined posteroanterior approach, with posterior instrumentation and anterior reconstruction. Nine years after surgery, the patient was asymptomatic, with no sign of local recurrence.

LESSONS

TES is a feasible technique to provide long-term survival in a select subgroup of patients, reducing the risk of local recurrence. The authors presented some anatomical and biomechanical factors that must be considered at the lumbosacral region. Despite the high rates of complication associated with TES, most patients benefit from local control provided by the technique.

Surgical approaches to L5 corpectomy: a systematic review

INTRODUCTION

Surgical approaches to pathologies of the L5 vertebra constitute a significant challenge. Our aim was to review the efficacy and safety of the surgical approaches to L5 corpectomy and reconstruction across the range of presenting pathology.

MATERIALS AND METHODS

This systematic review was conducted according to PRISMA guidelines, and databases were searched from 1970 to January 2020. The search inclusion criteria were L5 Corpectomy AND/OR Spondylectomy AND/OR Vertebrectomy. The outcome measures studied were length of surgery, blood loss, fusion or failure of fusion/instrumentation, complications and mortality.

RESULTS

Initial 36 articles were identified, and final 6 studies met our inclusion criteria. The mean reported blood loss was 2265 ml (400-4700 ml) and was higher for the two-stage posterior-anterior surgery group than the posterior-only surgery group (mean 3230 mls vs. 1260 mls) but not the operative time. All surgical approaches shared high fusion rates (94%) and relatively low complication rates (11.7%). However, surgical strategies incorporating an anterior approach were notable for vascular complications (4-7%), as well as perioperative mortality (9%) not seen in the posterior-only surgery group.

CONCLUSION

Where there is clinical and circumstantial equipoise regarding the choice of surgical approaches for a L5 corpectomy, this review indicates a reported mean blood loss of 2265 ml (400-4700 ml), high fusion rates (94%) and relatively low complication rates (11.7%). It is difficult to make direct comparisons between approaches due to small case series, the variability in primary pathology, clinical intent and surgeon experience.

Median Sacral Artery Rupture as a Complication of Posterior-Only Approach of L4 Total En Bloc Spondilectomy: A Case Report

CASE

A 6-year-old patient with Ewing sarcoma at L4 who was treated with total en bloc spondilectomy (TES) through a posterior-only approach. During the dissection of the anterior L4 body, there was uncontrollable bleeding from an unknown origin, which needed packing, massive transfusion, and urgent laparotomy. A median sacral artery (MSA) rupture was identified as the cause of this massive bleeding. Eventually, the patient was successfully stabilized.

CONCLUSIONS

To our knowledge, this is the first reported intraoperative bleeding of the MSA related to a lumbar TES through posterior-only approach. This life-threatening complication should be considered when planning for this type of surgery.

The first total vertebral involvement of benign fibrous histiocytoma: A case report and literature review

BACKGROUND

Benign fibrous histiocytoma (BFH) is a rare bone tumor, extremely seldom in the spine.

METHODS

We present a 52-year-old patient diagnosed with a BFH in the thoracic spine treated with total en bloc spondylectomy. A review of the published literature was also conducted.

RESULTS

Non-ossifying fibroma (NOF) and BFH are named as one tumor called NOF/BFH. A total of 20 spinal BFHs have been previously reported, mainly involving the posterior elements. We present a BFH with total vertebral involvement. Curettage and excision are the main treatment options with limited recurrence.

CONCLUSIONS

This is the first total vertebral BFH up to now. Spinal BFH occupies rather low aggressiveness. With rather limited recurrence and malignant degeneration, surgical interventions seem enough for its management.

Total En Bloc Spondylectomy for the Fifth Lumbar Solitary Metastasis by a Posterior-Only Approach

BACKGROUND

Relatively few cases of total en bloc spondylectomy (TES) for the L5 tumors have been reported. TES in the lower lumbar region is usually performed through a combined anterior and posterior approach. TES for L5 tumors by a posterior-only approach is technically challenging.

CASE DESCRIPTION

A 62-year-old woman with persistent pain in her lumbosacral area and lower extremities and numbness of her lateral left lower extremity for 2 months came to our department. She had undergone radical mastectomy 4 years earlier. X-ray and magnetic resonance imaging (MRI) showed that the tumor had destroyed the vertebral body of L5. No other lesions were revealed by emission computed tomography (ECT) or positron emission tomography/computed tomography (PET/CT). With a diagnosis of breast cancer and a solitary metastasis to L5, the patient was treated with posterior-only TES of the L5 tumor and reconstruction. The whole procedure took 10 hours, and her intraoperative blood loss was 9000 mL. The lumbar and leg pain of the patient disappeared postoperatively without serious complications. She started walking 4 weeks after surgery and resumed her daily life. New multiple metastases developed 6 months after surgery, with no sign of local recurrence. Despite active treatment, she died 18 months after surgery.

CONCLUSION

TES of the L5 tumor can be achieved by a posterior-only approach, with good results and limited complications.