Anterior Tumor Resection Research Articles

The surgical strategy for eosinophilic granuloma of the pediatric cervical spine complicated with neurologic deficit and/or spinal instability.

BackgroundVarious therapeutic approaches have been proposed for the treatment of pediatric patients with eosinophilic granuloma (EG) of the cervical spine. Our aim was to discuss and present our experience with the individualized surgical intervention of pediatric cervical EG complicated with neurologic deficits and/or spinal instability.MethodsWe retrospectively analyzed the clinical data of 19 children who were diagnosed with cervical EG comor spinal/or spinal instability (evaluated by the Spinal Instability Neoplastic Score, SINS ≥ 7) and treated surgically in our institution.ResultsLesions involved C1–2 in 7 patients and C3–7 in 12 patients. Anterior tumor resection combined with posterior pedicle screw fixation, anterior approach of excision and instrumentation, and posterior tumor resection combined with pedicle screws instrumentation were selected according to the different locations of tumors. Frankel scale and Oucher scale improved significantly after surgery. There was no morphologic alteration of the neck at follow-up.ConclusionsSurgery can significantly improve the neurologic status and symptoms. Surgical decision-making must be individually tailored to minimize the influence of surgery on spine growth.

Atlantoaxial instability secondary to eosinophilic granuloma of the axis in adults: long-term follow-up in six cases

Background contextEosinophilic granuloma (EG) involving the spine is uncommon in adults. Atlantoaxial instability (AAI) secondary to EG of the axis in adults is an extremely rare clinical condition that can give rise to severe neurologic morbidity or mortality if not treated appropriately. There have been no previous reports on the condition in adults. PurposeTo present the outcome and clinical experience for the management of AAI secondary to EG of the axis in adults. Study designA retrospective review study. Patient sampleAll adult patients with AAI secondary to EG of the axis who were admitted to the spine service at the study institution between January 1999 and April 2012. Outcome measuresClinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and/or complications were recorded and analyzed. MethodsSix consecutive adults who presented clinical and radiographic manifestations of AAI secondary to EG of axis were treated and monitored. All patients were treated surgically with anterior tumor resection and posterior reconstruction of spinal stability. Oral steroid therapy was administered after surgery as adjuvant therapy. ResultsThe mean duration of follow-up was 77 months (range, 37–140 months). The most common radiographic feature was osteolytic destruction of the vertebral body of the axis. All patients had favorable recoveries, with osseous fusion. There were no surgery-related postoperative complications, and neither recurrence nor spinal deformity had occurred by the final follow-up examination. ConclusionsSurgical intervention via anterior tumor resection and posterior reconstruction was found to be safe and effective for treating AAI secondary to EG in adults, in terms of recovering neurologic function, improving symptom relief, and reducing the risks resulting from osteolytic destruction. Surgical treatment plus oral steroid therapy can produce beneficial results and definitive local control during the follow-up period.

Anterior construction after resection for axis tumors through the sub mandible approach

Objective To investigate procedure and therapeutic effect of resection and reconstruction for axis tumors through the sub mandible approach. Methods Between December 2004 to June 2010,17 patients with axis neoplasm underwent tumor resection and antero-posterior reconstruction through the combined the sub mandible-inner sternocleidomastoid muscle (SMIS) approach and posterior approach. Tumor lesions involved C2 in 11 cases, C2-3 in 4, C2-4 in 2. Eight cases involved vertebral body, and 9 involved both vertebral body and element. Fourteen primary lesions including 4 giant cell tumors, 4 plasmocytomas, 2 chordomas, 2 eosinophilic granulomas, 1 hemangiopericytomas and 1 lymphoma, and 3 metastatic lesions were involved in this study. Three types of reconstruction in upper cervical spine including titanium mesh plus vertically placed titanium plate, titanium mesh plus obliquely placed titanium plate and trimmed titanium mesh alone, were adopted after anterior tumor resection, and then posterior tumor resection and reconstruction were performed. Results All patients experienced pain relief and neurological improvement after surgery. Except for one incidence of screw pull-out which was corrected by a revision surgery, solid fusion was achieved in all patients. A follow-up period of 6 months to 6 years was available for this study. One patient died of cerebral infarction 9 months postoperative. Two patients with chordoma relapsed 13 months and18 months postoperative, respectively, of whom one died of high plegia and respiratory failure, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases 12 months and 18 months postoperative, respectively. Conclusion Through the SMIS apporach, a satisfactory exposure can be obtained for axis tumor resection and reconstruction. Anterior reconstruction of upper cervical spine after tumor resection can be achieved with internal fixation system of cervical spine, which can improve intraopera-tive safety. The combined anterior reconstruction and posterior occipito-cervcial fixation can provide immediate stability, and benefit maintaining stability of upper cervical spine. Key words: Axis; Neoplasms; Surgical procedures, operative

Sequentially Staged Resection and 2-Column Reconstruction for C2 Tumors Through a Combined Anterior Retropharyngeal–Posterior Approach

Surgical treatment of C2 tumors remains challenging. Because of the deep location and unique anatomical complexity, anterior exposure in this region is considered difficult and dangerous, and few reports concerning anterior tumor resection and reconstruction exist. To describe a technique of sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach. Eleven patients with C2 tumors underwent sequentially staged tumor resection and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were involved. Tumor resections and anterior reconstructions with conventional constructs were accomplished by an anterior retropharyngeal approach, and occipitocervical fusions through posterior access were performed in the same anesthesia. No operative mortality occurred in this series. All patients experienced pain relief and neurological improvement after surgery. Except for 1 incidence of screw pullout, which was corrected by revision surgery, solid fusion was achieved in all patients. A follow-up period of 12 to 37 months was available for this study. Two patients with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases. No evidence of local recurrence was found in the other patients. The anterior retropharyngeal approach is a favorable route to treat tumor lesions of the C2 vertebral body that allows tumor resection and placement of anterior constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column reconstruction could safely be accomplished simultaneously through the combined anterior retropharyngeal-posterior approach.

Complicated Surgical Resection of Malignant Tumors in the Upper Cervical Spine After Failed Ion-Beam Radiation Therapy

Case report. To report 3 cases of malignant tumors in the upper cervical spine that were treated surgically by a combination of posterior tumor resection and stabilization and anterior tumor resection through a mandible-splitting approach after failed ion-beam radiation therapy. Few clinical reports have described in detail the postoperative complications associated with transoral surgical resection of tumors in the upper cervical spine after unsuccessful ion-beam radiation therapy. Three patients with malignant tumors in the upper cervical spine who had undergone ion-beam radiotherapy and experienced tumor recurrence were treated by a combination of posterior and anterior surgery through a mandible-splitting approach. One patient (patient 1, a 32-year-old man) had a hemangioendothelioma at the C2 and C3 level, whereas the other 2 patients (patient 2, a 66-year-old woman and patient 3, a 65-year-old man) had a chordoma at the C2 and C3 level. The intralesional but macroscopic total resection of the tumors was achieved in all 3 patients. However, serious complications developed after surgery, including deep wound infection, cerebrospinal fluid leakage, and meningitis in patient 1, prolonged swallowing difficulty, subsidence of the strut graft, and recurrence in patient 2, and deep wound infection and discitis causing progressive paralysis in patient 3. All patients underwent salvage surgery, including debridement of the wound in patient 1, posterior reinforcement using instrumentation and posterior tumor resection for the recurrent tumor in patient 2, and anterior debridement of the wound with a pedicle flap using the pectoral major muscle in patient 3 to address these problems. Patients 1 and 3 had no signs of recurrence at the time of a follow-up examination. Severe complications, mainly associated with the disturbance in healing of the retropharyngeal wall, were observed in all 3 patients. A preventive method, such as primary repair of the retropharyngeal wall using muscular/musculocutaneous flaps, should be considered for patients undergoing resection through a transoral approach after ion-beam irradiation.

Expandable vertebral body replacement in patients with thoracolumbar spine tumors

The objectives of surgical interventions for tumoral lesions of the spine include the establishment and improvement of tumor-related symptoms. Anterior tumor resection followed by reconstruction indicated if surgical treatment allowed a marginal removal of the tumor or could extend the individual survival rate in combination with adjuvant therapy options. Sufficient re-stabilization depends on adequate anterior column reconstruction. The purpose of this retrospective study was to present our experiences and results after anterior tumor resection followed by reconstruction with the expandable vertebral body replacement device (VBR, Ulrich, Germany) based on clinical application over 4 degrees years. We carried out an anterior tumor resection followed by reconstruction using an anterior extendable device in 32 patients with different spine tumors between 1996 and 2000. A retrospective evaluation was executed considering the patients medical records and radiological findings. Additionally, a clinical and radiological investigation of still living postoperative patients was carried out. The mean surgical time of all evaluated patients was 317.2 min. The average blood loss was 1,272.5 ml. According to the Tokuhashi score, patients with a postoperative survival time of at least 12 months demonstrated a score value > or = 9 points. According to our evaluated patients group metastatic lesions of the spine represented the largest group (78.1%). The average survival rate of this group amounted to 18.4 months postoperatively. Considering primary tumors the average survival rate at the time of last re-examination amounted to 34.8 months postoperatively. Preoperative neurological pathologies were present in 12 patients (Frankel stage C-D). During the postoperative monitoring period 58.3% of the patients demonstrated an improvement in initial neurological findings. There were no intraoperative complications or perioperative deaths. Implant dislocations were not observed. On account of the underlying, the anterior tumor resection with supplementary instrumentation represented a sufficient procedure in spinal tumor surgery. Adjuvant therapy can influence the postoperative survival period positively in addition to the surgical procedure. Following anterior tumor resection, extendable vertebral body replacements like the VBR device provide immediate spine stability by excellent defect adaptation. With regard to their intraoperative flexibility, expandable cages are more advantageous in contrast to non-expandable implants or bone grafts.