Total vertebrectomy for primary malignant tumours of the spine

Abstract

Primary malignant tumours should be resected with wide margins. This may be difficult to apply to lesions of the spine. We undertook total vertebrectomy on seven patients, four males and three females with a mean age at operation of 26.5 years (6.3 to 45.8). The mean follow-up was 52.3 months. Histological examination revealed a Ewing's sarcoma in two patients and osteosarcoma, leiomyosarcoma, spindle-cell sarcoma, chondrosarcoma and malignant schwannoma in one each. In five patients, histological examination showed that a wide resection had been achieved. At follow-up there was no infection and a permanent neurological deficit was only seen in those patients in whom the surgical procedure had required resection of nerve roots. Despite the high demands placed on the surgeon and anaesthetist and the length of postoperative care we consider total vertebrectomy to be an appropriate procedure for the operative treatment of primary malignant lesions of the spine. Metastases in the spine are common and account for 40% to 60% of secondary osseous lesions. Surgical treatment involves intralesional or marginal resection and stabilisation in order to release the neural structures, provide relief from pain and allow walking.1 In contrast to metastases, primary malignant tumours affect the spine in only 1% to 2% of patients. 2 Of the 4767 lesions listed in the Vienna Bone Tumour Registry, 1715 were primary malignant tumours of which 44 were in the spine, 2.5% of all primary malignancies of bone.Adequate surgical treatment of primary malignant bone tumours of the limbs involves wide or radical resection in combination with neoadjuvant chemotherapy and, if responsive, radiotherapy. The aim of preoperative chemotherapy is to reduce the viable tumour mass and to prevent further dissemination. The combination of systemic and surgical treatment offers the patient a good chance of survival with a satisfactory quality of life.

Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy

“…This study agrees with previous investigations [2,6,18,21,24,32,34,38] supporting en bloc spondylectomy for treatment of primary malignant vertebral bone tumors and solitary spinal metastasis of certain tumor entities. En bloc spondylectomy followed by dorsoventral reconstruction allowed radical resections with negative margins in all patients.…”

“…Nevertheless, intralesional surgery predisposes the patient to local recurrences and poor prognosis. To reduce the surgery-induced tumor cell dissemination, decrease local recurrence rates and to improve survival times, different techniques [8,15,16,20,23,25,26,32] for wide resections at the spine, involving either en bloc total [32] or hemilaminectomy [18] followed by en bloc corporectomy and dorso-ventral stabilization have been developed. In early 1980, Stener and Roy-Camille were the first to describe en bloc spondylectomy via a posterior approach after complete resection of the dorsal vertebral structures, i.e., both laminae, spinous process and parts of the pedicles, resulting in an oncological adequate resection for primary bone tumor locations not extending beyond the vertebral body [23,26].…”

En bloc spondylectomy reconstructions in a biomechanical in-vitro study

“…Since then, an increasing number of surgeons have performed and modified this procedure in order to apply the principles of tumor surgery [8] to the spine: attain wide resections, achieve long term local and systemic tumor control. The previously described techniques were modified [7,32,37,58,59], prognostic surgical scores [56,57,60,61] were established considering the underlying tumor biology, the number/presence of extraspinal metastases and an estimation of life expectancy. With the results of these scores and the tremendous advance in spine surgery technique the indication from primary spinal tumors is now extended to selected cases of solitary spinal metastases with biologically favorable tumor entities [1,54,62,70].…”

“…As an alternative treatment, en bloc spondylectomy of spinal malignancies has attracted growing interest. It circumvents direct exposure of the tumor tissue and enables the surgeon to reach wide resection margins of the spine [8,18,20,32,35,46,48,51,52,[58][59][60]70]. For selected patients, the en bloc resection is expected to decrease local recurrence rates and improve the patient's chances of overall survival.…”

En bloc spondylectomy in malignant tumors of the spine

“…In a later publication Tomita et al reported on five patients with primary malignant tumors of the spine [23]. Further authors adopted and modified these techniques and published their results with series of between seven and 29 patients [2,3,8,10,11].…”