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Gasbarrini A, Pasini S, Fu Z, Ghermandi R, Pipola V, Gargiulo M, Innocenti M, Boriani S. EnBloc Resection of a Chordoma of the Thoracic Spine by "L"-Shaped Osteotomy for Spinal Canal Preservation. J Clin Med 2025; 14:349. [PMID: 39860358 PMCID: PMC11766227 DOI: 10.3390/jcm14020349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 11/27/2024] [Accepted: 01/02/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: EnBloc resections of bone tumors of the spine are very demanding as the target to achieve a tumor-free margin specimen (sometimes impossible due to the extracompartimental tumor extension) is sometimes conflicting with the integrity of neurological functions and spine stability. Methods: The surgical treatment of a huge multi-level chordoma of the thoracic spine with unusual extension is reported. Anteriorly, the tumor widely invaded the mediastinum and displaced the aorta; on the left side, it expanded in the subpleuric region; posteriorly, it was uncommonly distant 13 mm from the posterior wall. Results: EnBloc resection is largely performed for primary bone tumors of the spine and many reports have been published concerning brilliant solutions to difficult issues of surgical anatomy. One of the major challenges is still the compatibility between oncological and functional requirements. Conclusions: Oncological staging, careful imaging analysis, a multidisciplinary surgical team, and utilization of the most recent technologies like navigation and robotics have made an oncologically appropriate EnBloc resection of a multi-level chordoma of the thoracic spine possible without affecting the continuity of the spinal canal and without any involvement of its content by an original "L"-shaped osteotomy.
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Affiliation(s)
- Alessandro Gasbarrini
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy
| | - Stefano Pasini
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Zhaozong Fu
- Department of Spine Surgery, Jiangmen Central Hospital, Jiangmen 529030, China;
| | - Riccardo Ghermandi
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Valerio Pipola
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Mauro Gargiulo
- Vascular Surgery Department, IRCCS Policlinico di Sant’Orsola, 40138 Bologna, Italy;
| | - Marco Innocenti
- Orthoplasty Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Stefano Boriani
- Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
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Luzzati A, Conti S, Sperduti I, Scotto Di Uccio A, Mazzoli S, Cannavò L, Scotto G, Zoccali C. En-bloc spondylectomy in the lumbar spine: indications, results and complications in a series of 47 patients affected by primary malignant bone tumors. Arch Orthop Trauma Surg 2024; 144:2027-2038. [PMID: 38589502 PMCID: PMC11093824 DOI: 10.1007/s00402-024-05274-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 03/06/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Wide Surgery is the reference treatment for malignant and aggressive benign primary bone tumors in the spine. When located in the lumbar spine, En-Bloc Spondylectomy (EBS) remains a complex challenge. Moreover, surgery is complicated by the presence of the diaphragm in the thoracolumbar junction and the hinderance of the iliac wings at the lumbosacral levels. Therefore, EBS in the lumbar spine frequently requires combined approaches. The purpose of this study is to describe clinical presentation, tumor characteristics and results of a series of 47 consecutive patients affected by malignant primary bone tumors of the lumbar spine who underwent EBS. MATERIALS AND METHODS 47 patients were reviewed. Complications were distinguished in early and late whether they occurred before or after 30 days from surgery. Overall survival (OS), disease-free survival (DFS) and local recurrence-free survival (LRFS) were calculated by the Kaplan-Meier product-limit method from surgery until relapse or death. RESULTS 27 patients presented to observation after a first intralesional approach in a non-specialized center. Chordoma was the most represented histotype. Vertebrectomies were: 23 one-level, 10 two-level, 12 three-level and 2 four-level. Reconstructions were always carried out with screws and rods. The main postoperative complication was blood loss, while hardware failure was the main long-term complication. The 5-year LRFS was 75.5%, the 5-year DFS was 54.3%, and 5-year OS was 63.6%. CONCLUSIONS The surgical margin obtained during the index surgery was statistically associated with Local Recurrence, DFS and OS, underlining the importance of treating patients in reference centers.
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Affiliation(s)
- Alessandro Luzzati
- Oncological and Reconstructive Surgery Unit, IRCCS-Galeazzi Orthopedic Institute, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Stefano Conti
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedic Science, University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Isabella Sperduti
- Statistical Department, IRCCS-Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy
| | - Alessandra Scotto Di Uccio
- General Surgery and Organ Transplantation Unit, School of General Surgery, Umberto I Polyclinic of Rome, Sapienza University of Rome, Rome, Italy
| | - Simone Mazzoli
- Oncological and Reconstructive Surgery Unit, IRCCS-Galeazzi Orthopedic Institute, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Luca Cannavò
- Oncological and Reconstructive Surgery Unit, IRCCS-Galeazzi Orthopedic Institute, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Gennaro Scotto
- Oncological and Reconstructive Surgery Unit, IRCCS-Galeazzi Orthopedic Institute, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Carmine Zoccali
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedic Science, University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
- Oncological Orthopedics Department, IRCCS-Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144, Rome, Italy.
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Morris JM, Wentworth A, Houdek MT, Karim SM, Clarke MJ, Daniels DJ, Rose PS. The Role of 3D Printing in Treatment Planning of Spine and Sacral Tumors. Neuroimaging Clin N Am 2023; 33:507-529. [PMID: 37356866 DOI: 10.1016/j.nic.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Three-dimensional (3D) printing technology has proven to have many advantages in spine and sacrum surgery. 3D printing allows the manufacturing of life-size patient-specific anatomic and pathologic models to improve preoperative understanding of patient anatomy and pathology. Additionally, virtual surgical planning using medical computer-aided design software has enabled surgeons to create patient-specific surgical plans and simulate procedures in a virtual environment. This has resulted in reduced operative times, decreased complications, and improved patient outcomes. Combined with new surgical techniques, 3D-printed custom medical devices and instruments using titanium and biocompatible resins and polyamides have allowed innovative reconstructions.
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Affiliation(s)
- Jonathan M Morris
- Division of Neuroradiology, Department of Radiology, Anatomic Modeling Unit, Biomedical and Scientific Visualization, Mayo Clinic, 200 1st Street, Southwest, Rochester, MN, 55905, USA.
| | - Adam Wentworth
- Department of Radiology, Anatomic Modeling Unit, Mayo Clinic, Rochester, MN, USA
| | - Matthew T Houdek
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - S Mohammed Karim
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Peter S Rose
- Division of Orthopedic Oncology, Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Pinter ZW, Moore EJ, Rose PS, Nassr AN, Currier BL. En bloc resection of a high cervical chordoma followed by reconstruction with a free vascularized fibular graft: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22305. [PMID: 36536523 PMCID: PMC9764371 DOI: 10.3171/case22305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Wide excision of chordoma provides better local control than intralesional resection or definitive radiotherapy. The en bloc excision of high cervical chordomas is a challenging endeavor because of the complex anatomy of this region and limited reconstructive options. OBSERVATIONS This is the first case report to describe reconstruction with a free vascularized fibular graft following the en bloc excision of a chordoma involving C1-3. LESSONS This report demonstrates the durability of this construct at 10-year follow-up and is the first case report demonstrating satisfactory long-term oncological outcomes after a true margin-negative resection of a high cervical chordoma.
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Affiliation(s)
| | - Eric J. Moore
- Department of Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Ahmad N. Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
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Wide Surgery in the Cervical Spine: Indications, Results, and Complications in a Series of 30 Patients Affected by Primary Bone Tumors. World Neurosurg 2021; 155:e240-e248. [PMID: 34419658 DOI: 10.1016/j.wneu.2021.08.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND En bloc surgery is the mainstay treatment for primary malignant bone tumors, as well as in the cervical spine. Unfortunately, literature on the topic is limited to case reports and small series. METHODS We reviewed all patients affected by primary cervical spine bone tumors treated with en bloc surgeries from 1996 to 2016 and identified 30 eligible cases. We evaluated the clinical presentation and tumor characteristics and reported surgical results, complications, recurrence, and survival rates. RESULTS Only 17 of 30 patients had not been previously treated at presentation. Osteosarcoma and chordoma were the most frequent tumors, and pain was reported in all cases. En bloc spondylectomy, hemispondylectomy, and posterior arch en bloc resection were performed in 16, 12, and 2 patients, respectively. The obtained margin was adequate (wide and marginal) in 60% of cases and intralesional in the remaining cases. Two deaths occurred in the immediate postoperative period. Neurological deterioration, dural tear, and dysphagia were the most frequent complications. The 5-year local recurrence-free survival was 70.4%. The recurrence rate was 38.5% and 11.7% in previously and non-previously treated patients, respectively (χ2: 2.94; P = 0.086). Overall survival at 5 years was 58% and 47% for all series and malignant tumors, respectively. CONCLUSION Primary cervical spine bone tumors present a difficult approach. Findings suggest that patients treated with en bloc surgery show recurrence and survival rates comparable to the same tumors located in the thoracolumbar spine.
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He LM, Ma X, Chen C, Zhang HY. Treatment of cervical spine metastasis with minimally invasive cervical spondylectomy: A case report and literature review. World J Clin Cases 2021; 9:644-650. [PMID: 33553403 PMCID: PMC7829725 DOI: 10.12998/wjcc.v9.i3.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cervical spondylectomy for the treatment of cervical tumors is traumatic, causes bleeding, and is risky. This study reports on the experience with minimally invasive cervical spondylectomy for a cervical metastasis and reviewed the literature on cervical spondylectomy. The purpose was to reduce the risk and trauma of spondylectomy.
CASE SUMMARY A 60-year-old woman presented with cervical pain and radiating pain in the left upper limb for more than 2 mo. Preoperative diagnosis was C4 metastasis of thyroid cancer. Preoperative visual analogue scale score was 5. American Spinal Cord Injury Association (ASIA) grade was E. Tomita classification was 7. Weinstein-Boriani-Biagini (WBB) classification was A-D, 3-9. Tomita score was 5. Modified Tokuhashi score was 9. Spinal instability neoplastic score (SINS) was 13. The patient underwent minimally invasive cervical spondylectomy on September 28, 2017. The operative time was 200 min; the estimated blood loss was 1200 mL. The operation was successful, without complications. The postoperative visual analogue scale score was 0. The patient remained classified as ASIA grade E at the last follow-up. She accepted regular iodine-131 therapy postoperatively. The serum thyroglobulin (Tg) level of this patient was 299.02 ng/mL at 1 mo after the operation and was 13.57 ng/mL at the last follow-up. There was no local recurrence at the 25-mo follow-up, according to images, single-photon emission computed tomography, and serum Tg levels. Obvious ossification and solid fusion of C3-C5 were found at the last follow-up.
CONCLUSION Minimally invasive cervical spondylectomy with tubular retractor could minimize soft tissue trauma, intraoperative traction injury, and paraspinal muscle injury, accelerating postoperative recovery. This technique requires a rich experience in cervical spine surgery with tubular retractors, so that surgeons can visualize the anatomical structure in a small field.
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Affiliation(s)
- Li-Ming He
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Xun Ma
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Chen Chen
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Hong-Yi Zhang
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
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Glukhov DA, Zorin VI, Yu. MA. Surgery of cervical spine tumors in the close vicinity to the vertebral artery: literature review. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2020. [DOI: 10.14531/ss2020.3.91-99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- D. A. Glukhov
- St.Petersburg Research Institute of Phthisiopulmonology
| | - V. I. Zorin
- St.Petersburg Research Institute of Phthisiopulmonology;
North-Western State Medical University n.a. I.I. Mechnikov
| | - Mushkin A. Yu.
- St. Petersburg Research Institute of Phthisiopulmonology
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Westbroek EM, Pennington Z, Ehresman J, Ahmed AK, Gailloud P, Sciubba DM. Vertebral Artery Sacrifice versus Skeletonization in the Setting of Cervical Spine Tumor Resection: Case Series. World Neurosurg 2020; 139:e601-e607. [PMID: 32330623 DOI: 10.1016/j.wneu.2020.04.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tumors of the cervical spine often encase 1 or both vertebral arteries (VA), presenting the treating surgeon with the dilemma of whether to sacrifice or skeletonize the artery. We propose an algorithm for VA management in surgeries for cervical neoplasms METHODS: A retrospective review was carried out of 67 patients undergoing resection of cervical spine tumors with VA involvement. Patients were categorized by tumor origin (primary vs. metastatic) and degree of circumferential VA involvement: 1) abutment only; 2) <180° circumferential involvement; 3) >180° circumferential involvement without complete encasement; or 4) complete encasement. RESULTS Twelve patients (18%) underwent VA sacrifice, whereas 55 (82%) underwent VA skeletonization. Compared with 11/30 patients with primary tumors (37%), only 1/37 patients (3%) with metastatic disease underwent VA sacrifice (P < 0.01). This patient had invasion of the V2 arterial wall, requiring VA sacrifice. Odds of VA sacrifice also increased with increasing circumferential involvement (P < 0.01). No patients with simple abutment or 0°-180° circumferential involvement underwent sacrifice, whereas 6 of 10 (60%) with 180°-359° involvement and 6 of 29 (21%) with complete encasement underwent VA sacrifice. Of the 27 patients with ≥180° involvement, the reasons for preserving the VA were metastatic disease at the time of treatment (n = 18), a compromised contralateral VA (n = 7), vertebrobasilar junction aplasia (n = 1), and presence of a radiculomedullary artery at the affected level (n = 1). CONCLUSIONS Primary tumor disease and >180° of circumferential VA involvement should be considered as indications for intraoperative sacrifice of the VA pending preoperative angiographic evaluation for contraindications.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Wang X, Eichbaum E, Jian F, Chou D. Two-Stage En Bloc Resection of Multilevel Cervical Chordomas With Vertebral Artery Preservation: Operative Technique. Oper Neurosurg (Hagerstown) 2019; 14:538-545. [PMID: 28961805 DOI: 10.1093/ons/opx178] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 07/08/2017] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Xingwen Wang
- Department of Neurological Surgery, Xuanwu Hospital, Capital Medical Univer-sity, Beijing, China
| | - Eldan Eichbaum
- Washington Hospital Healthcare System, Fremont, California
| | - Fengzeng Jian
- Department of Neurological Surgery, Xuanwu Hospital, Capital Medical Univer-sity, Beijing, China
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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Nisson PL, Berger GK, James WS, Hurlbert RJ. Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine. World Neurosurg 2018; 119:e32-e45. [PMID: 30026140 DOI: 10.1016/j.wneu.2018.06.189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/22/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment. METHODS A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision. RESULTS In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001). CONCLUSIONS CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.
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Affiliation(s)
- Peyton L Nisson
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Garrett K Berger
- College of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - R John Hurlbert
- Division of Neurosurgery, Banner University of Arizona Medical Center Tucson, Tucson, Arizona, USA.
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Zhou H, Yang X, Jiang L, Wei F, Liu X, Liu Z. Radiofrequency ablation in gross total excision of cervical chordoma: ideas and technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:3113-3117. [PMID: 29915886 DOI: 10.1007/s00586-018-5628-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/03/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE To use radiofrequency ablation (RFA) in the resection of C4 cervical chordoma with a giant paravertebral tumor mass to achieve tumor-free exposed margins and perform a gross total excision. METHODS A gross total excision using combined posterior and anterior approaches was performed. In the posterior stage, the C4 posterior arch was removed and the C4/C5 nerve roots and vertebral artery were released from the tumor. In the anterior stage, the giant soft mass of tumor from C3 to C6 was treated with RFA to make it shrink and solidify visually to achieve tumor-free exposed margins before resecting the tumor. Finally, a gross total excision was performed followed by the implantation of titanium plate and mesh filled with allograft bone. RESULTS A gross total excision was performed with tumor-free exposed margins and radiotherapy. The patient survived more than 5 years without recurrence. CONCLUSIONS RFA can help achieve tumor-free exposed margins. A gross total excision combined with RFA can improve the local relapse-free survival of patients with cervical chordoma. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Hua Zhou
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Xiaoxiong Yang
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.,Department of Surgery, Beijing North Hospital of Ordnance Industry, Beijing, 100081, China
| | - Liang Jiang
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Feng Wei
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Xiaoguang Liu
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.
| | - Zhongjun Liu
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.
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Abstract
Background Chordomas are rare malignant primary tumors of the spine. In the mobile spine and sacrum an en-bloc resection is associated with decreased rates of recurrence. Our objective was to identify the top cited articles in chordoma research and to further analyze characteristics of these articles. Methods In March 2017, we used ISI Web of Science (v5.11, Thomas Reuter, Philadelphia, Pennsylvania, USA) to search for the following key word: "chordoma". Articles were searched from 1900 to 2017. Articles were ranked based on number of citations. The results were evaluated to determine articles most clinically relevant to the management of chordomas. The top 50 articles that met the search criteria were further characterized on the basis of: title, author, citation density, journal of publication, year (and decade) of publication, institution and country of origin and paper topic. Results A total of 1,043 articles matched the search criteria. The most influential 50 articles were cited 65 to 290 times. The articles were published between 1926 and 2012, and all articles were published in English. Thirty-three publications (66%) originated from the United States and seven (14%) from Italy. Cancer accounted for the most frequent (n=9) destination journal followed by Journal of Bone and Joint Surgery (n=4). A total of 41 institutions contributed to the top 50 articles. The most common article types were: clinical 44% (n=22), papers that combined clinical and pathology findings 18% (n=9) and basic science research 14% (n=7). Conclusions The top 50 cited articles on chordomas are predominantly clinical papers, arising from the United States and most frequently published in Cancer and Journal of Bone and Joint Surgery.
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Affiliation(s)
- Tochukwu Ikpeze
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Addisu Mesfin
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, New York, USA
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An Approach to Primary Tumors of the Upper Cervical Spine With Spondylectomy Using a Combined Approach: Our Experience With 19 Cases. Spine (Phila Pa 1976) 2018; 43:81-88. [PMID: 26020844 DOI: 10.1097/brs.0000000000001007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine. SUMMARY OF BACKGROUND DATA Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine. METHODS Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization. RESULTS Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision. CONCLUSION The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin. LEVEL OF EVIDENCE 4.
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A Case of C5 Vertebral Chordoma in a 73-Year-Old Patient with More Than 8 Years of Follow-Up after Total Piecemeal Spondylectomy. Case Rep Orthop 2017; 2017:3284131. [PMID: 29138702 PMCID: PMC5613465 DOI: 10.1155/2017/3284131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/28/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022] Open
Abstract
Chordoma arising from the cervical spine is rare and the traditional long-term prognosis is typically poor. Total en bloc spondylectomy with a wide margin is generally accepted to be the most appropriate management for thoracic and lumbar malignant tumors. However, this method is still challenging for the cervical spine because of the proximity of the tumor to the vertebral arteries and neural elements. Here, we report a 73-year-old man with a C5 vertebral chordoma treated with total piecemeal spondylectomy. Histological examination revealed pathognomonic physaliphorous cells with mucus-filled cytoplasm in the tumor, and the ratio of Ki-67-positive cells within the tumor was high (19.0%), showing active proliferation rate. Local recurrences were found at 9 months, 4 years and 2 months, and 6 years after the initial surgery. All the recurrences were encapsulated and isolated and treated with an additional en bloc resection successfully at each stage. Eight years after the initial total piecemeal spondylectomy, the patient maintained his intact neurological status without local recurrence or metastasis. The prognosis of cervical chordoma depends on the patient's age, surgical procedures, and histological features. In this report, we present that piecemeal spondylectomy is an alternative management for aged patients with cervical chordoma, even for those with high MIB-1 index.
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15
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Lee YB. Diagnosis of occipital neuralgia due to upper cervical chordoma. Korean J Pain 2017; 30:163-164. [PMID: 28757915 PMCID: PMC5532522 DOI: 10.3344/kjp.2017.30.3.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 11/23/2022] Open
Affiliation(s)
- Young Bok Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Xiao JR, Huang WD, Yang XH, Yan WJ, Song DW, Wei HF, Liu TL, Wu ZP, Yang C. En Bloc Resection of Primary Malignant Bone Tumor in the Cervical Spine Based on 3-Dimensional Printing Technology. Orthop Surg 2017; 8:171-8. [PMID: 27384725 DOI: 10.1111/os.12234] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/07/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the feasibility and safety of en bloc resection of cervical primary malignant bone tumors by a combined anterior and posterior approach based on a three-dimensional (3-D) printing model. METHODS Five patients with primary malignant bone tumors of the cervical spine underwent en bloc resection via a one-stage combined anteroposterior approach in our hospital from March 2013 to June 2014. They comprised three men and two women of mean age 47.2 years (range, 26-67 years). Three of the tumors were chondrosarcomas and two chordomas. Preoperative 3-D printing models were created by 3-D printing technology. Sagittal en bloc resections were planned based on these models and successfully performed. A 360° reconstruction was performed by spinal instrumentation in all cases. Surgical margins, perioperative complications, local control rate and survival rate were assessed. RESULTS All patients underwent en bloc excision via a combined posterior and anterior approach in one stage. Mean operative time and estimated blood loss were 465 minutes and 1290 mL, respectively. Mean follow-up was 21 months. Wide surgical margins were achieved in two patients and marginal resection in three; these three patients underwent postoperative adjuvant radiation therapy. One vertebral artery was ligated and sacrificed in each of three patients. Nerve root involved by tumor was sacrificed in three patients with preoperative upper extremity weakness. One patient (Case 3) had significant transient radiculopathy with paresis postoperatively. Another (Case 4) with C 4 and C 5 chordoma had respiratory difficulties and pneumonia after surgery postoperatively. He recovered completely after 2 weeks' management with a tracheotomy tube and antibiotics in the intensive care unit. No cerebrovascular complications and wound infection were observed. No local recurrence or instrumentation failure were detected during follow-up. CONCLUSION Though technically challenging, it is feasible and safe to perform en bloc resection of cervical primary bone tumors. This is the most effective means of managing cervical spine tumors. Preoperative 3-D printing modelling enables better anatomical understanding of the relationship between the tumor and cervical spine and can assist in planning the surgical procedure.
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Affiliation(s)
- Jian-Ru Xiao
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wen-Ding Huang
- Department of Orthopaedics, 411th Hospital of the People's Liberation Army, Shanghai, China
| | - Xing-Hai Yang
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wang-Jun Yan
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Dian-Wen Song
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hai-Feng Wei
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Tie-Long Liu
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Peng Wu
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Cheng Yang
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Pham M, Awad M. Outcomes following surgical management of cervical chordoma: A review of published case reports and case series. Asian J Neurosurg 2017; 12:389-397. [PMID: 28761513 PMCID: PMC5532920 DOI: 10.4103/1793-5482.185066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim: This review aimed to summarize the clinical outcomes in relation to tumor resection margins of cervical chordomas. Methods: Studies that described any surgical intervention for cervical chordoma were identified. Cervical chordomas with cranial or spinal extension, purely retropharyngeal chordomas or where resection type was not reported, were excluded from the study. Results: Seventy-six articles were obtained and these reported a total of 195 patients. Seventy-six percent cervical chordoma patients had intralesional resection with adjuvant radiotherapy. Ninety-two percent chordoma recurrences and all chordoma metastases occurred in patients with intralesional resection. En bloc surgeries were longer (900 min vs. 619 min) and staged surgeries. Intralesional surgeries (2899 ml vs. 2661 ml) had greater intraoperative blood loss. Vertebral artery and nerve root sacrifice were greater in en bloc patients (35%, 39%) compared to intralesional patients (17%, 10%). Postoperative complications were more common in en bloc (54%) than in intralesional patients (11%). Conclusions: En bloc resection cervical chordomas are associated with less recurrence and no metastasis compared to intralesional resection. En bloc is possible through wide exposure of the vertebrae via a multidisciplinary team approach and utilization of particular surgical equipment. The higher rate of complications associated with en bloc surgeries may be acceptable, particularly when there is a chance of cure of disease.
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Affiliation(s)
- My Pham
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
| | - Mohammed Awad
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
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Lee CH, Min WK. Cervical subtotal en-bloc spondylectomy of C6 mesenchymal chondrosarcoma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 25:2117-23. [DOI: 10.1007/s00586-015-4297-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
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Kim WS, Park JT, Lee YB, Park WY. Atlantoaxial Chordoma in Two Patients with Occipital Neuralgia and Cervicalgia. J Lifestyle Med 2015; 4:104-8. [PMID: 26064862 PMCID: PMC4391017 DOI: 10.15280/jlm.2014.4.2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/05/2014] [Indexed: 11/22/2022] Open
Abstract
Chordoma arises from cellular remnants of the notochord. It is the most common primary malignancy of the spine in adults. Approximately 50% of chordomas arise from the sacrococcygeal area with other areas of the spine giving rise to another 15% of chordomas. Following complete resection, patients can expect a 5-year survival rate of 85%. Chordoma has a recurrence rate of 40%, which leads to a less favorable prognosis. Here, we report two cases of chordoma presenting with occipital neuralgia and cervicalgia. The first patient presented with a C1-C2 chordoma. He rejected surgical intervention and ultimately died of respiratory failure. The second patient had an atlantoaxial chordoma and underwent surgery because of continued occipital neuralgia and cervicalgia despite nerve block. This patient has remained symptom-free since his operation. The presented cases show that the patients' willingness to participate in treatment can lead to appropriate and aggressive management of cancer pain, resulting in better outcomes in cancer treatment.
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Affiliation(s)
- Won Seop Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong Taek Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Bok Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Woo Young Park
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Clarke MJ, Zadnik PL, Groves ML, Sciubba DM, Witham TF, Bydon A, Gokaslan ZL, Wolinsky JP. Fusion following lateral mass reconstruction in the cervical spine. J Neurosurg Spine 2014; 22:139-50. [PMID: 25431961 DOI: 10.3171/2014.10.spine13858] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Recently, aggressive surgical techniques and a push toward en bloc resections of certain tumors have resulted in a need for creative spinal column reconstruction. Iatrogenic instability following these resections requires a thoughtful approach to adequately transfer load-bearing forces from the skull and upper cervical spine to the subaxial spine. METHODS The authors present a series of 7 cases in which lateral mass reconstruction with a cage or fibular strut graft was used to provide load-bearing support, including 1 case of bilateral cage placement. RESULTS The authors discuss the surgical nuances of en bloc resection of high cervical tumors and explain their technique for lateral mass cage placement. Additionally, they provide their rationale for the use of these constructs throughout the craniocervical junction and subaxial spine. CONCLUSIONS Lateral mass reconstruction provides a potential alternative or adjuvant method of restoring the load-bearing capabilities of the cervical spine.
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Molina CA, Ames CP, Chou D, Rhines LD, Hsieh PC, Zadnik PL, Wolinsky JP, Gokaslan ZL, Sciubba DM. Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience. J Neurosurg Spine 2014; 21:348-56. [DOI: 10.3171/2014.5.spine121045] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Object
Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1–2 level versus the subaxial (SA) spine (C3–7).
Methods
The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1–2 versus subaxial spine via a Student t-test.
Results
Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1–2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1–2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1–2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1–2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1–2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1–2 tumors (C1–2: 29%; SA: 78%; p = 0.03). C1–2 tumors were associated with significantly higher rates of postoperative complications (C1–2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1–2 tumors (local C1–2: 29%; local SA: 11%; distant C1–2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8).
Conclusions
Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1–2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1–2 versus subaxial disease, but larger studies are needed to further study survival differences.
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Affiliation(s)
- Camilo A. Molina
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher P. Ames
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Laurence D. Rhines
- 3Department of Neurosurgery, The University of Texas, MD Anderson Cancer Center, Houston, Texas; and
| | - Patrick C. Hsieh
- 4Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Patricia L. Zadnik
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean-Paul Wolinsky
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ziya L. Gokaslan
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M. Sciubba
- 1Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Oppenlander ME, Maulucci CM, Ghobrial GM, Evans NR, Harrop JS, Prasad SK. En bloc resection of upper thoracic chordoma via a combined simultaneous anterolateral thoracoscopic and posterior approach. Neurosurgery 2014; 10 Suppl 3:380-6; discussion 386. [PMID: 24739365 DOI: 10.1227/neu.0000000000000368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved. OBJECTIVE To show the feasibility, safety, and utility of performing a thoracoscopy-assisted en bloc resection of a chordoma involving the upper thoracic spine. METHODS A case study is presented of a patient with biopsy-proven chordoma of T2-3 with predominantly paravertebral involvement who underwent multilevel en bloc resection via a simultaneous combined anterolateral thoracoscopic and posterior approach. Thoracoscopic assistance achieved separation of the tumor and ventral spine from the adjacent mediastinal structures. En bloc resection proceeded without complication. The spine was stabilized with posterior instrumentation. RESULTS A multilevel en bloc resection was achieved with negative margins, preserving more than half of the remaining vertebral bodies and allowing short segment posterior fixation without extension into the cervical spine. The patient remained neurologically intact. CONCLUSION A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach.
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Affiliation(s)
- Mark E Oppenlander
- *Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; ‡Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, Arizona; §Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Delfini R, Marruzzo D, Tarantino R, Marotta N, Landi A. Multilevel oblique corpectomies as an effective surgical option to treat cervical chordoma in a young girl. World J Clin Cases 2014; 2:57-61. [PMID: 24653986 PMCID: PMC3955801 DOI: 10.12998/wjcc.v2.i3.57] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/02/2014] [Accepted: 01/20/2014] [Indexed: 02/05/2023] Open
Abstract
Chordomas are malignant tumors arising from notochordal remnants. They are the most frequent tumors of the spine after plasmacytomas. Only 6% of chordomas are localized to the cervical level. In young patients, chordomas are rare and unpredictable. Despite this, the treatment of choice remains the total resection, as much as possible, followed by proton beam radiation. This case was managed using a precarotid and retrocarotid approach at the same time. The tumor was completely resected with the edges free from disease. The cervical spine was stabilized with an anterior plating C2-C4. Eighteen months after surgery the patient is still free from illness. Multilevel oblique corpectomies are an available and safe option for the treatment of upper cervical chordomas.
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Muro K, Das S, Raizer JJ. Chordomas of the craniospinal axis: multimodality surgical, radiation and medical management strategies. Expert Rev Neurother 2014; 7:1295-312. [DOI: 10.1586/14737175.7.10.1295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Guppy KH, Chakrabarti I, Isaacs RS, Jun JH. En bloc resection of a multilevel high-cervical chordoma involving C-2: new operative modalities. J Neurosurg Spine 2013; 19:232-42. [DOI: 10.3171/2013.5.spine121039] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
En bloc resection of cervical chordomas has led to longer survival rates but has resulted in significant morbidities from the procedure, especially when the tumor is multilevel and located in the high-cervical (C1–3) region. To date, there have been only 5 reported cases of multilevel en bloc resection of chordomas in the high-cervical spine. In this technical report the authors describe a sixth case. A complete spondylectomy was performed at C-2 and C-3 with spinal reconstruction and stabilization, using several new modalities that were not used in the previous cases. The use of 1) preoperative endovascular sacrificing of the vertebral artery, 2) CT image-guidance, 3) an ultrasonic aspirator for skeletonizing the vertebral artery, and 4) the custom design of an anterior cage all contributed to absence of intraoperative or long-term (20 months) hardware failure and pseudarthrosis.
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Affiliation(s)
- Kern H. Guppy
- 1Department of Neurosurgery,
- 2Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, California
| | - Indro Chakrabarti
- 1Department of Neurosurgery,
- 2Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, California
| | | | - Jae H. Jun
- 4Division of Maxillofacial Surgery, The Kaiser Permanente Medical Group, Sacramento, California; and
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Simşek S, Uz A, Er U, Apaydın N. Quantitative evaluation of the anatomical parameters for subaxial cervical spondylectomy: an anatomical study. J Neurosurg Spine 2013; 18:568-74. [PMID: 23600585 DOI: 10.3171/2013.3.spine12360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this investigation was to conduct a morphometric study in cadavers to determine anatomical structures, their relationships, and their morphometry for subaxial cervical spondylectomy. METHODS Forty sides of 20 cadavers were used for this study. Dissections were performed in 2 stages (anteriorly and posteriorly). Twenty-one morphometric measurements were performed for both sides of the C3-6 vertebrae. Data were analyzed statistically. RESULTS Morphometry of the laminas, tuberculum posterius, pedicle, corpus, foramen transversarium, and processus costalis were measured. CONCLUSIONS Detailed quantitative anatomical knowledge for operations requiring wide dissection and resection, such as cervical spondylectomy, lowers the morbidity rate.
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Affiliation(s)
- Serkan Simşek
- Neurosurgery Clinic, Dışkapı Yıldırım Beyazıt Education and Research Hospital
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Abstract
STUDY DESIGN A primary leiomyosarcoma located on the left side of the C2 is reported. Left-sided partial spondylectomy and anterior reconstruction with posterior stabilization was performed by a two-staged operation. OBJECTIVE To emphasize the occurrence of primary leiomyosarcoma and the importance of proper stabilization in the upper cervical spine. SUMMARY OF BACKGROUND DATA Leiomyosarcoma is a rare malignant neoplasm of the bone and the primary leiomyosarcoma of the spine is extremely rare. Radical tumor excision is the goal in case of vertebral leiomyosarcoma, but to both gain surgical access to the upper cervical spine and obtain anterior reconstruction is challenging. METHODS Leiomyosarcoma of the C2 in a 25-year-old woman with mild neurologic deficits is reported. A left-sided partial spondylectomy of C2 was performed. The defect of the vertebral body was reconstructed by expandable titanium prosthesis, and posterior craniocervical fixation was performed by the polyaxial screws in the lateral masses and rod/plates. RESULTS The surgical margin was very small. The pathology of the tumor was reported as leiomyosarcoma. No sign of local recurrence or metastasis was evident 1 year after surgery. CONCLUSION Leiomyosarcoma, although rare, should be kept in mind as one of the possible diagnoses when a patient with an upper cervical tumor is presented and complete tumor removal must be the goal.
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Cloyd JM, Acosta FL, Polley MY, Ames CP. En Bloc Resection for Primary and Metastatic Tumors of the Spine. Neurosurgery 2010; 67:435-44; discussion 444-5. [DOI: 10.1227/01.neu.0000371987.85090.ff] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
The efficacy of en bloc resection for spinal tumors is unknown because most of the current evidence is provided by small, single-institution clinical series or case reports.
OBJECTIVE
To combine all previously published reports of en bloc resection for primary and metastatic spinal tumors, to describe the overall pattern of disease-free survival, and to investigate potentially prognostic factors for recurrence.
METHODS
A complete MEDLINE search for all articles reporting survival data for en bloc resection of spinal tumors was undertaken; 44 articles met inclusion criteria from which 306 eligible patients were identified.
RESULTS
There were 229 cases of primary tumors with a mean follow-up of 65.0 months and 77 cases of solitary metastatic tumors with a mean follow-up of 26.5 months. Median time to recurrence was 113 months for the primary group and 24 months for the metastatic group. Disease-free survival rates at 1, 5, and 10 years were 92.6%, 63.2%, and 43.9%, respectively, for the primary group and 61.8%, 37.5%, and 0%, respectively, for the metastatic group; 5-year disease-free survival rates were 58.4% for chordoma and 62.9% for chondrosarcoma. After adjusting for covariates, age, male sex, metastatic tumors, and osteosarcomas were significantly associated with a tumor recurrence.
CONCLUSION
This study provides the largest published series of patients undergoing en bloc resection for spinal tumors. Median time to recurrence reached almost 10 years in patients with primary tumors; however, it was only 2 years in those with isolated metastatic tumors.
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Affiliation(s)
- Jordan M. Cloyd
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Frank L. Acosta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Mei-Yin Polley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Scheer JK, Tang J, Eguizabal J, Farin A, Buckley JM, Deviren V, McClellan RT, Ames CP. Optimal reconstruction technique after C-2 corpectomy and spondylectomy: a biomechanical analysis. J Neurosurg Spine 2010; 12:517-24. [DOI: 10.3171/2009.11.spine09480] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Primary spine tumors frequently involve the C-2 vertebra. Complete resection of the lesion may require total removal of the C-2 vertebral body, pedicles, and dens process. Authors of this biomechanical study are the first to evaluate a comprehensive set of reconstruction methods after C-2 resection to determine the optimal configuration depending on the degree of excision required.
Methods
Eight human heads (from the skull to C-6) from 4 males and 4 females with a mean age of 68 ± 18 years at death were cleaned of tissue, while leaving ligaments and discs intact. Nondestructive flexion and extension (FE), lateral bending (LB), and axial rotation (AR) tests were conducted using a nonconstraining, pure moment loading apparatus, and relative motion across the fusion site (C1–3) was measured using a 3D motion tracking system. Specimens were tested up to 1.5 Nm at 0.25-Nm intervals for 45 seconds each. The spines were instrumented using 3.5-mm titanium rods with a midline occipitocervical plate (4.0 × 12–mm screws) and lateral mass screws (excluding C-2) at the C-1 (3.0 × 40 mm) and C3–5 levels (3.0 × 16 mm). Testing was repeated for the following configurations: Configuration 1 (CF1), instrumentation only from occiput to C-5; CF2, C-2 corpectomy leaving the dens; CF3, titanium mesh cage (16-mm diameter) from C-3 to C-1 ring and dens; CF4, removal of cage, C-1 ring, and dens; CF5, titanium mesh cage from C-3 to clivus (16-mm diameter); CF6, removal of C-2 posterior elements leaving the C3–clivus cage (spondylectomy); CF7, titanium mesh cage from C-3 to clivus (16-mm diameter) with 2 titanium mesh cages from C-3 to C-1 lateral masses (12-mm diameter); and CF8, removal of all 3 cages. A crosslink was added connecting the posterior rods for CF1, CF6, and CF8. Range-of-motion (ROM) differences between all groups were compared via repeated-measures ANOVA with paired comparisons using the Student t-test with a Tukey post hoc adjustment. A p < 0.05 indicated significance.
Results
The addition of a central cage significantly increased FE rigidity compared with posterior instrumentation alone but had less of an effect in AR and LB. The addition of lateral cages did not significantly improve rigidity in any bending direction (CF6 vs CF7, p > 0.05). With posterior instrumentation alone (CF1 and CF2), C-2 corpectomy reduced bending rigidity in only the FE direction (p < 0.05). The removal of C-2 posterior elements in the presence of a C3–clivus cage did not affect the ROM in any bending mode (CF5 vs CF6, p > 0.05). A crosslink addition in CF1, CF6, and CF8 did not significantly affect primary or off-axis ROM (p > 0.05).
Conclusions
Study results indicated that posterior instrumentation alone with 3.5-mm rods is insufficient for stability restoration after a C-2 corpectomy. Either C3–1 or C3–clivus cages can correct instability introduced by C-2 removal in the presence of posterior instrumentation. The addition of lateral cages to a C3–clivus fusion construct may be unnecessary since it does not significantly improve rigidity in any direction.
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Affiliation(s)
- Justin K. Scheer
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - Jessica Tang
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - Johnny Eguizabal
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - Azadeh Farin
- 3Neurological Surgery, University of California, San Francisco, California
| | - Jenni M. Buckley
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - Vedat Deviren
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - R. Trigg McClellan
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 2Departments of Orthopaedic Surgery and
| | - Christopher P. Ames
- 1Biomechanical Testing Facility, Orthopaedic Trauma Institute, San Francisco General Hospital; and
- 3Neurological Surgery, University of California, San Francisco, California
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Cloyd JM, Chou D, Deviren V, Ames CP. En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature. Spine J 2009; 9:928-35. [PMID: 19716772 DOI: 10.1016/j.spinee.2009.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 07/02/2009] [Accepted: 07/21/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Survival data and rates of recurrence after en bloc resection for cervical spinal tumors are limited to single case reports and small case series, making the true risk of recurrence after this procedure unknown. PURPOSE To report two cases of cervical chordoma managed via en bloc resection. To conduct a systematic review of the existing literature to determine the overall incidence of disease-free survival and investigate potential prognostic factors of recurrence. STUDY DESIGN Case report and systematic review. METHODS We present the cases of a 60-year-old woman and a 76-year-old man who underwent en bloc resection of C3-C6 and C2 chordomas, respectively. A complete MEDLINE search was then undertaken for all articles reporting survival data for en bloc resections of primary tumors of the cervical spine. Exclusion criteria included non-English articles, lack of explicit mention or description of en bloc technique, age less than 16, no demographic or survival information reported, and follow-up less than 1 month. Survivorship analysis was conducted, and Kaplan-Meier plots were created with the primary outcome of interest being any tumor recurrence. RESULTS A total of 10 articles comprising 18 cases were included for analysis with a mean follow-up of 47.4+/-41.5 months. Mean operative time, estimated blood loss, and length of hospitalization were 18.6 hours, 2.9L, and 34.6 days, respectively. Postoperative complications occurred in eight of the nine patients in which these data were reported. There were three cases of local recurrence, occurring at 12, 44, and 113 months, and one case of distant metastasis, occurring at 12 months postoperatively. With the available data, 1- and 5-year disease-free survival rates of 88.2% and 73.5% were calculated. On Cox proportional hazards analysis, no factors were found to be predictive of recurrence. CONCLUSIONS In this systematic review of the literature, en bloc resection provided good disease-free survival rates in patients with primary tumors of the cervical spine. However, there are insufficient data on long-term subjective outcomes in these patients, and larger series are needed to determine the efficacy compared with piecemeal resection techniques. Other investigators should be encouraged to publish their results so that combined analyses like these may be performed with larger sample sizes.
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Affiliation(s)
- Jordan M Cloyd
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, Box 0112, San Francisco, CA 94143, USA
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State of the art management in spine oncology: a worldwide perspective on its evolution, current state, and future. Spine (Phila Pa 1976) 2009; 34:S7-20. [PMID: 19816243 DOI: 10.1097/brs.0b013e3181bac476] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A review of the past and current status of the evolving field of spine oncology. OBJECTIVE To provide a framework of reference for developments in the field, particularly the rapidly evolving field of molecular biology, as well as contemporary practice in the management of spine tumors. METHODS Literature review of the surgical treatment of spine tumors in the past and present, the emerging radiologic and biologic technologies, as well as the field of targeted therapy in cancer and the economic implications of technological advances. RESULTS A vast contemporary literature is currently available that provides a clear rational basis for treatment. Most treatment recommendations are currently based on retrospective data and small Phase II prospective studies. Treatment paradigms continue to evolve without their relative merits being evaluated by randomized controlled trials. The current lack of randomized trials in spine oncology reflect both the rarity of spine tumors and strongly held biases based on retrospective studies and institutional bias. CONCLUSION Spine oncology is a rapidly evolving field with contributions in surgery, radiation therapy, and targeted chemotherapy resulting in overall improvement in quality of life and survival in patients with spine tumors. However, the economic consequences of these improvements are substantial and need to be kept in proper perspective.
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Boriani S, Saravanja D, Yamada Y, Varga PP, Biagini R, Fisher CG. Challenges of local recurrence and cure in low grade malignant tumors of the spine. Spine (Phila Pa 1976) 2009; 34:S48-57. [PMID: 19829277 DOI: 10.1097/brs.0b013e3181b969ac] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and ambispective multicenter cohort study. OBJECTIVE 1. To compare the effects of wide/marginal (en bloc) resection with intralesional resection on local recurrence and survival for chordomas and chondrosarcomas of the spine. 2. To determine the influence of radiation therapy in the management of chordomas and chondrosarcomas. SUMMARY OF BACKGROUND DATA Chordomas and chondrosarcomas of the spine are prone to local recurrence and death despite being low-grade malignant tumors. No study to date has enough numbers or adequate scientific rigor to determine the influence of resection or radiation therapy on outcome. METHODS A systematic review was performed to evaluate the 2 objectives. In addition an ambispective multicenter cohort analysis of chordomas and chondrosarcomas was performed. The GRADE system of analysis integrating the results of the systematic review, the multicenter cohort study and the expert opinion of the Spine Oncology Study Group (SOSG) was used to arrive at treatment recommendations. RESULTS A total of 63 articles were included in the systematic reviews. Evidence was low quality. En bloc resection appeared to improve both local recurrence and disease free survival in Chordoma and Chondrosarcoma. Radiation therapy had a positive impact on the management of Chordoma and Chondrosarcoma with predictably low side effects. The cohort analysis showed significantly decreased local recurrence for Chordoma (P < 0.0001) and Chondrosarcoma (P < 0.0001) with en bloc resection, and significantly decreased death for both Chordoma (P = 0.0001) and Chondrosarcoma (P = 0.0015) with en bloc resection. CONCLUSION When wide or marginal margins (en bloc) are achieved in surgical resection of chordomas and chondrosarcomas of the spine there is a decrease in local recurrence and mortality. Therefore, en bloc resection should be undertaken for the treatment of chordomas and chondrosarcomas of the spine. Strong Recommendation, Moderate Quality Evidence.Radiation therapy of at least 60 to 65 Gy equivalents is indicated as an adjuvant treatment for chordoma and chondrosarcoma of the spine when there has been incomplete resection or an intralesional margin. Weak Recommendation, Low Quality Evidence.
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Affiliation(s)
- Stefano Boriani
- Department of Orthopedic Oncology, Rizzoli Institute, Bologna, Italy
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Boriani S, Weinstein JN. The Role of “Tumor-Free Margins” in the Resection of Spinal Tumors: Who Should Be Treating Spine Tumors? ACTA ACUST UNITED AC 2009. [DOI: 10.1053/j.semss.2009.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Chou D, Acosta F, Cloyd JM, Ames CP. Parasagittal osteotomy for en bloc resection of multilevel cervical chordomas. J Neurosurg Spine 2009; 10:397-403. [DOI: 10.3171/2009.2.spine08472] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
En bloc resection of chordoma has been shown to be critical for prolonging long-term survival and disease-free intervals in patients. Cervical spine chordomas pose special challenges because of the vertebral arteries and critical nerve roots involved. Multilevel chordomas pose even greater challenges because of the need to remove multiple segments of the spine in 1 piece without tumor violation. Although there have been 2 case reports describing multilevel spondylectomy for cervical chordoma, to the authors' knowledge, there are no reports of parasagittal osteotomies for en bloc resection of multilevel cervical chordomas. The use of these osteotomies allows us to avoid intralesional resection and adhere to the oncological principle of en bloc tumor excision. The authors report their management of 3 multilevel cervical chordomas and describe their technique of en bloc tumor removal using parasagittal osteotomy.
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Abstract
Giant cell tumors (GCT) are rare in the cervical spine in adolescent children. This tumor is histologically benign, but there is a high recurrence rate. Although surgical resection of GCT arising in the cervical spine is commonly regarded as recommended treatment method, it is still a challenge to achieve satisfactory results. The authors describe a case of a patient of adolescent age with a GCT in the cervical spine. It was necessary to study the embolization of the vertebral artery to planning the vertebrectomy surgery for resection of the entire tumor to avoid recurrence. The resection of the tumor was carried out by combined access (anteriorly and posteriorly) and was stabilized with plate, posterior lateral mass screws, and autologous iliac crest graft.
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Abstract
Primary malignant bone tumors of the vertebral column, i.e., bone sarcomas of the spine, are inherently rare entities. Vertebral osteosarcomas and chordomas represent the largest groups, followed by the incidence of chondro-, fibro-, and Ewing's sarcomas. Detailed clinical and neurological examination, complete radiographic imaging [radiographs, computed tomography (CT), magnetic resonance imaging (MRI)], and biopsy are the decisive diagnostic steps. Oncosurgical staging for spinal tumors can serve as a decision-guidance system for an individual's oncological and surgical treatment. Subsequent treatment decisions are part of an integrated, multimodal oncological concept. Surgical options comprise minimally invasive surgery, palliative stabilization procedures, and curative, wide excisions with complex reconstructions to attain wide or at least marginal resections. The most aggressive mode of surgical resection for primary vertebral column tumors is the total en bloc vertebrectomy, i.e., single- or multilevel en bloc spondylectomy. En bloc spondylectomy involves a posterior or combined anterior/posterior approach, followed by en bloc laminectomy, circumferential (360 degrees) vertebral dissection, and blunt ventral release of the large vessels, intervertebral discectomy and rotation/ en bloc removal of the vertebra along its longitudinal axis. Due to the complex interdisciplinary approach and the challenging surgical resection techniques involved, management of vertebral bone sarcomas is recommended to be performed in specific musculoskeletal tumor centers.
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Affiliation(s)
- Klaus-Dieter Schaser
- Section for Musculoskeletal Tumor Surgery, Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Abstract
Primary malignant tumors of the spine account for less than 5% of primary bone tumors. Data from the SEER program suggest that the most common bone sarcomas are osteosarcoma, chondrosarcoma, Ewing's sarcoma, chordoma, and malignant fibrous histiocytoma/fibrosarcoma. During the last two decades, tremendous progress has been made in clinical aspects, surgical approaches, and reconstruction with instrumentation at all levels of the spine. Stabilization procedures, including vertebroplasty and kyphoplasty, have further allowed palliation of pain and symptom relief from compression fractures. Improved radiation techniques have offered the potential for improved local control. This article reviews the changes in surgical philosophy in the management of malignant spinal tumors during the past two decades.
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