Three Level Thoracolumbar Spondylectomy for Recurrent Giant Cell Tumour of the Spine: A Case Report

@#Giant cell tumour (GCT) is a benign tumour but can be locally aggressive and with the potential to metastasise especially to the lungs. Successful treatments have been reported for long bone lesions; however, optimal surgical and medical treatment for spinal and sacral lesions are not well established. In treating spinal GCTs, the aim is to achieve complete tumour excision, restore spinal stability and decompress the neural tissues. The ideal surgical procedure is an en bloc spondylectomy or vertebrectomy, where all tumour cells are removed as recurrence is closely related to the extent of initial surgical excision. However, such a surgery has a high complication rate, such as dura tear and massive blood loss. We report a patient with a missed pathological fracture of T12 treated initially with a posterior subtraction osteotomy, who had recurrence three years after the index surgery and subsequently underwent a three level vertebrectomy and posterior spinal fusion.

Invasiveness Reduction of Recent Total En Bloc Spondylectomy: Assessment of the Learning Curve

STUDY DESIGN: Case-control study. PURPOSE: To evaluate the surgical magnitude and learning curve of "second-generation" total en bloc spondylectomy (TES). OVERVIEW OF LITERATURE: In June 2010, we developed second-generation TES combined with tumor-induced cryoimmunology, which does not require autograft harvesting. METHODS: TES was performed in 63 patients between June 2010 and September 2013. Three groups of patients were evaluated: 20 undergoing surgery in the first year of development of second-generation TES (group I), 20 in the second year (group II), and 23 in the third year (group III). Patient backgrounds showed no remarkable differences. Operating time, intraoperative blood loss, blood transfusion, and postoperative C-reactive protein and creatine phosphokinase were compared among the groups. RESULTS: Mean±standard deviation operating time was 486±130 minutes in group I, 441±85 minutes in group II, and 396±75 minutes in group III. The time was significantly shorter in group III than in group I (p<0.05). Intraoperative blood loss was 901±646 mL in group I, 433±177 mL in group II, and 411±167 mL in group III. Blood loss was significantly lower in groups II and III than in group I (p<0.01). Transfusion was not required in 20 of 23 patients in group III, and mean C-reactive protein levels on postoperative day 3 were significantly lower in this group than in group I (6.12 mg/L vs. 10.07 mg/L; p<0.05). Postoperative creatine phosphokinase levels did not differ among the groups. CONCLUSIONS: TES is associated with a significant learning curve. Thus, second-generation TES can no longer be considered highly invasive.

Invasiveness Reduction of Recent Total En Bloc Spondylectomy: Assessment of the Learning Curve

STUDY DESIGN: Case-control study. PURPOSE: To evaluate the surgical magnitude and learning curve of "second-generation" total en bloc spondylectomy (TES). OVERVIEW OF LITERATURE: In June 2010, we developed second-generation TES combined with tumor-induced cryoimmunology, which does not require autograft harvesting. METHODS: TES was performed in 63 patients between June 2010 and September 2013. Three groups of patients were evaluated: 20 undergoing surgery in the first year of development of second-generation TES (group I), 20 in the second year (group II), and 23 in the third year (group III). Patient backgrounds showed no remarkable differences. Operating time, intraoperative blood loss, blood transfusion, and postoperative C-reactive protein and creatine phosphokinase were compared among the groups. RESULTS: Mean±standard deviation operating time was 486±130 minutes in group I, 441±85 minutes in group II, and 396±75 minutes in group III. The time was significantly shorter in group III than in group I (p<0.05). Intraoperative blood loss was 901±646 mL in group I, 433±177 mL in group II, and 411±167 mL in group III. Blood loss was significantly lower in groups II and III than in group I (p<0.01). Transfusion was not required in 20 of 23 patients in group III, and mean C-reactive protein levels on postoperative day 3 were significantly lower in this group than in group I (6.12 mg/L vs. 10.07 mg/L; p<0.05). Postoperative creatine phosphokinase levels did not differ among the groups. CONCLUSIONS: TES is associated with a significant learning curve. Thus, second-generation TES can no longer be considered highly invasive.

Total En Bloc Thoracic and Lumbar Spondylectomy for Non-Small Cell Lung Cancer with Favorable Prognostic Indicators: Is It Merely Indicated for Solitary Spinal Metastasis?

A fifty-year-old female non-smoker with no other specific medical history visited our institute. She complained of axial back pain with no other neurological deficit. Chest X-ray, chest computed tomography (CT) scan, CT-guided needle aspiration biopsy, whole-body positron emission tomography, spine CT and spine magnetic resonance image findings suggested NSCLC with epidermal growth factor receptor (EGFR) mutation, multiple brain metastases, and two isolated metastases to the T3 and L3 vertebral bodies. She underwent chemotherapy with gefitinib (Iressa(TM)) for NSCLC and gamma knife surgery for multiple brain metastases. We performed a two-staged, total en bloc spondylectomy of the T3 and L3 vertebral bodies based on several good prognostic characteristics, such as the lack of metastases to the appendicular bone, good preoperative performance status, and being an excellent responder (Asian, never-smoker and adenocarcinoma histology) to EGFR inhibitors. Improved axial back pain after the surgery enabled her to walk with the aid of a thoracolumbosacral orthosis brace on the third postoperative day. Her Karnofsky performance status score (KPS) was 90 at the time of discharge and has been maintained to date 3 years after surgery. In selected NSCLC patients with good prognostic characteristics, we suggest that locally curative treatment such as total en bloc spondylectomy or radiosurgery should be emphasized to achieve longer term survival for the selected cases.

Total En Bloc Lumbar Spondylectomy of Follicular Thyroid Carcinoma

The presence of distant metastases from differentiated thyroid carcinoma decreases the 10-year survival rates of patients by 50%. This is a report of a 61-year-old female with follicular thyroid carcinoma who presented initially with low back pain. 2-deoxy-2-[18F] fluoro-D-glucose whole-body positron emission tomography/computed tomography (PET/CT) demonstrated a hypointensity lesion in the left thyroid gland with malignant uptake in L1 vertebra and magnetic resonance images revealed paravertebral and epidural extension of mass in L1 vertebra. After thyroidectomy, histopathological study showed a follicular carcinoma. We performed L1 total en bloc spondylectomy with expandable cage for long-term local control. The technical details of total en bloc spondylectomy in follicular carcinoma are described herein.

Total en bloc spondylectomy for tumor of the thoracolumbar spine / 中国矫形外科杂志

[Objective]To evaluate the possibility and clinical value of total en bloc spondylectomy for the treatment of spinal tumors. [Method]Four cases of primary tumor of the thoracolumbar spine were treated with total en bloc spondylectomy TES through a single posterior approach performed in three cases(T10 solitary plasmacytoma,T8 hemangioma,and T12 hemangioma),and one case through a single stage anterior and posterior combined approach(L4 neuroblastoma with paraspinal mass).Improvements in osteotomy apparatus and surgical technique of TES were investigated.[Result]All patients attained significant clinical improvement after surgery without any severe complications.Patients were observed for 13 to 22 months.There was no local recurrence and distal metastasis by the last follow-up.[Conclusion]Total en bloc spondylectomy includes resection of the involved vertebra in two major blocs,rather than a piecemeal pattern.It is one of the most effective therapies for spinal tumors.Howerer,some components of TES remain to be further improved.

Total en bloc spondylectomy——a new surgical technique for primary malignant vertebral tumors / 中国矫形外科杂志

[Objective]To report a new surgical technique of total en bloc spondylectomy for complete resection of primary spinal malignancy and for oncologic curability.The conventional approach for primary spinal malignancy is via intralesional piecemeal resection,and very few reports have described en bloc extralesional resectioning with histopathologically wide or marginal surgical margins.[Method]Total en bloc spondylectomy,consisting of en bloc laminectomy and en bloc corpectomy followed by anterior instrumentation with spacer grafting and posterior spinal instrumentation,was performed in five patients with primary malignant tumors and two patients with giant cell tumors.Patients were observed for 2 years to 6.5 years,except for one patient who died 7 months after surgery because of mediastinal metastasis.[Result]All patients attained significant clinical improvement after surgery with no major complications except one.Histologically,the margins were wide or marginal except for the pedicles,and occasionally the spinal canal and the posterior,where they were accepted to be intralesional.One patient died of metastasis that was not directly related to surgery itself.There was no local recurrence.[Conclusion]The advantages of total en bloc spondylectomy include resection of the involved vertebra(e)in two major blocs,rather than in a piecemeal pattern,and completion of the procedure during one surgical session posteriorly.The"total en bloc spondylectomy"offers one of the most aggressive modes of therapy for primary spinal malignancy.

Total en bloc Spondylectomy for Solitary Metastatic Spinal Tumor / 대한척추외과학회지

STUDY DESIGN: To analyze the clinical and radiological outcomes retrospectively. PURPOSE: To evaluate the efficacy of a total en bloc spondylectomy in solitary metastatic spinal tumors. SUMMERY OF LITERATURE REVIEW: In a conventional operation of a spinal metastatic tumor it is difficult to perform a wide excision, and several reports have suggested a total en bloc spondylectomy for wide or marginal resections. MATERIALS AND METHODS: Ten patients, with solitary spinal metastasis, were underwent a total en bloc spondylectomy, with a mean follow-up of 15 months. The locations of the tumors were the thoracic spine and lumbar spine in 4 and 6 cases, respectively. The clinical and radiological outcomes were assessed using the McAfee pain scale, Frankel neurologic grading, radiological extent of the lesion and local recurrence. Metastatic spinal tumors were classified by the system of Tomita. A pathological study of the resected vertebra was performed to evaluate the surgical margin. RESULTS: The preoperative back pain was grades IV, III, II and 0 in 4, 3, 2 and 1 case, respectively. The postoperative back pain was grades III, I and 0 in 3, 1 and 6 cases by the McAfee pain scale, respectively. The neurologic deficit was improved completely in all cases. There were 3 and 7 cases of types 4 and 5 by the Tomita's classification, respectively. The pathological results were wide margin and marginal margin in 4 and 6 cases, respectively. There were no local recurrences at the time of the last follow-up. CONCLUSION: All patients maintained good clinical and radiological results. A total en bloc spondylectomy was a useful treatment option for solitary metastatic tumors.