Total spondylectomy for primary tumor of the thoracolumbar spine

Clinical and radiological outcomes of n-HA/PA66 cages in anterior spine reconstruction following total en bloc spondylectomy for tumors

Objective

This retrospective monocentric study was conducted to evaluate the clinical and radiological outcomes of the nano-hydroxyapatite/polyamide66 (n-HA/PA66) cage in reconstructing the anterior column of the spine following total en bloc spondylectomy (TES).

Methods

A cohort of 24 patients, 20 diagnosed with primary malignant tumors and 4 with metastatic malignancies, was selected based on specific inclusion criteria. All were subjected to TES and anterior column reconstruction with the n-HA/PA66 cage from January 2013 to July 2023 at a single institution. Pre-operative embolization was performed on all patients. Documented factors included operation duration, intraoperative blood loss, length of hospital stay, treatment history, and involved level. Mechanical complications and radiological parameters such as the local kyphotic angle (LKA), anterior vertebral height (AVH), posterior vertebral height (PVH), cage subsidence, and bone fusion time were evaluated. Quality of life and neurological function were gauged using tools like the Visual Analog Scale (VAS), Eastern Cooperative Oncology Group (ECOG) performance score, Karnofsky Performance Score (KPS) scale, and American Spinal Injury Association (ASIA) grading.

Results

All patients were followed up for 12-127 months, with an average period of 39.71 months. An average operation time of approximately 8.57 h and a blood loss volume of about 1,384 ml were recorded. No instances of tumor recurrence or multiple organ metastases were reported, though recurrence was detected in 2 living patients. Solid fusion was achieved in all patients at a mean time of 6.76 ± 0.69 months. Cage breakage or migration was not observed. Subsidence into the adjacent vertebral bodies was identified in 3 patients but was deemed clinically irrelevant. Significant improvements in VAS, ECOG performance score, KPS scale, and ASIA scores were noted from pre- to post-surgery (P < 0.05). A marked enhancement in the AVH was observed from before surgery to immediately after (P < 0.05). LKA, AVH, and PVH values between postoperative and final follow-up showed no significant variance (P > 0.05).

Conclusion

The integration of TES and the n-HA/PA66 cage was found to yield promising clinical and radiological outcomes in anterior column spine reconstruction. The use of this material did not hinder oncological care, including the provision of adjuvant treatments (chemo/radiotherapy), ultimately contributing to the enhanced long-term quality of life for spinal tumor patients.

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.

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.

Mechanical Failure After Total En Bloc Spondylectomy and Salvage Surgery

Objective

Total en bloc spondylectomy (TES) is a curative surgical method for spinal tumors. After resecting the 3 spinal columns, reconstruction is of paramount importance. We present cases of mechanical failure and suggest strategies for salvage surgery.

Methods

The medical records of 19 patients who underwent TES (9 for primary tumors and 10 for metastatic tumors) were retrospectively reviewed. Previously reported surgical techniques were used, and the surgical extent was 1 level in 16 patients and 2 levels in 3 patients. A titanium-based mesh-type interbody spacer filled with autologous and cadaveric bone was used for anterior support, and a pedicle screw/rod system was used for posterior support. Radiotherapy was performed in 11 patients (pre-TES, 5; post-TES, 6). They were followed up for 59 ± 38 months (range, 11–133 months).

Results

During follow-up, 8 of 9 primary tumor patients (89%) and 5 of 10 metastatic tumor patients (50%) survived (mean survival time, 124 ± 8 months vs. 51 ± 13 months; p=0.11). Mechanical failure occurred in 3 patients (33%) with primary tumors and 2 patients (20%) with metastatic tumors (p=0.63). The mechanical failure-free time was 94.4 ± 14 months (primary tumors, 95 ± 18 months; metastatic tumors, 68 ± 16 months; p=0.90). Revision surgery was performed in 4 of 5 patients, and bilateral broken rods were replaced with dual cobalt-chromium alloy rods. Repeated rod fractures occurred in 1 of 4 patients 2 years later, and the third operation (with multiple cobalt-chromium alloy rods) was successful for over 6 years.

Conclusion

Considering the difficulty of reoperation and patients’ suffering, preemptive use of a multiple-rod system may be advisable.

Single-stage posterior total en bloc spondylectomy in the treatment of lumbar spinal metastases

OBJECTIVE

To report the clinical and radiographic outcomes of single-stage posterior total en bloc spondylectomy (TES) of lumbar spinal metastases.

PATIENTS AND METHODS

From January 2012 to January 2015, 20 consecutive cases with lumbar spinal metastases who received single-stage posterior TES were retrospectively analyzed. A visual analog scale (VAS) was used to evaluate patients' pain status, American Spinal Injury Association (ASIA) classification was used to evaluate neurological status, and Eastern Cooperative Oncology Group (ECOG) score system was used to evaluate patients' performance status at pre- and post-operation and final follow-up. In addition, Intraoperative blood loss, operative time, postoperative complications, local kyphosis angle, and the postoperative duration of hospital stay were analyzed.

RESULTS

The median follow-up time was 16 months (ranging from 3 to 39 months), and 4 patients were still alive at the last follow-up. The mean amount of intraoperative blood loss and operation time was 970 mL and 232.5 min, respectively. The average VAS score improved from 7.5 preoperative to 2.8 postoperative and 3.2 at the last follow-up. Postoperative complications occurred in 3 cases. Sixteen patients died within 2 years after surgery, 10 of which died within 1 year. In the remaining 4 patients, the mean follow-up period was 37.25 months. One case of local recurrence occurred but no implant failure presented during follow-up.

CONCLUSIONS

Single-stage posterior TES is a challenging but rewarding procedure in the treatment of lumbar spinal metastases. Due to unique anatomy and biomechanics, surgeons should be aware of important vessels, and nerve root injury should be avoided.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSION

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

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

STUDY DESIGN

A retrospective study.

OBJECTIVE

To describe a new surgical technique for total en bloc spondylectomy (TES) of the fifth lumbar (L5) tumor and evaluate the efficacy and safety of this new technique.

SUMMARY OF BACKGROUND DATA

TES has been considered an optimal treatment for tumor, including certain spinal tumors, but it requires a combined posterior-anterior approach, which is often complicated by a long operation time, considerable blood loss and severe trauma.

METHODS

Seven patients with primary or solitary metastatic tumors of L5 were treated with this new technique in our center between March 2014 and November 2017. The critical points were fabrication of the iliac graft, dissection, resection, and reconstruction. Other parameters including surgical time, blood loss, complications, pre- and postoperative neurological function, tumor control, and overall survival (OS) were presented and analyzed.

RESULTS

All the included patients received one stage TES. The mean surgical time was 365.7 minutes with an average blood loss of 2514.3 mL. No serious perioperative complication was observed or reported during the mean follow-up period of 27.4 months. Wound disruption occurred in one patient and numbness of the left lower limb in another, but both recovered rapidly after appropriate management. Adventitial avulsion of the abdominal aorta occurred during dissection in one patient. Two patients died during the follow-up period due to advanced malignancy. One patient was alive but developed a newly diagnosed thoracolumbar tumor in 40 months. The other four patients recovered well without evidence of disease. All patients were able to walk independently 3 to 4 weeks after operation, with satisfied fusion of the iliac grafts in a mean period of 6.7 months after operation. No evidence of internal fixation failure occurred.

CONCLUSION

This new technique offers satisfactory surgical exposure, total en bloc spondylectomy, reliable reconstruction, and good tumor control for certain L5 tumors through the posterior-only approach.

LEVEL OF EVIDENCE

4.

FOUR-LEVEL EN BLOC VERTEBRECTOMY: A NOVEL TECHNIQUE AND LITERATURE REVIEW

Objective:

To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction.

Methods:

A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital.

Results:

The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient.

Conclusion:

The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine

BACKGROUND

Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment.

METHODS

A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision.

RESULTS

In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001).

CONCLUSIONS

CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.

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.

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

BACKGROUND

Total en bloc spondylectomy (TES) for the treatment of spinal tumors decreases local recurrence and improves survival compared with intralesional resection. TES approaches vary in both the number of stages to complete the procedure and instruments with which osteotomies are performed.

METHODS

We describe a 2-stage technique that employs the use of threadwire saws. We performed a retrospective review of cases of primary tumors and solitary metastases involving the thoracic or lumbar spine treated with use of our modified technique at our institution between 2010 and 2016, identifying eligible patients by searching for specific phrases in operative reports found in our oncologic database. Clinical notes, operative notes, imaging reports, and pathology reports were reviewed for all patients.

RESULTS

Thirty-three patients underwent our modified technique, in which we pass a threadwire saw between the vertebral body and the thecal sac. The most common tumor type was chordoma (64%), and tumors were most commonly located in the lumbar spine (61%). There were no intraoperative injuries to the spinal cord or great vessels. One patient experienced a dural tear secondary to the passage of a saw. Seventeen (52%) of the patients had perioperative complications, with 1 death. Seven (22%) of the patients had complications occurring within 90 days after discharge, and 8 (25%) had complications occurring >90 days after discharge. Instrumentation failure was observed in 8 cases (25%). Negative margins were obtained in 94% of the cases. Local recurrence was observed in 2 cases (6%). The majority of patients had normal motor function at the time of the most recent follow-up.

CONCLUSIONS

Our modified en bloc spondylectomy represents an effective technique for the resection of spinal tumors in selected patients, allowing for visualization of vessels anterior to the spine and the avoidance of spinal cord injury.

LEVEL OF EVIDENCE

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

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.

The role of revision surgery and adjuvant therapy following subtotal resection of osteosarcoma of the spine: a systematic review with meta-analysis

OBJECTIVE Primary osteosarcoma of the spine is a rare osseous neoplasm. While previously reported retrospective studies have demonstrated that overall patient survival is impacted mostly by en bloc resection and chemotherapy, the continued management of residual disease remains to be elucidated. This systematic review was designed to address the role of revision surgery and multimodal adjuvant therapy in cases in which en bloc excision is not initially achieved. METHODS A systematic literature search spanning the years 1966 to 2015 was performed on PubMed, Medline, EMBASE, and Web of Science to identify reports describing outcomes of patients who underwent biopsy alone, neurological decompression, or intralesional resection for osteosarcoma of the spine. Studies were reviewed qualitatively, and the clinical course of individual patients was aggregated for quantitative meta-analysis. RESULTS A total of 16 studies were identified for inclusion in the systematic review, of which 8 case reports were summarized qualitatively. These studies strongly support the role of chemotherapy for overall survival and moderately support adjuvant radiation therapy for local control. The meta-analysis revealed a statistically significant benefit in overall survival for performing revision tumor debulking (p = 0.01) and also for chemotherapy at relapse (p < 0.01). Adjuvant radiation therapy was associated with longer survival, although this did not reach statistical significance (p = 0.06). CONCLUSIONS While the initial therapeutic goal in the management of osteosarcoma of the spine is neoadjuvant chemotherapy followed by en bloc marginal resection, this objective is not always achievable given anatomical constraints and other limitations at the time of initial clinical presentation. This systematic review supports the continued aggressive use of revision surgery and multimodal adjuvant therapy when possible to improve outcomes in patients who initially undergo subtotal debulking of osteosarcoma. A limitation of this systematic review is that lesions amenable to subsequent resection or tumors inherently more sensitive to adjuvants would exaggerate a therapeutic effect of these interventions when studied in a retrospective fashion.

L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature

Study Design Case report and review of the literature.

Objective We present the case of a two-level lumbar spondylectomy at L4 and L5 for en bloc resection of a giant cell tumor (GCT) and lumbopelvic reconstruction.

Methods A 58-year-old woman presented with a 7-month history of progressive intractable back and leg pain secondary to a biopsy-proven Enneking stage III GCT of the L4 and L5 vertebrae. The patient underwent a successful L4–L5 spondylectomy and lumbopelvic reconstruction using a combined posterior and anterior approach over two operative stages.

Results Postoperative complications included a deep wound infection and a cerebrospinal fluid leak; however, following surgical debridement and long-term antibiotic treatment, the patient was neurologically intact with minimal pain and there was no evidence of tumor recurrence or instrumentation failure at more than 2 years of follow-up.

Conclusion Spondylectomy that achieves en bloc resection is a viable and effective treatment option that can be curative for Enneking stage III GCTs involving the lower lumbar spine. The lumbosacral junction represents a challenging anatomic location for spinal reconstruction after spondylectomy with unique technical considerations.

[Chordoma]

PURPOSES

To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature.

MATERIALS

The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine.

METHODS

In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups.

RESULTS

In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection.

CONCLUSIONS

Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

[Solitary spinal metastases. Is aggressive surgical management justified?]

Advances in oncological and surgical therapies have led to a significant increase in life expectancy of cancer patients and also prolonged survival of patients with isolated or multiple metastases. Among the skeletal manifestations the spine is the most often affected site. Using novel imaging techniques with higher resolution and use of metabolic signatures, the screening of cancer patients has improved considerably. Consequently, the diagnosis of metastases is becoming increasingly more sensitive. Therefore, but also due to more effective polychemotherapy protocols, singular or solitary metastases are more frequently observed either in the early stages or as a result of a controlled malignant tumor entity (stable disease). The questions whether a solitary metastasis really exists (illusion or reality?) and its radical oncological and surgical treatment as a circumscribed singular tumor manifestation, is really relevant for the overall prognosis, remains controversial. However, it seems evident that a biologically favorable underlying tumor biology, radical treatment of the primary tumor and a long metastasis-free interval are valid predictors of a good oncological outcome. In the presence of a solitary metastasis under these circumstances (typical example: solitary metastasis of renal cell carcinoma many years after radical tumor nephrectomy) a radical surgical procedure (en bloc spondylectomy) can significantly improve the long-term prognosis of this patient group in combination with adjuvant chemotherapy and/or radiotherapy. However, a thorough evaluation of the overall survival prognosis, a detailed and complete staging followed by a treatment consensus in the interdisciplinary tumor board has to precede any therapeutical decisions.

Giant cell tumor of the lumbar spine with intraperitoneal growth: case report and review of literature

Giant cell tumors of the spine are uncommon. Usually they are benign and solitary, but locally very aggressive. Most of them occur at the sacral spine. There are only 26 reported cases in the literature involving this type of tumor in the lumbar spine, in particular exhibiting an intraperitoneal growth. We present the case of a woman with a primary tumor of the lumbar spine (giant cell tumor) with intraperitoneal growth, the outcome as well as a review of the literature. Furthermore, after reviewing all spinal cases in the literature above the sacral spine, we carefully suggest a management algorithm.

[Multisegmental en bloc spondylectomy. Indications, staging and surgical technique]

OBJECTIVE

Description of the surgical technique including approaches and spinal reconstruction principles for patients scheduled for multilevel en bloc excision of vertebral tumors (multisegmental total en bloc spondylectomy) with the aim to attain tumor-free margins and minimize the risk of local and systemic tumor recurrence. Restoration of biomechanically sufficient spinal stability. Functional preservation and/or regaining of adequate neurological function.

INDICATIONS

Primary malignant and benign, aggressive spinal tumors. Solitary metastatic tumors of biologically and prognostically favorable primary tumor (good prognostic scores). Extracompartmental, multisegmental vertebral tumor manifestations according to Tomita type 6.

CONTRAINDICATIONS

Diffuse spinal/vertebral tumor spread according to Tomita type 7 (disseminated spinal metastatic disease). Detection of distant metastases in the staging investigation. Biologically unfavorable tumor entities or primary systemic malignant tumors/diffuse disseminated malignoma (Tomita score < 4-5 points, Tokuhashi score < 12 points).

SURGICAL TECHNIQUE

Depending on tumor growth, sequential performance of the anterior and posterior approach for local tumor release and preparation/replacement of encased large vessels. Posterior approach via dorsomedial incision and exposure of the posterior vertebral elements. Costotransversectomy, resection of the facets, resection of paravertebral rib segments. Laminectomy in the tumor-free lamina segment, resection of the ligamentum flavum and paradural ligation of affected nerve roots, bilateral ligation of the segmental arteries. Digital extrapleural palpation and dissection to the anterior vertebral body parts. Insertion of S-shaped spatulas ventral to the anterior aspect of the spine, and dissection of the disc spaces and the posterior longitudinal ligament. Instrumentation of pedicle screws and unilateral rod fixation, mobilization and careful, manual turning out/rotation of the affected vertebral segments around the longitudinal axis of the spinal cord. Interpositioning of a carbon-composite cage from posterior filled with autologous bone. Completion of the posterior stabilization, soft tissue closure, Goretex patch fixation if required in cases of chest wall resections.

POSTOPERATIVE MANAGEMENT

Intensive care monitoring with balanced volume replacement/transfusion. Postoperative adjuvant radiotherapy or chemotherapy, depending on the protocol and resection margins.

Two-stage multilevel en bloc spondylectomy with resection and replacement of the aorta

OBJECTIVE

We report a case of multilevel spondylectomy in which resection and replacement of the adjacent aorta were done. Although spondylectomy is nowadays an established technique, no report on a combined aortic resection and replacement has been reported so far.

METHODS

The case of a 43-year-old man with a primary chondrosarcoma of the thoracic spine is presented. The local pathology necessitated resection of the aorta. We did a two-stage procedure with resection and replacement of the aorta using a heart-lung machine followed by secondary tumor resection and spinal reconstruction.

RESULTS

The procedure was successful. A tumor-free margin was achieved. The patient is free of disease 48 months after surgery.

CONCLUSION

En bloc spondylectomy in combination with aortic resection is feasible and might expand the possibility of producing tumor-free margins in special situations.

Primary chordomas of the cervical spine: a consecutive series of 14 surgically managed cases

OBJECT

Cervical chordomas are rare lesions and usually bring about challenges in treatment planning because of their wide extension and complicated adjacent anatomy. There are few large published series at present focusing on cervical chordomas. The authors studied a consecutive series of 14 patients with primary cervical chordomas who underwent surgical treatment and were observed between 1989 and 2008. By reviewing the clinical patterns and follow-up data, they sought to investigate the clinical characters, tailor the appropriate surgical techniques, and establish prognosis factors for cervical chordomas.

METHODS

Hospitalization and follow-up data in the 14 patients were collected. All patients underwent piecemeal tumor excision and reconstruction for stability; total spondylectomy was achieved in 5 cases. Postoperative radiotherapy was administered in all patients. Kaplan-Meier plots were used to represent tumor recurrence and patient survival, and log-rank testing was used to determine the risk factors of local recurrence.

RESULTS

Follow-up ranged from 8 to 120 months (mean 58.6 months). Symptom and neural status in most patients improved after surgery. The 1- and 5-year disease-free survival rates were 78.6% and 50%, respectively, and the 1- and 5-year survival rates were 92.9% and 85.7%, respectively. Log-rank tests revealed that the following variables were significantly associated with a high rate of tumor recurrence: age less than 40 years or greater than 70 years (p = 0.006) and an upper cervical tumor location (p = 0.019).

CONCLUSIONS

Chordomas in the cervical spine are usually neoplasms that exhibit insidious growth and a wide extension by the time of diagnosis. Radical intralesional debulking surgery and postoperative radiotherapy have been effective treatment. A limited application of en bloc tumor resection and the highly likely intraoperative intralesional tumor seeding may partially explain the high local recurrence rate, whereas the chance of distant metastases, fortunately, is very low. Most recurrence were documented within 3 years. Some specific surgical techniques should be emphasized to minimize tumor seeding. Patients with upper cervical chordomas, younger adults, and elderly adults have worse prognosis. For patients with chordoma extending to both the anterior and posterior spinal columns, total spondylectomy combined with piecemeal excision is recommended for a better prognosis.

Malignant fibrous histiocytoma of the spine: a series of 13 clinical case reports and review of 17 published cases

STUDY DESIGN

Retrospective case study of 13 primary malignant fibrous histiocytomas (MFH) of the spine.

OBJECTIVE

To analyze the clinic, radiologic, histologic, and prognostic features of 13 cases with the MFH of the spine.

SUMMARY OF BACKGROUND DATA

MFH, a soft tissue sarcoma, rarely occurs at the spine. Only sporadical cases have been reported in the English literature concerning the clinical and prognostic features of the primary MFH at the spine.

METHODS

Between January 1999 and December 2006, 13 cases with primary MFH of the spine were treated in the authors' spine center. Clinical history, radiographic, surgery resection, and pathologic features were recorded. The patients were followed up regarding their local recurrence and survivals. The 17 cases with primary MFH at the spine in the literature were reviewed.

RESULTS

Paraspinal or epidural mass at multiple spinal levels developed in 11 cases, with osteolytic destruction in all 13 cases. The tumor size averaged on 10.4 cm in greatest dimension. Metastases occurred in 10 of 13 cases. Compared with the 14 ± 0.60-months median survival of the debulking surgeries in seven cases, the median survival of the en bloc resection in six cases was 25 ± 6.12 months (P ∇ 0.009). The median survival was 8.7 months in 10 cases of the literature group, with 30% 1-year survival and 6.7% 2-year survival, respectively; while the median survival was 18.0 months in the authors' series, with 92.3% 1-year survival and 38.5% 2-year survival, respectively. The 5-year survival was between 25% and 69% in the extremities of MFH, but it was 28% in the head and neck and 26.7% in the abdominal cavity, compared with 7.7% in the spine in the authors' series.

CONCLUSION

The MFH of the spine tends to extensively invade paraspinal structures at multiple spinal levels, with aggressive osteolytic destruction in the vertebrae, resulting to local huge mass, radiculopathy, and myelopathy. Regardless of recent advancements in the diagnosis, treatment methods, and adjuvant therapies, for its biologically aggressive nature, it frequently recurs at the primary site and metastasizes. It has a worse prognosis than that of MFH in other sites.

Aneurysmal bone cyst secondary to giant cell tumor of the mobile spine: a report of 11 cases

STUDY DESIGN

A retrospective analysis was performed.

OBJECTIVE

To analyze the characteristics of aneurysmal bone cyst arising from giant cell tumor of the mobile spine and to discuss the outcome of corresponding surgical and nonsurgical treatment.

SUMMARY OF BACKGROUND DATA

Giant cell tumors are generally benign neoplasms that exhibit aggressive behavior with a tendency to recur locally. Aneurysmal bone cysts are benign, highly vascular osseous lesions. Although both of them have been described separately in previous literatures, few reports have described aneurysmal bone cyst secondary to giant cell tumor of the mobile spine.

METHODS

Between January 2004 and December 2009, 11 patients were identified with an aneurysmal bone cyst arising from giant cell tumor of the mobile spine. Four patients underwent subtotal tumor resection followed by radiotherapy, and the other 7 patients underwent total tumor resection. Patients with lesions located below T6 were treated with selective arterial embolization before surgery. Clinical data and the efficacy of surgery were analyzed via chart review

RESULTS

Of the eleven patients identified for inclusion in this study, the average age was 33 months (range ∇ 14-65 months). The mean length of follow-up was 31 months. Seven patients kept disease-free during the follow-ups. The remaining four patients recurred and one died of local re-recurrence and lung metastasis.

CONCLUSION

Unlike primary aneurysmal bone cyst, secondary aneurysmal bone cyst arising from giant cell tumor of the mobile spine has a more aggressive tendency to recurrence locally. Complete resection with systematic radiotherapy should be undertaken for the treatment of aneurysmal bone cyst secondary to giant cell tumor of the mobile spine, which is associated with a good prognosis for local tumor control. As complete or as radical an operation as possible should be performed at first presentation. The best chance for the patient is the first chance. Selective preoperative embolization is advised to minimize intraoperative blood loss.

Partial spondylectomy for primary leiomyosarcoma of C2 vertebra

STUDY DESIGN

A primary leiomyosarcoma located on the left side of the C2 is reported. Left-sided partial spondylectomy and anterior reconstruction with posterior stabilization was performed by a two-staged operation.

OBJECTIVE

To emphasize the occurrence of primary leiomyosarcoma and the importance of proper stabilization in the upper cervical spine.

SUMMARY OF BACKGROUND DATA

Leiomyosarcoma is a rare malignant neoplasm of the bone and the primary leiomyosarcoma of the spine is extremely rare. Radical tumor excision is the goal in case of vertebral leiomyosarcoma, but to both gain surgical access to the upper cervical spine and obtain anterior reconstruction is challenging.

METHODS

Leiomyosarcoma of the C2 in a 25-year-old woman with mild neurologic deficits is reported. A left-sided partial spondylectomy of C2 was performed. The defect of the vertebral body was reconstructed by expandable titanium prosthesis, and posterior craniocervical fixation was performed by the polyaxial screws in the lateral masses and rod/plates.

RESULTS

The surgical margin was very small. The pathology of the tumor was reported as leiomyosarcoma. No sign of local recurrence or metastasis was evident 1 year after surgery.

CONCLUSION

Leiomyosarcoma, although rare, should be kept in mind as one of the possible diagnoses when a patient with an upper cervical tumor is presented and complete tumor removal must be the goal.

Surgical management of recurrent thoracolumbar spinal sarcoma with 4-level total en bloc spondylectomy: description of technique and report of two cases

INTRODUCTION

The descriptions of total spondylectomy and further development of the technique for the treatment of vertebral sarcomas offered for the first time the opportunity to achieve oncologically sufficient resection margins, thereby improving local tumor control and overall survival. Today, single level en bloc spondylectomies are routinely performed and discussed in the literature while only few data are available for multi-level resections. However, due to the topographic vicinity of the spinal cord and large vessels, the multisegmental resections are technically demanding, represent major surgery and only few case reports are available. Surgical options are even more limited in cases of revision surgery and local recurrences when en bloc spondylectomy was considered to be not feasible due to high risk of vital complications in expanding resection margins. Deranged anatomy, implants in situ and extensive intra-/paraspinal scar tissue formation resulting from previously performed approaches and/or radiation are considered the principal complicating factors that usually hold back spine surgeons to perform revision for resection leaving the patient to palliative treatment.

METHODS

We present two patient cases with previously performed piecemeal vertebrectomy in the thoracic spine due to a solitary high-grade spinal sarcoma. After extensive re-staging, both patients underwent a multi (4)-level en bloc spondylectomy in our department (one patient with combined en bloc lung resection). Except a local wound disturbance, there was no severe intra- or postoperative complication.

RESULTS

After multilevel en bloc spondylectomy both patients showed a good functional outcome without neurological deficits, except those resulting from oncologically scheduled resection of thoracic nerve roots. After a median follow-up of 13 months, there was no local recurrence or distant metastasis. The reconstruction using a posterior screw rod system that is interconnected to an anterior vertebral body replacement with a carbon composite cage showed no implant failure or loosening. In summary, the approach of a multilevel en bloc surgery for revision and oncologically sufficient resection in cases of spinal sarcoma recurrences seems possible. However, interdisciplinary decision making in a tumor board, realistic evaluation of surgical resectability to attain tumor free margins, advanced experiences in spinal reconstructions and involvement of vascular, visceral and thoracic surgical expertise are essential preconditions for acceptable oncological and functional outcome.

Oncosurgical results of multilevel thoracolumbar en-bloc spondylectomy and reconstruction with a carbon composite vertebral body replacement system

STUDY DESIGN

Retrospective clinical study for patients receiving multilevel en-bloc spondylectomy resection for sarcomas and solitary metastases of the thoracolumbar spine.

OBJECTIVE

Assess the clinical and radiologic outcome after multilevel en-bloc spondylectomy and reconstruction.

SUMMARY OF BACKGROUND DATA

Monolevel en-bloc spondylectomies have proven their oncosurgical effectiveness while reports on multilevel resections for extracompartmental tumor localizations are rare.

METHODS

Patients treated by multilevel en-bloc spondylectomy and restoration with a carbon composite vertebral body replacement system were investigated. Patient charts, and clinical follow-up investigations were analyzed for histopathological tumor origin, preoperative symptoms, surgical peri- and postoperative data, applied adjuvant therapies, as well as the course of disease. Solitary metastases time until occurrence and prognostic scores were evaluated (Tomita/Tokuhashi Score). CT-scans were performed and analyzed at follow up. Oncological status was evaluated including local recurrence rates, cumulative disease specific, and metastases-free survival.

RESULTS

Multilevel (2-5 segments) en-bloc spondylectomy of the thoracolumbar spine was performed in 20 patients (15 sarcomas and 5 solitary spinal metastases 9 male/11 female, mean age at surgery: 54 ± 15 years.). Wide and marginal surgical margins were achieved in 7 and 13 patients, respectively. Mean follow-up period was 25.0 (9-53) months. Thirteen patients received adjuvant therapy. No implant breakage or loosening was observed. Local recurrence occurred in one patient. Thirteen of the 18 surviving patients showed no evidence of the disease, two died of systemic disease.

CONCLUSION

Multilevel en-bloc spondylectomy offers a radical resection option for extracompartmental tumor involvement. It provides oncologically adequate resection margins with low local recurrence. However, the procedures are complex; the patient's stress is high and metastatic disease developed in one-third of patients. A judicious patient selection and a realistic feasibility evaluation must precede the decision for surgery. Reconstruction using a carbon composite cage system showed low complication rates and offers advantages for oncosurgical procedures.

Total en bloc spondylectomy of the lower lumbar spine: a surgical techniques of combined posterior-anterior approach

STUDY DESIGN

Ten patients with a spinal tumor of the lower lumbar spine underwent total en bloc spondylectomy (TES) by combined posterior-anterior approach. The oncological and neurologic results are analyzed.

OBJECTIVE

To describe the surgical technique and evaluate the clinical outcome of this surgery.

SUMMARY OF THE BACKGROUND DATA

TES at lower lumbar spine is technically challenging because of its anatomy such as the presence of major vessels and lumbosacral plexus nerves.

METHODS

Six aggressive benign tumors and 4 solitary spinal metastases involving L4 or L5 were treated. The approache of operative procedure are discussed as follows: Posterior approach: Dissection of the lumbar nerve roots to the conjunction of the adjacent nerves were performed after en bloc laminectomy by T-saw pediculotomy. The psoas muscle was dissected away, from the vertebral body. The posterior halves of the anterior column at the craniocaudal adjacent levels of the lumbar tumor were cut. Anterior approach: Major vessels were dissected from the vertebral body. Anterior halves of the anterior column were cut at the corresponding levels. The tumor vertebral body was removed en bloc, followed by anterior spinal reconstruction.

RESULTS

Seven of 10 cases had no evidence of disease at 57 months on average, 1 case was alive with disease at 66 months, 1 case had death of disease at 42 months, and 1 case had death of another disease at 14 months after surgery. All patients improved or preserved neurologic in the last follow up. The resected specimen of vertebral bodies and laminae showed marginal or wide margin in all cases, although pedicles showed intralesional margin in 8 cases. No local recurrence was observed during lifetime with mean 52 months.

CONCLUSION

TES for spinal tumor of L4 or L5 preserving lumbar nerves was achieved by combined posterior- anterior approach.

En Bloc Resection for Primary and Metastatic Tumors of the Spine

BACKGROUND

The efficacy of en bloc resection for spinal tumors is unknown because most of the current evidence is provided by small, single-institution clinical series or case reports.

OBJECTIVE

To combine all previously published reports of en bloc resection for primary and metastatic spinal tumors, to describe the overall pattern of disease-free survival, and to investigate potentially prognostic factors for recurrence.

METHODS

A complete MEDLINE search for all articles reporting survival data for en bloc resection of spinal tumors was undertaken; 44 articles met inclusion criteria from which 306 eligible patients were identified.

RESULTS

There were 229 cases of primary tumors with a mean follow-up of 65.0 months and 77 cases of solitary metastatic tumors with a mean follow-up of 26.5 months. Median time to recurrence was 113 months for the primary group and 24 months for the metastatic group. Disease-free survival rates at 1, 5, and 10 years were 92.6%, 63.2%, and 43.9%, respectively, for the primary group and 61.8%, 37.5%, and 0%, respectively, for the metastatic group; 5-year disease-free survival rates were 58.4% for chordoma and 62.9% for chondrosarcoma. After adjusting for covariates, age, male sex, metastatic tumors, and osteosarcomas were significantly associated with a tumor recurrence.

CONCLUSION

This study provides the largest published series of patients undergoing en bloc resection for spinal tumors. Median time to recurrence reached almost 10 years in patients with primary tumors; however, it was only 2 years in those with isolated metastatic tumors.

En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature

BACKGROUND CONTEXT

Survival data and rates of recurrence after en bloc resection for cervical spinal tumors are limited to single case reports and small case series, making the true risk of recurrence after this procedure unknown.

PURPOSE

To report two cases of cervical chordoma managed via en bloc resection. To conduct a systematic review of the existing literature to determine the overall incidence of disease-free survival and investigate potential prognostic factors of recurrence.

STUDY DESIGN

Case report and systematic review.

METHODS

We present the cases of a 60-year-old woman and a 76-year-old man who underwent en bloc resection of C3-C6 and C2 chordomas, respectively. A complete MEDLINE search was then undertaken for all articles reporting survival data for en bloc resections of primary tumors of the cervical spine. Exclusion criteria included non-English articles, lack of explicit mention or description of en bloc technique, age less than 16, no demographic or survival information reported, and follow-up less than 1 month. Survivorship analysis was conducted, and Kaplan-Meier plots were created with the primary outcome of interest being any tumor recurrence.

RESULTS

A total of 10 articles comprising 18 cases were included for analysis with a mean follow-up of 47.4+/-41.5 months. Mean operative time, estimated blood loss, and length of hospitalization were 18.6 hours, 2.9L, and 34.6 days, respectively. Postoperative complications occurred in eight of the nine patients in which these data were reported. There were three cases of local recurrence, occurring at 12, 44, and 113 months, and one case of distant metastasis, occurring at 12 months postoperatively. With the available data, 1- and 5-year disease-free survival rates of 88.2% and 73.5% were calculated. On Cox proportional hazards analysis, no factors were found to be predictive of recurrence.

CONCLUSIONS

In this systematic review of the literature, en bloc resection provided good disease-free survival rates in patients with primary tumors of the cervical spine. However, there are insufficient data on long-term subjective outcomes in these patients, and larger series are needed to determine the efficacy compared with piecemeal resection techniques. Other investigators should be encouraged to publish their results so that combined analyses like these may be performed with larger sample sizes.

Bone sarcoma of the spine

Primary malignant bone tumors of the vertebral column, i.e., bone sarcomas of the spine, are inherently rare entities. Vertebral osteosarcomas and chordomas represent the largest groups, followed by the incidence of chondro-, fibro-, and Ewing's sarcomas. Detailed clinical and neurological examination, complete radiographic imaging [radiographs, computed tomography (CT), magnetic resonance imaging (MRI)], and biopsy are the decisive diagnostic steps. Oncosurgical staging for spinal tumors can serve as a decision-guidance system for an individual's oncological and surgical treatment. Subsequent treatment decisions are part of an integrated, multimodal oncological concept. Surgical options comprise minimally invasive surgery, palliative stabilization procedures, and curative, wide excisions with complex reconstructions to attain wide or at least marginal resections. The most aggressive mode of surgical resection for primary vertebral column tumors is the total en bloc vertebrectomy, i.e., single- or multilevel en bloc spondylectomy. En bloc spondylectomy involves a posterior or combined anterior/posterior approach, followed by en bloc laminectomy, circumferential (360 degrees) vertebral dissection, and blunt ventral release of the large vessels, intervertebral discectomy and rotation/ en bloc removal of the vertebra along its longitudinal axis. Due to the complex interdisciplinary approach and the challenging surgical resection techniques involved, management of vertebral bone sarcomas is recommended to be performed in specific musculoskeletal tumor centers.

Solitary vertebral metastasis

As survival time increases for many cancers, it is likely that the incidence and prevalence of spinal metastases will increase also. Given that most patients first present with solitary lesions in the spine, proper initial diagnosis and management are of paramount importance in minimizing pain, improving neurologic function, and potentially lengthening survival. Although pain control and standard radiation are still used, spinal stereotactic radiosurgery, vertebroplasty and kyphoplasty, and spinal cord decompression and fusion are now consistently used in aggressive management and offer exciting preliminary results.

Biomechanical consequences of cervical spondylectomy versus corpectomy

OBJECTIVE

To evaluate the differences in spinal stability and stabilizing potential of instrumentation after cervical corpectomy and spondylectomy.

METHODS

Seven human cadaveric specimens were tested: 1) intact; 2) after grafted C5 corpectomy and anterior C4-C6 plate; 3) after adding posterior C4-C6 screws/rods; 4) after extending posteriorly to C3-C7; 5) after grafted C5 spondylectomy, anterior C4-C6 plate, and posterior C4-C6 screws/rods; and 6) after extending posteriorly to C3-C7. Pure moments induced flexion, extension, lateral bending, and axial rotation; angular motion was recorded optically.

RESULTS

After corpectomy, anterior plating alone reduced the angular range of motion to a mean of 30% of normal, whereas added posterior short- or long-segment hardware reduced range of motion significantly more (P < 0.003), to less than 5% of normal. Constructs with posterior rods spanning C3-C7 were stiffer than constructs with posterior rods spanning C4-C6 during flexion, extension, and lateral bending (P < 0.05), but not during axial rotation (P > 0.07). Combined anterior and C4-C6 posterior fixation exhibited greater stiffness after corpectomy than after spondylectomy during lateral bending (P = 0.019) and axial rotation (P = 0.001). Combined anterior and C3-C7 posterior fixation exhibited greater stiffness after corpectomy than after spondylectomy during extension (P = 0.030) and axial rotation (P = 0.0001).

CONCLUSION

Circumferential fixation provides more stability than anterior instrumentation alone after cervical corpectomy. After corpectomy or spondylectomy, long circumferential instrumentation provides better stability than short circumferential fixation except during axial rotation. Circumferential fixation more effectively prevents axial rotation after corpectomy than after spondylectomy.

[En-bloc spondylectomy and reconstruction for primary tumors and solitary metastasis of the spine]

In primary tumors of the spine and, with limitations, solitary metastasis, the surgical approach should aim for curative treatment of the disease. Because the prognosis of malignant bone tumors is extremely limited, if an intralesional approach is performed, an extralesional en bloc resection is the treatment of choice. Therefore, it is mandatory to use an appropriate staging system. For the spine, the WBB staging system has been approved, which transfers the principles of the Enneking classification for treating primary malignant tumors of the limb to the spine. After en bloc spondylectomy, rigid and primary stable instrumented dorsoventral reconstruction must be performed - posteriorly with a dual-rod system using pedicle screws, and anteriorly in the ideal case by means of a vertebral body replacement cage. The possibility of extralesional (wide or marginal) resection of spinal tumors depends on tumor size and location. Extralesional resection and, if indicated, other neoadjuvant, adjuvant, or local therapeutic modalities have a strong positive influence on long-term survival rates. A good prognosis for primary tumors is associated with a good response to chemotherapy and extralesional resection. Solitary metastases have a much worse quod vitam prognosis. Therefore, local control of the disease in en bloc resections of solitary metastasis is a second relevant goal, although curative treatment is the primary aim.

Giant cell tumor of the cervical spine: a series of 22 cases and outcomes

STUDY DESIGN

A consecutive series of 22 giant cell tumor (GCTs) of the cervical spine which underwent surgical treatment was observed from 1990-2003.

OBJECTIVE

This study reviews the clinical patterns and follow-up data of (GCT) of bone arising in the cervical spine which underwent surgical treatment. We attempt to correlate treatment and outcomes over time.

SUMMARY OF BACKGROUND DATA

GCTs of bone are common, aggressive, or low-grade malignant tumors that occur infrequently in the spine above the sacrum, and their presence in the cervical vertebrae is even more exceptional. Though surgical resection of GCT arising in the cervical spine is commonly regarded as a recommended treatment method, it is still a challenge to achieve satisfactory results, especially for the late or recurrent cases, and there are few large series of cases reported with long-term follow-up of this tumor that are found in special segments in the literature.

METHODS

All clinical and follow-up data of 22 cases of GCT arising in cervical spine which received surgical treatment in our spine center from January 1990-December 2003 were collected. The choice of surgical intervention was based on the Weinstein-Boriani-Biagini grading system. Two meanly different protocols of surgical treatment were applied: 8 patients underwent subtotal resection (one of them died shortly after surgery and could not be followed up), 13 cases received total spondylectomy. One special lesion located in the posterior element of C7 received "en bloc" resection. For reconstructing the stability of the cervical spine, we used autologous ilium for pure bone graft, or titanium plate and titanium mesh for anterior instrumented fusion or anterior and posterior combined instrumented fusion. Postoperative radiation therapy was given in 18 cases as an adjunctive therapy method.

RESULTS

One patient with C1-C2 GCT (vertebral body and posterior element involvement) who received subtotal resection of the tumor showed aggravation of neurologic deficit and died shortly after the surgery. So we had 21 cases for mid and long-term follow-up, with an average of 67.8 months, that ranged from 36 to 124 months. The symptom of radicular pain almost disappeared, and patients suffering from spinal cord compression recovered well with at least 1 or 2 levels based on Frankel grading system when re-evaluated at 3 months after operation. The rate of fusion for the bone graft is 100%. All the internal fixations were well fused and no spine instability could be seen in our series. Local recurrence was detected in 5 of 7 cases (71.4%) that underwent subtotal resection, but in only 1 of the 13 cases (7.7%) for total spondylectomy. Four cases died within follow-up and all these patients were recurrent cases. One patient developed pulmonary metastases.

CONCLUSION

GCT of the cervical spine easily onsets between 20 and 40 years of age. As a kind of benign but local aggressive or low potential malignancy tumor, we should take an aggressive attitude to excise the tumor as much as possible while reserving the neural function as a precondition. Unlike in the thoracic and lumbar spine, a strictly "en bloc" resection is often not a feasible option because of the involvement of critical neurovascular structures. Total spondylectomy (even intralesional) with radiation therapy as an adjunctive treatment has significantly lowered the local recurrence rate of the GCT in the special segments.

Total L-5 spondylectomy and reconstruction of the lumbosacral junction

✓The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4–5 and L5–S1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4–5 and L5–S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

Surgical management of chordomas of the cervical spine

OBJECT

Chordomas of the cervical spine are rare tumors. Although en bloc resection has proven to be the ideal procedure in other areas, there is controversy regarding this approach in the cervical spine. The goal in this study was to determine whether piecemeal tumor resection was efficient in the management of chordomas that arise in this location.

METHODS

The authors retrospectively reviewed all 74 cases of chordoma treated by their group. Seven patients with isolated cervical chordomas who were treated between October 1992 and January 2006 were identified. There were four male and three female patients, whose ages ranged from 6 to 61 years (mean 34.4 years). Follow-up duration ranged from 7 to 169 months (median 23 months). All cases were managed using a retrocarotid approach with mobilization of the vertebral artery. When the tumor could not be completely resected via the initial anterior approach, a subsequent posterior resection was performed. Tumor resection was intralesional in all cases, and gross-total tumor resection was achieved in six cases. One patient required a second resection 4 months later. In all cases, a posterior stabilization procedure was performed. Five patients underwent anterior fusion (three with fibular allograft and two with iliac crest), whereas two underwent occipitocervical fusion. In two patients with dedifferentiated chordoma metastasis developed, and one of them died 7 months later. The other patient with metastasis died suddenly at home 26 months postsurgery, presumably from aspiration. At the time of this submission, there were no signs of recurrence in five patients.

CONCLUSIONS

The authors believe that, in most cases, en bloc resection of cervical chordoma is not feasible. This is due to the tendency of chordomas to involve multiple compartments at the time of diagnosis. In the authors' experience, intralesional radical resection remains an effective surgical approach to this disease entity.

Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note

Chordomas are locally invasive, malignant bone tumors that rarely occur in the cervical spine. En bloc resection or even fully resecting the tumor along its margin offers improved patient survival and a potential disease cure. Complete resection of tumors involving the upper cervical vertebrae requires a combined anterior-posterior approach but is complicated by the presence of vertebral arteries (VAs). In addition, reconstruction of the postresection defect may be prone to failure. The authors present a case of a chordoma involving the axis that was treated using a single-stage total intralesional C-2 spondylectomy with preservation of both VAs because the patient did not tolerate a preoperative occlusion test. A three-column reconstruction technique is also presented.

Extensive total spondylectomy for recurrent giant cell tumor in the thoracic spine

✓The authors report the case of a 47-year-old woman who harbored a giant cell tumor at the T-5 level. She had undergone curettage of the tumor via a combined anterior and posterior approach at a regional hospital and was later referred to the authors' institution for treatment after the tumor recurred. On examination she exhibited progressive paraparesis and was nonambulatory due to cord compression caused by the tumor, which had invaded the spinal canal and extended to the right paravertebral muscles and right thoracic cavity. A spondylectomy was performed through a single posterior approach. The tumor, together with a portion of the dura mater, pleura, and muscles, was resected en bloc from T-4 to T-6. After resection, spinal reconstruction was performed by placement of an anterior titanium mesh cage as well as posterior pedicle screw and rod instrumentation. The patient's postoperative course was uneventful, and she exhibited substantial neurological recovery and became ambulatory. Two and a half years after surgery, the patient was tumor free.

En bloc resection of a recurrent giant cell tumor was successfully achieved through a single posterior approach. This surgical technique can be an effective option for this pathological condition, which is difficult to manage using other conventional treatment options including repeated curettage and radiotherapy.

Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy

Primary malignant spinal tumors and solitary vertebral metastases of selected tumor entities in the thoracolumbar spine are indications for total en bloc spondylectomy (TES). This study aimed to describe our oncological and surgical management and to analyze the treatment results by management with TES for extra- and intracompartmental solitary spinal metastases and primary malignant vertebral bone tumors. In 15 patients (3 malignant bone tumors and 12 solitary metastases), tumors were distributed in the thoracic (n = 8) and lumbar (n = 7) spine. Tumors were classified as intra- (n = 8) and extracompartmental (n = 7). All patients underwent TES via a laterally extended posterior approach followed by dorsoventral reconstruction. Function and quality of life were assessed by Oswestry disability index (ODI) and SF-36 score. At follow-up (100%; mean: 33 +/- 22 months), 11 patients had no evidence of disease. Two patients were alive with the disease and two were dead of the disease (no primary bone tumors). Histology revealed negative margins (R0) in all patients with wide (n = 11) and marginal (n = 4) resections. Two patients developed pulmonal metastases of which they died at 4 and 16 months of survival. No local recurrence was observed. Major complications did not occur. TES resulted in an acceptable outcome in the quality of life and function. TES is a demanding procedure reaching wide to marginal resections in a curative approach. In conjunction with multimodal therapies, local recurrences can effectively be prevented while control of distant disease needs to be improved. Proper selection of adequate patients combined with careful surgical planning are prerequisites for low complication rates, acceptable function and improved overall prognosis.

Margin-free spondylectomy for extended malignant spine tumors: surgical technique and outcome of 13 cases

STUDY DESIGN

Description of surgical technique and retrospective review of 13 cases.

OBJECTIVES

To describe the surgical technique of margin-free spondylectomy and the outcome of 13 cases and to discuss the advantages and limitations of the procedure.

SUMMARY OF BACKGROUND DATA

Recently, spondylectomy became a standard procedure by several pioneers. For extended malignant spine tumors involving pedicles or epidural space, however, performing an "en bloc" resection with a tumor-free margin remains a challenge.

METHODS

Our procedure consists of a combined anterior and posterior procedure with one or two stages. In the anterior procedure, tumor vertebrae are covered by the pleura or psoas muscles as a barrier. The posterior procedure includes decompression through the intact posterior elements, coverage of the tumor with all possible soft tissue barriers, and en bloc extirpation by rotating the tumor vertebrae around the spinal cord. We performed this procedure in 13 cases: 3 chondrosarcoma, 3 giant cell tumor, 1 osteosarcoma, 1 chordoma, and 5 metastases.

RESULTS

Neurologic status and pain improved in all cases except asymptomatic cases. There was no local recurrence, except in 2 cases (chondrosarcoma with extirpation of 5 vertebrae, chordoma with multiple previous surgeries). Two cases of chondrosarcoma were disease-free 14 years and 13 years after surgery, respectively.

CONCLUSION

Although the best chance for a cure in extended malignant tumors of the spine is realized through wide resection, the procedure is not yet standardized. Margin-free spondylectomy is technically demanding, but the procedure can be used with a confidence as a more radical surgery for tumors extending to the epidural space and the unilateral pedicle. A key to success is the surgical technique, including a 360 degree dissection around the tumor vertebrae, instrumentation, and removal of the lesion with all possible soft tissues maintained intact to function as a barrier, like the dura mater.

En bloc vertebrectomy and dural resection for chordoma: a case report

STUDY DESIGN

Case report.

OBJECTIVES

Report a surgical technique for dural reconstruction after vertebrectomy.

SUMMARY OF BACKGROUND DATA

None available.

METHODS

Clinical case analysis: chordoma from T12 to L2 with infiltration of the dura.

RESULTS

Forty-six months after vertebral resection and reconstruction, the patient is disease free.

CONCLUSIONS

Wide en bloc resection is required for local control in chordoma. When the tumor permeates the dura, resection not including the dura is intralesional with high risk of local recurrence. Therefore, a proper wide resection consists in vertebrectomy removing the dura infiltrated by the tumor. The two-stage dural reconstruction had strongly limited the leakage of liquor during surgery, and the dural patch provided extra strength anteriorly, where the dural suture is more difficult.

Total cervical spondylectomy for primary osteogenic sarcoma. Case report and description of operative technique

The authors describe a technique for total spondylectomy for lesions involving the cervical spine. The method involves separately staged anterior and posterior approaches and befits the unique anatomy of the cervical spine. The procedure is described in detail, with the aid of radiographs, intraoperative photographs, and illustrations. Unlike in the thoracic and lumbar spine--for which methods of total en bloc spondylectomy have previously been described--a strictly en bloc resection is not possible in the cervical spine because of the need to preserve the vertebral arteries and the nerve roots supplying the upper limbs. Although the resection described in this case is by definition intralesional, it is oncologically sound, given the development of effective neoadjuvent chemotherapeutic regimens for osteosarcoma.

Total en bloc lumbar spondylectomy. Case report

The authors describe a technique for total en bloc spondylectomy that can be used for lesions involving the lumbar spine. The technique involves a combined anterior-posterior approach and takes into account the unique anatomy of the lumbar spine. This technique allows for the en bloc resection of lumbar vertebral tumors, thus optimizing outcome while minimizing the risk of neurological injury. The technique is described in detail with the aid of neuroimaging studies, photographs of gross pathological specimens, and illustrations, and a discussion of other authors' experiences is provided for comparison.