Intentional Dural Resection during en bloc Spinal Resection Could Provide a Secure Surgical Margin for Patients with Recurrent Spinal Tumors.

OBJECTIVE: It is always difficult to obtain a comfortable surgical margin for patients with recurrent malignant or invasive benign spinal tumors. Tumor intraspinal invasion and dural adhesion are the essential reasons. There are always residual tumor cells maintained at the edge of dura. Dural resection is a key point to obtain a comfortable surgical margin for such cases. Whether such patients benefit from this risky surgical procedure is unknown. This study aims to understand better the oncological results, associated risks, and neurological function of this risky surgical procedure. METHODS: We retrospectively reviewed clinical data from six consecutive patients who registered spinal tumors in our institute and underwent dural resection during en bloc spinal resection from June 2013 to May 2020. The demographic and perioperative data, oncological outcomes, complications, and neurological status were collected and analyzed. RESULTS: All six patients were followed up for 24 to 46 months (mean follow-up time: 32.8 months). Local recurrence was detected in one patient (1/6, 16.7%) at 36 months postoperatively and in five patients with no evidence of disease at the last follow up (survival rate 83.3%). Eleven complications occurred in four patients (66.7%), and the dural resection-related complications included only four cases of cerebrospinal fluid leakage (CSFL), which accounted for 36.4% (4/11) of all complications. Neurologic status evaluated by the Frankel grade showed improvement of one grade in one case and deterioration of one to two grades in five patients immediately after surgery. All deterioration cases recovered to the preoperative level 6 months after the operation. CONCLUSION: Dural resection is significant for patients with dura matter invaded by recurrent primary malignant or invasive benign spinal tumors with the purpose of clinical cure. This study demonstrated that in strictly selected cases, intentional dural resection could provide satisfying local control and long-term disease-free survival with acceptable complications and satisfying neurological function.

Mature Spinal Teratoma: A Case Report.

We presented an unusual case of a teratoma in a 76-year-old female who began four years ago with paresthesias and hypoesthesias in the sacral and gluteal regions. She denied weakness or gait instability. The magnetic resonance imaging showed an intradural lesion within the cauda equina at levels L2-L3. We decided to perform a posterior midline approach to the lumbar region to expose L2-L3 levels. After doing the L2-L3 laminectomy and the durotomy, we found a solid lesion surrounded by nerve roots with heterogeneous content. Through the meticulous separation of the nerve roots surrounding the lesion, we punctioned it, observing the exit of melanocytic material. Histopathological findings showed germinal neoplasia without immature neuroepithelium or malignant component; therefore, the diagnosis of mature teratoma was made. The patient was discharged without any aggregate neurological deficit. At the six-month follow-up visit, the patient continued with paresthesia in the gluteal region without motor weakness and reported minimal gait improvement.

Does Preoperative Bilsky Score Predict Outcome Following Surgical Resection of Primary Tumors of the Spine?

OBJECTIVE: In patients undergoing surgery for primary bone tumors of the spine, we sought to compare Bilsky score 0-1 versus 2-3 in: 1) preoperative presentation, 2) perioperative variables, and 3) long-term outcomes. METHODS: A single-center, retrospective cohort study was undertaken of patients undergoing surgery for extradural, primary bone tumors of the spine between January 2010 and January 2021. The primary exposure variable was Bilsky score, dichotomized as 0-1 versus 2-3. Survival analysis was performed to assess local recurrence (LR) and overall survival (OS). RESULTS: Of 38 patients undergoing resection of primary spinal tumors, 19 (50.0%) patients presented with Bilsky 0-1 and 19 (50.0%) Bilsky 2-3 grades. The most common diagnosis was chondrosarcoma (33.3%), followed by chordoma (16.7%). There were 15 (62.5%) malignant tumors. Preoperatively, there was no significant difference in demographics, Karnofsky Performance Scale (KPS) (P > 0.999), or motor deficit (P > 0.999). Perioperatively, no difference was found in operative time (P = 0.954), blood loss (P = 0.416), length of stay (P = 0.641), neurologic deficit (P > 0.999), or discharge disposition (P = 0.256). No difference was found in Enneking resection status (69.2% vs. 54.5%, P = 0.675). Long-term, no differences were found regarding reoperation (P = 0.327), neurologic deficit (P > 0.999), postoperative KPS (P = 0.605) and modified McCormick Scale (MMS) (P = 0.870). No difference was observed in KPS (P = 0.418) and MMS (P = 0.870) at last follow-up. However, patients with Bilsky 2-3 had shorter time to LR (1715.0 vs. 513.0 ± 633.4 days, log-rank; P = 0.002) and shorter OS (2025.0 ± 1165.3 vs. 794.0 ± 952.6 days, log-rank; P = 0.002). CONCLUSIONS: Bilsky 2-3 lesions were associated with shorter time to LR and shorter OS. Patients harboring primary spinal tumors with higher grade Bilsky score appear to be at a higher risk for worse outcomes.

Solitary Plasmacytoma of the Spine in a Young Male and the Outcome of Inpatient Rehabilitation Stay.

Solitary plasmacytoma (SP) can be classified into two groups: a solid mass of neoplastic monoclonal plasma cells in bone, also called a solitary bone plasmacytoma (SBP), or less likely solitary extramedullary plasmacytoma (SEP) without any evidence of systemic disease of multiple myeloma. The diagnosis should be made by biopsy confirmation, revealing monoclonal plasma cell infiltration from the mass. The SBP usually affects the axial skeleton. Males have a higher incidence than females, as the ratio is 2/1, and the average age is 55. SP incidence usually increases with age. SBP has a significantly higher risk for progression to myeloma, usually within two years, and radiotherapy (RT) is the treatment of choice. Patients with acute declining neurologic dysfunction require urgent surgery before radiation therapy. We report a middle-aged man who presented with bilateral lower extremity weakness. Thoracic MRI with and without contrast revealed a large soft tissue and osseous mass centered at the T8 vertebral body with a large paravertebral extension, causing spinal cord compression at the T8-T9 level. The patient's clinical presentation, assessment, and rehabilitation management are discussed. Patients with this diagnosis are not properly diagnosed for approximately six months.

Primary Spinal Glioblastoma Mimicking Neuroschistosomiasis: A Case Report.

Primary glioblastoma of the spinal cord (sGB) is a rare and challenging diagnosis. In the diagnostic algorithm, reversible causes should be considered while the diagnosis of sGB is under evaluation. We present a case of cervical sGB mimicking neuroschistosomiasis. A 21-year-old Somali man presented with neck pain, sensory disturbances, and spastic tetraplegia. Cervical spine magnetic resonance imaging with contrast showed a heterogeneously enhancing intramedullary mass spanning from the level of the C1 to T3 vertebrae. Cerebrospinal fluid analysis showed a lymphocytic predominance and elevated protein. Due to the patient's history of poorly treated schistosomiasis, praziquantel and dexamethasone were initiated while the diagnostic work-up was completed. Three days after the patient was discharged to a rehabilitation facility where he experienced worsened motor function with radiographic progression of the lesion and increased cord edema. The patient underwent a surgical biopsy which confirmed a diagnosis of primary sGB. sGB is an unusual diagnosis that can masquerade as a non-neoplastic lesion. However, the diagnosis of sGB should be considered in patients with an intramedullary spinal cord lesion who exhibit rapid radiographic and clinical progression.

Clinical characteristics, prognostic factors, and predictive model for elderly primary spinal tumor patients who are difficult to tolerate surgery or refuse surgery.

Background: As a rare tumor, surgery is the best treatment for primary spinal tumors. However, for elderly patients who cannot undergo surgery, the prognosis is often difficult to evaluate. The purpose of this study was to identify the risk factors that may lead to death and predict the prognosis of elderly patients with primary spinal tumors who have not undergone surgical treatment. Methods: In this study, 426 patients aged 60 years or older diagnosed with a primary spinal tumor between 1975 and 2015 were selected and included from the Surveillance, Epidemiology, and End Results database. A retrospective analysis was performed by using the Cox regression algorithm to identify independent prognostic factors. A nomogram model was developed based on the results. Multiple evaluation methods (calibration curve, receiver operating characteristic curve, and decision curve analyses) were used to evaluate and validate the performance of the nomogram. Results: A nomogram was developed, with age, histological type, and stage as independent prognostic factors. The results indicated that the prognostic risk tended to increase significantly with age and tumor spread. Osteosarcoma was found to have the most prominent risk prognosis in this patient group, followed by chondrosarcoma and chordoma. The area under the curve and the C-index of the model were both close to or greater than 0.7, which proved the high-differentiation ability of the model. The calibration curve and decision curve analyses showed that the model had high predictive accuracy and application value. Conclusions: We successfully established a practical nomogram to assess the prognosis of elderly patients with primary spinal tumors who have not undergone surgical treatment, providing a scientific basis for clinical management.

Primary Spinal Cord Glioblastoma.

We present the case of a 29-year-old patient whose pain began with the interscapular region, progressing to paresthesia and loss of muscle strength in the lower extremities. MRI of the spine was done, a lesion was found in T2 to T6, ependymoma was suspected and was taken to subtotal resection with laminectomy, the histopathological report, as well as the immunohistochemistry, was compatible with glioblastoma type not otherwise specified (NOS). He received adjuvant with radiotherapy and concomitant chemotherapy, but he progressed to the cervical and lumbar spine, the patient died 16 months after diagnosis. A review of the literature is made and the clinical and radiological characteristics and treatment protocols that have been used in this entity are reported.

Outcomes of Surgery for Sacral Chordoma and Impact of Complications: A Report of 50 Consecutive Patients With Long-Term Follow-Up.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To determine predictive factors of overall survival (OS) and local recurrence (LR), report complications, and assess the impact of complications on survival, recurrence, and function in patients undergoing en bloc resection of sacral chordoma. METHODS: This retrospective case series was obtained from a prospective database (1995-2016). All patients underwent en bloc resection of sacral chordoma. Demographic, perioperative, and complication data were collected. Outcomes included: overall survival(OS), local recurrence(LR), and complications. Survival analysis with multivariable cox regression was performed. RESULTS: Among 50 patients, median follow-up was 5.3 years (range = 1.3-17.2). The majority (82%) underwent a negative margin resection. Survival: 17 patients died (34%) with a median OS of 10.0 years (range = 1.3-17.2). Multivariable cox regression revealed that a negative margin resection was not significantly associated with improved survival (HR = 3.35, 95%CI 0.87-12.80, P = .078). Recurrence: 20 patients (40%) experienced LR with a median time of 6.2 years (range = 0-16.9). Multivariable cox regression revealed that a negative margin resection was associated with a significant decreased risk of LR (HR = 4.96, 95%CI 1.84-13.34, P = 0.002,). A 62% overall complication rate was seen (42% major), with 26% reoperation rate. Of the reoperations, 54% were delayed (>6 weeks after the index surgery). Multivariable cox regression demonstrated that neither major complication nor reoperation significantly impacted OS (HR = 0.62, 95%CI 0.22-1.79, P = 0.380), LR (HR = 1.28, 95%CI 0.49-3.36, P = 0.611), or functional outcomes (OR = 2.94, 95%CI 0.25-34.8, P = 0.393). CONCLUSIONS: Negative margin resection was associated with decreased LR. Neither major complication nor reoperation significantly impacted OS, LR, or functional outcome. Though additional studies are needed, it appears that despite the morbidity associated with sacral chordoma resection, the long-term clinical outcomes are favorable.

Acute onset of paraplegia due to melanocytic cervicodorsal lesion.

BACKGROUND: Melanocytomas are rare pigmented tumors of the central nervous system (CNS). They are more frequent in females in their fifties and are typically benign, but locally aggressive lesions that very are rarely found in the spine. They can occur in all the age groups. CASE DESCRIPTION: A 62-year-old male presented with acute paraplegia a attributed to a C7-T1 intradural extramedullary melanocytoma. Urgent surgery, consisting of subtotal removal of the lesion, resulted in subtotal recovery of motor function with full resolution of his sensory deficit. Histologically, the lesion proved to be a melanocytoma. CONCLUSION: Rarely, patients with intradural extramedullary melanocytomas of the spine may present with acute paralytic deficits warranting emergent surgical intervention.

Multidisciplinary surgical planning for en bloc resection of malignant primary cervical spine tumors involving 3D-printed models and neoadjuvant therapies: report of 2 cases.

Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.

A multicenter cohort study of spinal osteoid osteomas: results of surgical treatment and analysis of local recurrence.

BACKGROUND CONTEXT: Spinal osteoid osteomas are benign primary tumors arising predominantly from the posterior column of the spine. These "osteoblastic" lesions have traditionally been treated with intralesional excision. PURPOSE: The purpose of the present study was to review the treatment and local recurrence rates for symptomatic spinal osteoid osteomas. STUDY DESIGN/SETTING: Multicenter ambispective cross-sectional observational cohort study. PATIENT SAMPLE: During the study period, a total of 84 patients (65 males, 19 females) were diagnosed with a spinal osteoid osteoma and received surgical treatment. The mean age at surgery was 21.8 ± 9.0 years (range: 6.7-52.4 years) and the mean follow-up was 2.7 years (13 days-14.5 years). OUTCOME MEASURES: Local recurrence, perioperative morbidity, and cross-sectional survival. METHODS: Using the AOSpine Knowledge Forum Tumor multicenter ambispective database, surgically treated osteoid osteoma cases were identified. Patient demographic, clinical and diagnostic, treatment, local recurrence, perioperative morbidity, and cross-sectional survival data were collected and retrieved. Descriptive statistics were summarized using mean/standard deviation or frequency/percentage. RESULTS: In our study, most of the tumors were localized in the mobile spine (81 of 84 [96%]); all patients reported pain as a symptom. According to the postoperative assessment, 10 (12%) patients received an en bloc resection with marginal or wide margins, whereas two (2%) patients received en bloc resections with intralesional margins, 69 (82%) patients were treated by piecemeal "intralesional" resection, and three (4%) patients were not assessed. A total of six patients (7%) experienced a local recurrence, all of which occurred in patients who had received an intralesional resection. CONCLUSIONS: Benign bone-forming tumors of the spine are uncommon. Most patients in our series underwent a piecemeal resection with intralesional margins. This remains safe with a low local recurrence rate. En bloc excision may provide more chance of complete excision of the nidus but is not mandatory. The importance of complete excision of the nidus cannot be overemphasized.

Differentiation of spinal giant cell tumors from chordomas by using a scoring system.

INTRODUCTION: Few reports have compared the clinical features and imaging characteristics of giant cell tumor and chordoma of the spine. The aim of the present study was to investigate whether the two types of tumors could be differentially diagnosed, by comparing clinical characteristics as well as magnetic resonance imaging (MRI) or computed tomography (CT) findings and then scoring the characteristic findings. METHODS: A total of 18 patients were retrospectively assessed. To elucidate the characteristic findings, we investigated the following 10 items: age at diagnosis, sex, and site of occurrence; for MRI findings, the pattern of tumor expansion, T1-weighted images, T2-weighted images, septal structure, and cystic changes; and for CT findings, calcification or residual bone fragments and incomplete bone shells. Then, we developed a unique scoring system and investigated whether the two tumors could be differentiated by this scoring system. RESULTS: Six items, including, age, site of occurrence, tumor expansion pattern, T2-weighted images, septal structure, and incomplete bone shells, were significantly different between giant cell tumor and chordoma patients. By using newly developed scoring system, the mean scores of 0.9 ± 0.6 (range 0-2) for giant cell tumor and 4.8 ± 1.5 (range 3-6) for chordoma patients were significantly different (P < 0.001), thereby allowing the differential diagnosis by setting the cutoff value to three. CONCLUSIONS: We found that the six items were useful for differentially diagnosing giant cell tumor and chordoma. These results indicate that it may be possible to distinguish the two types of tumor by scoring these items.

Primary pleomorphic liposarcoma of the thoracic epidural space: case report.

BACKGROUND CONTEXT: Pleomorphic liposarcoma (PLS) is a rare malignant soft tissue tumor comprising 5%-15% of liposarcomas and characterized by high malignant potential. To our knowledge only three cases of this entity have been reported in the spine. PURPOSE: We describe the only reported case of a purely epidural PLS with no macroscopic bone involvement at diagnosis. STUDY DESIGN/SETTING: A case presenting clinical evidence that PLS may arise from the epidural fat is reported. METHODS: The clinical presentation, management, and outcome in a case of primary PLS of the thoracic spine, and a review of the literature, are presented. RESULTS: A 70-year-male presented with sudden onset lower extremity weakness, constipation, and back pain. Magnetic resonance imaging revealed an epidural lesion at T5 with noted mass effect compressing the spinal cord and extension to the T5-T6 foramen. Urgent decompressive laminectomy with gross total resection was performed. Histopathology revealed high-grade PLS. Adjunct radiotherapy was prescribed. The tumor recurred 3 months later. In spite of repeat surgery, additional radiation, and chemotherapy, the patient developed widespread metastases and succumbed to his disease 1 year after treatment began. CONCLUSIONS: Spinal PLS is a rare entity, but nonetheless may arise from epidural fat and should be considered in the differential diagnosis of primary spinal cord lesions.

Patient-reported outcome and quality of life after total en bloc spondylectomy for a primary spinal tumour.

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour. Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs. The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery.

Triple primary origin tumor: a case report.

Generally, among the extradural spinal tumors, metastatic spinal tumor is much more common than primary spinal tumors. Thus, in the case of a spinal tumor patient with cancer history (such as lung cancer, breast cancer, etc.), we used to infer that the spinal lesion is the metastasis from, primary malignancy. We introduce an experience of a case of triple primary origin tumor in a 57-year-old man. When the spinal lesion was found on the abdominal computed tomography scan, he already had a history of colon cancer and liver cancer. Initially, it was thought that the lesion would probably be a metastatic tumor from the liver or colon cancers, and the operation was performed accordingly. In the pathologic final report, however, the mass was proven to plasmacytoma - the third primary lesion. The patient underwent chemotherapy after surgery. Globally, the triple primary origin tumor has been reported very rarely. With this report, we wish to emphasize the necessity of pathologic confirmation and adequate treatment even in a patient with known malignancies.

Triple Primary Origin Tumor: A Case Report

Generally, among the extradural spinal tumors, metastatic spinal tumor is much more common than primary spinal tumors. Thus, in the case of a spinal tumor patient with cancer history (such as lung cancer, breast cancer, etc.), we used to infer that the spinal lesion is the metastasis from, primary malignancy. We introduce an experience of a case of triple primary origin tumor in a 57-year-old man. When the spinal lesion was found on the abdominal computed tomography scan, he already had a history of colon cancer and liver cancer. Initially, it was thought that the lesion would probably be a metastatic tumor from the liver or colon cancers, and the operation was performed accordingly. In the pathologic final report, however, the mass was proven to plasmacytoma - the third primary lesion. The patient underwent chemotherapy after surgery. Globally, the triple primary origin tumor has been reported very rarely. With this report, we wish to emphasize the necessity of pathologic confirmation and adequate treatment even in a patient with known malignancies.