Resection of a retropharyngeal craniovertebral junction chordoma through a posterior cervical approach.

STUDY DESIGN: This illustrative case report is designed to provide technical data regarding the use of a posterior approach to resect a retropharyngeal chordoma involving the craniovertebral junction. OBJECTIVE: The objective of this report is to emphasize the utility of the posterior approach when treating anterior tumors of the craniovertebral junction. SUMMARY OF BACKGROUND DATA: Traditionally, a transoral transpharyngeal or extended anterior approach was used to resect anterior tumors of the craniovertebral junction. These approaches have several limitations unique to these exposures, limitations not applicable to a posterior midline cervical approach. METHODS: A case report is provided that illustrates the use of a posterior cervical approach used to resect a retropharyngeal craniovertebral junction chordoma. RESULTS: Gross total resection of a retropharyngeal chordoma was achieved using a posterior cervical approach. Although local tumor recurrence did occur, this was resected and adjuvant radiotherapy prescribed. This resulted in an ongoing 4-year recurrence free survival. CONCLUSIONS: The posterior cervical midline exposure could be used to dissect and remove anterior retropharyngeal tumors, with minimal morbidity.

Feasibility and safety of en bloc resection for primary spine tumors: a systematic review by the Spine Oncology Study Group.

STUDY DESIGN: Systematic review. OBJECTIVES: To determine the general feasibility and safety of en bloc resection for primary spine tumors by analyzing (1) the effect of incisional biopsy performed before definitive en bloc resection and (2) the rate of achievement of disease-free margins, morbidity, mortality, and health resource utilization. SUMMARY OF BACKGROUND DATA: The feasibility of en bloc resection is determined by careful surgical and oncologic staging, and a key step in this process is obtaining a tissue diagnosis. There is currently good evidence to support the premise that the best chance for surgical cure in primary tumors of the spine is by en bloc resection with disease-free margins; however, the early morbidity of these procedures begs the question of whether they are justified. METHODS: A formal systematic review with search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews databases was undertaken. Included reports described patients with low grade malignant spine tumors, the method of staging and surgical resection, and the complications. Two blinded, independent reviewers used a standardized study selection worksheet. RESULTS: About 89 articles were identified, with 8 selected after excluding small case series and studies that included other pathologies (e.g., metastatic disease). Weinstein, Boriani, Biagini staging accurately predicted the attainment of wide or marginal en bloc resection in 88% of cases. There was a clear increase in tumor recurrence when intralesional procedures were performed before the definitive en bloc resection. Tumor recurrence significantly shortened patient survival. Surgical complication rates ranged from 13% to 56% and mortality ranged from 0% to 7.7%. CONCLUSION: (1) Incisional biopsy or intralesional resection significantly increases the risk of local recurrence, therefore, transcutaneous computed tomography-guided trocar biopsy is recommended. When there is a suspicion of primary spine tumor, the surgeon who performs the definitive surgery should ideally perform or direct the biopsy procedure. (2) En bloc resection is achievable if staging determines that it is feasible. The adverse event profile of these surgeries is high even at experienced centers. Therefore, experienced, multidisciplinary teams should perform these surgeries. (3) Grade of Recommendation can be "strong recommendation, low-quality evidence."

Surgical management of cervical spondylotic myelopathy with laminectomy and instrumented fusion.

OBJECTIVE: The indications for treating cervical spondylotic myelopathy (CSM) with laminectomy and instrumented fusion remain ill-defined. Cervical laminectomy without instrumented fusion has been associated with suboptimal outcomes, particularly in the setting of cervical kyphosis. This work's purpose is to retrospectively review our experience in patients who underwent laminectomy with instrumented fusion for CSM and to assess the neurological and radiological outcomes of patients treated with this technique. METHODS: Fifty-four consecutive patients underwent multilevel laminectomy and instrumented fusion for CSM. The indications were patients with (1) cervical stenosis > or = 3 spinal segments and (2) absence of a cervical kyphosis or (3) patients older than 65 years with significant medical comorbidities. Nurick myelopathy grades and cervical radiographs were obtained preoperatively and at 3, 6, 12 and 24 months post-operatively. Perioperative complications, radiographic and clinical outcomes were assessed and reported in this paper. RESULTS: Forty-four (81%) of patients showed improvement in Nurick grade after surgery by a mean of 17 months. Ten patients (19%) demonstrated stable but unimproved myelopathy. Increasing pre-operative Nurick grade was associated with an improved post-operative outcome (p<0.02). Increasing duration of pre-operative myelopathy was associated with a decreased likelihood of myelopathy improvement (p<0.001). DISCUSSION: Multilevel cervical laminectomy with instrumented fusion for patients with CSM resulted in an improvement in myelopathy in the majority of cases. Efficacy was similar for patients who may not have tolerated an anterior decompression, such as elderly patients with significant medical comorbidities. Hardware-related complication rates were relatively low.

Evaluation of factors associated with postoperative infection following sacral tumor resection.

OBJECT: Resection of sacral tumors has been shown to improve survival, since the oncological prognosis is commonly correlated with the extent of local tumor control. However, extensive soft-tissue resection in close proximity to the rectum may predispose patients to wound complications and infection. To identify potential risk factors, a review of clinical outcomes for sacral tumor resections over the past 5 years at a single institution was completed, paying special attention to procedure-related complications. METHODS: Between 2002 and 2007, 46 patients with sacral tumors were treated with surgery. Demographic data, details of surgery, type of tumor, and patient characteristics associated with surgical site infections (SSIs) were collected; these data included presence of the following variables: diabetes, obesity, smoking, steroid use, previous surgery, previous radiation, cerebrospinal fluid leak, number of spinal levels exposed, instrumentation, number of surgeons scrubbed in to the procedure, serum albumin level, and combined anterior-posterior approach. Logistic regression analysis was implemented to find an association of such variables with the presence of SSI. RESULTS: A total of 46 patients were treated for sacral tumor resections; 20 were male (43%) and 26 were female (57%), with an average age of 46 years (range 11-83 years). Histopathological findings included the following: chordoma in 19 (41%), ependymoma in 5 (11%), rectal adenocarcinoma in 5 (11%), giant cell tumor in 4 (9%), and other in 13 (28%). There were 18 cases of wound infection (39%), and 2 cases of repeat surgery for tumor recurrence (1 chordoma and 1 giant cell tumor). Factors associated with increased likelihood of infection included previous lumbosacral surgery (p = 0.0184; odds ratio [OR] 7.955) and number of surgeons scrubbed in to the operation (p = 0.0332; OR 4.018). Increasing age (p = 0.0864; OR 1.031), presence of complex soft-tissue reconstruction (p = 0.118; OR 3.789), and bowel and bladder dysfunction (p = 0.119; OR 2.667) demonstrated a trend toward increased risk of SSI. CONCLUSIONS: Patients undergoing sacral tumor surgery may be at greater risk for developing wound complications due to the extensive soft-tissue resections often required, especially with the increased potential for contamination from the neighboring rectum. In this study, it appears that previous lumbosacral surgery, number of surgeons scrubbed in, patient age, bowel and bladder dysfunction, and complex tissue reconstruction may predict those patients more prone to developing postoperative SSIs.

An unusual case of spinal column metastasis after orthotopic transplantation for cardiac sarcoma.

The authors describe a patient who underwent orthotopic cardiac transplantation after an undifferentiated cardiac sarcoma was diagnosed. While receiving immunosuppressive therapy, the patient developed spinal column metastases and cauda equina syndrome requiring surgical decompression and stabilization. This occurred despite an exhaustive search for metastatic disease prior to the transplantation. To the authors' knowledge, this represents the first reported case of an undifferentiated cardiac sarcoma metastasis to the spine. This previously healthy 18-year-old woman presented with a myocardial infarction. Investigations revealed a left atrial tumor, which was resected. Following local recurrence, the patient underwent extensive studies to rule out systemic disease. Orthotopic heart-lung transplantation was then performed. While receiving postoperative immunosuppressive therapy the patient presented with cauda equina syndrome secondary to metastatic tumor compression at the L-5 level. Despite a comprehensive screening process to exclude metastatic disease prior to transplantation, spinal metastases occurred while this patient was receiving immunosuppressive therapy. This represents a previously unreported and clinically significant complication for undifferentiated cardiac sarcoma.

Surgical treatment of cervical spondylotic myelopathy with anterior compression: a review of 67 cases.

OBJECT: In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications. METHODS: Retrospectively, 67 cases involving consecutive patients with CSM requiring an anterior decompression were reviewed: 46 patients underwent anterior surgery only (1-to3-level anterior cervical discectomy and fusion [ACDF] or 1-level corpectomy), and 21 patients who required > 3-level ACDF or > or = 2-level corpectomy underwent anterior surgery supplemented by a posterior instrumented fusion procedure. RESULTS: Postoperative improvement in Nurick grade was seen in 43 (93%) of 46 patients undergoing anterior decompression and fusion alone (p < 0.001) and in 17 (81%) of 21 patients undergoing anterior decompression and fusion with supplemental posterior fusion (p = 0.0015). The overall complication rate for this series was 25.4%. Interestingly, the overall complication rate was similar for both the lone anterior surgery and combined anterior-posterior groups, but the incidence of adjacent-segment disease was greater in the lone anterior surgery group. CONCLUSIONS: Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.

Revision surgery for cervical spondylotic myelopathy: surgical results and outcome.

OBJECTIVE: The role of additional or revision surgery in patients with cervical spondylotic myelopathy (CSM) is challenging. Postoperative pseudoarthrosis, instability, hardware failure, and recurrent cervical stenosis are conditions that require detailed clinical and radiographic assessment to define the pathology and assess the need for surgical decompression and fusion. The purpose of this study is to assess the neurological outcome, radiological outcome, and complications of patients undergoing additional or revision surgery for CSM. METHODS: Between 2002 and 2006, 30 patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or recurrent stenosis underwent surgical decompression and stabilization. The specific procedure was selected according to each patient's medical condition, cervical sagittal alignment, and extent of stenosis. All patients underwent an anterior, posterior, or combined anterior and posterior decompression and instrumented fusion. The charts of these patients were reviewed to assess neurological and radiographic outcomes. RESULTS: Twenty-five patients (83%) improved postoperatively as measured by the Nurick Myelopathy Scale over a mean follow-up period of 19 months (range, 2-64 mo). The overall complication rate was 27%, consisting of transient monoradiculopathy (7%), dysphagia (10%), and infection (7%). The incidence of nonunion during the follow-up period was 3%. CONCLUSION: Although patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or junctional stenosis who require revision surgery may risk a substantial likelihood of surgical complications (25% in this series), a significant proportion of patients may experience improved neurological outcomes. In our experience, the cervical sagittal alignment and the extent of stenosis are critical factors to consider when selecting the eventual procedure.

En bloc total sacrectomy performed in a single stage through a posterior approach.

OBJECTIVE: Total sacrectomies are performed for extensive en bloc tumor resections. Exposure traditionally combines a posterior approach with a laparotomy to facilitate vascular control. We present a case of a total en bloc sacrectomy performed entirely through the posterior approach, thereby avoiding the need for a laparotomy. CLINICAL PRESENTATION: A 57-year-old man presented with sacral pain and loss of bowel and bladder function. A large sacral mass was identified and submitted to biopsy. Results were consistent with an osteoblastoma, although osteosarcoma could not be excluded on pathological examination. The patient was taken to the operating room for a total sacrectomy and en bloc resection of the mass. TECHNIQUE: Lateral iliac osteotomies were performed, followed by an L5-S1 discectomy and resection of the annulus, thus mobilizing the sacrum. Gradual distraction of the interspace coupled with upward traction of the sacrum provided an anterior exposure through which the internal iliac vessels were controlled, dissected, and divided. A combined transperineal approach completed the posterior dissection and the tumor was delivered en bloc. Lumbopelvic reconstruction was performed simultaneously. CONCLUSION: With the use of interspace distraction and sacral elevation to facilitate vascular control, a total sacrectomy was performed without the need for the anterior exposure of a laparotomy.

Mediastinal lymphangioma presenting as an acute epidural hematoma.

Lymphangiomas are benign collections of blind-ended lymphatic and vascular channels. Lesions typically occur in the soft tissues of the head and neck, although any region of the body can be affected. Involvement of the spine is very rare. A complete resection is generally curative. On rare occasions, these tumors are complicated by infection or hemorrhage. The authors present an unusual case of a hemorrhagic lymphangioma in a 1-year-old male child. The lesion originated in the mediastinum and extended into the cervicothoracic epidural space via a neural foramen. This resulted in an acute epidural hematoma and quadriparesis. Emergency decompression resulted in full neurological recovery. This may be the first report of a lymphangioma resulting in an acute epidural hematoma and quadriparesis.

The learning curve of minimally-invasive lumbar microdiscectomy.

OBJECT: The safe integration into practice of a new surgical technique requires an appreciation of the learning curve. The object of this study was to assess the learning curve for minimally invasive microdiscectomy (MIM) utilizing a tubular retractor system. METHODS: A prospective evaluation of a single surgeon's first 52 consecutive MIM cases for radiculopathy secondary to single-level posterolateral lumbar disc herniation was performed. The learning curve was assessed using operative time, conversion to open rate, complications, and length of hospitalization. RESULTS: The duration of operative time decreased over the course of the study (range, 49-151 min). By case 15, operative time was typically 60 min or less. There was only one conversion to an open procedure (Case 2). Complications occurred in three cases. All but nine patients were discharged home on the day of surgery. CONCLUSION: The learning curve for MIM was demonstrated. Further assessment of this curve for a large group of surgeons is necessary before a randomized controlled trial comparing standard microdiscectomy to MIM can be conducted.

Chondroma/Chondrosarcoma of the spine.

Chondromas and chondrosarcomas are cartilage-forming tumors that occur rarely in the spine. These neoplasms exist on opposite ends of the pathologic spectrum, ranging from the benign chondroma to the malignant, high-grade chondrosarcoma. Unlike other sarcomas, a patient's long-term prognosis is influenced by the grade of the tumor. A complete en bloc resection is the ideal method of surgical management. This method holds especially true for chondrosarcomas, and can result in prolonged survival. These tumors are resistant to conventional chemotherapy and radiation therapy. Hypofractionated stereotactic radiation therapy may slow tumor progression, although the long-term effect of this modality is unknown.

Pediatric tumors involving the spinal column.

Primary pediatric spinal column tumors are rare lesions, but they can lead to serious morbidity if left untreated. Progressive pain, deformity, and neurologic decline may result from destructive and compressive insults on neighboring structures. In addition, histologic diagnosis is paramount in determining overall survival and management options. Evolution of spinal instrumentation has allowed safe and effective application of spinal reconstruction to the developing spine. As a result, aggressive surgical decompression, deformity correction, fusion, and gross total tumor resections may improve functional and oncologic outcomes without sacrifice of spinal stability.

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma?

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.