Surgical Technique of Vertebral Body Removal and Anterior Reconstruction in L5 Spondylectomy

Abstract

Introduction: L5 spondylectomy for the treatment of spinal tumor is a technically demanding surgery because of the complex anatomy of major vessels, the obscurity of the posterior exposure from the iliac wings, and the increased comparative size of the L5 vertebral body. In this study, we present a surgical technique of L5 spondylectomy, vertebral body removal, and anterior reconstruction for a case with solitary spinal metastatic renal cell carcinoma (RCC). Technical Note: A 54-year-old man underwent right total nephrectomy for RCC one year ago. At the one-year postoperative follow-up, CT scan and MRI revealed a solitary L5 spinal metastasis. A two-stage posteroanterior approach was performed. To facilitate vertebral body removal, transverse processes were separated from the vertebral body by using the posterior approach. On the basis of the anterior approach, the vertebral body was removed via the interval space between the left common iliac vessels. Reconstruction was performed by using a liquid-nitrogen-frozen, tumor-bearing bone mixed with an autogenous bone graft in an expandable titanium cage. Results: No intraoperative complications were observed. Postoperatively, the patient exhibited muscle weakness in the tibialis anterior and extensor hallucis longus bilaterally but improved with time. Seven months after the operation, the patient was able to walk independently. At the recent 2.5-year follow-up, the local recurrence of lesions was nonexistent. The bone graft had fused with the adjacent vertebrae. Conclusion: This report described a novel technique for L5 spondylectomy that can facilitate safe L5 vertebral body removal and demonstrated the effectiveness of liquid-nitrogen-frozen, tumor-bearing bone mixed with autogenous bone graft in anterior reconstruction both in terms of oncologic safety and biological healing.

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

“…The reason for this is the complex anatomy represented by the iliac wing and lumbosacral plexus nerves and the size of the L5 vertebral body, which may cause damage of lumbar nerve roots when vertebra are removed. 24 , 29 D’Aquino et al 28 studied in a systematic revision the different surgical approaches to L5 corpectomy and reconstruction. Three studies evaluated outcomes after a combined posteroanterior performance; one study followed anterior-only corpectomy and the other two followed a posterior-only approach.…”

“…Consequently, the surgical approach varies depending on several factors, such as the primary tumor and surgical objectives and the level of surgeon experience. 28 Technique Considerations at the L5 Level Regarding the safest interval to deal with this procedure, Sangsin et al 29 used the interval space between the left common iliac vein and artery during the anterior stage, and Gallia et al 32 used the space between the bifurcation of the common iliac vessels. Because of the biomechanics of the lumbosacral junction (characterized by a sloping transition from a dynamic lower lumbar region to a relatively motionless sacrum and pelvis), there are stabilization problems (the L5 vertebra is affected by sliding and compressive forces).…”