Surgery for malignant extradural tumours of the spine

We have reviewed 41 patients with malignant extradural tumours of the spine treated by anterior decompression for cord compression, or uncontrolled back pain or both. An anterior operation alone was performed in 37 cases, four had combined or staged anterior and posterior decompression. An anterior operation on its own achieved major neurological recovery in 18 of the 33 cases with neurological loss (56%); only four remained unchanged. Eleven had minor improvement but not enough to allow them to walk or to regain bladder function. No patient with complete paraplegia gained a useful neurological recovery. Back pain was improved in 30 of the 41 patients (73%), sound internal fixation being important in this respect. There were four early deaths and another 23 died from disseminated disease after a mean survival of 4.1 months. Fourteen patients are still alive with a mean survival of 14 months.     

Total en bloc spondylectomy for locally aggressive and primary malignant tumors of the lumbar spine

Purpose

To report outcomes after total en bloc spondylectomy (TES) for primary aggressive/malignant tumors of the lumbar spine.

Methods

We performed a retrospective review of 23 neurosurgical patients operated between 2004 and 2014. Outcomes included perioperative complication rates and reoperation rates for instrumentation failure. The relationship between patient/operative parameters and complication development/instrumentation failure was investigated.

Results

There were 15 men (65.2 %) and eight women (24.8 %), with a median of 47 years. The most common tumor was chordoma in 11 patients (47.8 %), followed by sarcoma in four (17.4 %), and giant cell tumor in three (13.0 %). All patients but one underwent a two-staged operation; median total estimated blood loss was 3200 mL and median total operative time was 18.5 h. Fifteen patients developed at least one perioperative complication (65.2 %), with the most common being wound infection and ileus (26.1 % each). There was one case of intraoperative iliac vein injury (4.4 %). Instrumentation failure occurred in 9 patients (39.1 %) at a median time of 23 months after index spondylectomy. Following logistic regression, there were no factors associated with complication development. On the other hand, postoperative radiation was significantly associated with instrumentation failure (OR 7.49; 95 % CI, 1.02–54.9). Local recurrence and 5-year survival was 8.7 and 84.4 %, respectively. Median follow-up time was 50 months.

Conclusions

Although favorable oncological outcomes after en bloc resection of spinal tumors may be achieved in terms of recurrence and survival, TES in the lumbar spine remains a challenging procedure. Future investigation into complication avoidance and reconstruction techniques is encouraged.

     

Limb-sparing surgery for primary malignant tumours of the pelvis

Treatment of malignant tumours of the pelvis represents one of the most difficult problems in musculoskeletal oncology. The aim of this paper is to present our results in 16 cases of primary malignant pelvic tumours following resection only or following reconstruction with autogenous or allogenous bone grafts without using megaprostheses, and to assess the possibility to restore acceptable function with autogenous or allogenous bone grafts while avoiding the high risks of massive endoprostheses. Wound complication was the most common complication in our series, with 10 patients requiring additional treatment in the form of local surgical debridement, appropriate multi-drug antimicrobial therapy and wound care. Secondary pelvic reconstruction was performed in two patients with chondrosarcoma, due to local recurrence. External hemipelvectomy was not required in any patient. Morbidity also included the sacrifice of nerve roots in 4 patients. The mean follow-up was 42.4 months (range, 24 to 60). One patient is alive with disease, five patients have died of metastatic disease (2 of them had evidence of local recurrence), and the remaining ten patients are alive with no evidence of disease. Major blood loss and long operation time, aggressive radical surgery due to the frequent delay in diagnosis, and wound complications after surgery are important points that should be considered in the treatment of primary malignant pelvic tumours. Therefore, the management requires meticulous preoperative investigation, a multidisciplinary approach and experienced surgeons.     

Total spondylectomy for primary tumor of the thoracolumbar spine

STUDY DESIGN: Six patients with primary malignant tumor of the thoracolumbar spine who underwent total spondylectomy (TS) by en bloc resection were reviewed retrospectively. OBJECTIVES: To report surgical technique and preliminary results of TS and to evaluate its oncological curability. SETTING: Japan. METHODS: Six patients were treated by TS by en bloc resection of the vertebral tumor. TS through a posterior approach was performed in three cases (T1 osteosarcoma, L1 osteosarcoma and L1 chordoma) and in the others through a single stage anterior and posterior combined approach (T6-8 recurrent giant cell tumor. L4 chordoma and L5 giant cell tumor). Surgical margins of the specimens were evaluated histologically. All patients were followed, and their status was evaluated by clinical and imaging studies. RESULTS: There were no complications related to surgery. Programmed sacrifice of nerve roots were performed in three cases for oncologic excision. A wide surgical margin was achieved in one case, a marginal one in four, and an intralesional margin in one. Five patients were alive without evidence of tumor and one was alive with disease at follow-up evaluation after 2.0-4.8 years. Local recurrence was found in one case of T1 osteosarcoma with an intralesional margin. CONCLUSIONS: These preliminary results suggested that TS is an effective procedure in control of local recurrence with acceptable complications.     

Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine

The records of 14 patients with malignant or aggressive benign vertebral tumors of the thoracolumbar spine who underwent total spondylectomy (TS) were evaluated retrospectively. Total spondylectomy was performed by bisecting the affected vertebra through the pedicle using fine threadwire saws and removing the vertebra en bloc through the posterior procedure alone or the one-stage anteroposterior combined procedure. Remarkable pain relief and ambulation after surgery were achieved in all 14 patients. No serious complications occurred. Nerve roots were sacrificed in seven cases. A marginal surgical margin was achieved in 10 cases and an intralesional surgical margin was achieved in four. At the site of the osteotomized pedicle, the surgical margin was marginal, with the possibility of tumor-cell contamination in 10 cases. Local recurrence was found in three cases of posterior total spondylectomy at 0.3 to 3.5 years (mean, 3.2 years) follow-up evaluation at the other site of the osteotomized pedicle. These results suggest that this type of total spondylectomy is effective in controlling local recurrence without incurring major complications and is a clinically useful procedure.     

Minimally invasive transpedicular vertebrectomy for metastatic disease to the thoracic spine

STUDY DESIGN AND OBJECTIVE: We present a series of 8 patients with thoracic metastatic disease causing acute neurologic decline. We present minimally invasive posterolateral vertebrectomy and decompression as an effective approach in patients with significant comorbidities and as palliative care. BACKGROUND: Metastatic disease to the spine is common and frequently occurs in the thoracic vertebrae. Posterior laminectomy alone has generally been found to be ineffective in the management of spinal metastatic disease with neurologic compromise as most compression occurs ventrally. Patients with significant comorbidities are often unable to tolerate extensive surgery involving a thoracotomy. Limited life expectancy and quality of life issues also often argue against extensive surgery. METHODS: Eight patients (mean age 74 y) with thoracic metastatic disease and acute neurologic compromise underwent a minimally invasive posterolateral vertebrectomy and partial tumor resection. Patients were considered unsuitable for an open anterior approach owing to age, comorbidities, and limited life expectancies. In the operating room, patients were positioned prone. A paramedian incision measuring 3 cm allowed the introduction of sequential dilators and the placement of a 22-mm diameter tubular retractor. Dorsal decompression was accomplished and partial vertebrectomy was performed for ventral decompression. Radiation was used postoperatively in all patients. RESULTS: There were no complications due to the procedure. Improvement of at least 1 grade on the Nurick scale was noted in 5 of 8 (62.5%) patients. Two patients were able to ambulate independently immediately after surgery despite having significant paraparesis preoperatively. Pain improved in 5 of 8 (62.5%) patients postoperatively according to the numerical pain score. Average inpatient length of stay was 4 days after the procedure. Mean blood loss was 227 mL and mean length of the procedure was 2.2 hours. CONCLUSIONS: Minimally invasive transpedicular vertebrectomy is an effective palliative treatment option for thoracic metastatic disease in patients not eligible for more extensive anterior transthoracic surgery and stabilization.     

Primary malignant bone tumours of spine and pelvis in children

PurposeAxial malignant bone tumours are rare in children and adolescents, and their prognosis is still relatively poor due to non-specific symptoms, such as back or groin pain, which may result in late hospital presentation. Therefore, it is very important to raise awareness regarding this pathology.MethodsWe performed a narrative review, including scientific publications published in English. We searched Medline and Google Scholar databases for information on the incidence and prognosis of axial malignant bone tumours in children and adolescents (< 18 years). Outcomes of different surgical management strategies and reconstruction options were assessed.ResultsThe incidence of primary malignant bone tumours before the age of 18 years is approximately five per one million population; around 25% of these tumours are located in the axial skeleton. With a five-year survival rate of 50%, tumours in an axial location (chest cage, spine, pelvis) are associated with a poorer prognosis than tumours in more peripheral locations. En bloc excision with clear margins has been shown to improve local control and overall survival, even though obtaining adequate surgical margins is difficult due to the close location of large neurovascular structures and other major organs. Spinal reconstruction options include instrumented fusion with allograft or expandable cage. Pelvic reconstruction is needed in internal hemipelvectomy, and the options include biological, endoprosthetic reconstructions, hip transposition, arthrodesis or creation of pseudoarthrosis and lumbopelvic instrumentation.ConclusionEarly diagnosis, a timely adequate multidisciplinary management, appropriate en bloc excision, and reconstruction improve survival and quality of life in these patients.Level of EvidenceV     

全骶骨切除术治疗骶骨多节段恶性肿瘤

目的:探讨对骶骨多节段恶性肿瘤施行全骶骨切除术的手术入路、手术方式及适应证。方法:2007年7月至2009年7月,共有6例骶骨恶性肿瘤患者在我院骨肿瘤科接受一期前后联合入路全骶骨切除钉棒系统内固定重建腰骶稳定性手术。其中男性4例,女性2例。年龄20～59岁,平均38.8岁。肿瘤位于S1～S54例,S1～S31例,L5～S41例。脊索瘤2例,软骨肉瘤2例,恶性神经鞘瘤1例,尤文肉瘤1例。结果:6例患者均安全度过围手术期。手术时间11～13h,平均12h。术中出血量3800～5500ml,平均4500ml。6例患者均未出现直肠、膀胱瘘等严重并发症。术中6例患者切断双侧S1神经根,术后出现双足跖屈运动障碍。所有患者经钉棒系统固定重建恢复了腰骶部连续性,术后6例患者均定制矫形鞋,术后6周穿矫形鞋扶拐可下地行走。随访3～25个月,平均10.3个月,未发现局部复发及远处转移病例。结论:一期前后联合入路全骶骨切除重建腰骶稳定性手术对于累及骶骨多个节段的恶性肿瘤可以获得满意的肿瘤学切除边界,但手术难度大,应严格把握手术适应证。     

Pathology of primary malignant bone and cartilage tumours

Bone- and cartilage-forming tumours (osteosarcomas and chondrosarcomas) are rare malignant neoplasms. These tumours are clinically aggressive and often need extensive local and/or systemic treatment. Whereas no other treatment but surgery is currently available for chondrosarcomas, osteosarcomas show an approximately 50–80% response rate to adjuvant chemotherapy. Surgical removal of these tumours is currently mostly performed with limb salvage, but amputation may be required in some cases. In addition, the tumours have a risk of local recurrences adversely affecting the prognosis compared to the primary tumour. In this report we will mainly focus on two of the most prevalent malignant bone tumours, conventional osteosarcoma and conventional chondrosarcoma, and use these to illustrate the problems with the diagnosis of bone sarcomas in general.

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Résumé Les tumeurs malignes d’origine osseuse ou cartilagineuse (ostéosarcomes et chondrosarcomes) sont rares. Elles sont cliniquement agressives et nécessite souvent un traitement extensif, local ou général. Tandis qu’aucun autre traitement que la chirurgie est possible pour le chondrosarcome, l’ostéosarcome a un taux de réponse de 50 à 80% à la chimiothérapie adjuvante. L’ablation chirurgicale de ces tumeurs est le plus souvent menée avec conservation du membre mais une amputation est parfois nécessaire. De plus ces tumeurs ont un risque de récidive, avec un moins bon pronostic que la tumeur initiale. Dans ce rapport, nous considérons essentiellement les deux tumeurs les plus fréquentes—ostéosarcome et chondrosarcome conventionnels—et les utilisons pour illustrer les problèmes de diagnostic des sarcomes osseux en général.

     

“en-bloc” vertebrectomy in the mobile lumbar spine

BACKGROUND Primary tumors of the vertebral bodies have previously been treated with total or subtotal excision in a piecemeal fashion (intralesional excision). Radiation therapy has been used to help control tumor growth. Recurrence rates with an intralesional, piecemeal removal of vertebral tumors have been unacceptably high. This study describes a method to excise a lumbar vertebra “en-bloc,” and in the process, to perform a marginal (extralesional) resection of a primary tumor of the mobile lumbar spine that allows for a potential surgical cure.

METHODS A combined posterior-anterior procedure allows for an extralesional, marginal resection of the tumor and the involved vertebra. All posterior bony elements, including the pedicles and the adjacent intervertebral discs, are removed via a posterior approach. An anterior, retroperitoneal approach is then used to remove the vertebral body/tumor as a single specimen. The nerve roots at the involved levels are spared and the spine is instrumented and fused both posteriorly and anteriorly.

RESULTS Three patients successfully had combined posterior-anterior resections of lumbar vertebral chordomas. No permanent neurological complications occurred. Overall morbidity of the procedure was acceptable. At 31-month follow-up, no tumor recurrence has been detected.

CONCLUSIONS “En-bloc” resection of a primary vertebral tumor of the lumbar spine is technically demanding, but potentially curative. The alternative approaches—intralesional excision, radiation therapy, or a combination—are unable to cure these tumors. Long-term, 10-year follow-up will be necessary to confirm whether this en-bloc approach provides a surgical cure.     

Treatment of primary malignant bone tumours of the distal tibia

We treated 15 patients with primary malignant bone tumours of the distal tibia of which 14 were treated by limb salvage surgery. Reconstructions were done by allografts with or without microvascular fibula transfer, by bone transport, by fibula transfer alone or by endoprosthetic replacement. The most successful methods were bone transport and endoprosthetic replacement. However, serious complications with deep infections leading to secondary amputation occurred in four patients and in all reconstruction groups. After a mean follow up of 7 years, no local recurrence occurred, and all patients were alive and free of disease. After radical resection, bone transport in defects less than 15 cm is a viable option. In larger defects in children, allograft with vascularised fibula is an acceptable alternative, but amputation still has a role in this group. In adults, endoprosthetic replacement with proper soft tissue coverage is a viable option in cases with large bony defects.

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Résumé Nous avons traité 15 malades avec une tumeur maligne primitive du tibia distal avec pour 14 dentre eux une chirurgie conservatrice du membre. Les reconstructions ont été faites par allogreffe avec ou sans transfert de péroné vascularisé, transport osseux, transfert du péroné seul ou par remplacement prothétique. Les meilleures méthodes étaient le transport osseux et le remplacement prothétique. Des complications sérieuses avec infection profonde menant à une amputation secondaire, se sont cependant produites chez quatre malades et dans tous les groupes de reconstruction. Après un suivi moyen de 7 ans, aucune récidive locale nest survenue et tous les malades sont vivants et libres de maladie. Après une résection radicale, le transport osseux dans les défauts de moins de 15 centimètres est une option valable. Dans plus grands défauts chez les enfants, lallogreffe avec péroné vascularisé est une alternative acceptable, mais lamputation a encore un rôle dans ce groupe. Chez les adultes le remplacement prothétique avec couverture cutanée adéquate est un choix valable dans les grands défauts osseux.

     

Navigation-assisted resections with image-guided surgery for primary and metastatic tumours of the spine and sacrum

Primary tumours and solitary metastases of the spine and sacrum are indications for wide/marginal en bloc excisions. Due to deranged spinal anatomy and spatial vicinity of neurovascular structures oncological sufficient resections of the spine are technically demanding. New concepts of imageguided navigation of resection planes and implant positioning have attracted major interest. This report aimed to describe the technique and oncosurgical treatment results of navigation-assisted resections of tumours/solitary metastatic lesions of the thoracolumbar spine and sacrum.Using an CT-based optoelectronic navigation system 14 patients (spinal/sacral primary tumours n=10, solitary metastatic diseases n=4) have been included. At the thoracolumbar spine, in 3 patients an anterior-posterior navigated resection was performed while an anterior-only approach was used in 1 patient. In 10 patients CT-based guidance of sacrectomy was scheduled. 6 patients received neoadjuvant polychemotherapy. Navigation was successful in 11 patients. Resections were performed at the thoracolumbar spine as hemivertebrectomies in 4 patients. In sacrectomy, segments S2-5, S3-5 and S4-5 were resected in 5, 5 and 1 patients, respectively. Resection margins were tumour-free in 11 patients and marginal with microscopic residual disease in 3 patients. Local recurrence was observed in 3 patients after free interval of 21.5 months. 11 patients have currently no evidence of disease with a mean follow up of 47.7 ± 7.0 months. Mean survival time for patients with solitary metastases was 290 ± 23 months. 1 patient with sacral Ewing sarcoma developed pulmonary metastatic disease of which he died 60 months postoperatively. The mean disease specific survival for navigated sacrectomies and hemivertebrectomies was 48.3 ± 28.5 and 32.7 ± 22.0 months.In particular in segments of the non-exposed spine navigated resections of spinal/ sacral tumours allows for a excellent intraoperative 3D-visualization of spinal anatomy, the tumour and planned resection planes. Potential problems may be caused by erroneous surface matching, insufficient exposure of landmarks and increased mobility of the resected bone segment leading to inaccuracy of navigation and reference. Tremendous gain in orientation along with decreased intraoperative radiation exposure appears to result in avoidance of unnecessarily large resection defects and improved local recurrence rates with acceptable systemic tumour control.     

Total vertebrectomy (Th2) and dissection of the subclavian artery for a superior sulcus tumor invading the spine: A case report

IntroductionSurgery for primary lung cancer invading the spine remains challenging. Here, we present a case of superior sulcus tumor (SST) with vertebral invasion, successfully resected with total vertebrectomy (Th2) and dissection of involved apical chest wall and the subclavian artery (SCA).Presentation of caseA 62-year-old man was referred with the diagnosis of lung squamous cell carcinoma originating from left upper lobe (clinical stage IIIA/T4N0M0) involving the thoracic vertebrae (Th2) as well as the apical chest wall including three ribs (1st, 2nd and 3rd) and SCA. After induction concurrent chemo-radiotherapy, we achieved complete resection by three-step surgical procedures as follows: first, the anterior portion of involved chest wall including SCA was dissected through the trans-manubrial approach (TMA); next, the posterior portion of involved chest wall including ribs was dissected and left upper lobectomy with nodal dissection was performed through posterolateral thoracotomy; finally, total vertebrectomy (Th2) was performed through posterior mid-line approach.DiscussionThis tumor was existence of anterior and posterior position in pulmonary apex region. So that, it is very important for complete resecting this complicated tumor to work out operation’s strategy.ConclusionSurgery may be indicated for SST invading the spine, when complete resection is expected.     

The results of surgery on primary malignant tumors of the spine

The results of surgery on primary malignant tumors of the spine in 18 patients treated in our hospital between 1976 and 1993 were reviewed. Curettage was less effective in controlling primary malignant lesions than wide excision, and the condition of the resected margin was closely related to the prognosis of the disease. Some patients in the hematopoietic tumor group receiving combined adjuvant therapy survived for a long time. The role of surgery is important in tumors such as chordoma and chondrosarcoma that have low sensitivity to adjuvant therapy, and it is essential to secure tumor-free resected margins.     

前路椎体切除钛网植骨钉棒多节段内固定治疗胸腰段剪力型骨折脱位1例

1病例资料 患者,男,20岁,战士。高处坠落致腰部被杠杆顶压受伤,双下肢感觉障碍、不能活动4 h于2010年6月16日入院。查体：脊柱胸腰段皮下淤血、压痛,腹股沟以下双下肢及会阴部深浅感觉消失,下肢诸肌肌力0级,肛门括约肌反射、球海绵体肌反射、提睾反射消失,跖底反射消失,腱反射消失,病理反射阴性。     

En bloc partial vertebrectomy for lung cancer invading the spine after induction chemoradiotherapy.

OBJECTIVE: The optimal surgical treatment for non-small cell lung cancer (NSCLC) with vertebral body invasion remains both controversial and challenging. We reviewed our experiences of NSCLC with vertebral body invasion, in which we have performed induction chemoradiotherapy followed by lung resection with en bloc partial vertebrectomy. METHODS: Six NSCLC patients with vertebral invasion underwent an operation following chemoradiotherapy from January 2001 to July 2006. Vertebral invasion was evaluated by the chest CT and MRI findings. Either carboplatin-paclitaxel (n=3) or carboplatin-docetaxel (n=3) was used. Two cycles of chemotherapy were performed with concurrent radiation (50 Gy) treatment. RESULTS: In all of the six cases, a complete resection with en bloc partial vertebrectomy was performed with no operative mortality. The histological complete response rate and major response rate were 16.7% (1/6) and 83.3% (5/6), respectively. The 5-year overall survival rate was 67.7%. In addition, no local failure was observed after surgery. CONCLUSIONS: Surgery after chemoradiotherapy (carboplatin/paclitaxel or docetaxel and 50 Gy radiation) for NSCLC with vertebral invasion could thus be performed with acceptable morbidity.     

Cryosurgery for malignant tumours of the liver

Objective

To evaluate the safety and efficacy of ultrasound-guided cryosurgery to treat malignant tumours of the liver.

Design

A prospective nonrandomized trial. The follow-up was complete and ranged from 8 to 35 months.

Setting

A university-affiliated hospital.

Patients

Ten patients with secondary malignant tumours of the liver; 1 with primary hepatoma.

Interventions

Computed portography for preoperative staging; laparotomy and ultrasonographic examination of the liver; cryosurgical ablation of liver tumours with or without a concomitant resection. Thirteen procedures were performed on 11 patients.

Main Outcome Measures

Preoperative morbidity, disease-free and overall survival.

Results

Of 24 lesions frozen, the procedure on 4 lesions was considered a technical failure because of persistent disease. There were no perioperative deaths. One patient had a liver abscess that resolved with percutaneous drainage. One patient had a biliary fistula that resolved spontaneously, and one had a transient rise in the serum creatinine level. Of 11 patients treated, 7 had a recurrence in the liver (persistent disease in 2 and new liver metastases in 5); 2 of these patients died. One patient died of distant disease with no local recurrence. At the time of writing, one patient was alive with extrahepatic disease and no local recurrence and two were free of disease.

Conclusions

Cryosurgery of the liver is a relatively safe procedure that allows treatment of otherwise un-resectable malignant disease. Proof of long-term benefit requires further experience and follow-up.     

En bloc resection of primary malignant bone tumors of the cervical spine

Background

Due to the poor response of primary malignant bone tumors to adjuvant therapies, surgical resection performed in an en bloc fashion with free margins remains the best option for long-term recurrence-free survival of patients harboring such lesions.

Methods

In this article the authors provide a stepwise review of the technical details involved in the performance of en bloc resections of tumoral lesions in the cervical spine.

Conclusions

Due to the anatomical peculiarities of the cervical spine related to the presence of functional nerve roots as well as the vertebral arteries, en bloc resections in this region remains a challenging surgical procedure.