Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach

Comparation of tumor-free margin or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications and prognosis

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Chondrosarcoma of mobile spine is a rare aggressive malignant tumor and postsurgical local recurrence rates remain high. En bloc resection is currently the preferred treatment. Resection that achieves tumor-free margin removal of the tumor may enable more complete removal of tumor tissue but significantly increases the complexity and risk of surgery and results in more postoperative complications. We sought to compare surgical outcomes, complications, and prognoses between patients who underwent en bloc resection with and without intralesional removal of the tumor.

METHODS

We reviewed 56 patients with spinal chondrosarcoma who underwent en bloc tumor resection and reconstructive surgery at our center between 2000 and 2024 with a minimum postoperative follow-up of 1 year. We collected and analyzed data regarding surgical procedures, complication characteristics, and local tumor control and recurrence.

RESULTS

We included 56 patients. Of these, 36 patients underwent the first surgery, and 20 experienced recurrences. All patients underwent en bloc tumor resection; 36 and 20 underwent intralesional and tumor-free margin resections, respectively. We recorded 83 complications; the incidence and the number of major complications were significantly higher in the tumor-free margin surgery group. Thirty patients experienced tumor recurrence and 26 patients died. Tumor-free margin en bloc resection and conventional-type chondrosarcoma were predictive factors for reduced long-term postoperative recurrence and mortality risk.

CONCLUSIONS

Tumor-free margin resection carries higher risks and is associated with a greater number of perioperative complications, but reduces the risk of local tumor recurrence and prolongs recurrence-free survival and overall survival, providing patients with better prognoses.

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.

[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.

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.

Clinical results of total en bloc spondylectomy using a single posterior approach in spinal metastasis patients: Experiences from Thailand

AIM

To demonstrate a single posterior approach, total en bloc spondylectomy (TES) could be performed safely without preoperative embolization in spinal metastasis patients.

MATERIALS AND METHODS

Thirteen solitary spinal metastasis patients (five males) underwent single posterior approach TES at the thoracolumbar spine without preoperative embolization from January 2018 to January 2020. The primary sites were the breast (n = 4), hepatocellular carcinoma (n = 2), colon (n = 2), and others (n = 5). All patients underwent single posterior TES. The Eastern Cooperative Oncology Group, Frankel neurological status, operative time and blood loss, and any complications were all recorded. The patients were regularly followed-up with radiography, computed tomography, and magnetic resonance imaging to detect any local recurrences.

RESULTS

The mean operative time was 354.6 min, and the mean operative blood loss was 2134.62 ml. None of the patients experienced any perioperative complications. Within the follow-up period (3-24 months), no local recurrences were detected. Two patients (15.38%) were found to have distant metastasis to adjacent and remote vertebrae. Three patients were lost to follow-up, and three patients died of disease. Six patients showed an improved ECOG functional status by at least one grade. Four of Frankel A patients improved their neurological status by at least one grade.

CONCLUSION

Even without embolization, single posterior TES at the thoracolumbar spine is safe and effective for short-term local control in solitary spinal metastasis. However, TES cannot prevent distant metastasis. Longer-term follow-up studies will be able to further identify the benefits of TES for the long-term local control of diseases.

Anatomical method for rib disconnection during posterior costotransversectomy for paravertebral access to the ventral thoracic spine

Posterior surgical approaches to the thoracic spine are commonly used for degenerative diseases, tumors, trauma, and other operative indications. A posterior approach for access to the paravertebral space is advantageous because it allows for resection of the vertebral body without violating the pleural cavity. Posterior costotransversectomy (PCT) is widely used for this purpose. It involves resection of the rib head after the ligamentous complexes have been disconnected from the transverse process and lateral vertebral body. The current literature provides only vague descriptions of the steps involved in rib disconnection with respect to PCT. A comprehensive knowledge of the anatomical relationships of the ligamentous and soft tissue complexes connecting the rib to the vertebral body is paramount for completing an efficient and safe surgery. This manuscript describes an anatomically directed method for rib disconnection during costotransvrersectomy.

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.

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 of Isolated Spinal Metastasis: A Systematic Review Update

STUDY DESIGN

This work was a systematic review.

OBJECTIVE

The objective of this work was to review the literature on the outcomes of en bloc resection of isolated spinal metastasis.

SUMMARY

Of background data: En bloc resection of isolated spinal metastasis is rarely performed and its utility debated, with the last review of the literature being performed over a decade ago. With significant advances in adjunctive oncology treatments, an updated review of whether there remains a role for this type of surgery is necessary.

METHODS

The authors performed a systematic review of English literature over the last decade on en bloc resection of isolated spinal metastasis in adults using the PubMed, Google Scholar, OVID, and Cochrane database. They excluded studies with <5 reported cases. The studies were appraised by 2 coauthors and examined for the patient and tumor characteristics, surgical time, estimated blood loss, length of hospital stay, cost, complications, functional outcomes, rates of local recurrence, metastasis, and survival.

RESULTS

Only 5 articles (148 patients) were included in this study. The average operative time was 6.5 hours, and estimated blood loss was 1742 mL. Only 73% of patients maintained their functional independence, but 35.1% experienced a complication, 6.1% had local recurrence, and the overall survival was 52% with an average time to death of 15 months.

CONCLUSIONS

There remains a paucity of data limiting the understanding of the value of en bloc resection for isolated spinal metastasis. However, despite this limitation, our literature review suggests that en bloc resection offers a low local recurrence rate (6.1%) and maintained functional independence (73%), but requires long operative times (mean 6.5 h), causes significant blood loss (mean 1742 mL), and results in high complication rates (35.1%) with poor overall survival (52% with an average time to death of 15 mo).

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.

Intraosseous Malignant Peripheral Nerve Sheath Tumor of 2 Consecutive Lumbar Vertebrae: A Case Report and Literature Review

BACKGROUND

Malignant peripheral nerve sheath tumor (MPNST), which refers to any malignant tumor that originates from peripheral nerve sheath cells, is rarely found in the spine. Primary intraosseous spinal MPNSTs are extremely uncommon; in fact, such an occurrence has been reported in a very limited number of cases hitherto. We report here one case of low-grade intraosseous MPNST in the lumbar vertebrae and review clinical research related to this rare tumor and modus operandi to its treatment.

CASE DESCRIPTION

A 51-year-old man suffering from lower back pain was initially diagnosed with lumbar tuberculosis. The intraoperative histopathologic examination, however, revealed that the occupying lesion was synovial sarcoma when surgeons intended to perform a debridement surgery of what was thought to be tuberculosis. The operation was therefore suspended. Two months later, the patient was referred to our institution. The pathologic sections were reexamined. Its results refuted the earlier thought of being synovial sarcoma, and a final diagnosis of MPNST was made. In addition, preoperative examination revealed that the tumor had advanced rapidly to the adjacent inferior vena cava and pedicle, which ruled out the possibility of performing a total en bloc spondylectomy. Therefore, a marginal resection for 2-level consecutive lumbar vertebrae was performed successfully via an anterior-posterior combined approach. No serious complications were detected at 18-month follow-up.

CONCLUSIONS

Preoperative biopsy is of great importance for the diagnosis of spinal tumors. Marginal resection of a complicated intraosseous spine MPNST via an anterior-posterior combined approach, despite being technically challenging, resulted in good survival and functional outcomes.

Three-Level Lumbar En Bloc Spondylectomy with Three-Dimensional-Printed Vertebrae Reconstruction for Recurrent Giant Cell Tumor

BACKGROUND

Primary malignancies involving the mobile spine often require total en bloc spondylectomy with complex mechanical reconstruction, which can be augmented with novel application of the 3-dimensional (3D)-printing technique.

CASE DESCRIPTION

A 51-year-old man presented with a 12-month history of progressive thigh pain and lower limb motor function loss, 36 months after T12-L4 instrumentation and fusion for giant cell tumor (GCT) of the L2 vertebrae before referral. The patient subsequently underwent successful curative management of recurrent GCT through denosumab treatment, L1-L3 total en bloc spondylectomy (TES), and a novel lumbopelvic reconstruction method with a 3D-printed lumbar vertebrae and screw-rod system.

CONCLUSIONS

To our knowledge, this is the first reported case of multilevel lumbar TES for GCT reconstructed using a 3D-printed vertebrae. Although TES-specifically in the lumbosacral spine-remains challenging due to its unique anatomy and increased risk of neurologic insult, it is an effective option for curative management of GCTs.

Total en bloc spondylectomy for primary tumors of the lumbar spine

This was a retrospective clinical study.This study aimed to evaluate our institution's experience with total en bloc spondylectomy (TES) in patients treated for primary lumbar spine tumors and investigate postoperative clinical outcomes.TES is a widely accepted by spinal and musculoskeletal surgical oncologists and results in favorable health-related quality of life outcomes. However, this procedure still imposes major risks and complications.The cases of TES performed for primary lumbar spine tumors between 1993 and 2015 were retrospectively analyzed. Primary outcome measures were the rates of perioperative complications and reoperation for instrumentation failure.We enrolled 30 patients (13 men and 17 women; median age and follow-up, 38 years and 87 months, respectively). Three, 7, and 5 cases involved previous radiotherapy, intralesional resection, and chemotherapy, respectively. The most common tumor was giant cell tumor (14 cases) followed by osteosarcoma (4 cases) and plasmacytoma (3 cases). The median estimated blood loss was 1450 mL, and the median operative time was 11 hours. At least 1 perioperative complication occurred in 26 patients (86.7%), with the most common being postoperative muscle weakness (24 patients, 80.0%) followed by surgical site infection and postoperative cerebrospinal fluid leakage (7 patients, respectively; 23.3% each). Revision surgery for instrumentation failure was required in 6 patients (20.0%) at a median of 33 months after the index TES. Four patients experienced local tumor recurrence (13.3%), and their 10-year disease-free rate was 75.0%.TES is a feasible and effective procedure for primary lumbar spine tumors, but the risks of perioperative complications and late instrumentation failure should be acknowledged. Surgical oncologic outcomes were good, especially in patients who underwent TES as their first surgical treatment. Therefore, being familiar with the indications for TES and the surgical technique is important.

Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach

BACKGROUND

Total en bloc spondylectomy (TES) significantly decreases the rate of local recurrence and provides long-term survival in patients with malignant tumor of the spine. This procedure can be performed through a posterior-only approach. However, TES for lower lumbar spine through a posterior-only approach is technically challenging.

METHODS

We retrospectively reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES in a posterior-only approach from June 2012 to December 2015. This series included 5 female and 4 male patients, with a mean age of 54.1 years. Endpoints included length of surgery, estimated blood loss, visual analogue scale for pain, instrumentation failure, perioperative complications, local control rate, and overall survival.

RESULTS

All patients underwent TES and circumferential reconstruction of the involved level. Average operative time and estimated blood loss were 282 minutes and 2421 mL, respectively. The mean follow-up time was 41.2 months. We encountered nerve roots stretches in all patients during the surgeries. Three patients experienced acute lower-extremity neurologic dysfunction, but the symptoms were significantly alleviated in 4 weeks postoperatively and fully resolved within 6 months. Five patients showed no evidence of disease at the latest follow-up. Three patients died of metastasis and systemic failure. One patient developed new metastases and was alive with disease. Titanium mesh cage subsidence was observed in 3 patients, but no implant failures or related clinical symptoms were found.

CONCLUSIONS

TES for the fourth lumbar spine in a posterior-only approach is feasible. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.

Logistic regression analysis of risk factors for postoperative recurrence of spinal tumors and analysis of prognostic factors

The aim of the present study was to investigate the risk factors for postoperative recurrence of spinal tumors by logistic regression analysis and analysis of prognostic factors. In total, 77 male and 48 female patients with spinal tumor were selected in our hospital from January, 2010 to December, 2015 and divided into the benign (n=76) and malignant groups (n=49). All the patients underwent microsurgical resection of spinal tumors and were reviewed regularly 3 months after operation. The McCormick grading system was used to evaluate the postoperative spinal cord function. Data were subjected to statistical analysis. Of the 125 cases, 63 cases showed improvement after operation, 50 cases were stable, and deterioration was found in 12 cases. The improvement rate of patients with cervical spine tumor, which reached 56.3%, was the highest. Fifty-two cases of sensory disturbance, 34 cases of pain, 30 cases of inability to exercise, 26 cases of ataxia, and 12 cases of sphincter disorders were found after operation. Seventy-two cases (57.6%) underwent total resection, 18 cases (14.4%) received subtotal resection, 23 cases (18.4%) received partial resection, and 12 cases (9.6%) were only treated with biopsy/decompression. Postoperative recurrence was found in 57 cases (45.6%). The mean recurrence time of patients in the malignant group was 27.49±6.09 months, and the mean recurrence time of patients in the benign group was 40.62±4.34. The results were significantly different (P<0.001). Recurrence was found in 18 cases of the benign group and 39 cases of the malignant group, and results were significantly different (P<0.001). Tumor recurrence was shorter in patients with a higher McCormick grade (P<0.001). Recurrence was found in 13 patients with resection and all the patients with partial resection or biopsy/decompression. The results were significantly different (P<0.001). Logistic regression analysis of total resection-related factors showed that total resection should be the preferred treatment for patients with benign tumors, thoracic and lumbosacral tumors, and lower McCormick grade, as well as patients without syringomyelia and intramedullary tumors. Logistic regression analysis of recurrence-related factors revealed that the recurrence rate was relatively higher in patients with malignant, cervical, thoracic and lumbosacral, intramedullary tumors, and higher McCormick grade and patient received partial resection or biopsy. Tumor property, tumor location, McCormick grade, tumor resection, and intramedullary tumors are risk factors for the recurrence of spinal tumors. Clinical assessment of these risk factors may be helpful in selecting appropriate treatment strategies.

Complete Spondylectomy Using Orthogonal Spinal Fixation and Combined Anterior and Posterior Approaches for Thoracolumbar Spinal Reconstruction: Technical Nuances and Clinical Results

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To determine the long-term efficacy of 2-stage total en bloc spondylectomy (TES).

SUMMARY OF BACKGROUND DATA

TES is a well-described technique to achieve tumor-free margins, but it is a highly destabilizing procedure that necessitates spinal reconstruction. A 2-stage anterior/posterior approach for tumor resection and instrumentation has been shown to be biomechanically superior to the single-stage approach in achieving rigid fixation, but few clinical studies with long-term outcomes exist.

METHODS

A retrospective review was performed on patients undergoing a 2-stage TES for a spinal tumor between 1999 and 2011. Results were compared with those from a literature review of case series, with a minimum of 2-year follow-up, reporting on a single-stage posterior-only approach for TES.

RESULTS

Seven patients were identified (average follow-up 52.7 mo). Tumor location ranged from T1 to L3 with the following pathologies: metastasis (n=3), hemangioma (n=1), leiomyosarcoma (n=1), giant cell tumor (n=1), and chordoma (n=1). There were no significant surgical complications. All 7 patients had intact spinal fixation. There were no failures of the orthogonal fixation (pedicle screws or anterior fixation). The average modified Rankin Scale scores improved from 2.7 preoperatively to 0.7 at last follow-up. None of the patients in our series suffered local disease recurrence at last follow-up or suffered neurological deterioration. These results were comparable with those noted in the literature review of posterior-only approach, where 12% of patients experienced instrument failure.

CONCLUSIONS

TES is a highly destabilizing procedure requiring reconstruction resistant to large multiplanar translational and torsional loads. A 2-stage approach utilizing orthogonal vertebral body screws perpendicular to pedicle screws is a safe and effective surgical treatment strategy. Orthogonal spinal fixation may lower the incidence of instrumentation failure associated with complete spondylectomy and appears to be comparable with a single-stage procedure. However, larger prospective series are necessary to assess the efficacy of this approach versus traditional means.

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

BACKGROUND AND OBJECTIVE

En bloc resections aim at surgically removing a tumor in a single, intact piece. Approach must be planned for the complete removal of the tumor without violation of its margins. The shared knowledge of the morbidity, mortality, risk assessment for local disease recurrence, complications, and death, related to spine tumors excised en bloc could improve the treating physician's apprehension of the diseases and decision making process before, during, and after surgical treatment. The purpose of this study was to review and report the experience gained during 25 years in one of the world's biggest spine oncologic centers.

METHODS

A retrospective study of prospective collected data of 1681 patients affected by spine tumors, of whom 220 had en bloc resections performed.

RESULTS

Most tumors were primary-165 cases (43 benign and 122 malignant); metastases occurred in 55 patients. A total of 60 patients died from the disease and 33 local recurrences were recorded. A total of 153 complications were observed in 100 of 216 patients (46.2%); 64 of these patients (30%) suffered 1 complication, whereas the rest had 2 or more. All complications were categorized according to temporal distribution and severity. These were further divided into 7 groups according to the type of complication. There were 105 major and 48 minor complications. Seven patients (4.6%) died as a result of complications. There were 33 local recurrences (15.28%) recorded. Contaminated cases, surgical margins of the resected tumor-intralesional, marginal, and malignant tumors-were statistically significant independent risk factors for local recurrence of the tumor. Contamination, local recurrence, neoadjuvant radiotherapy, number of levels resected, and metastatic tumors compared with primary malignant tumor were shown to be independent risk factors for a patient's death.

CONCLUSIONS

Treatment of spinal aggressive benign and malignant bone tumors with en bloc resection is beneficial in terms of better local control and prognosis, although it is a highly demanding and risky procedure. Margins are the key point of this procedure, thus a careful preoperative oncologic and surgical staging is necessary to define the optimal surgical approach. The adverse event profile of these surgeries is high. Therefore, it should be performed by experienced and multidisciplinary teams in specialized high volume centers.

A Systematic Review With Consensus Expert Opinion of Best Reconstructive Techniques After Osseous En Bloc Spinal Column Tumor Resection

STUDY DESIGN

Systematic literature review and consensus expert opinion.

OBJECTIVE

To provide recommendations on reconstructive constructs for large tumor resections of the spinal column. Four questions were studied: (1) What are the best reconstructive options for single versus multilevel resections? (2) Should short segment fixation be considered in primary tumor reconstruction? (3) How should reconstructive techniques differ at various regions of the spine? (4) Does planned postoperative radiation change the fusion strategy?

SUMMARY OF BACKGROUND DATA

Primary spinal tumors requiring en bloc resection are rare. Most studies focus on disease-free survival and local recurrence rates. Few studies focus on reconstructive options and outcomes with respect to fusion rates and need for revision.

METHODS

A literature search was performed from January 1990 to December 2013. Data were combined and construct survivorship summarized. A survey was administered to international spine tumor surgeons, evaluating reconstructive preferences.

RESULTS

The search yielded 381 articles, 12 included in the final analysis. Revision rates for anterior reconstruction were similar for autogenous strut grafts (10%), cages (7.7%), and allograft strut grafts (8.3%). There were two reports of revision from short to long segment constructs and three reports of broken pedicle screws, one requiring revision. Expert survey results revealed that most surgeons preferred cages packed with morcelized allograft and autograft (75%) for anterior reconstruction of single-level vertebrectomies, and strut bone grafting at the cervicothoracic junction (65%) and when more than one vertebrae was resected in the mid-thoracic spine (75%). Surgeons may alter their fusion technique if postoperative radiation is planned.

CONCLUSION

Posterior reconstruction with at least two vertebral levels above and below is recommended. Cages should be used for single-level defects and structural bone graft alone, or in combination with a cage, should be used when spanning a defect greater than two vertebral bodies. Planned postoperative radiation may affect fusion strategy.

LEVEL OF EVIDENCE

N/A.

[Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]

OBJECTIVE

To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES).

METHODS

A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes.

RESULTS

A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance.

CONCLUSION

TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation.

Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team

PURPOSE

Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries.

METHODS

A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team.

RESULTS

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection.

CONCLUSION

The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.