En bloc spondylectomy for spinal metastases: a review of techniques

En-bloc resection for spinal giant cell tumors: superior outcomes-a comprehensive meta-analysis and trial sequential analysis

Spinal giant cell tumors (GCTs) management primarily involves surgical resection; however, the optimal surgical approach continues to be a subject of debate. This study aims to comprehensively compare the efficacy of en-bloc resection with that of control resection techniques, specifically intralesional curettage and piecemeal resection, in the treatment of spinal GCTs. A comprehensive search of English databases, including the Cochrane Library, Embase, PubMed, Scopus, and Web of Science, as well as Chinese databases such as the National Knowledge Infrastructure (CNKI), Chongqing VIP (VIP), and Wan Fang, was conducted up to January 2024. This search identified twelve studies encompassing 492 participants. The meta-analysis indicated that en-bloc resection significantly reduces recurrence rates (OR = 0.27, 95% CI: 0.15-0.47, P < 0.00001) and mortality (OR = 0.16, 95% CI: 0.03-0.88, P = 0.04) when compared to control resection techniques. Notably, en-bloc resection demonstrated superior performance over control methods in both 1-year and 5-year relapse-free survival (RFS) rates (P = 0.001 and P < 0.00001, respectively), as well as in overall RFS (HR = 0.27, 95% CI: 0.08-0.91; P = 0.04). Despite its advantages, en-bloc excision was associated with a higher overall complication rate (P = 0.01). Furthermore, trial sequential analysis (TSA) suggests that the current sample size is inadequate to draw definitive conclusions, thereby underscoring the necessity for further investigations. En-bloc resection shows significant advantages over control resection techniques in reducing recurrence rates, mortality, and improving RFS. However, the higher complication rates and TSA findings stress the need for more high-quality studies to verify the benefits and safety of en-bloc resection in spinal GCT treatment.

Advances in the multidisciplinary surgical approach to primary spinal sarcomas: insights from a retrospective case series on outcomes and survival

INTRODUCTION

The management of spinal sarcomas is complex, given their widespread involvement and high recurrence rates. Despite consensus on the need for a multidisciplinary approach with surgery at its core, there is a lack of definitive guidelines for clinical decision-making. This study examines a case series of primary spinal sarcomas, focusing on the surgical strategies, clinical results, and survival data to inform and guide therapeutic practices.

METHODS

We conducted a retrospective analysis of patients who underwent surgical resection for primary spinal sarcomas between 2005 and 2022. The study focused on gathering data on patient demographics, surgical details, postoperative complications, overall hospital stay, and mortality within 90 days post-surgery.

RESULTS

The study included 14 patients with a primary diagnosis of spinal sarcoma, with an average age of 48.6 ± 12.6 years. Chondrosarcoma emerged as the most common tumor type, representing 57.1% of cases, followed by Ewing sarcoma at 35.7%, and synovial sarcoma at 7.1%. Patients with chondrosarcoma were treated with en-bloc resection, while the patient with synovial sarcoma underwent intra-lesional excision and those with Ewing sarcoma received decompression and tumor debulking. Postoperative assessments revealed significant improvements in neurological conditions. Notably, functional status as measured by the Karnofski Performance Index (KPI), improved substantially post-surgery (from 61.4 to 80.0%) The mean follow-up was 34.9 ± 9.2 months. During this time period one patient experienced fatal bleeding after en-bloc resection complications involving the vena cava. None of the patient needed further surgery.

CONCLUSIONS

Our 16-year study offers vital insights into managing primary spinal sarcomas, showcasing the effectiveness of surgical intervention, particularly en-bloc resection. Despite their rarity and complexity, our multidisciplinary treatment approach yields improved outcomes and highlights the potential for refined surgical strategies to become standardized care in this challenging domain.

Efficacy and safety of en-bloc resection versus debulking for spinal tumor: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to consolidate the existing evidence regarding the comparison between en-bloc resection surgery and debulking surgery for spinal tumors, including both primary and metastatic tumors.

MATERIALS AND METHODS

The databases of PubMed, Embase, Cochrane database, Web of Science, Scopus, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP Database (VIP), and Wan Fang Database was carried out and included all studies that directly compared en-bloc resection surgery with debulking surgery for spinal tumors in patients through March 2024. The primary outcomes included recurrence rate, postoperative metastasis rate, mortality rate, overall survival (OS), recurrence-free survival (RFS), complication, and so on. The statistical analysis was conducted using Review Manager 5.3.

RESULTS

We systematically reviewed 868 articles and included 27 studies involving 1135 patients who underwent either en-bloc resection surgery (37.89%) or debulking surgery (62.11%). Our meta-analysis demonstrated significant advantages of en-bloc resection over debulking surgery. Specifically, the en-bloc resection group had a lower recurrence rate (OR = 0.19, 95%CI: 0.13-0.28, P < 0.00001), lower postoperative metastasis rate (P = 0.002), and lower mortality rate (P < 0.00001). Additionally, en-bloc resection could improve OS and RFS (HR = 0.45, 95%CI: 0.32-0.62, P < 0.00001 and HR = 0.37, 95%CI: 0.17-0.80, P = 0.01, respectively). However, en-bloc resection required longer operative times and was associated with a higher overall complication rate compared to debulking surgery (P = 0.0005 and P < 0.00001, respectively).

CONCLUSION

The current evidence indicates that en-bloc surgical resection can effectively control tumor recurrence and mortality, as well as improve RFS and OS for patients with spinal tumors. However, it is crucial not to overlook the potential risks of perioperative complications. Ultimately, these findings should undergo additional validation through multi-center, double-blind, and large-scale randomized controlled trials (RCTs).

Total En Bloc Spondylectomy in a Case of Solitary Metastatic Breast Carcinoma With Intact Neurology: A Case Report

The management of spinal metastasis varies from patient to patient, depending on the type of lesion, stage of the disease, extension into the spinal canal, associated fractures, and life expectancy. We present a case of solitary metastasis with intact neurology in a 48-year-old lady who underwent a radical mastectomy for T2 N3 M0 breast carcinoma 34 months ago. Total en bloc spondylectomy in a neurologically intact patient is a challenging one. In all posterior approaches, there is a high chance of postoperative neurodeficiency. In our case, a combined approach seems to be a much safer procedure with easy accessibility to remove the total D8 vertebra.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Outcomes of Total En Bloc Spondylectomy for Previously Irradiated Spinal Metastases: A Retrospective Propensity Score-Matched Comparative Study

This study aimed to investigate the clinical outcomes of total en bloc spondylectomy (TES) for spinal metastases previously treated with radiotherapy (RT). This study enrolled 142 patients who were divided into two groups: those with and those without an RT history. Forty-two patients were selected from each group through propensity score matching, and postoperative complications, local recurrence, and overall survival rates were compared. The incidence of postoperative complications was significantly higher in the group with an RT history than in the group without an RT history (57.1% vs. 35.7%, respectively). The group with an RT history had a higher local recurrence rate than the group without an RT history (1-year rate: 17.5% vs. 0%; 2-year rate: 20.8% vs. 2.9%; 5-year rate: 24.4% vs. 6.9%). The overall postoperative survival tended to be lower in the group with an RT history; however, there was no significant difference between the two groups (2-year survival: 64.3% vs. 66.7%; 5-year survival: 47.3% vs. 57.1%). When planning a TES for irradiated spinal metastases, the risk of postoperative complications and local recurrence should be fully considered.

Case report: L5 tomita En bloc spondylectomy for oligometastatic liposarcoma with post adjuvant stereotactic ablative radiotherapy

Introduction

Tomita En-bloc spondylectomy of L5 is one of the most challenging techniques in radical oncological spine surgery. A 42-year-old female was referred with lower back pain and L5 radiculopathy with a background of right shoulder liposarcoma excision. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation hence wasn't suitable for Stereotactic Ablative Radiotherapy (SABR) alone. The seeding nature of sarcoma prevents the indication of separation surgery hence excisional surgery is considered for radical curative treatment. This case report demonstrates dual-staged modified TES including the utilisation of novel techniques to allow for maximum radical oncological control in the era of SABR and lesser invasive surgery.

Methods

First-stage: Carbonfibre pedicle screws planned from L2 to S2AI-Pelvis, aligned, to her patient-specific rods. Radiofrequency ablation of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone-cutter assisted inferior L4 and superior S1 endplate osteotomies. Second-stage: Vascular-assisted retroperitoneal approach at L4–S1 was undertaken protecting the great vessels. Completion of osteotomies at L4 and S1 to En-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4–S1 promontory.

Results

Patient rehabilitated well and was discharged after 42 days. Cyberknife of 30Gy in 5 fractions was delivered two months post-op. Despite left foot drop, she's walking independently 9 months post-op.

Conclusion

These are challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR to achieve maximum local control in spinal oligometastatic disease. This case promotes our modified TES technique in the era of SABR and separation surgery in carefully selected cases.

Efficacy and safety of erythropoietin in isolated spinal metastasis patients with total en bloc spondylectomy surgery: a case-control study

OBJECTIVE

The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS).

METHODS

From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused.

RESULTS

The average follow-up duration was 38.13 months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011).

CONCLUSIONS

Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.

Surgical Management of the Metastatic Spine Disease: A Review of the Literature and Proposed Algorithm

STUDY DESIGN

Narrative Review. The spine remains the most common site for bony metastasis. It is estimated that up to 70% of cancer patients harbor secondary spinal disease. And up to 10% will develop a clinically significant lesion. The last two decades have seen a substantial leap forward in the advancements of the management of spinal metastases. What once was a death sentence is now a manageable, even potentially treatable condition. With marked advancements in the surgical treatment and post-operative radiotherapy, a standardized approach to stratify and manage these patients is both prudent and now feasible.

OBJECTIVES

This article looks to examine the best available evidence in the stratification and surgical management of patients with spinal metastases. So the aim of this review is to offer a standardized approach for surgical management and surgical planning of patients with spinal metastases.

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

BACKGROUND

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

OBSERVATIONS

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

LESSONS

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

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.

Development and Validation of Nomograms to Assess Risk Factors and Overall Survival Prediction for Lung Metastasis in Young Patients with Osteosarcoma: A SEER-Based Study

BACKGROUND

To establish two nomograms to quantify the diagnostic factors of lung metastasis (LM) and their role in assessing prognosis in young patients with LM osteosarcoma.

METHODS

A total of 618 osteosarcoma young patients from 2010 to 2015 were included from the Surveillance, Epidemiology, and End Results (SEER) database. Another 131 patients with osteosarcoma from local hospitals were also collected as an external validation set. Patients were randomized into training sets (n = 434) and validation sets (n = 184) with a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to identify the risk factor for LM and were used to construct the nomogram. Risk variables for the overall survival rate of patients with LM were evaluated by Cox regression. Another nomogram was also constructed to predict survival rates. The results were validated using bootstrap resampling and retrospective research on 131 osteosarcoma young patients from 2010 to 2019 at three local hospitals.

RESULTS

There were 114 (18.45%) patients diagnosed as LM at initial diagnosis. The multivariate logistic regression analysis suggested that T stage, N stage, and bone metastasis were independent risk factors for LM in newly diagnosed young osteosarcoma patients (P < 0.001). The ROC analysis revealed that area under the curve (AUC) values were 0.751, 0.821, and 0.735 in the training set, internal validation set, and external validation set, respectively, indicating good predictive discrimination. The multivariate Cox proportional hazard regression analysis suggested that age, surgery, chemotherapy, primary site, and bone metastasis were prognostic factors for young osteosarcoma patients with LM. The time-dependent ROC curves showed that the AUCs for predicting 1-year, 2-year, and 3-year survival rates were 0.817, 0.792, and 0.815 in the training set and 0.772, 0.807, and 0.804 in the internal validation set, respectively. As for the external validation set, the AUCs for predicting 1-year, 2-year, and 3-year survival rates were 0.787, 0.818, and 0.717.

CONCLUSIONS

The nomograms can help clinicians strengthen their personal decision-making and can improve the prognosis of osteosarcoma patients.

A comparison of two different surgical procedures in the treatment of isolated spinal metastasis patients with metastatic spinal cord compression: a case-control study

OBJECTIVE

The aim of the study was to compare total en bloc spondylectomy (TES) and separation surgery with postoperative stereotactic radiosurgery (SSRS) for isolated metastatic patients with spinal cord compression by assessing recurrence-free survival (RFS), overall survival (OS), postoperative complications, and quality of life scores (QoL).

METHODS

From October 2013 to December 2020, 52 isolated spinal metastasis patients with cord compression were selected and separated into two groups based on the surgical method used (TES group, n = 26; and SSRS group, n = 26). Indexes for evaluation included postoperative Frankel grade, postoperative ECOG-PS, RFS, OS, postoperative complications, operation time, intraoperative blood loss, and QoL.

RESULTS

The average follow-up duration was 31.44 months. There was no significant difference (P > 0.05) in postoperative complications and OS between the two groups. However, a significant difference in operation time, intraoperative blood loss, postoperative ECOG-PS, RFS, and mental health domain (6 months after surgery) was found between the two groups (P < 0.05). According to The Spine Oncology Study Group Outcomes Questionnaire assessment, the total pain and physical function domains scores were also elevated after surgery in both groups. However, no significant difference was observed between groups A and B (p = 0.450 and 0.446, respectively).

CONCLUSIONS

TES and SSRS were efficient methods for treating solitary spinal metastasis patients with metastatic spinal cord compression. Better local tumor control and mental health were found in the TES group, and most patients felt as if they were free of spinal tumors. Compared with TES, the SSRS caused less operation-related trauma. However, there was no significant difference in OS between the two groups.

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).

Minimally invasive lateral approaches for the treatment of spinal tumors: single-position surgery without the "flip"

Although primary tumors of the spine and neural elements are rare, metastatic disease to the spine is quite common. Traditionally, surgical treatment for spinal tumor patients involves open decompression with or without stabilization. The single-position minimally invasive (MIS) lateral approach, which has been recently described over the recent decade, allows simultaneous access to the anterior and posterior columns with the patient positioned in the lateral decubitus position. Herein, we review the application of single-position MIS lateral surgery for the treatment of spinal neoplasm. The aim was to review the evolution, operative technique, outcomes, and complications associated with MIS lateral approaches for spinal tumors. The history of spinal tumor diagnosis and management are reviewed and discussed as well as the author's experience and literature regarding spinal tumor treatment outcome and surgical complications, with particular attention to single-position, MIS lateral approaches. In addition, the author's surgical technique is outlined in detail for thoracic, thoracolumbar and lumbar tumors. Furthermore, there are specific indications and complications associated with the surgical treatment of spinal tumors, and the MIS, single-position lateral approach, when applied appropriately, allows for concurrent access to the anterior and posterior column while mitigating the complications associated with traditional, open posterior-based approaches. In the treatment of spinal neoplasms, the goals of surgery are dictated by a number of tumor-specific and patient-specific factors. Therefore, operative treatment of tumors in the future may be a consolidation of historical surgical techniques and MIS, single-position lateral approaches. Regardless, multidisciplinary management is imperative for the individualized treatment of the patient and optimization of outcome.

Impact of decompressive laminectomy on the functional outcome of patients with metastatic spinal cord compression and neurological impairment

Metastatic spinal cord compression (MSCC) is a frequent phenomenon in advanced tumor diseases with often severe neurological impairments. Affected patients are often treated by decompressive laminectomy. To assess the impact of this procedure on Karnofsky Performance Index (KPI) and Frankel Grade (FG) at discharge, a single center retrospective cohort study of neurologically impaired MSCC-patients treated with decompressive laminectomy between 2004 and 2014 was performed. 101 patients (27 female/74 male; age 66.1 ± 11.5 years) were identified. Prostate was the most common primary tumor site (40%) and progressive disease was present in 74%. At admission, 80% of patients were non-ambulatory (FG A–C). Imaging revealed prevalently thoracic MSCC (78%). Emergency surgery (< 24 h) was performed in 71% and rates of complications and revision surgery were 6% and 4%, respectively. At discharge, FG had improved in 61% of cases, and 51% of patients had regained ambulation. Univariate predictors for not regaining the ability to walk were bowl dysfunction (p = 0.0015), KPI < 50% (p = 0.048) and FG < C (p = 0.001) prior to surgery. In conclusion, decompressive laminectomy showed beneficial effects on the functional outcome at discharge. A good neurological status prior to surgery was key predictor for a good functional outcome.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Two-Stage En Bloc Resection of Multilevel Cervical Chordomas With Vertebral Artery Preservation: Operative Technique

BACKGROUND

En bloc excision of cervical chordoma is a technically complex procedure, due to the involvement and closeness of the tumor to the spinal cord, cervical nerve roots, and vertebral arteries. Studies have previously shown that en bloc excision of chordomas with negative margins improves local control and prolongs disease-free survival compared with intralesional excision. True en bloc spondylectomy in the cervical spine is not feasible since bilateral vertebral artery sacrifice is not possible. However, for lateralized tumors, en bloc excision of chordoma can be performed with unilateral vertebral artery preservation by parasagittal osteotomy.

OBJECTIVE

To describe the operative technique of performing en bloc excision of cervical chordoma via parasagittal osteotomy.

METHODS

Four patients underwent en bloc excision of multilevel cervical chordomas via parasagittal osteotomy between 2008 and 2016. These 4 cases of chordoma were at the upper-cervical, mid-cervical, and cervicothoracic regions. We analyzed the tumor location, oncological staging, surgical technique, and perioperative complications.

RESULTS

All 4 patients underwent en bloc excision of chordoma with expandable cage reconstruction and posterior instrumentation. Cervical nerve roots were sacrificed in 2 patients, and vertebral artery ligation was performed in 3 patients. Complications include new neurologic deficit, implant failure, and pharyngeal erosion after radiation. No tumor recurrence was seen.

CONCLUSION

Parasagittal osteotomy is a useful alternative to en bloc spondylectomy in the treatment of lateralized multilevel cervical chordoma, preserving one vertebral artery while still achieving an en bloc resection.

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.

Outcomes of Posterior Thoracic Corpectomies for Metastatic Spine Tumors: An Analysis of 90 Patients

OBJECTIVE

To retrospectively analyze the outcomes and complications of patients with metastatic thoracic spinal tumors (MTTs) who underwent posterior corpectomies.

METHODS

Ninety patients with MTTs who underwent posterior corpectomies were retrospectively analyzed. Characteristics evaluated included number of MTTs per year, location, involved vertebrae numbers, sex, histology, pre- and postoperative American Spinal Injury Association (ASIA) grade, visual analog scale (VAS) pain scores, operative time, blood loss, and length of hospital stay.

RESULTS

The average follow-up was 20.8 ± 27.9 months (range, 0.5-139.4 months). Of the patients, 76.67% had a single metastasis and 23.33% had multiple metastases. For histology, 16.67% were breast, 15.56% were lung, 12.22% were prostate, and 12.22% were renal cell carcinoma. Of the patients with paraplegia and paraparesis, 74% improved. One patient improved from ASIA grade A to D, 3 patients improved from grade B to C, 8 patients improved from grade C to D or E, and 25 patients improved from grade D to E. Three patients (6%) with ASIA grade A and 1 patient (2%) with ASIA grade B had no improvement. One patient with ASIA grade C and 8 patients (16%) with grade D had no improvement. After surgery, VAS pain scores decreased from 8.45 ± 1.57 to 1.211 ± 1.81. In terms of complications, 2 patients (2.22%) had deep vein thrombosis and 1 patient had pulmonary embolism (1.11%). Other complications included wound infection (4.44%), cerebrospinal fluid leak (4.44%), pleural effusion (3.33%), wound dehiscence (2.22%), cellulitis (1.11%), epidural hematoma (1.11%), and pneumothorax (1.11%). Of the patients, 2.22% had implant failure and pseudoarthrosis, with 1 patient needing revision surgery. One patient (1.11%) had tumor recurrence.

CONCLUSIONS

Our results suggest that posterior thoracic corpectomies for MTTs have a reasonable complication rate with favorable outcomes.

Total En Bloc Spondylectomy for Lumbar Spinal Tumors by Paraspinal Approach

OBJECTIVE

To report and describe a modified posterior-only approach (paraspinal approach) for total en bloc spondylectomy (TES) of lumbar spinal tumors.

METHODS

From February 2013 to June 2014, 5 patients with lumbar spinal tumors who underwent TES through a posterior-only paraspinal approach were studied retrospectively; operative time, blood loss, complications, neurologic outcomes, and degree of resection were recorded to evaluate the efficacy of this surgical method.

RESULTS

Patients included 3 men and 2 women with a mean age of 48.4 years (range, 46-52 years). Two lesions were located in L2, 2 lesions were located in L3, and 1 lesion was located in L4. Three patients had solitary metastatic tumors (lung cancer in 2 cases, breast cancer in 1 case), and 2 patients had primary tumors (osteosarcoma and plasma cell tumor). According to the surgical classification of spinal tumors by Tomita et al., 4 cases were type 4 and 1 case was type 1. Mean operative time was 464 minutes (range, 420-510 minutes), and mean blood loss was 1280 mL (range, 1000-1500 mL). One patient had cerebrospinal fluid leakage, and 1 had transient motor weakness because of nerve root traction. Mean follow-up time was 20.6 months (range, 12-30 months), and all patients had improved or stable neurologic function. No local recurrence was observed at last follow-up.

CONCLUSIONS

The posterior-only paraspinal approach is a valid alternative for TES of lumbar spinal tumors, especially for overweight or muscular patients.

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.

Surgical management of spinal metastases

INTRODUCTION

Metastatic spinal disease is a source of significant morbidity in patients with cancer. Recent advancements in adjuvant oncologic therapy has led to increased survival for many patients who harbor neoplastic disease. As a result of this, the chance of developing metastatic spinal disease over the course of a cancer patient's lifespan has increased. Symptomatic metastatic spinal disease can cause significant morbidity including severe pain, neurologic deficit, and loss of ambulation. Current treatment of these patients typically involves the use of multiple modalities, including surgery, radiation, and chemotherapy. Areas covered: An extensive literature review was performed to support the author's opinion on the matter of surgical management of spinal metastatic disease. Pubmed was utilized as a primary search engine. Expert commentary: Despite advances in chemotherapy and radiation therapy, surgery remains a mainstay in many of these patients, particularly with those with either significant metastatic spinal epidural compression or spinal instability. This review discusses the surgical management of metastatic spinal disease including a framework for decision making and technical considerations when deciding to operate on these patients.

Spinal stereotactic body radiotherapy following intralesional curettage with separation surgery for initial or salvage chordoma treatment

OBJECTIVE Chordoma is a rare malignant tumor for which en bloc resection with wide margins is advocated as primary treatment. Unfortunately, due to anatomical constraints, en bloc resection to achieve wide or marginal margins is not feasible for many patients as the resulting morbidity would be prohibitive. The objective of this study was to evaluate the efficacy of intralesional curettage and separation surgery followed by spinal stereotactic body radiation therapy (SBRT) in patients with chordomas in the mobile spine. METHODS The authors performed a retrospective chart review of all patients with chordoma in the mobile spine treated from 2004 to 2016. Patients were identified from a prospectively collected database. Initially 22 patients were identified with mobile spine chordomas. With inclusion criteria of cytoreductive separation surgery followed closely by SBRT and a minimum of 6 months of follow-up imaging, 12 patients were included. Clinical and pathological characteristics of each patient were collected and data were analyzed. Patients were divided into two cohorts-those undergoing intralesional resection followed by SBRT as initial chordoma treatment at Memorial Sloan Kettering Cancer Center (MSKCC) (Cohort 1) and those undergoing salvage treatment following recurrence (Cohort 2). Treatment toxicities were classified according to the Common Terminology Criteria for Adverse Events version 4.03. Overall survival was analyzed using Kaplan-Meier analysis. RESULTS The 12 patients had a median post-SBRT follow-up time of 26 months. Cohort 1 had 5 patients with median post-SBRT follow-up time of 65.9 months and local control rate of 80% at last follow-up. Only one patient had disease progression, at 48.2 months following surgery and SBRT. Cohort 2 had 7 patients who had been treated at other institutions prior to undergoing both surgery and SBRT (salvage therapy) at MSKCC. The local control rate was 57.1% and the median follow-up duration was 10.7 months. One patient required repeat irradiation. Major surgery- and radiation-related complications occurred in 18% and 27% of patients, respectively. Epidural spinal cord compression scores were collected for each patient pre- and postoperatively. CONCLUSIONS The combination of surgery and SBRT provides excellent local control following intralesional curettage and separation surgery for chordomas in the mobile spine. Patients who underwent intralesional curettage and spinal SBRT as initial treatment had better disease control than those undergoing salvage therapy. High-dose radiotherapy may offer several biological benefits for tumor control.

Thirty-day readmission and reoperation after surgery for spinal tumors: a National Surgical Quality Improvement Program analysis

OBJECTIVE

The goal of this study was to use a large national registry to evaluate the 30-day cumulative incidence and predictors of adverse events, readmissions, and reoperations after surgery for primary and secondary spinal tumors.

METHODS

Data from adult patients who underwent surgery for spinal tumors (2011–2014) were extracted from the prospective National Surgical Quality Improvement Program (NSQIP) registry. Multivariable logistic regression was used to evaluate predictors of reoperation, readmission, and major complications (death, neurological, cardiopulmonary, venous thromboembolism [VTE], surgical site infection [SSI], and sepsis). Variables screened included patient age, sex, tumor location, American Society of Anesthesiologists (ASA) physical classification, preoperative functional status, comorbidities, preoperative laboratory values, case urgency, and operative time. Additional variables that were evaluated when analyzing readmission included complications during the surgical hospitalization, hospital length of stay (LOS), and discharge disposition.

RESULTS

Among the 2207 patients evaluated, 51.4% had extradural tumors, 36.4% had intradural extramedullary tumors, and 12.3% had intramedullary tumors. By spinal level, 20.7% were cervical lesions, 47.4% were thoracic lesions, 29.1% were lumbar lesions, and 2.8% were sacral lesions. Readmission occurred in 10.2% of patients at a median of 18 days (interquartile range [IQR] 12–23 days); the most common reasons for readmission were SSIs (23.7%), systemic infections (17.8%), VTE (12.7%), and CNS complications (11.9%). Predictors of readmission were comorbidities (dyspnea, hypertension, and anemia), disseminated cancer, preoperative steroid use, and an extended hospitalization. Reoperation occurred in 5.3% of patients at a median of 13 days (IQR 8–20 days) postoperatively and was associated with preoperative steroid use and ASA Class 4–5 designation. Major complications occurred in 14.4% of patients: the most common complications and their median time to occurrence were VTE (4.5%) at 9 days (IQR 4–19 days) postoperatively, SSIs (3.6%) at 18 days (IQR 14–25 days), and sepsis (2.9%) at 13 days (IQR 7–21 days). Predictors of major complications included dependent functional status, emergency case status, male sex, comorbidities (dyspnea, bleeding disorders, preoperative systemic inflammatory response syndrome, preoperative leukocytosis), and ASA Class 3–5 designation (p < 0.05). The median hospital LOS was 5 days (IQR 3–9 days), the 30-day mortality rate was 3.3%, and the median time to death was 20 days (IQR 12.5–26 days).

CONCLUSIONS

In this NSQIP analysis, 10.2% of patients undergoing surgery for spinal tumors were readmitted within 30 days, 5.3% underwent a reoperation, and 14.4% experienced a major complication. The most common complications were SSIs, systemic infections, and VTE, which often occurred late (after discharge from the surgical hospitalization). Patients were primarily readmitted for new complications that developed following discharge rather than exacerbation of complications from the surgical hospital stay. The strongest predictors of adverse events were comorbidities, preoperative steroid use, and higher ASA classification. These models can be used by surgeons to risk-stratify patients preoperatively and identify those who may benefit from increased surveillance following hospital discharge.

Electrophysiological monitoring during preoperative angiography to guide decisions regarding permanent occlusion of major radicular arteries in patients undergoing total en bloc spondylectomy

OBJECTIVE

Preoperative embolization is performed before spine tumor surgery when significant intraoperative hemorrhage is anticipated. Occlusion of radicular and segmental arteries may result in spinal ischemia. The goal of this study was to check whether neurophysiological monitoring during preoperative angiography in patients scheduled for total en bloc spondylectomy (TES) of spine tumors improves the safety of vessel occlusion.

METHODS

This was a case series study of patients who underwent tumor embolization under somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring in preparation for TES in treating spine tumors. The angiography findings, the embolized vessels, and the results are presented.

RESULTS

Five patients whose ages ranged from 33 to 75 years and who had thoracic spine tumors are reported. Four patients suffered from primary tumor and 1 patient had a metastatic tumor. Radicular arteries at the tumor level, 1 level above, and 1 level below were permanently occluded when SSEPs and MEPs were preserved during temporary occlusion. No complications were encountered during or after the angiography procedure and embolization.

CONCLUSIONS

Temporary occlusion with electrophysiological monitoring during preoperative angiography may improve the safety of permanent radicular artery occlusion, including the artery of Adamkiewicz in patients undergoing TES for the treatment of spine tumors.

En bloc resection of a C-1 lateral mass osteosarcoma: technical note

Osteosarcoma is an aggressive primary bone tumor. It is currently treated with multimodality therapy including en bloc resection, which has been demonstrated to confer a survival benefit over intralesional resection. The authors present the case of an 8-year-old girl with a C-1 lateral mass osteosarcoma, which was treated with a 4-stage en bloc resection and spinal reconstruction. While technically complex, the feasibility of en bloc resection for spinal osteosarcoma should be explored in the pediatric population.

Osteosarcoma of the spine: prognostic variables for local recurrence and overall survival, a multicenter ambispective study

OBJECTIVE

Primary spinal osteosarcomas are rare and aggressive neoplasms. Poor outcomes can occur, as obtaining marginal margins is technically demanding; further Enneking-appropriate en bloc resection can have significant morbidity. The goal of this study is to identify prognostic variables for local recurrence and mortality in surgically treated patients diagnosed with a primary osteosarcoma of the spine.

METHODS

A multicenter ambispective database of surgically treated patients with primary spine osteosarcomas was developed by AOSpine Knowledge Forum Tumor. Patient demographic, diagnosis, treatment, perioperative morbidity, local recurrence, and cross-sectional survival data were collected. Tumors were classified in 2 cohorts: Enneking appropriate (EA) and Enneking inappropriate (EI), as defined by pathology margin matching Enneking-recommended surgical margins. Prognostic variables were analyzed in reference to local recurrence and survival.

RESULTS

Between 1987 and 2012, 58 patients (32 female patients) underwent surgical treatment for primary spinal osteosarcoma. Patients were followed for a mean period of 3.5 ± 3.5 years (range 0.5 days to 14.3 years). The median survival for the entire cohort was 6.7 years postoperative. Twenty-four (41%) patients died, and 17 (30%) patients suffered a local recurrence, 10 (59%) of whom died. Twenty-nine (53%) patients underwent EA resection while 26 (47%) patients underwent EI resection with a postoperative median survival of 6.8 and 3.7 years, respectively (p = 0.048). EI patients had a higher rate of local recurrence than EA patients (p = 0.001). Patient age, previous surgery, biopsy type, tumor size, spine level, and chemotherapy timing did not significantly influence recurrence and survival.

CONCLUSIONS

Osteosarcoma of the spine presents a significant challenge, and most patients die in spite of aggressive surgery. There is a significant decrease in recurrence and an increase in survival with en bloc resection (EA) when compared with intralesional resection (EI). The effect of adjuvant and neoadjuvant chemotherapeutics, as well as method of biopsy, requires further exploration.

Epithelial-myoepithelial carcinoma metastasis to the thoracic spine

Epithelial-myoepithelial carcinoma (EMC) is a very rare salivary gland malignancy accounting for less than 1% of salivary gland tumors, and classically arises from the parotid gland in females. Spinal cord compression caused by EMC metastasized from the parotid gland has only been described once in the literature to our knowledge. We report the first case of a patient with parotid EMC spinal metastasis undergoing a gross total resection with instrumented fusion. This case illustrates that an en bloc resection with a planned transgression through the spinal canal may be a reasonable option for EMC metastasized to the spine.

[Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT). Alternative therapy for patients with oligometastatic spinal metastases]

BACKGROUND

Due to a more effective systemic therapy the survival of patients suffering from malignant tumors has been significantly improved but a longer life span is often associated with a higher incidence of osseous metastases. The majority of these metastases are localized in the spine causing pain, instability and neurological impairments. The interdisciplinary management of spinal metastases previously consisted of stabilization followed by fractionated external body radiation therapy. A reduction in procedural severity and morbidity as well as consideration of self-sufficiency and hospitalization time are important target parameters for these palliative patients.

METHOD AND RESULTS

Kyphoplasty combined with intraoperative radiotherapy (Kypho-IORT) is one of several modern treatment options, which involves a minimally invasive procedure with local high-dose transpedicular irradiation of the spine with low-energy (50 kV) X-rays. Immediately following irradiation, stabilization of the spine is carried out using kyphoplasty via the same access route so that a single stage procedure with excellent pain reduction and good local tumor control can be achieved. This article presents clinical data for this procedure and the different fields of indications are critically reviewed and compared to other therapy options. Methodological improvements and options for further individualization of therapy are demonstrated.

CONCLUSION

The Kypho-IORT procedure is a safe, feasible and beneficial modern treatment option for instant stabilization and local tumor control in patients with spinal metastases. More than 100 operations have been successfully performed so that the method can be deemed suitable for inclusion in the clinical routine. A phase II dose escalation study has now been completed and submitted for publication and a 2-arm non-inferiority trial (phase III study) for comparison with conventional irradiation is in progress.

Quality of life after en bloc resection of tumors in the mobile spine

BACKGROUND CONTEXT

Little has been reported regarding the patient-centered quality-of-life (QOL) outcomes after en bloc spondylectomy (ES). Despite lower local recurrence rates, it is unknown whether outcomes justify the surgical morbidity.

PURPOSE

The purpose of this study was to report on patient QOL after ES as measured by validated instruments and to identify factors that may predict better postoperative QOL.

STUDY DESIGN

This is a retrospective case-control study (Level III).

PATIENT SAMPLE

Thirty-five consecutive patients with mobile spine tumors were included. Twenty-seven patients underwent en bloc resection, whereas 8 patients received definitive radiation and no surgery. Minimum follow-up was 6 months (median, 32 months).

OUTCOME MEASURES

The outcome measures were European Quality Group 5-Dimensional Questionnaire (EQ5D), four Patient-Reported Outcome Measurement Information System (PROMIS) short-form metrics, Neck Disability Index, and Oswestry Disability Index (ODI).

METHODS

We performed statistical comparisons between the surgery and radiation groups, of the general US population, and within the study group itself to identify predictors of higher QOL scores.

RESULTS

We identified a significant difference in QOL between the surgery and radiation groups in only one instrument, PROMIS pain interference, with surgery having more pain interference (15.7 vs. 10.1, p=.04). For most metrics, including EQ5D, pain interference, pain behavior, and ODI, scores were around one standard deviation worse than the US population mean. Multivariable linear regression for each instrument demonstrated that preoperative factors such as better performance status, tumor location in the cervical spine, lack of mechanical back or neck pain, and shorter fusion span were independently predictive of better QOL scores. Postoperative factors such as poor performance status, chronic narcotic use, and local recurrence were more dominant than preoperative factors in predicting worse QOL.

CONCLUSIONS

Patients may experience more pain interference after surgery as opposed to definitive radiotherapy, but we did not identify a difference for most metrics. Quality of life in our study group was significantly worse than the general population for most metrics. Cervical tumors, lack of mechanical pain, better baseline performance status, and less extensive surgery predict better QOL after surgery.

Disappearance of lung adenocarcinoma after total en bloc spondylectomy using frozen tumor-bearing vertebra for reconstruction

PURPOSE

Total en bloc spondylectomy (TES) is a surgical procedure performed to achieve complete resection of an aggressive benign spinal tumor or a malignant spinal tumor. When reconstructing the spine after resection, we have been using liquid nitrogen-frozen resected spine bearing tumor as a bone graft, expecting an immunological response to tumor-specific antigen(s). The purpose of this article is to report a successful treatment case of lung adenocarcinoma metastasis with TES and this cryotherapy.

METHODS

A 59-year-old male presented with rapid progression of neurological deterioration of the lower limbs due to a spinal metastasis from T8 to T10. The primary lung adenocarcinoma had already been excised under thoracoscopy. The patient underwent TES with reconstruction using frozen tumor-bearing vertebra for the bone graft.

RESULTS

One month after surgery, a new nodule appeared at the right middle lobe of the lung. However, we carried out no biopsy of the newly emerged nodule and the patient received no adjuvant chemotherapy or radiotherapy. Six months after surgery, the tumor vanished. No local recurrence or metastasis of the tumor has been observed until now.

CONCLUSIONS

TES with a liquid nitrogen-frozen tumor specimen could be a promising therapeutic option for cancer patients with spine metastasis.

En bloc hemisacrectomy and internal hemipelvectomy via the posterior approach

OBJECT

Traditionally, hemisacrectomy and internal hemipelvectomy procedures have required both an anterior and a posterior approach. A posterior-only approach has the potential to complete an en bloc tumor resection and spinopelvic reconstruction while reducing surgical morbidity.

METHODS

The authors describe 3 cases in which en bloc resection of the hemisacrum and ilium and subsequent lumbopelvic and pelvic ring reconstruction were performed from a posterior-only approach. Two more traditional anterior and posterior staged procedures are also included for comparison.

RESULTS

In all 3 cases, an oncologically appropriate surgery and spinopelvic reconstruction were performed through a posterior-only approach.

CONCLUSIONS

The advantage of a midline posterior approach is the ability to perform a lumbosacral reconstruction, necessary in cases in which the S-1 body is iatrogenically disrupted during tumor resection.

En bloc resection of primary tumors of the thoracic spine: indications, planning, morbidity

OBJECTIVES

We aimed to describe surgical planning, technique, and complications of en bloc resection in the thoracic spine in patients who opted for surgery with en bloc resection and a tumor-free margin.

METHODS

Oncologic and functional results were recorded for 134 patients (53% male, age 44 ± 18 years) who had undergone en bloc resection for primary tumors (90 cases) and bone metastases (44 cases). Patients were followed until death or the latest follow-up examination (0-211 months, median 47 months). Surgeries were performed from 1990 to 2007 by the same team. An ongoing critical analysis of local control rates, surgical complications, and expected versus actual loss of function enabled the authors to refine the surgical technique and propose seven different types of resection.

RESULTS AND DISCUSSION

En bloc resection is a demanding procedure and requires careful planning after a careful decision-making process. The patient has to correctly understand the purpose of the surgery, based on oncological staging, in order to accept or decide against the procedure after weighing the possible morbidity and functional loss against the expected final result. TECHNIQUES OF EN BLOC RESECTION: Seven different strategies to perform en bloc resection in the thoracic spine, based on four combinations of surgical approaches (anterior, posterior, anterior followed by posterior, and posterior followed by simultaneous anterior and posterior) are identified and proposed. This planning is based on Weinstein-Boriani-Biagini (WBB) surgical staging. The surgical plan was designed to achieve the required oncologic margin with the minimum achievable morbidity.

Is Kiva implant advantageous to balloon kyphoplasty in treating osteolytic metastasis to the spine? Comparison of 2 percutaneous minimal invasive spine techniques: a prospective randomized controlled short-term study

STUDY DESIGN

Prospective, parallel-group, controlled, comparative randomized study.

OBJECTIVE

To compare cement leakage rate and efficacy for vertebral body restoration of balloon kyphoplasty (BK) versus Kiva novel implant with polymethylmethacrylate (PMMA) for treating osteolytic vertebral body metastasis.

SUMMARY OF BACKGROUND DATA

Minimally invasively vertebral augmentation techniques with PMMA are mostly performed for treating osteoporotic compression fractures. The Kiva implant with PMMA offers better vertebral body restoration and less PMMA leakage than BK in osteoporotic fractures. No previous study compared leakage rate and efficacy for vertebral body restoration in traditional BK and Kiva with PMMA in osteolytic vertebral body metastases.

METHODS

This study examined 23 patients (71 ± 13 yr) with 41 osteolytic vertebral bodies, who received Kiva with low viscosity PMMA and 24 patients (70 ± 11 yr) with 43 vertebral body osteolyses, who were reinforced with BK and high viscosity PMMA. All osteolyses were graded as Tomita 1 to 3. Anterior vertebral body height ratio (AVBHr), posterior vertebral body height ratio (PVBHr), and middle vertebral body height ratio (MVBHr), Gardner kyphotic deformity, PMMA leakage and were measured and compared between the groups. Visual analogue scale and Oswestry Disability Index were used for functional outcome evaluation.

RESULTS

No patient survived after 3 months. Asymptomatic PMMA leakage occurred in 4 (9.3%) vertebrae in the BK group solely (2 to the spinal canal, in Tomita grade 3 osteolysis) Anterior, posterior and middle vertebral body height ratio, Gardner angle improved insignificantly in both groups. Visual anlogue scale and Oswestry Disability Index improved postoperatively similarly in both groups (P < 0.001).

CONCLUSION

BK and Kiva provided equally significant spinal pain relief in patients with cancer with osteolytic metastasis. The absence of cement leakage in the Kiva group and absence of neurological complication in the BK group leakages reflects the safety of both augmentation techniques even in significant osteolysis. The lack of cement leakage in the Kiva cases, although low viscosity PMMA was used, increases this implant safety in augmenting severely destructed thoracolumbar vertebrae and sacrum from osteolytic metastasis.

LEVEL OF EVIDENCE

1.

Minimally invasive anterolateral corpectomy for spinal tumors

Traditional open anterior and posterior approaches for the thoracic and thoracolumbar spine are associated with approach-related morbidity and limited surgical access to the level of abnormality. This article describes the minimally invasive anterolateral corpectomy for the treatment of spinal tumors, and reviews the current literature.

[Surgical treatment of vertebral metastases]

The multiplicity of clinical presentations and the lack of consensus explain that the treatment of spine metastasis remains controversial. Optimal treatment requires a truly multidisciplinary approach, involving oncologists, interventional radiologists, radiation oncologists, rheumatologists and spine surgeons. Recent progress in all these areas have allowed to provide safe and effective therapeutic solutions tailored to each situation. We remind, in this work, the main progress in the surgical field, specifying the role of surgery in the current therapeutic arsenal.

Preliminary Results of High-Dose Single-Fraction Radiotherapy for the Management of Chordomas of the Spine and Sacrum

BACKGROUND:

En bloc wide-margin excision significantly decreases the risk of chordoma recurrence. However, a wide surgical margin cannot be obtained in many chordomas because they arise primarily in the sacrum, clivus, and mobile spine. Furthermore, these tumors have shown resistance to fractionated photon radiation at conventional doses and numerous chemotherapies.

OBJECTIVE:

To analyze the outcomes of single-fraction stereotactic radiosurgery (SRS) in the treatment of chordomas of the mobile spine and sacrum.

METHODS:

Twenty-four patients with chordoma of the sacrum and mobile spine were treated with high-dose single-fraction SRS (median dose, 2400 cGy). Twenty-one primary and 3 metastatic tumors were treated. Seven patients were treated for postoperative tumor recurrence. In 7 patients, SRS was administered as planned adjuvant therapy, and in 13 patients, SRS was administered as neoadjuvant therapy. All patients had serial magnetic resonance imaging follow-up.

RESULTS:

The overall median follow-up was 24 months. Of the 24 patients, 23 (95%) demonstrated stable or reduced tumor burden based on serial magnetic resonance imaging. One patient had radiographic progression of tumor 11 months after SRS. Only 6 of 13 patients who underwent neoadjuvant SRS proceeded to surgery. This decision was based on the lack of radiographic progression and the patient's preference. Complications were limited to 1 patient in whom sciatic neuropathy developed and 1 with vocal cord paralysis.

CONCLUSION:

High-dose single-fraction SRS provides good tumor control with low treatment-related morbidity. Additional follow-up is required to determine the long-term recurrence risk.

[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.

Spinal cord compression

OPINION STATEMENT

Malignant epidural spinal cord compression (MESCC) remains a common neuro-oncologic emergency with high associated morbidity. Despite widespread availability of MRI, the diagnosis frequently goes unmade until myelopathy supervenes, which is unfortunate because the strongest predictor of neurologic outcome with treatment is the neurologic status when treatment is initiated. Once the diagnosis of MESCC is suspected, patients with neurologic deficits should be started on high-dose corticosteroids (eg, dexamethasone, 10-100 mg intravenously, followed by 16 to 100 mg/d in divided doses). Definitive therapy of MESCC almost always includes radiation therapy and in some cases surgical intervention; factors considered include the patient's performance status and extent of visceral and skeletal disease, spinal stability, the tumor's underlying radiosensitivity, and the degree of spinal cord compression. Patients with spinal instability or radioresistant tumors are likely to have a much better neurologic outcome with tumor resection and spinal stabilization prior to radiation; the same may also pertain to patients with moderately radiosensitive tumors who have good life expectancy in terms of their systemic tumor. Conventional radiation has historically been beneficial after surgery and in patients who are not surgical candidates. Recent studies suggest a role for stereotactic body radiation therapy in patients with spinal metastasis from radioresistant tumors and in patients who have received prior standard radiotherapy, so long as the spinal cord has been decompressed.

Spinal intradural myxoid chondrosarcoma

The authors present a rare case of intradural extramedullary spinal chondrosarcoma. This 38-year-old man presented with urinary retention and lower-limb weakness. Magnetic resonance imaging demonstrated a thoracic intradural extramedullary spinal tumor, which was resected. Histopathology revealed a meningeal myxoid chondrosarcoma. Despite adjuvant radiotherapy, the patient had multiple recurrences and metastases and died 18 months following his first surgery. The management of the rare entity of spinal canal chondrosarcoma is discussed.

Comparison of mini-open anterior corpectomy and posterior total en bloc spondylectomy for solitary metastases of the thoracolumbar spine

Object

The object of this study was to compare the mini-open anterior corpectomy procedure with posterior total en bloc spondylectomy (TES) in treating patients with solitary metastases of the thoracolumbar spine.

Methods

From 2004 to 2010, 41 patients with solitary metastases of the thoracolumbar spine were treated in our hospital using either a mini-open anterior corpectomy or posterior TES. Intraoperative and diagnostic data, including perioperative complications, were collected using retrospective chart review. The surgical outcomes were assessed according to survival status, neurological function, local recurrence, and pain before and after surgery.

Results

Seventeen patients underwent posterior TES and 24 underwent mini-open anterior corpectomy. Mean blood loss (TES, 1721 ± 293 ml; mini-open corpectomy, 1058 ± 263 ml; p < 0.05), and mean operative time (TES, 403 ± 55 minutes; mini-open corpectomy, 175 ± 38 minutes; p < 0.05) were recorded and calculated. Neurological improvement by at least 1 American Spinal Injury Association Impairment Scale grade was noted in 35 (97.2%) of the 36 cases with preoperative deficits. After the operation, 68.4% of nonambulatory patients became ambulatory again, including 84.6% after mini-open corpectomy and 33.3% after posterior TES (p > 0.05). The visual analog scale scores of the patients were significantly reduced after both procedures, with no difference between the procedures (p > 0.05). The local tumor recurrence rate of the TES group was significantly lower than that of the mini-open corpectomy group (p < 0.05), while the postoperative survival rates within 2 years after surgery were similar. The complication rate in the mini-open corpectomy group (29.2%) was higher than that in the TES group (11.8%), but this difference was not statistically significant (p = 0.185). There was no hardware failure and no loss of the sagittal Cobb angle in either group. Slight subsidence (< 3 mm) of the mesh cage was observed with a successful fusion in 3 (17.6%) of 17 patients in the TES group. No subsidence of polymethylmethacrylate block/autograft was recorded in the mini-open group.

Conclusions

Mini-open anterior corpectomy can be accomplished with less blood loss, fewer fixation instrumentations, and shorter surgical time than that required for TES, but patients who undergo a mini-open corpectomy might have a greater tendency to experience local recurrence. A mini-open anterior corpectomy has a relatively mild learning curve and involves fewer technical difficulties. With smaller incisions, mini-open anterior corpectomy is an option in treating solitary metastases of the thoracolumbar spine.

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

PURPOSE

The objectives of this study were to describe our surgical management with a modified total en bloc spondylectomy (TES) and to evaluate the clinical effects in patients with thoracolumbar tumors.

METHODS

Sixteen consecutive patients with thoracolumbar neoplasms underwent a modified TES via single posterior approach followed by dorsoventral reconstruction from December 2008 to July 2011. Details of the modified technique were described and the patients' clinical information was retrospectively reviewed and analyzed.

RESULTS

Significant improvements in neurological function were achieved in most of the patients. Local pain or radicular leg pain was relieved postoperatively. The mean operation time was 7.2 h, with an average blood loss of 2,300 ml. No major complications, instrumentation failure or local recurrence was found at the final follow-up. Five patients died of the disease during mean 14-month (3.0-23) follow-up.

CONCLUSIONS

The modified TES with a single posterior approach is feasible, safe and effective for thoracolumbar spine tumors.

Expert's comment concerning Grand Rounds case entitled "a novel 'pelvic ring augmentation construct' for lumbo-pelvic reconstruction in tumor surgery" (by Sathya Thambiraj, Daren Forward, James Thomas and Bronek Boszczyk)

INTRODUCTION

Historically, metastatic spine tumor surgery has been palliative for pain control, to maintain neurologic and ambulatory function. The thought of curing cancer with limited metastatic disease by resecting the primary and the metastatic lesions is becoming more common. Multilevel spondylectomy for resection of metastatic disease has been reported in the literature, mostly at the thoracic or lumbar level with some success. Reconstruction of the lumbosacral junction after tumor resection is a difficult endeavor and several techniques have been utilized. Subcutaneous anterior pelvic fixation has been described for the treatment of unstable pelvic fractures.

MATERIALS AND METHODS

Review of the Grand Rounds case "A novel Pelvic Ring Augmentation Construct for Lumbo-Pelvic Reconstruction in Tumour Surgery" by Sathya Thambiraj, Daren Forward, James Thomas, Bronek Boszczyk and review of the pertinent literature.

CONCLUSION

The authors describe a novel percutaneous rod technique and construct for buttressing a posterior spinal construct to a subcutaneous anterior pelvic fixator after tumor resection of the lumbo-pelvic junction. They manage to salvage a difficult situation for which they should be commended. This technique may be useful in situations where instrumentation has to be preformed to the pelvis: i.e., in tumor reconstruction, fusions such as neuromuscular scoliotic disease to the pelvis, to augment a lumbo-pelvic construct when a nonunion occurs or in osteoporotic patients as a salvage procedure.

Surgical Management of Metastatic Spinal Tumors

Background

The spine is the most common site of skeletal metastases. The evolution of surgical methods, medical treatment, and radiation therapy has led to improved survival, functional status, and quality of life for patients with cancer. The role of surgery in the treatment of patients with spinal metastases has evolved over time.

Methods

A review of publications describing the role of open surgery and vertebroplasty was performed and the results are summarized.

Results

The treatment goals of spinal metastases include the preservation and restoration of neurologic function and spinal stability. Modern imaging modalities provide accurate methods of tumor diagnosis. A variety of approaches and stabilization techniques are available and should be tailored to the location of the tumor and systemic comorbidities.

Conclusions

As part of multidisciplinary treatment that includes radiation therapy and chemotherapy, surgery provides an effective method of restoration and preservation of neurologic function and spinal stability for patients with metastatic spinal tumors.

Clinical outcome and quality of life after surgery for peri-acetabular metastases

We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 (sd 13.7)) to that found at the latest follow-up (58.0 (sd 12.5)) (p = 0.001). The only statistically significant change in the nine symptom domains of the QLQ-C30 was a reduction in the mean level of pain (from 59.1 to 29.5 (out of 100)) (p < 0.001).

Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.