Modified En Bloc Spondylectomy for Tumors of the Thoracic and Lumbar Spine: Surgical Technique and Outcomes

Safety and risk analysis of total resection surgery for thoracic and lumbar spinal tumors: a decadal analysis of 103 cases

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To explore the complications and risk factors for total resection (TR) of primary thoracic and lumbar spinal tumors over the past decade at our institution.

METHODS

Patients meeting inclusion criteria (primary spinal tumors, thoracic or lumbar location, TR at our center) were included. Demographic characteristics, surgical data, perioperative complications and management results were reviewed. Patients were stratified by tumor site, the number of excised segments, and recurrence status to elucidate distinctive characteristics.

RESULTS

The cohort comprised 103 patients, with a mean age of 35.8 years. On average, 1.83 vertebral segments were resected per patient. Perioperative complications were substantial, totaling 166 events, with 71 classified as major and 95 as minor, yielding an average of 1.61 complications per patient. No perioperative deaths occurred, but 79 patients (76.7%) experienced at least one complication. Multiple vertebral sections correlated with a higher complication rate (P = 0.031), and lumbar surgeries exhibited elevated risks of large vascular injury (P = 0.001), neurological deterioration, and cerebrospinal fluid leakage compared to thoracic cases. Conversely, thoracic spinal procedures showed a higher rate of pleural effusion (P = 0.004). Binary logistics stepwise regression identified multi-segmental resection as the independent risk factor for major perioperative complications.

CONCLUSIONS

TR of primary spinal tumors is associated with a high perioperative complication rate, although most events have a favorable prognosis. Complication characteristics vary based on the surgical site, number of excised segments, and surgical history. A nuanced preoperative evaluating approach considering patient age, surgical segments, and extent of resection is crucial.

Single-Stage Combined Approach Sagittal En Bloc Spondylectomy for L3 Vertebral Chondrosarcoma: A Technical Note

BACKGROUND

Primary malignant tumors of the spine are rare and most commonly occur in lumbar and thoracic vertebrae. We report a rare case of retroperitoneal chondrosarcoma of L3 that was managed with sagittal en bloc spondylectomy following chemoradiation.

CASE DESCRIPTION

A 26-year-old woman was evaluated for abdominal pain with contrast-enhanced computed tomography of the abdomen and pelvis, which revealed a soft tissue retroperitoneal mass arising from L3. She underwent laparotomy and biopsy, which revealed chondrosarcoma, and she received chemoradiation over a period of 28 weeks 6 days. After repeat imaging, she underwent single-stage combined approach sagittal en bloc spondylectomy of retroperitoneal chondrosarcoma of L3 with right nephrectomy and spine reconstruction. At 3-year follow-up, there was no evidence of recurrence on contrast-enhanced computed tomography of the abdomen and pelvis. She demonstrated no gait abnormality or spinal deformity.

CONCLUSIONS

Sagittal en bloc spondylectomy is a preferred surgical approach for eccentrically placed spinal tumors that offers better oncological and functional outcomes.

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.

New technique of En bloc vertebral resection in the thoracolumbar region assisted by retroperitoneal laparoscopy in a single prone position: first results

PURPOSE

To describe the technique and review the oncological and surgical results of the En Bloc resection assisted by retroperitoneal laparoscopy in a single prone position for tumors in the thoracolumbar region.

METHODS

Monocentric retrospective case study. Procedure was performed in a single prone position by a dual team of spine and thoracovascular surgeons. An endoscopic balloon was inflated in the right retroperitoneal cavity. A plan was developed between the anterior spine and vena cava as well as abdominal aorta with segmental vessels ligation. Structures at risk were safely protected under endoscopy during horizontal or sagittal osteotomies.

RESULTS

From 2021, seven patients aged a median 52 years old (range, 34-67) were included. Involved spinal segments went from T11 to L3. Surgery was aborted in one case due to massive bleeding and ventilating difficulties. There were two partial and four total vertebral resections. Median operating duration and estimated blood loss were 405 min (range, 360-540) and 2.1 L (range, 1.2-19), respectively. Postoperative complications consisted of 1 urinary infection; 1 transient urinary retention; 1 posterior wound infection; 1 pneumothorax; 1 persistent partial motor deficit; 1 transient confusion; 1 pulmonary embolism; 1 CSF leak; 1 subdural hematoma; 1 retroperitoneal lymphocele. All margins were uncontaminated. All patients were alive and ambulatory at last follow-up.

CONCLUSION

Early results suggest En Bloc resection assisted by retroperitoneal videoscopy in tumors from T11 to L3/4 disk space is feasible, less invasive and safe. Careful surgical planning and experience in endoscopic vascular surgery are mandatory.

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.

Complications and local recurrence of chondrosarcoma and chordoma treated by total tumor resection in thoracic and lumbar spine

BACKGROUND

En bloc resection of spinal tumors is challenging and associated with a high incidence of complications; however, it offers the potential to reduce the risk of recurrence when a wide margin is achieved. This research aims to investigate the safety and efficacy of en bloc resection in treating thoracic and lumbar chondrosarcoma/chordoma.

METHODS

Data from patients diagnosed with chondrosarcoma and chordoma in the thoracic or lumbar region, who underwent total en bloc or piecemeal resection at our institution over a 7-year period, were collected and regularly followed up. The study analyzed overall perioperative complications and compared differences in complications and local tumor recurrence between the two surgical methods.

RESULTS

Seventeen patients were included, comprising 12 with chondrosarcoma and 5 with chordoma. Among them, 5 cases underwent intralesional piecemeal resection, while the remaining 12 underwent planned en bloc resection. The average surgical time was 684 min (sd = 287), and the mean estimated blood loss was 2300 ml (sd = 1599). Thirty-five complications were recorded, with an average of 2.06 perioperative complications per patient. 82% of patients (14/17) experienced at least one perioperative complication, and major complications occurred in 64.7% (11/17). Five patients had local recurrence during the follow-up, with a mean recurrence time of 16.2 months (sd = 7.2) and a median recurrence time of 20 months (IQR = 12.5). Hospital stays, operation time, blood loss, and complication rates did not significantly differ between the two surgical methods. The local recurrence rate after en bloc resection was lower than piecemeal resection, although not statistically significant (P = 0.067).

CONCLUSIONS

The complication rates between the two surgical procedures were similar. Considering safety and local tumor control, en bloc resection is recommended as the primary choice for patients with chondrosarcoma/chordoma in the thoracic and lumbar regions who are eligible for this treatment.

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.

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.

Implant failure and revision strategies after total spondylectomy for spinal tumors

Background

Although there have been several risk factors reported for implant failure (IF), little consensus exists. Potential applicable measures to protect patients from IF are relatively few. This study aimed to discover new risk factors for IF and explore potential protective measures from IF after total spondylectomy for spinal tumors.

Methods

A total of 145 patients undergoing total spondylectomy for thoracic and lumbar spinal tumors between 2010 and 2021 were included from three tertiary university hospitals. Patient demographic and surgical characteristics and follow-up outcomes were collected.

Results

During a mean follow-up of 53.77 months (range, 12 to 149 months), 22 of 145 patients (15.17%) developed IF. Patients undergoing thoracolumbar junctional region (T12/L1) resection were more likely to develop IF compared to those undergoing surgery at other vertebral levels (HR = 21.622, 95% CI = 3.567-131.084, P = 0.001). Patients undergoing titanium mesh cage reconstruction were more likely to develop IF compared to patients undergoing expandable titanium cage reconstruction (HR = 8.315, 95% CI = 1.482-46.645, P = 0.016). Patients with bone cement augmentation around the cage were less likely to develop IF compared to those not receiving bone cement augmentation (HR = 0.015, 95% CI = 0.002-0.107, P < 0.001). Of the 22 patients with IF, 14 (63.63%) accepted personalized revision surgery.

Conclusion

The use of an expandable cage and the use of bone cement augmentation around the anterior column support cage are protective measures against IF after total spondylectomy.

Biomechanical effects of transverse connectors on total en bloc spondylectomy of the lumbar spine: a finite element analysis

BACKGROUND

The influence of total en bloc spondylectomy (TES) on spinal stability is substantial, necessitating strong fixation to restore spinal stability. The transverse connector (TC) serves as a posterior spinal instrumentation that connects the left and right sides of the pedicle screw-rod system. Several studies have highlighted the potential of a TC in enhancing the stability of the fixed segments. However, contradictory results have suggested that a TC not only fails to improve the stability of the fixed segments but also might promote stress associated with internal fixation. To date, there is a lack of previous research investigating the biomechanical effects of a TC on TES. This study aimed to investigate the biomechanical effects of a TC on internal fixation during TES of the lumbar (L) spine.

METHODS

A single-segment (L3 segment) TES was simulated using a comprehensive L spine finite element model. Five models were constructed based on the various positions of the TC, namely the intact model (L1-sacrum), the TES model without a TC, the TES model with a TC at L1-2, the TES model with a TC at L2-4, and the TES model with a TC at L4-5. Mechanical analysis of these distinct models was conducted using the Abaqus software to assess the variations in the biomechanics of the pedicle screw-rod system, titanium cage, and adjacent endplates.

RESULTS

The stability of the surgical segments was found to be satisfactory across all models. Compared with the complete model, the internal fixation device exhibited the greatest constraint on overextension (95.2-95.6%), while showing the least limitation on left/right rotation (53.62-55.64%). The application of the TC had minimal effect on the stability of the fixed segments, resulting in a maximum reduction in segment mobility of 0.11° and a variation range of 3.29%. Regardless of the use of a TC, no significant changes in stress were observed for the titanium cage. In the model without the TC, the maximum von Mises stress (VMS) for the pedicle screw-rod system reached 136.9 MPa during anterior flexion. Upon the addition of a TC, the maximum VMS of the pedicle screw-rod system increased to varying degrees. The highest recorded VMS was 459.3 MPa, indicating a stress increase of 335.5%. Following the TC implantation, the stress on the adjacent endplate exhibited a partial reduction, with the maximum stress reduced by 27.6%.

CONCLUSION

The use of a TC in TES does not improve the stability of the fixed segments and instead might result in increased stress concentration within the internal fixation devices. Based on these findings, the routine utilisation of TC in TES is deemed unnecessary.

The Impact of Frailty on Postoperative Complications in Total En Bloc Spondylectomy for Spinal Tumors

Total en bloc spondylectomy (TES) is an effective treatment for spinal tumors. However, its complication rate is high, and the corresponding risk factors remain unclear. This study aimed to clarify the risk factors for postoperative complications after TES, including the patient's general condition, such as frailty and their levels of inflammatory biomarkers. We included 169 patients who underwent TES at our hospital from January 2011-December 2021. The complication group comprised patients who experienced postoperative complications that required additional intensive treatments. We analyzed the relationship between early complications and the following factors: age, sex, body mass index, type of tumor, location of tumor, American Society of Anesthesiologists score, physical status, frailty (categorized by the 5-factor Modified Frailty Index [mFI-5]), neutrophil-to-lymphocyte ratio, C-reactive protein/albumin ratio, preoperative chemotherapy, preoperative radiotherapy, surgical approach, and the number of resected vertebrae. Of the 169 patients, 86 (50.1%) were included in the complication group. Multivariate analysis showed that high mFI-5 scores (odds ratio [OR] = 2.99, p < 0.001) and an increased number of resected vertebrae (OR = 1.87, p = 0.018) were risk factors for postoperative complications. Frailty and the number of resected vertebrae were independent risk factors for postoperative complications after TES for spinal tumors.

Complications and prognosis of primary thoracic and lumbar giant cell tumors treated by total tumor resection

BACKGROUND

Spinal giant cell tumor (SGCT) is a relatively rare primary tumor. En bloc resection is the preferred surgical procedure for it due to its aggressiveness, meanwhile leading to more complications. We reported the characteristics of perioperative complications and local control of total tumor resection including en bloc resection and piecemeal resection for primary thoracic and lumbar spinal giant cell tumors in a single center over 10 years.

METHODS

This is a retrospective cross-sectional and cohort study. Forty-one consecutive patients with SGCTs who underwent total tumor resection from 2010 to 2020 at our institution and were followed up for at least 24 months were reviewed. Surgery data, complication characteristics and local tumor control were collected and compared by different surgical procedure.

RESULTS

Forty-one patients were included, consisting of 18 males and 23 females, with a mean age of 34.2 years. Thirty-one had thoracic vertebra lesions, and 10 had lumbar vertebra lesions. Thirty-five patients were primary cases, and 6 patients were recurrent cases. Eighteen patients were treated by total en bloc spondylectomy (TES), 12 patients underwent en bloc resection according to WBB surgical system, and 11 patients underwent piecemeal resection. The average surgical time was 498 min, and the mean estimated blood loss was 2145 ml. A total of 58 complications were recorded, and 30 patients (73.2%) had at least one perioperative complication. All patients were followed up after surgery for at least 2 years. A total of 6 cases had postoperative internal fixation failure, and 4 cases presented local tumor recurrence (9.8%).

CONCLUSIONS

Although the surgical technique is difficult and accompanied by a high rate of perioperative complications, en bloc resection can achieve favorable local control in SGCT. When it is too difficult to complete en bloc resection, thoroughly piecemeal resection without residual is also acceptable, given the relatively low recurrence rate.

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.

The tentative application of en bloc concept in the pediatric brain tumor: Experience from a large pediatric center in china

Background

Children are more susceptible to the higher rate of massive blood transfusion because of the less allowable blood loss and lower intraoperative tolerance to blood loss during the resection of brain tumors. The surgical concept of en bloc resection, which is widely used in other tumors, may contribute to the improvement of brain tumor resection. However, there is still a lack of comprehensive research on its application in pediatric brain tumors.

Objective

The aim of this study is to investigate the outcomes of the en bloc concept and the factors associated with the application of the en bloc concept in pediatric brain tumors.

Methods

According to the surgical concept involved, the patients were divided into three subgroups: complete en bloc concept, partial en bloc concept, and piecemeal concept. The matching comparison (complete and partial en bloc concept groups vs. piecemeal concept group) was conducted to investigate the effect of the en bloc concept on the outcomes. Then, the patient data from January 2018, when the en bloc concept was routinely integrated into the brain tumor surgery in our medical center, were reviewed and analyzed to find out the predictors associated with the application of en bloc concept.

Results

In the en bloc group, the perioperative parameters, such as hospital stay (p = 0.001), pediatric intensive care unit (PICU) stay (p = 0.003), total blood loss (p = 0.015), transfusion rate (p = 0.005), and complication rate (p = 0.039), were all significantly improved. The multinomial logistic regression analysis showed that tumor volume, bottom vessel, and imaging features, such as encasing nerve or pass-by vessel, finger-like attachment, ratio of “limited line”, and ratio of “clear line”, were independent predictors for the application of the en bloc concept in our medical center.

Conclusion

This study supports the application of complete and partial en bloc concept in the pediatric brain tumor surgery based on the preoperative evaluation of imaging features, and compared with the piecemeal concept, the en bloc concept can improve the short outcomes without significant increases in the neurological complications. Large-series and additional supportive pieces of evidence are still warranted.

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BACKGROUND

Malignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.

METHODS

Between 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14-62 years old). The mean postoperative follow-up period was 159.7 months (range, 84-245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.

RESULTS

All surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.

CONCLUSIONS

En bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.

Hybrid Therapy Versus Total En Bloc Spondyectomy in the Treatment of Solitary Radioresistant Spinal Metastases: A Single-center, Retrospective Study

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

To compare the treatment efficacy of hybrid therapy (HT) with that of total en bloc spondylectomy (TES) in patients with solitary radioresistant high-grade epidural spinal cord compression (ESCC) spinal metastases.

SUMMARY OF BACKGROUND DATA

Both HT and TES can yield good results for solitary radioresistant metastatic spinal tumors with high-grade ESCC. However, there is still a lack of comparative studies on the treatment efficacy of these 2 methods.

MATERIALS AND METHODS

We retrospectively reviewed patients with the above-mentioned tumors between January 2012 and May 2019. A total of 157 patients underwent surgery, 64 of whom received HT and 93 were treated with TES. Propensity score matching (1:1 ratio) allowed the generation of best-matched pairs for the 2 categories. Local control rates and survival rates were estimated using the Kaplan-Meier method.

RESULTS

All patients had a minimum 2-year follow-up. The longest follow-up period was 88 months. The survival rates and local progression-free survival rates after HT were comparable with those after TES at 1 year (84.6% vs. 83.1% and 90.2% vs. 90%, respectively), 2 years (60.8% vs. 64.3% and 64.1% vs. 62.1%, respectively), and 5 years (18.8% vs. 24.1% and 24.4% vs. 28.4%, respectively). There were no significant differences in pain control, improvement in neurological status, spine stabilization restoration, incidence of perioperative complications, and improvement in quality of life between the groups. However, HT showed more advantages than TES in that it had a shorter operative time and lower intraoperative blood loss.

CONCLUSIONS

HT can obtain satisfactory results comparable to TES for solitary radioresistant metastatic spinal tumors with high-grade ESCC. In addition, HT has a shorter operative time and fewer perioperative complications than TES. HT may be a promising treatment for solitary radioresistant metastatic spinal tumors with high-grade ESCC.

Pathological Clinical Analysis and Imaging Manifestations for Spinal Bone Tumors Based on Cement Injection

In order to explore the imaging manifestations and pathological characteristics of spine tumors, this article explores the clinical diagnosis and treatment methods through multi-sample case analysis with the support of imaging, and proposes a targeted treatment method that uses a special PVP needle with a beveled puncture surface for puncture. Moreover, this article uses the supporting PVP syringe for bone cement injection, develops a health status questionnaire, and adopts a scoring method for comprehensive assessment. The purpose of this article is to show that through the combination of preoperative radiotherapy and postoperative bracing, bone cement injection to treat vertebral tumors can immediately obtain satisfactory pain relief. Finally, through case analysis and image performance, we can see that the method proposed in this article has a certain effect.

Factors associated with spinal fixation mechanical failure after tumor resection: a systematic review and meta-analysis

Background

No available meta-analysis has been published that systematically assessed spinal fixation mechanical failure after tumor resection based on largely pooled data. This systematic review and meta-analysis aimed to investigate the spinal fixation failure rate and potential risk factors for hardware failure.

Methods

Electronic articles published between January 1, 1979, and January 30, 2021, were searched and critically evaluated. The authors independently reviewed the abstracts and extracted data on the spinal fixation failure rate and potential risk factors.

Results

Thirty-eight studies were finally included in the meta-analysis. The pooled spinal fixation mechanical failure rate was 10%. The significant risk factors for hardware failure included tumor level and cage subsidence. Radiotherapy was a potential risk factor.

Conclusion

The spinal fixation mechanical failure rate was 10%. Spinal fixation failure is mainly associated with tumor level, cage subsidence and radiotherapy. Durable reconstruction is needed for patients with these risk factors.

Anterior Column Reconstruction with Vascularized Rib After Thoracic Spondylectomy: A Case Report

CASE

A 35-year-old man with a chondrosarcoma of the thoracic spine was treated with neoadjuvant proton radiotherapy (RT), total en bloc spondylectomy (TES), and adjuvant RT. Multiple vertebrae were removed to ensure negative margins, which created a sizable midthoracic defect. A vascularized rib autograft was harvested and intussuscepted within a femoral allograft for reconstruction of the anterior column and supplemented with posterior and lateral instrumentation.

CONCLUSION

This report demonstrates the feasibility of using a rib autograft within a femoral allograft sleeve to achieve immediate robust biomechanical support and eventual osseous union after thoracic TES for malignant tumors.

Video-Assisted Thoracoscopic En Bloc Vertebrectomy for Spine Tumors: Technique and Outcomes in a Series of 33 Patients

BACKGROUND

In en bloc vertebrectomy, the posterior approach is associated with limited access to anterior structures (vertebral body, esophagus, aorta, azygos vein). Video-assisted thoracoscopic surgery (VATS) might prove to be advantageous during thoracic en bloc vertebrectomy by allowing a combined anterior-posterior access in the prone position. We describe the technique and review the outcomes of 33 cases of video-assisted thoracoscopic en bloc vertebrectomy.

METHODS

A retrospective, single-center cohort study included all cases of VATS with a minimum follow-up of 1 year. A team of thoracic and orthopaedic surgeons performed the surgical procedure with the patient in a single, prone position. Anterior release was carried out thoracoscopically, followed by posterior en bloc tumor removal.

RESULTS

From 2003 to 2019, 33 patients were included. Nine patients underwent total vertebrectomy (8 had single-level and 1 had 3-level), and 24 patients underwent partial vertebrectomy (1 had single-level, 8 had 2-level, 13 had 3-level, and 2 had 4-level). Ten patients had pulmonary resection. Histology revealed 18 cases (55%) of primary bone tumors, 6 cases (18%) of lung cancer invading the spine, 6 cases (18%) of solitary metastasis, and 3 other cases (9%). The margins were tumor-free in 28 cases (85%). The median operative time was 240 minutes (range, 150 to 510 minutes), with a median blood loss of 1,200 mL (range, 400 to 6,700 mL), and there were 2 cases of conversion to thoracotomy. A total of 33 complications occurred in 18 patients (55%), and these were predominantly pulmonary. One death was surgery-related (infection). One patient had a persistent monoplegia. At a median follow-up of 63 months (range, 12 to 156 months), there were 21 surviving patients (64%) with 2 local recurrences and 1 distant recurrence, and 2 patients (6%) were lost to follow-up. The survival rates were 94% at 1 year, 71% at 2 years, and 68% at 5 years.

CONCLUSIONS

VATS en bloc vertebrectomy may be indicated for T2-to-T11 spine tumors with the exception of massive tumors, substantial chest wall and/or mediastinal invasion, and lung cancer exceeding 7 cm. The technique yielded satisfactory surgical and oncologic outcomes.

LEVEL OF EVIDENCE

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

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.

Perioperative complications of total en bloc spondylectomy for spinal tumours

AIMS

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

METHODS

In total, 307 patients who underwent TES in a single centre were reviewed retrospectively. There were 164 male and 143 female patients with a mean age at the time of surgery of 52.9 years (SD 13.3). A total of 225 patients were operated on for spinal metastases, 34 for a malignant primary tumour, 41 for an aggressive benign tumour, and seven with a primary of unknown origin. The main lesion was located in the thoracic spine in 213, and in the lumbar spine in 94 patients. There were 97 patients who underwent TES for more than two consecutive vertebrae.

RESULTS

Major and minor perioperative complications were observed in 122 (39.7%) and 84 (27.4%) patients respectively. The breakdown of complications was as follows: bleeding more than 2,000 ml in 60 (19.5%) patients, hardware failure in 82 (26.7%), neurological in 46 (15.0%), surgical site infection in 23 (7.5%), wound dehiscence in 16 (5.2%), cerebrospinal fluid leakage in 45 (14.7%), respiratory in 52 (16.9%), cardiovascular in 11 (3.6%), digestive in 19 (6.2%)/ The mortality within two months of surgery was four (1.3%). The total number of complications per operation were 1.01 (SD 1.0) in the single vertebral resection group and 1.56 (SD 1.2) in the group with more than two vertebral resections. Cardiovascular and respiratory complications, along with hardware failure were statistically higher in the group who had more than two vertebrae resected. Also, in this group the amount of bleeding in patients with a lumbar lesion or respiratory complication in patients with a thoracic lesion, were statistically higher. Multivariate analysis showed that using a combined anterior and posterior approach, when more than two vertebral resections were significant independent factors.

CONCLUSION

The characteristics of perioperative complications after TES were different depending on the extent and level of the tumour resection. In addition to preoperative clinical and pathological factors, it is therefore important to consider these factors in patients who undergo en bloc resection for spinal tumours. Cite this article: Bone Joint J 2021;103-B(5):976-983.

Augmented reality-mediated stereotactic navigation for execution of en bloc lumbar spondylectomy osteotomies

En bloc spinal tumor resections are technically demanding procedures with high morbidity because of the conventionally large exposure area and aggressive resection goals. Stereotactic surgical navigation presents an opportunity to perform the smallest possible resection plan while still achieving an en bloc resection. Augmented reality (AR)-mediated spine surgery (ARMSS) via a mounted display with an integrated tracking camera is a novel FDA-approved technology for intraoperative "heads up" neuronavigation, with the proposed advantages of increased precision, workflow efficiency, and cost-effectiveness. As surgical experience and capability with this technology grow, the potential for more technically demanding surgical applications arises. Here, the authors describe the use of ARMSS for guidance in a unique osteotomy execution to achieve an en bloc wide marginal resection of an L1 chordoma through a posterior-only approach while avoiding a tumor capsule breach. A technique is described to simultaneously visualize the navigational guidance provided by the contralateral surgeon's tracked pointer and the progress of the BoneScalpel aligned in parallel with the tracked instrument, providing maximum precision and safety. The procedure was completed by reconstruction performed with a quad-rod and cabled fibular strut allograft construct, and the patient did well postoperatively. Finally, the authors review the technical aspects of the approach, as well as the applications and limitations of this new technology.

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case

BACKGROUND

Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.

OBSERVATIONS

Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.

LESSONS

The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

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.

Total en bloc spondylectomy combined with the satellite rod technique for spinal tumors

Background

Instrumentation failure (IF) is a common complication after total en bloc spondylectomy (TES) in spinal tumors. This study aims to evaluate the clinical outcomes of TES combined with the satellite rod technique for the treatment of primary and metastatic spinal tumors.

Methods

The clinical data of 15 consecutively treated patients with spinal tumors who underwent TES combined with the satellite rod technique by a single posterior approach from June 2015 to September 2018 were analyzed retrospectively. Radiographic parameters including the local kyphotic angle (LKA), anterior vertebral height (AVH), posterior vertebral height (PVH), and intervertebral titanium mesh cage height (ITMCH) were assessed preoperatively, postoperatively, and at the final follow-up. The visual analog scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association (ASIA) scale were used to assess quality of life and neurological function. The operative duration, volume of blood loss, and complications were also recorded.

Results

The mean operation time and volume of blood loss were 361.7 min and 2816.7 mL, respectively. During an average follow-up of 31.1 months, 2 patients died of tumor recurrence and multiple organ metastases, while recurrence was not found in any other patients. Solid fusion was achieved in all but one patient, and no implant-related complications occurred during the follow-up. The VAS, ODI, and ASIA scores significantly improved from before to after surgery (P < 0.05). The LKA, AVH, and PVH significantly improved from before to immediately after surgery and to the final follow-up (P < 0.05), and the postoperative and final follow-up values did not significantly differ (P > 0.05).

Conclusions

TES combined with the satellite rod technique can yield strong three-dimensional fixation and reduce the occurrence of rod breakage, thereby improving the long-term quality of life of patients with spinal tumors.

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.

Free Vascularized Fibula Graft with Femoral Allograft Sleeve for Lumbar Spine Defects After Spondylectomy of Malignant Tumors: A Case Report

CASE

We present a 65-year-old man with an L4 conventional chordoma. Total en bloc spondylectomy (TES) of the involved vertebral bodies and surrounding soft tissues with reconstruction of the spine using a free vascularized fibula autograft (FVFG) is a proven technique, limiting complications and recurrence. However, graft fracture has occurred only in the lumbar spine in our institutional cases. We used a technique in our patient to ensure extra stability and support, with the addition of a femoral allograft sleeve encasing the FVFG.

CONCLUSIONS

Our technique for the reconstruction of the lumbar spine after TES of primary malignant spinal disease using a femoral allograft sleeve encasing the FVFG is viable to consider.

Sagittal en bloc resection of primary tumors in the thoracic and lumbar spine: feasibility, safety and outcome

This study is to test feasibility, safety and the outcome of sagittal en bloc resection of paravertebral primary tumors in the thoracic and the lumbar spine. Sagittal en bloc resection was planned based on WBB classification and performed via combined anterior-posterior or anterior-posterior-lateral approach in 9 consecutive patients with aggressive benign or malignant paravertebral primary tumors in the thoracic and lumbar spine. Surgical margins were evaluated both radiologically and histopathologically. Follow-up data regarding survival rate, local control, morbidity, hardware failure and postoperative function were collected at around 2 years after surgery. En bloc resection was achieved in all patient with wide margin in 7/9 patients, marginal and intralesional margin in 2/9 patients. Survival rate and local control rate were 100%. There were 4/9 cases of major complications and 2/9 cases of minor complications with an overall morbidity rate of 67% (6/9). All but one patient with intraoperative spinal cord injury were free of neurological deficits and fully mobile in absence of any indication of hardware failure. With a careful choice of surgical procedure, sagittal en bloc resection of paravertebral primary tumor in the thoracic and lumbar spine is feasible, safe and effective.

Surgical strategies for primary malignant tumors of the thoracic and lumbar spine

BACKGROUND

Primary malignant tumors of the thoracic and lumbar spine are rare. They are mainly hematologic malignancies and more rarely sarcomas or chordomas. Giant-cell tumors and osteoblastomas, while benign, are locally very aggressive and their excision should be discussed as an option. Other possibilities are tumors from nearby organs invading the spine, which are actually carcinomas, but may benefit from radical excision in select cases.

METHODS

Excision of these tumors is complex and must be integrated in the diagnostic and therapeutic strategy established by a specific multidisciplinary tumor board at a designated cancer center. Surgical resection must combine tumor excision with long-lasting reconstruction of the spine and neighboring soft tissues. The initial excision must be as complete as possible as the possibilities of repeat excision are nearly impossible if the first resection is not complete.

RESULTS

An exhaustive preoperative imaging workup is essential for determining the tumor's spread and for determining the best surgical strategy. This will often require participation of other surgical specialties, which are well versed in teamwork. Thanks to this multidisciplinary care, especially the participation of thoracic and plastic surgeons, significant progress has been made recently. The first is the possibility of doing very extensive tumor excisions at the spine and in the neighboring organs, thus expanding the surgical indications to patients who were previously considered as being inoperable. We will discuss the surgical strategy and surgical approaches by spine level. Bone and soft tissue reconstruction is more effective thanks to the introduction of new spinal instrumentation and coverage flaps, which have drastically reduced the intra- and postoperative complications. Lastly, the risk factors for neurological complications are better understood, making them easier to prevent and to treat, if they were to occur.

CONCLUSION

These advances have translated to better cancer outcomes, especially better control of the tumor with neoadjuvant therapies (targeted chemotherapy) and preoperative conformal radiotherapy.

Surgical treatment of metastatic mesenchymal chondrosarcoma to the spine: A case report

INTRODUCTION

Metastatic mesenchymal chondrosarcoma of the spine is a highly unusual disease without standard curative managements yet. The objective of this case report is to present a very rare case of metastatic chondrosarcoma to the spine successfully operated by surgical treatment. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 34-year-old woman presented with a 4-month history of continuous and progressive back pain and a 1-month history of radiating pain of bilateral lower extremities. The patient, who had been diagnosed of mesenchymal chondrosarcoma of maxillary sinus for 3 years, received surgical treatment of palliative endoscopic-assisted total left maxillary resection via mini Caldwell-Luc approach, and palliative enlarged resection due to the progress of residual lesions, followed by no adjuvant therapy. Multiple lytic, expanding lesions of the spine and paraspinal region with severe epidural spinal cord compression was identified.

DIAGNOSIS

CT, MRI and bone scan of spine showed spinal cord compression secondary to the epidural component of the metastatic lesions. Post-operative pathology confirmed the diagnosis of metastatic spinal mesenchymal chondrosarcomas.

INTERVENTIONS

The patient underwent posterior spinal canal decompression, resection of T12 and L3 lesions, internal fixation of T11-L5 pedicles, and cement augmentation of T12 and L3.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 1-year follow-up visit. There were no complications associated with the spinal surgery during the follow-up period.

CONCLUSION

Metastatic spinal mesenchymal chondrosarcoma, although rare, should be part of the differential diagnosis when the patient presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression and total resection of the metastatic chondrosarcoma when the tumor has caused neurological deficits or other severe symptoms. Osteoplasty by cement augmentation is also a good choice for surgical treatment in some patients.

Surgical treatment of chondrosarcoma of the sacrum with cement augmentation: A case report

RATIONALE

Chondrosarcoma of the sacrum is a highly unusual disease without standard curative managements yet. The objective of this study is to report a very rare case of chondrosarcoma of the sacrum successfully operated by percutaneous vertebroplasty. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 45-year-old woman presented with a five-month history of continuous and progressive pain and numbness of left extremity. A lytic, expanding lesion of the sacrum and paraspinal region with severe epidural spinal cord compression was identified.

DIAGNOSIS

MRI of spine showed spinal cord compression secondary to the epidural componant of the giant mass, with increased marrow infiltration of the left S2 vertebral and paravertebral region, which presented as a solid tumor. Post-operative pathology confirmed the diagnosis of sacral well-differentiated chondrosarcoma (stage I B).

INTERVENTIONS

The patient underwent percutaneous vertebroplasty and cement augmentation of sacrum via a posterior approach.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, but the patient died of multiple systemic metastases at the 2-year follow-up visit. There were no complications associated with the operation during the follow-up period.

LESSONS

Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Combined efforts of specialists from orthopedics, radiology, neurosurgery, pathology, and medical oncology led to the successful diagnosis and management of this patient. Giant sacral chondrosarcoma, although rare, should be part of the differential diagnosis when the patient presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression of the sacral chondrosarcoma when the tumor has caused neurological deficits or other severe symptoms. Osteoplasty by cement augmentation is also a good choice for surgical treatment.

Risk Factors for Instrumentation Failure After Total En Bloc Spondylectomy of Thoracic and Lumbar Spine Tumors Using Titanium Mesh Cage for Anterior Reconstruction

OBJECTIVE

The present study investigated the risk factors for instrumentation failure (IF) after total en bloc spondylectomy (TES) of thoracic and lumbar spine tumors using a titanium mesh cage (TMC) for anterior reconstruction.

METHODS

The data from patients who had undergone TES for thoracic and lumbar spine tumors in our institution were retrospectively reviewed. Anterior reconstruction was performed using a TMC filled with morcelized allograft or morcelized autograft. Posterior reconstruction was performed using pedicle fixation. Survival analysis from TES to IF was conducted. The Kaplan-Meier method was used for univariate analysis. Factors of statistical significance were included in the multivariate analysis using Cox regression analysis.

RESULTS

A total of 30 patients (20 men and 10 women), with a mean age of 37.1 ± 14.3 years (range, 14-65 years) were included. The mean follow-up period was 41.8 ± 21.3 months (range, 13-120 months). Bone fusion was achieved in 23 patients (76.7%). IF occurred in 8 patients. The mean interval from TES to the first IF was 31.8 ± 15.1 months (range, 13-64 months). On univariable analysis, a body mass index >28 kg/m², perioperative radiotherapy, and the TMC in an oblique position were associated with IF. On multivariable analysis, these 3 factors were entered into the Cox regression model and were also significant.

CONCLUSIONS

The use of TES can achieve durable oncological control. However, IF, a not uncommon late complication that leads to reoperation, should be a cause for concern. We found perioperative radiotherapy, a TMC in an oblique position, and a body mass index >28 kg/m² were significant predictive factors for IF.

Sagittal spinal parameters after en bloc resection of mobile spine tumors

BACKGROUND CONTEXT

En bloc resection and reconstruction (EBR) in patients with spinal malignancy aims to achieve local disease control. This is an invasive procedure with significant alterations of the physiological anatomy and subsequently, the spino-pelvic alignment. Sagittal spinal parameters are useful measurements to objectively identify disproportionate alignment on a radiograph. In the field of spinal deformities, there is increasing evidence for a relationship between sagittal alignment and patient reported outcomes.

PURPOSE

To determine sagittal spino-pelvic alignment after EBR in patients with spinal malignancies and the effect of these parameters on surgical and patient reported outcomes.

STUDY DESIGN

A retrospective case series.

METHODS

We included 35 patients who underwent EBR for spinal malignancies between 2000 and 2018. Radiographic measurements were performed using semi-automatic software; the parameters included were pelvic incidence (PI), sacral slope, pelvic tilt (PT), global tilt and lumbar lordosis. We calculated PI-based Global Alignment and Proportion (GAP) scores and prospective patient reported outcome scores Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF) were used.

RESULTS

Twenty-one (60%) patients filled out the PROMIS-PF score at a median of 16 months (Interquartile Range (IQR) 4-108) after surgery with a median score of 39 (IQR 32-42), the median GAP score was 7 (IQR 5-9). Bivariate analysis showed no statistically significant relationship between GAP score and instrumentation failure or need for revision surgery. Multivariable analysis of GAP score and PROMIS-PF score corrected for local disease recurrence showed a statistically significant correlation coefficient of -1.721 (p=.026; 95%CI=-3.216, -0.226).

CONCLUSION

In this cohort, all patients had a moderate or severe disproportioned spinal alignment after EBR and reconstruction surgery. The degree of sagittal spino-pelvic misalignment after EBR for spinal malignancies seems to be associated with patient reported health status in terms of PROMIS-PF scores. Further research with a larger patient cohort and standardized imaging and follow-up protocols is necessary in order to accurately use sagittal alignment as a predictive value for instrumentation failure and revision surgery.

Feasibility of total en-bloc spondylectomy on L5 by a posterior-only approach: An autopsy study

Purpose

To obtain a better understanding of the structures around L5 vertebra and provide some anatomical evidence of the feasibility of total en-bloc spondylectomy (TES) on L5 in a posterior-only approach.

Methods

12 simulated TESs on L5 by a posterior-only approach were conducted on human cadavers. The distance between the traction point of L4 nerve root and the dural sac (Da), the anterior-posterior diameter of the vertebral body,(Va), the distance between the start point of L4 nerve root and the traction point of L5 nerve root (Dh) and the height of the vertebral body (Vh) were measured. Paired t-test and liner regression were performed to determine the difference and correlation between Da and Va, and between Dh and Vh. The risk of nerve roots or blood vessels damages, and the obstruction caused by iliac wings were evaluated.

Results

Liner correlations were found between Da and Va, and between Dh and Vh. The regression equations were Da = 0.6673Va + 11.28 and Dh = 1.009Vh + 1.003. There are statistical significant differences between Dh and Vh, and between Da and Va in those whose Va < 34.96 mm. Nerve roots or blood vessels damages and the obstruction caused by iliac wing were able to be avoided.

Conclusions

If the patient has an anterior-posterior diameter of L5 vertebral body shorter than 34.96 mm, it is possible that the vertebral body can be taken out during TES in a posterior-only approach. Prevention of nerve roots or blood vessels damages, and the obstruction caused by iliac wings are difficulties of this procedure yet not insurmountable. TES on L5 by a posterior-only approach might a possible alternative in treating diseases like L5 vertebral body tumors.

Chordoma of the mobile spine and sacrum: clinical management and prognosis

Background

Chordomas are rare malignant tumors of the spinal column often afflicting the upper cervical spine and sacrum. There are few large single center series on chordomas due to its rarity. The purpose of this study is to report a single center's experience with the operative and non-operative management of chordomas.

Methods

We evaluated our institution's pathology database from 1994 to 2016 to identify patients diagnosed with chordomas. Inclusion criteria were chordomas of the mobile spine and sacrum. Exclusion criteria were chordomas of the clivus and resection performed at another institution. We collected patient demographics as well as the type of resection performed, intra-operative complications, wound complications and recurrence/prognosis.

Results

We identified 18 patients diagnosed with chordomas at our institution, and 12 met our inclusion criteria. There were four females and eight males with an average age of 64 [32-87] years. All patients were Caucasian and 10 of the 12 had surgery. Of the two patients with sacral chordomas that did not have surgery, one received chemotherapy and the other did not elect for any treatment. One is alive 161 months following diagnosis and the second died 96 months following diagnosis. Five of the lesions were in the mobile spine (one cervical, two thoracic, two lumbar) and seven were in the sacrum. Six patients underwent an en bloc resection [two via total en bloc spondylectomy (TES)]. Average length of follow up is 60 [3-161] months and eight of 12 patients are alive at latest follow up. Intraoperative complications included cardiac arrest, pleural tear, and excessive blood loss (8 L). Two patients, with sacral chordomas, had wound complications. Recurrence occurred in one patient with piecemeal resection and one patient with incomplete resection had post-operative metastatic lesions to the liver and lung.

Conclusions

We found less recurrence in patients managed with an en bloc resection as opposed to piece meal or intralesional resections. Sacral chordoma patients had higher wound complication rates as compared to chordomas of the mobile spine. The long life expectancy of non-surgically managed patients underscores the indolent nature of chordomas.

Thirty-day complication and readmission rates associated with resection of metastatic spinal tumors: a single institutional experience

Background

This study aims to assess 30-day complication and unplanned readmission rates associated with resection of metastatic spinal tumors.

Methods

Medical records were reviewed for 135 adults who underwent elective resection of a spinal cord tumor. Patient demographics, comorbidities, and tumor characteristics were collected. Tumor pathology was analyzed and diagnosed by a pathologist. The primary outcomes were intra- and 30-day post-operative complication and readmission rates.

Results

Of the 135 spinal tumor resections, 30 (22.2%) cases were metastatic. The most common tumor pathology was bone (13.3%) and the most common locations were thoracic (45.2%), and cervical (32.7%). Most patients had an open surgery (96.7%), with a mean laminectomy/laminoplasty level of 1.9±1.5 and mean operative time of 328.4±658.0 min. There was a 3.3% incidence rate of intraoperative durotomies, with no spinal cord or nerve root injuries. Post-operatively, 44.8% of patients were transferred to the intensive care unit (ICU). The most common post-operative complications were weakness (20.0%), new sensory deficits (16.7%), and hypotension (13.3%). The mean length of stay was 8.8±7.6 days, with the majority of patients discharged home (96.7%). The 30-day readmission rate was 9.7%, with the most common 30-day complications being uncontrolled pain (16.7%), sensory-motor deficits (13.3%), and fever (10.0%).

Conclusions

Our study suggests that weakness, sensory deficits, and uncontrolled pain are the most common complications after resection of spinal metastases, with a relatively high associated 30-day readmission rate. Further studies are necessary to corroborate our findings and identify strategies to reduce complication and readmission rates after resection of spinal metastases.