Total En Bloc Spondylectomy Research Articles

Complications and prognosis of primary thoracic and lumbar giant cell tumors treated by total tumor resection

BackgroundSpinal giant cell tumor (SGCT) is a relatively rare primary tumor. En bloc resection is the preferred surgical procedure for it due to its aggressiveness, meanwhile leading to more complications. We reported the characteristics of perioperative complications and local control of total tumor resection including en bloc resection and piecemeal resection for primary thoracic and lumbar spinal giant cell tumors in a single center over 10 years.MethodsThis is a retrospective cross-sectional and cohort study. Forty-one consecutive patients with SGCTs who underwent total tumor resection from 2010 to 2020 at our institution and were followed up for at least 24 months were reviewed. Surgery data, complication characteristics and local tumor control were collected and compared by different surgical procedure.ResultsForty-one patients were included, consisting of 18 males and 23 females, with a mean age of 34.2 years. Thirty-one had thoracic vertebra lesions, and 10 had lumbar vertebra lesions. Thirty-five patients were primary cases, and 6 patients were recurrent cases. Eighteen patients were treated by total en bloc spondylectomy (TES), 12 patients underwent en bloc resection according to WBB surgical system, and 11 patients underwent piecemeal resection. The average surgical time was 498 min, and the mean estimated blood loss was 2145 ml. A total of 58 complications were recorded, and 30 patients (73.2%) had at least one perioperative complication. All patients were followed up after surgery for at least 2 years. A total of 6 cases had postoperative internal fixation failure, and 4 cases presented local tumor recurrence (9.8%).ConclusionsAlthough the surgical technique is difficult and accompanied by a high rate of perioperative complications, en bloc resection can achieve favorable local control in SGCT. When it is too difficult to complete en bloc resection, thoroughly piecemeal resection without residual is also acceptable, given the relatively low recurrence rate.

Characteristics and risk factors of instrumentation failure following total en bloc spondylectomy.

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction.Cite this article: Bone Joint J2023;105-B(2):172-179.

Efficacy and safety of erythropoietin inisolated spinal metastasis patients withtotal en bloc spondylectomy surgery: acase-control study.

The purpose of our study is to identify the effect of short-term and high-dose use of erythropoietin (EPO) in spinal isolated metastatic patients with Total en bloc spondylectomy (TES) surgery by assessing hematological parameters, transfusion volume, postoperative complications, recurrence-free survival (RFS), and overall survival (OS). From January 2015 and January 2022, 93 isolated spinal metastasis patients were selected and separated into 2 groups based on the treatment method used (EPO + TXA (Tranexamic acid) group, n = 47; and TXA group, n = 46). Indexes for evaluation included hemoglobin (Hb), hematocrit (Hct), red blood cells (RBC), RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, transfusion rate, and mean units transfused. The average follow-up duration was 38.13months. There was no significant difference (P > 0.05) in RFS, OS, postoperative complications, postoperative Frankel Grade, drainage volume, and transfusion rate between the two groups. However, patients in EPO + TXA group have significantly higher Hb, Hct, and RBC values than those in the TXA group on postoperative days 1, 2, 3, and 5. Moreover, the mean transfusion volume in EPO + TXA group was significantly lower than those in the TXA group (P = 0.011). Perioperative short-term and high-dose administration of EPO could improve the anemia-related hematological parameters and reduce the requirement for blood transfusion without increasing the risk of deep vein thrombosis and tumor progression in solitary spinal metastatic patients with TES surgery.

Treatment of spinal rhabdomyosarcoma in adults: A case report and literature review of current evidence.

Spinal rhabdomyosarcoma (RMS) is a rare yet highly malignant tumor in adults. Literature on this entity is lacking and no mature treatment guideline is currently available. The treatment arsenals include surgery, radiotherapy and chemotherapy, being used singly or jointly. However, the prognosis is dismal, with a mean overall survival period of 10 months. Thus, any case of this disease with encouraging outcomes shall be shared. A case of a middle-aged female patient with spinal RMS was presented in the current report. The patient suffered from back pain but was neurologically intact. The patient underwent a total en-bloc spondylectomy of the T11-L2 vertebrae and spinal reconstruction with 3D-printed prosthetic vertebrae. Afterwards, the patient received a rigid schedule of stereotactic body radiotherapy (SBRT) and chemotherapy. To date, the patient has survived for 40 months, with the preservation of neurological function and sustained mitigation of local pain after the operation. The patient suffered subcutaneous colonization of tumor cells and pulmonary metastasis 10 months postoperatively, but obtained a long locoregional control of 19 months. In conclusion, total en-bloc lesion resection is indicated for the treatment of isolated, primary spinal RMS in adults. Some authors reported that the usage of new surgical tools and instruments has facilitated surgery, which was previously invasive and technically challenging. Advanced radiotherapy techniques, such as SBRT, which were proven effective for local lesion control, should be implemented early after the operation. Chemotherapy remains the mainstay of treatment, but further research and evidence for the efficacy of regimens specifically for adults are required.

A Modified Spinal Reconstruction Method Reduces Instrumentation Failure in Total En Bloc Spondylectomy for Spinal Tumors.

Long-term spinal stability after total en bloc spondylectomy (TES) is challenging. The aim of this study was to examine whether the new method could reduce the incidence of instrumentation failure (IF). We retrospectively compared 116 patients with spinal tumors who underwent TES between 2010 and 2019 and were followed up for >1 year. IF, cage subsidence, and complications were evaluated. Propensity score matching between conventional and new method groups was performed for age, sex, body mass index, preoperative radiotherapy, number of resected vertebrae, number of instrumented vertebrae, tumor level, and follow-up period. There were 25 cases each in the conventional and new method groups. The conventional method used a titanium mesh cage for anterior reconstruction and 5.5-mm-diameter titanium alloy rods for posterior fixation. The new method used a more robust cage for anterior reconstruction, bone grafting was performed around the cage, and 6.0-mm-diameter cobalt chromium rods were used for posterior fixation. We compared the incidence of IF and cage subsidence after TES between the conventional and new method groups. While 5 out of 25 patients (20.0%) in the conventional method group experienced IF, none from the new method group experienced IF. Three-year implant survival rates were 87.3% in the conventional and 100% in the new method groups. The new method group had a significantly higher implant survival rate (p<0.01). Cage subsidence was observed in 11 of 25 (44/0%) patients in the conventional method and 1 of 25 (4.0%; significantly lower, p<0.05) in the new method group. The new reconstruction method significantly reduced IF incidence in patients with TES.

Improvement of sleep quality in isolated metastatic patients with spinal cord compression after surgery

BackgroundThis study aimed to assess changes in quality of sleep (QoS) in isolated metastatic patients with spinal cord compression following two different surgical treatments and identify potential contributing factors associated with QoS improvement.MethodsWe reviewed 49 patients with isolated spinal metastasis at our spinal tumor center between December 2017 and May 2021. Total en bloc spondylectomy (TES) and palliative surgery with postoperative stereotactic radiosurgery (PSRS) were performed on 26 and 23 patients, respectively. We employed univariate and multivariate analyses to identify the potential prognostic factors affecting QoS.ResultsThe total Pittsburgh Sleep Quality Index (PSQI) score improved significantly 6 months after surgery. Univariate analysis indicated that age, pain worsening at night, decrease in visual analog scale (VAS), increase in Eastern Cooperative Oncology Group performance score (ECOG-PS), artificial implant in focus, and decrease in epidural spinal cord compression (ESCC) scale values were potential contributing factors for QoS. Multivariate analysis indicated that the ESCC scale score decreased as an independent prognostic factor.ConclusionsPatients with spinal cord compression caused by the metastatic disease had significantly improved QoS after TES and PSRS treatment. Moreover, a decrease in ESCC scale value of > 1 was identified as a favorable contributing factor associated with PSQI improvement. In addition, TES and PSRS can prevent recurrence by achieving efficient local tumor control to improve indirect sleep. Accordingly, timely and effective surgical decompression and recurrence control are critical for improving sleep quality.

Posterior only for Approach Total EN Bloc Spondylectomy: A Case Report

Total en bloc spondylectomy (TES) is a surgical technique that removes the tumor in a margin-free surgical resection of an entire vertebral body in primary malignant tumors, which can be used by multiple approaches to surgery and is beneficial in reducing complications and totally removing the vertebral column. Although the primary technique requires maximally exposed normal anatomy, our technique can be applied to many lesions in the lumbar area. We reported the first case in Vietnam with a single malignant spinal tumor that was successfully treated with TES surgery. The patient was admitted to our hospital with the primary complaint of back pain that had not responded to conventional treatment as well as neurogenic bowel dysfunction. He was treated with preoperative embolization and underwent TES in L1 by only one posterior approach. Postoperative histological examination revealed myeloid sarcoma. This technique still has many challenges with lumbar vertebrae lesions due to the complex neuroanatomy and vascular structure.

Biomechanical comparison of different prosthetic reconstructions in total en bloc spondylectomy: a finite element study

ObjectiveTo analyse and compare the biomechanical differences between 3D-printed prostheses, titanium mesh cages and poorly matched titanium mesh cages in total en bloc spondylectomy (TES).MethodsThe finite element model of T10-L2 for healthy adults was modified to make three models after T12 total spondylectomy. These models were a 3D-printed prosthesis, titanium mesh cage and prosthesis-endplate mismatched titanium mesh cage for reconstruction. The range of motion (ROM), stress distribution of the endplate and internal fixation system of three models in flexion and extension, lateral bending and axial rotation were simulated and analysed by ABAQUS.ResultIn flexion, due to the support of the anterior prosthesis, the fixation system showed the maximum fixation strength. The fixation strength of the 3D-printed prosthesis model was 26.73 N·m /°, that of the TMC support model was 27.20 N·m /°, and that of the poorly matched TMC model was 24.16 N·m /°. In flexion, the L1 upper endplate stress of the poorly matched TMC model was 35.5% and 49.6% higher than that of the TMC and 3D-printed prosthesis, respectively. It was 17% and 28.1% higher in extension, 39.3% and 42.5% higher in lateral bending, and 82.9% and 91.2% higher in axial rotation, respectively. The lower endplate of T11 showed a similar trend, but the magnitude of the stress change was reduced. In the stress analysis of the 3D-printed prosthesis and TMC, it was found that the maximum stress was in flexion and axial rotation, followed by left and right bending, and the least stress was in extension. However, the mismatched TMC withstood the maximum von Mises stress of 418.7 MPa (almost twice as much as the buckling state) in rotation, 3 times and 5.83 times in extension, and 1.29 and 2.85 times in lateral bending, respectively.ConclusionDifferent prostheses with good endplate matching after total spondylectomy can obtain effective postoperative stable support, and the reduction in contact area caused by mismatch will affect the biomechanical properties and increase the probability of internal fixation failure.

Prognostic Analysis of Spinal Metastasis Secondary to Lung Cancer after Surgeries: A Unicentric, Large-Cohort, Retrospective Study.

Spinal metastases of lung cancer (SMLC) usually have high degree of malignancy and require surgical treatment. However, there are several controversies about the efficacy of surgery. This study aimed to investigate factors predicting prognosis of SMLC after surgery-based comprehensive treatment. A cohort of 112 cases of SMLC who underwent surgical treatment between 2009 and 2020 were retrospectively reviewed and analyzed. The surgical strategies included total en-bloc spondylectomy, debulking surgery, palliative decompression, and vertebral augmentation procedures. The patients were regularly followed-up. Survival analysis was performed, as well as analysis of the patients' neurological recovery, pain relief, and improvement of Karnosky performance score (KPS). Cox regression was used to analyze influencing factors of survival time, and Kaplan-Meier method was performed in survival analysis. The cohort included 63 males and 49 females, with an average age of 60.6 ± 10.6 years. Median survival time was 16months. A total of 86.7% of paralysis patients' neurological function recovered and 83.9% of patients with low KPS score (10-40) improved. Surgical method was significantly correlated with improvement of neurological function (p < 0.001) and KPS (p < 0.001). The mean bleeding volume was 502 ml and operative time was 170 min. The survival rates at 3, 6, 12, 24, and 36months were 92.0%, 80.4%, 63.4%, 63.4%, and 22.6%, respectively. Postoperative Frankel grade (p < 0.001), postoperative KPS score (p=0.001), and application of molecular targeted drugs (p < 0.001) were significantly correlated with survival time in univariate analysis, while application of molecular targeted drugs was an independent predictor for a longer survival by a multivariate analysis. Surgery-based comprehensive treatment brought a fair outcome, with elongated survival time. Surgery can significantly improve patients' neurological function and physical performance status. Adjuvant targeted therapy is an independent positive factor for patients' survival.

Blood loss in total en bloc spondylectomy for primary spinal bone tumours: a comparison of estimated blood loss versus actual blood loss in a single centre over 10 years.

BackgroundTotal en bloc spondylectomy (TES) is a widely accepted surgical technique for primary spinal bone tumours but is frequently accompanied by substantial peri-operative blood loss. Prior studies have reported estimated blood loss (EBL) can reach up to 3,200 mL. The aim of this study is to estimate the blood loss during TES procedures performed in the last ten years at our tertiary referral centre and compare EBL with actual blood loss (ABL).MethodsWe performed a retrospective review of all cases managed surgically with TES referred to our centre between 2005 and 2015. We recorded the oncological characteristics of each tumour and surgical management in terms of resection margins, operative duration and instrumentation. Data relating to peri-operative blood loss was also recorded including an estimation of total blood loss, the use of cell salvage where applicable and transfusion rates.ResultsA total of 21 patients were found to meet our inclusion criteria. There were 11 men and 10 women, with a median age of 40 years. The mean total ABL was 3,310 mL. Total operation time ranged from 6.53 to 19.7 h. Compared to ABL, in 59% of cases EBL had been underestimated by an average of 78% by volume. The EBL of the remaining 41% cases had been overestimated by 43%. This was not statistically significant (P=0.373). Cell salvage was used in 62% patients with a mean blood loss of 2,845 mL (884–4,939 mL) and transfusion of 3.8 units (0–12 units) versus 4,069 mL (297–8,335 mL) and 9.3 units (0–18 units) in those not managed with cell salvage. There was no significant difference in ABL between the cell salvage and non-cell salvage groups.ConclusionsWe report one of the largest case series in TES for primary bone tumours. EBL is not a reliable predictor for ABL. A large blood loss should be anticipated and use of cell salvage is recommended.

Application of Image-Fusion 3D Printing Model in Total En Bloc Spondylectomy for Spinal Malignant Tumors.

Purpose To examine the effects of 3D printing model in total en bloc spondylectomy (TES). Methods We performed a retrospective chart review of 41 cases of spinal tumors at our institution between 2017 and 2020, in which TES was applied. There were 19 cases with 3D printing model and 22 cases without 3D printing model. Operation time, intraoperative blood loss, excision range, complications, VAS, and ASIA grades were recorded. Statistical methods were used to analyze the data. KaplanMeier survival curve was made to evaluate the survival. Result There were significant differences in intraoperative blood loss between the two groups. The rate of R0 resection and tumor envelope preservation were higher in 3D group than that in non-3D group. In 3D group, the complications included surgical site infection (5.2%) and cerebrospinal fluid leak (15.7%). In non-3D group, the complications included cerebrospinal fluid leak (27.3%) and nerve root injury (13.6%). The pain and neurological dysfunction were significantly relieved before and after surgery in 3D group. However, the neurological relief in non-3D group patients was not complete. The VAS scores of non-3D group at 6 months after surgery were much higher than that of 3D group. Conclusion The application of 3D printing model not only helps surgeons observe the morphology, invasion range, and anatomic relationship of the tumor preoperatively, but also assists surgeons to judge, locate, and separate the tumor intraoperatively. For spinal malignancies, the 3D printing model is worth promoting.

Customized Multilevel 3D Printing Implant for Reconstructing Spine Tumor: A Retrospective Case Series Study in a Single Center.

ObjectiveTo investigate the clinical efficacy and safety of 3D printed artificial vertebral body for patients who underwent multilevel total en bloc spondylectomy (TES) and analyze whether it could reduce the incidence of implant subsidence.MethodsThis is a retrospective study. From January 2017 to May 2018, eight consecutive cases with spine tumor undergoing multilevel TES were analyzed. All patients underwent X‐ray and CT examinations to evaluate the stability of internal fixation during the postoperative follow‐up. Demographic, surgical details, clinical data, and perioperative complications was collected. Visual analog scale, Frankel score, and spinal instability neoplastic score (SINS) classification were also recorded.ResultsThere were six cases of primary spinal tumor and two cases of metastatic spinal tumor. All patients achieved remarkable pain relief and improvement in neurological function. Five patients underwent operation through the posterior approach, one patient underwent operation through the anterior approach and the remaining two patients through a combined anterior and posterior approach. At the last follow‐up period, X‐rays showed that the 3D printed artificial vertebral body of all cases matched well, and the fixation was reliable. Hardware failure such as loosening, sinking, breaking, and displacement wasn't observed during the follow‐up period.Conclusion3D printed customized artificial vertebral body can provide satisfying good clinical and radiological outcomes for patients who have undergone multilevel TES.

Clinical results of total en bloc spondylectomy using a single posterior approach in spinal metastasis patients: Experiences from Thailand.

To demonstrate a single posterior approach, total en bloc spondylectomy (TES) could be performed safely without preoperative embolization in spinal metastasis patients. Thirteen solitary spinal metastasis patients (five males) underwent single posterior approach TES at the thoracolumbar spine without preoperative embolization from January 2018 to January 2020. The primary sites were the breast (n = 4), hepatocellular carcinoma (n = 2), colon (n = 2), and others (n = 5). All patients underwent single posterior TES. The Eastern Cooperative Oncology Group, Frankel neurological status, operative time and blood loss, and any complications were all recorded. The patients were regularly followed-up with radiography, computed tomography, and magnetic resonance imaging to detect any local recurrences. The mean operative time was 354.6 min, and the mean operative blood loss was 2134.62 ml. None of the patients experienced any perioperative complications. Within the follow-up period (3-24 months), no local recurrences were detected. Two patients (15.38%) were found to have distant metastasis to adjacent and remote vertebrae. Three patients were lost to follow-up, and three patients died of disease. Six patients showed an improved ECOG functional status by at least one grade. Four of Frankel A patients improved their neurological status by at least one grade. Even without embolization, single posterior TES at the thoracolumbar spine is safe and effective for short-term local control in solitary spinal metastasis. However, TES cannot prevent distant metastasis. Longer-term follow-up studies will be able to further identify the benefits of TES for the long-term local control of diseases.

Hybrid Therapy Versus Total En Bloc Spondyectomy in the Treatment of Solitary Radioresistant Spinal Metastases: A Single-center, Retrospective Study.

This was a retrospective study. To compare the treatment efficacy of hybrid therapy (HT) with that of total en bloc spondylectomy (TES) in patients with solitary radioresistant high-grade epidural spinal cord compression (ESCC) spinal metastases. Both HT and TES can yield good results for solitary radioresistant metastatic spinal tumors with high-grade ESCC. However, there is still a lack of comparative studies on the treatment efficacy of these 2 methods. We retrospectively reviewed patients with the above-mentioned tumors between January 2012 and May 2019. A total of 157 patients underwent surgery, 64 of whom received HT and 93 were treated with TES. Propensity score matching (1:1 ratio) allowed the generation of best-matched pairs for the 2 categories. Local control rates and survival rates were estimated using the Kaplan-Meier method. All patients had a minimum 2-year follow-up. The longest follow-up period was 88 months. The survival rates and local progression-free survival rates after HT were comparable with those after TES at 1 year (84.6% vs. 83.1% and 90.2% vs. 90%, respectively), 2 years (60.8% vs. 64.3% and 64.1% vs. 62.1%, respectively), and 5 years (18.8% vs. 24.1% and 24.4% vs. 28.4%, respectively). There were no significant differences in pain control, improvement in neurological status, spine stabilization restoration, incidence of perioperative complications, and improvement in quality of life between the groups. However, HT showed more advantages than TES in that it had a shorter operative time and lower intraoperative blood loss. HT can obtain satisfactory results comparable to TES for solitary radioresistant metastatic spinal tumors with high-grade ESCC. In addition, HT has a shorter operative time and fewer perioperative complications than TES. HT may be a promising treatment for solitary radioresistant metastatic spinal tumors with high-grade ESCC.

Safety and Neurologic Recovery of L2 Nerve Root Sacrificed in Total En Bloc Spondylectomy Involving the L2 Vertebra.

The L2 nerve root is considered part of the lumbar plexus that innervates the iliopsoas (IP) and quadricep muscles (Qd). Total en bloc spondylectomy (TES) at the L2 vertebra requires bilateral nerve root transection to facilitate surgical dissection and vertebral body removal. Information regarding neurological function recovery of the IP and Qd in patients with muscle weakness before TES is lacking. We aimed to report the neurological recovery of IP and Qd after TES involving the L2 vertebra in preoperative lower extremity weakness in spinal tumor patients. We prospectively recorded all L2-involved spinal tumor patients undergoing TES between January 2018 and November 2020. As a primary outcome, we recorded the Manual Muscle Testing (MMT) grade of the IP and Qd preoperatively, immediately postoperatively, and at follow-up. Secondary outcomes included the Frankel neurological status, sensation impairment, and the Eastern Cooperative Oncology Group score. From 8 TES-involving L2 patients, 6 (4 males) met the inclusion criteria. One patient had first-grade deterioration of the Qd MMT immediately postoperatively. All patients could ambulate independently 6 months after surgery. Five patients required follow-up for more than 1 year and could walk without any gait aids. All patients had persistent anterior groin and bilateral thigh numbness until the final follow-up. Neurological recovery of the IP and Qd muscles as measured by MMT can occur within 6 months of bilateral L2 nerve root transection. Bilateral L2 nerve root sacrifice can have acceptable neurological outcomes and recovery, even in patients with preoperative IP and Qd weakness. 4.

En Bloc Resection of Tumors of the Lumbar Spine: A Systematic Review of Outcomes and Complications.

The literature on total en bloc spondylectomy (TES) of bone tumors of the lumbar spine is sparse and heterogeneous. Therefore, the aim was to systematically pool the data from the published studies to quantitatively summarize the morbidity and mortality and to identify factors associated with favorable outcomes and complications. A systematic literature search for studies with individual patient-level data was conducted using specific medical subject heading(MeSH) terms. The outcome measures assessed included complications, tumor recurrence, survival, and function. Individual patient data were pooled from all the studies and quantitatively analyzed to assess the association of different factors with outcomes and complications. Twelve studies were included in this review with a total of 145 TES cases. Of all patients, 50% had at least 1 reported complication post surgery and this was associated with advancing age (OR 1.04, P < 0.001), metastatic disease (OR 5.61, P < 0.001), and adjuvant chemo and/or radiotherapy (OR 20.3, P = 0.001). Intralesional excision (OR 5.2, P = 0.01) and primary malignant tumors (OR 3.3, P = 0.02) were associated with a high recurrence rate. However, the surgical approach was not associated with differences in survival (P = 0.874) or recurrence (P = 0.525) rates. L5 tumor resection was associated with excessive bleeding. Postoperatively, there was an overall improvement in the Frankel grades in most patients. TES is associated with high rates of complications especially in association with primary malignant and metastatic diseases. However, the number of publications on this topic remain scarce and heterogeneous. Hence, there is a need for standardization in the reporting of the outcomes and complications to help with decision-making and consenting for this procedure.

A Rare Manifestation of a Presumed Non-Osteophilic Brain Neoplasm: Extensive Axial Skeletal Metastases From Glioblastoma With Primitive Neuronal Components.

BackgroundGlioblastoma multiforme (GBM) is the most common malignant tumor of the central nervous system. GBM with primitive neuronal component (GBM-PNC) is an aggressive variant identified in 0.5% of GBMs. Extracranial metastasis from GBM-PNC is a rare and challenging situation.MethodsA special case of early-onset GBM with systemic bone metastasis was enrolled. Clinical data, including patient characteristics, disease course, and serial radiological images were retrieved and analyzed. Tumor tissues were obtained by surgical resections and were made into formalin-fixed paraffin-embedded sections. Histopathological examinations and genetic testing were performed for both the primary and metastatic tumor specimens.ResultsA 20-year-old man suffered from GBM with acute intratumoral hemorrhage of the left temporal lobe. He was treated by gross total resection and chemoradiotherapy following the Stupp protocol. Seven months later, he returned with a five-week history of progressive neck pain and unsteady gait. The radiographic examinations identified vertebral collapse at C4 and C6. Similar osteolytic lesions were also observed at the thoracolumbar spine, pelvic, and left femur. Anterior spondylectomy of C4 and C6 was performed. The resected vertebral bodies were infiltrated with greyish, soft, and ill-defined tumor tissue. One month later, he developed mechanical low-back pain and paraplegia caused by thoracolumbar metastases. Another spine surgery was performed, including T10 total en-bloc spondylectomy, T7-9, L2-3, and L5-S1 laminectomy. After the operation, the patient’s neurological function and spinal stability remained stable. However, he finally succumbed to the rapidly increased tumor burden and died 15 months from onset because of cachexia and multiple organ failure. In addition to typical GBM morphology, the histological examinations identified monomorphic small-round cells with positive immunohistochemical staining of synaptophysin and CD99, indicating the coexistence of PNC. The next-generation sequencing detected pathogenic mutations in TP53 and DNMT3A. Based on above findings, a confirmed diagnosis of systemic metastases from GBM-PNC (IDH-wild type, WHO grade IV) was made.ConclusionsThe present case highlights the occurrence and severity of extensive axial skeletal metastases from GBM-PNC. This rare variant of GBM requires aggressive multimodal treatment including surgery and chemoradiotherapy targeting PNC. The pathological screening of PNC is recommended in patients with early-onset GBM and intratumoral hemorrhage. Surgery for spinal metastasis is appropriate in patients with chemoradioresistance and relatively good general status, with the objectives of restoring spinal stability and relieving spinal cord compression.

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

The aim of the study was to compare total en bloc spondylectomy (TES) and separation surgery with postoperative stereotactic radiosurgery (SSRS) for isolated metastatic patients with spinal cord compression by assessing recurrence-free survival (RFS), overall survival (OS), postoperative complications, and quality of life scores (QoL). From October 2013 to December 2020, 52 isolated spinal metastasis patients with cord compression were selected and separated into two groups based on the surgical method used (TES group, n = 26; and SSRS group, n = 26). Indexes for evaluation included postoperative Frankel grade, postoperative ECOG-PS, RFS, OS, postoperative complications, operation time, intraoperative blood loss, and QoL. The average follow-up duration was 31.44months. There was no significant difference (P > 0.05) in postoperative complications and OS between the two groups. However, a significant difference in operation time, intraoperative blood loss, postoperative ECOG-PS, RFS, and mental health domain (6 months after surgery) was found between the two groups (P < 0.05). According to The Spine Oncology Study Group Outcomes Questionnaire assessment, the total pain and physical function domains scores were also elevated after surgery in both groups. However, no significant difference was observed between groups A and B (p = 0.450 and 0.446, respectively). TES and SSRS were efficient methods for treating solitary spinal metastasis patients with metastatic spinal cord compression. Better local tumor control and mental health were found in the TES group, and most patients felt as if they were free of spinal tumors. Compared with TES, the SSRS caused less operation-related trauma. However, there was no significant difference in OS between the two groups.

Compressive vertebral hemangiomas with neurological deficits: diagnosis, surgical strategies and long term outcome

Purpose Compressive vertebral hemangiomas with neurological deficits (CVHND) form a rare, unique subset of lesions comprising of differing clinico-imaging findings, pathologic behavior and treatment, when compared to the commoner and usually incidental intra-osseus vertebral hemangiomas (VH). Though various surgical strategies and a broad array of adjuncts have evolved and changed over the years, there is paucity of comprehensive data from sizeable series of such patients treated surgically with long term follow up. The purpose of this study is to device an optimum management strategy in CVHND based on our surgical experience. Materials and methods The data from electronic medical records of 26 consecutive patients operated in our department from 2009 to 2019 were retrospectively analyzed. Results There were 11 males and 15 females with a mean age of 34.7 years. Neurological examination revealed paraparesis or paraplegia with myelopathy in all patients with Frankel score of B, C and D in 1 (3.9%), 11 (42.3%) and 14 (53.8%) patients respectively. Sixteen patients (61%) underwent laminectomy and gross total excision of extradural soft tissue component, 7 (27%) laminectomy with posterolateral fusion, three (12%) underwent additional anterior interbody support. The mean follow up was 72.4 months and at last follow-up 24 patients (92%) were Frankel E. Symptomatic recurrence was seen in two patients operated early in the series, they underwent re-surgery, gross total excision with posterolateral fusion, remaining neurologically intact at last follow up. Conclusions Pre-operative embolization, surgical excision of extradural component and intra-operative vertebroplasty form the mainstay of treatment for CVHND. Instrumented posterolateral fusion with optional anterior interbody support accomplished through the same approach is required only in a minority of cases. The long-term outcome following timely and appropriate treatment is excellent. Anterior or anterolateral approaches for intervertebral support and radical procedures like total en-bloc spondylectomy (TES) are not usually required.

Perioperative complications of total en bloc spondylectomy for spinal tumours.

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection. In total, 307 patients who underwent TES in a single centre were reviewed retrospectively. There were 164 male and 143 female patients with a mean age at the time of surgery of 52.9 years (SD 13.3). A total of 225 patients were operated on for spinal metastases, 34 for a malignant primary tumour, 41 for an aggressive benign tumour, and seven with a primary of unknown origin. The main lesion was located in the thoracic spine in 213, and in the lumbar spine in 94 patients. There were 97 patients who underwent TES for more than two consecutive vertebrae. Major and minor perioperative complications were observed in 122 (39.7%) and 84 (27.4%) patients respectively. The breakdown of complications was as follows: bleeding more than 2,000 ml in 60 (19.5%) patients, hardware failure in 82 (26.7%), neurological in 46 (15.0%), surgical site infection in 23 (7.5%), wound dehiscence in 16 (5.2%), cerebrospinal fluid leakage in 45 (14.7%), respiratory in 52 (16.9%), cardiovascular in 11 (3.6%), digestive in 19 (6.2%)/ The mortality within two months of surgery was four (1.3%). The total number of complications per operation were 1.01 (SD 1.0) in the single vertebral resection group and 1.56 (SD 1.2) in the group with more than two vertebral resections. Cardiovascular and respiratory complications, along with hardware failure were statistically higher in the group who had more than two vertebrae resected. Also, in this group the amount of bleeding in patients with a lumbar lesion or respiratory complication in patients with a thoracic lesion, were statistically higher. Multivariate analysis showed that using a combined anterior and posterior approach, when more than two vertebral resections were significant independent factors. The characteristics of perioperative complications after TES were different depending on the extent and level of the tumour resection. In addition to preoperative clinical and pathological factors, it is therefore important to consider these factors in patients who undergo en bloc resection for spinal tumours. Cite this article: Bone Joint J2021;103-B(5):976-983.