- Email: [email protected]
Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach
Original Article
Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach Wending Huang1,2, Haifeng Wei3, Weiluo Cai1, Wei Xu3, Xinghai Yang3, Tielong Liu3, Zhipeng Wu3, Quan Huang3, Wangjun Yan1, Jianru Xiao3
BACKGROUND: Total en bloc spondylectomy (TES) significantly decreases the rate of local recurrence and provides long-term survival in patients with malignant tumor of the spine. This procedure can be performed through a posterior-only approach. However, TES for lower lumbar spine through a posterior-only approach is technically challenging.
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METHODS: We retrospectively reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES in a posterior-only approach from June 2012 to December 2015. This series included 5 female and 4 male patients, with a mean age of 54.1 years. Endpoints included length of surgery, estimated blood loss, visual analogue scale for pain, instrumentation failure, perioperative complications, local control rate, and overall survival.
3 patients, but no implant failures or related clinical symptoms were found. CONCLUSIONS: TES for the fourth lumbar spine in a posterior-only approach is feasible. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.
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RESULTS: All patients underwent TES and circumferential reconstruction of the involved level. Average operative time and estimated blood loss were 282 minutes and 2421 mL, respectively. The mean follow-up time was 41.2 months. We encountered nerve roots stretches in all patients during the surgeries. Three patients experienced acute lower-extremity neurologic dysfunction, but the symptoms were significantly alleviated in 4 weeks postoperatively and fully resolved within 6 months. Five patients showed no evidence of disease at the latest followup. Three patients died of metastasis and systemic failure. One patient developed new metastases and was alive with disease. Titanium mesh cage subsidence was observed in
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INTRODUCTION
S
urgical management of tumors in the spine has evolved significantly over the last 4 decades with the advent of advanced spinal tumor classification, staging, and surgical techniques. Total en bloc spondylectomy (TES), an approach coined by Tomita et al.1,2 in 1990s that has been perfected and standardized by his team ever since, has become one of the most popular techniques for the management of spinal tumor and a widespread term in the literature on this field.3-6 The operative time, intraoperative blood loss, and perioperative complications have been remarkably decreased with this procedure. More importantly, studies have shown that the long-term clinical outcomes after TES are favorable and encouraging.7,8 Clinical and anatomic studies have concluded the indications for TES include malignant primary spinal tumors, benign aggressive primary spinal tumors, and solitary metastatic spinal disease.3,4,6 A posterior-only approach is the most often preferred technique, which can be achieved for lesions located from T1 to L3.6,9 However, for tumors at lower lumbar spine, due to the close relationship between the spine and main blood vessels, together
Key words Lumbar spine - Metastatic tumors - Outcomes - Surgical approach - Total en bloc spondylectomy
Hospital, Navy Military Medical University, Shanghai; and 3Spine Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Navy Military Medical University, Shanghai, China
Abbreviations and Acronyms TES: Total en bloc spondylectomy
Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.06.251
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To whom correspondence should be addressed: Wangjun Yan, M.D.; Jianru Xiao, M.D. [E-mail: [email protected]; [email protected]] Wending Huang, Haifeng Wei, and Weiluo Cai contributed equally to this work.
Journal homepage: www.WORLDNEUROSURGERY.org From the 1Spine Tumor Center, Department of Musculoskeletal Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai; 2Department of Orthopaedics, Hongkou Medicine Center, Changhai
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Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Published by Elsevier Inc.
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with the obstruction caused by the bilateral iliopsoases and the iliac wings when exposing the L4 or L5 vertebral bodies, a posterior-only approach can be extremely challenging.10-12 Therefore, it is usually deemed that combined anterior and posterior approaches should be performed for TES of these neoplasms.11-21 The aims of this study were to report our experience and results of TES for patients with solitary metastatic tumors of the fourth lumbar spine in a posterior-only approach and to assess the feasibility and safety of this surgical technique. PATIENTS AND METHODS
Tomita score25 and revised Tokuhashi score26 were assessed preoperatively. Visual analogue scale for back and leg pain also was obtained. Spinal angiography and selective embolization of the feeding arteries and segmental arteries above and below the diseased vertebra were performed on the day before the operation. All the data were shown in Table 2. Surgical Procedure Step 1. The patient was placed prone on the operating table. A posture mat was used to lift the lumbar spine. A vertical midline incision was made over the spinous process. The length of the incision should extend 2e3 spinal levels above and below the lesion. The paraspinal muscles were dissected subperiosteally from the spinous process, lamina, and transverse process. Then, the paraspinal soft tissues were retracted laterally by retractor. To maintain spinal stability after removal of the vertebra, instrumented fixation was performed at least 2 levels above and below the involved vertebra (Video 1).
Patient Sample This study was approved by our institutional review board. We reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES at our institutions from June 2012 to December 2015. The series included 5 women and 4 men. The mean age at the time of admission was 54.1 years (range 39e65 years). We Video available at collected data on patient demographics, primary WORLDNEUROSURGERY.org Step 2. The supraspinous and interspinous ligaments cancer, date of diagnosis of the spinal metastatic were dissected and removed with a scalpel. A wide disease, treatment history, clinical images, surgery, laminectomy was then performed at the adjacent and follow-up. levels above and below the lesion to expose the spinal canal. The superior and inferior articular processes of the immediate neighPreoperative Evaluation boring vertebra were osteotomized and removed, respectively. All patients in our series were evaluated meticulously by our group After the dissection and removal of the soft tissues attached to the after admission. All patients underwent lumbar radiography, articular processes and laminas, the nerve root canals were fully computed tomography with 3-dimensional reconstruction of the exposed to avoid iatrogenic nerve injury. spine, and magnetic resonance imaging, positron-emission toA curved malleable T-saw guide was passed around the medial mography/computed tomography, or single-photon emission aspect of the pedicles and then through the intervertebral foramen computed tomography bone scan. Neurologic function was 22 in a cephalocaudal direction. Threadwire saws were then passed assessed according to the modified Frankel grading system through the foramen in the wire guide and tightened/wrapped (Table 1). All tumors were evaluated according to Weinstein, around the pedicles so as not to damage the thecal sac and nerve Boriani, and Biagini surgical staging systems.23 Tumor-related roots. The bilateral pedicles were then cut with a reciprocating instability is assessed preoperatively by Spinal Instability motion of the wire saws. The entire posterior elements of the Neoplastic Score system, which classifies patients as stable, involved vertebra were then removed in an en bloc fashion. After potentially unstable, and unstable based on the total score.24 the removal of the posterior elements, the cut surfaces of the pedicles were sealed with bone wax to reduce bleeding and minimize contamination of the tumor. Once the posterior eleTable 1. Modified Frankel Grading System ments were removed, the dural sac was dissected from the posterior longitudinal ligament with the help of an operative Grade Neurologic Function microscope (Video 2). A
Complete motor loss and sensory loss
B
Preserved sensation only, voluntary motor function absent
C
Preserved motor less than fair grade (nonfunctional for any useful purpose)
D1
Preserved motor at lowest functional grade (3þ/5þ) and/or with bowel or bladder paralysis with normal or reduced voluntary motor function
D2
Preserved motor at mid-functional grade (3þ to 4þ/5þ) and/or with neurogenic bowel or bladder dysfunction
D3
Preserved motor at high-functional grade (4þ to 5þ) and normal voluntary bowel or bladder function
E
Complete motor loss and sensory function normal (may still have abnormal reflexes)
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Step 3. If the tumor had violated the epidural space and venous plexus, the thecal sac also was dissected from the capsule of the tumor. Because the tumor could invade and compress the outer layer of the dura mater, meticulous attention was taken to guarantee the integrity of the capsule and the thecal sac. Once the dural mater was freed up circumferentially, a nerve retractor could be used for gentle traction so that an unobstructed access was provided for the dissection of the vertebral body. The bilateral nerve roots of L3 and L4 were mobilized to the lumbosacral plexus nerves. Then, the segmental vessels were identified before blunt dissection of the paraspinal tissues of the vertebral body. The segmental vessels should be ligated if they were injured. The psoas muscles were dissected from the anterolateral wall of L4 by using lance-shaped dissectors along the
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WBB, WeinsteineBorianieBiagini; SINS, Spine Instability Neoplastic Score (stable: 0～6 points; potentially unstable: 7～12 points; unstable: 13～18 points); M, male; RT, radiotherapy; F, female; CT, chemotherapy.
I131 Wide/marginal excision 1 year 13 1e2 years 9 5e8, BeD 56/M 9
Thyroid cancer
Type 2
4
CT Wide/marginal excision 1 year 12 >2 years
CT Wide/marginal excision 1 year 15 >2 years
9
3
8
Type 2
5e6, BeC
5e8, BeD
Brest cancer 39/F
49/M
7
8
Renal cell carcinoma
Type 1
2
I131 Wide/marginal excision 1 year 14 >2 years 12 6e8, BeD 60/F 6
Thyroid cancer
Type 2
2
CT
1 year >2 years
CT
Marginal excision
Wide/marginal excision
6 months 10
15
1e2 years 5 9
12
Type 4
6e9, BeC
4e8, BeD
52/F 5
Brest cancer
50/F 4
Nonesmall cell lung cancer
Type 2
2
RT 1y >2 years
Immune therapy Marginal excision
Wide/marginal excision
6 months 9
13
1e2 years 5
3
9
8 5e6, BeC
Type 2 5e8, BeD
53/F 3
Endometrial cancer
65/M 2
Hepatocellular carcinoma
Type 1
Wide/marginal excision 1 year 15 >2 years 2 9 5e9, BeD 63/M 1
Prostate cancer
Type 4
Surgical Strategy Case
Pathology
SINS
Predicted Prognosis Revised Tokuhashi Score Predicted Prognosis WBB Staging
Tomita Classification
Tomita Score
RT þ endocrine
TES FOR TUMORS OF THE FOURTH LUMBAR SPINE
Age/ Sex
Table 2. Baseline Characteristics of Patients with Solitary Metastatic Tumor of the Fourth Lumbar Spine
Adjuvant Therapy Before Surgery
WENDING HUANG ET AL.
lateral wall to the ventral vertebral body. Then, the dissection was extended rostally and caudally by exposing the intervertebral discs above and below the vertebra. Once the dissection was completed, a malleable baffle was placed around the vertebral body after filling with gauze to protect the paraspinal structures and maintain the exposure. Then, 2 T-saws were placed in the L3eL4 and L4eL5 disk spaces, respectively. A titanium rod contoured to the lumbar lordosis was temporarily placed to ensure spinal stability. Complete discectomy was divided into 2 steps. The first step was to cut the intervertebral disc to a level about two-thirds anteriorly to posteriorly gradually with a T-saw. Then an osteotome was used to cut the rest of the disc in a posterior to anterior direction. In recent cases, an osteotome was used to cut the discs and anterior longitudinal ligament without support of the T-saw. After complete discectomy, the affected vertebra was detached from the spinal column. Nerve root retractors were used to protect the dura mater and mobilize the nerve roots. The freed vertebra was pushed ventrally and rotated around the thecal sac. Once the tumor excised, it was subjected to radiographic examination to confirm radiographic margins (Video 3). Step 4. After completion of en bloc spondylectomy, circumferential reconstruction of L4 vertebra was performed. Anterior reconstruction was done with a titanium mesh cage (DePuy Synthes Companies, Zuchwil, Switzerland) or VLIFT expandable cage (Stryker, Kalamazoo, Michigan, USA) filled with autogenous bone, allograft bone, or bone cement. Once the titanium mesh cage was placed, the posterior instrumentation was slightly compressed to allow for the cage to properly seat between the vertebral endplates. Finally, a drain was placed and the wound was closed by layers (Video 4). Postoperative Management and Follow-up Rehabilitation management is recommended and performed for every patient in the first 3 months after the operation. The aim is to improve patients’ quality of life, physical function, and mood. Adjuvant therapies are added depending on the type of pathology. Follow-up was by outpatient evaluation every 3 months during the first year and semiannually thereafter. Statistical Analysis Data analysis was performed in SPSS, version 19.0 (IBM Corp., Armonk, New York, USA). The KaplaneMeier method was used to estimate postoperative survival and survival curves were analyzed and depicted. RESULTS General Data Patients' surgical and follow-up data are summarized in Table 3. All patients underwent TES through a posterior-only approach as well as circumferential reconstruction of the involved level (Figure 1). The mean operation time was 282 minutes (range, 245 ～320 minutes). The average estimated blood loss was 2421 mL, with a range of 1900e3000 mL. Surgical margins were classified as wide in 5 patients, marginal in 2 patients, and intralesional in 2 patients due to significant tumor extension into the pedicles.
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Table 3. Surgical Data and Outcomes of Patients Who Underwent En Bloc Spondylectomy Modified Frankel OT, Case PE Approach minutes BL, mL
Reconstruction
Pre- Post-1 day Post-6 months
VAS Complications
Adjuvant Therapy
FU, Pre- Post-6 months months/Status
No
P
245
1900
VLIFT with AIBS, L2eL3, L5eS1 PS
E
D2
E
Transient nerve root palsy CSF leak
Endocrine
5
0
43/DOD
2
Yes
P
280
3000
TC with bone cement, L2eL3, L5eS1 PS
D2
C
E
Transient nerve root palsy CSF leak, recurrence
Bisphosphonate þ RT
7
2
24/DOD
3
No
P
270
3000
TC with allogenic bone, L2eL3, L5eS1 PS
D3
D3
E
Case substance
Bisphosphonate þ RT
8
0
65/NED
4
Yes
P
255
1940
TC with bone cement, L2eL3, L5eS1 PS
D3
D3
E
Recurrence
Bisphosphonate þ RT
6
0
42/DOD
5
Yes
P
265
2100
TC with bone cement, L2eL3, L5eS1 PS
D3
D3
D3
Cage substance
Bisphosphonate þ CT
5
2
54/AWD
6
Yes
P
290
3000
VLIFT with allogenic bone, D3 L2eL3, L5eS1 PS
D3
E
e
Bisphosphonate þI131
3
0
32/NED
7
Yes
P
300
2050
TC with allogenic bone, L2eL3, L5eS1 PS
E
E
E
Cage substance
Bisphosphonate þ endocrine
4
1
58/NED
8
Yes
P
320
2500
TC with allogenic bone, L2eL3, L5eS1 PS
E
D3
E
6
2
28/NED
9
No
P
310
2300
VLIFT with allogenic bone, D3 L2eL3, L5eS1 PS
D3
E
8
0
25/NED
Transient nerve root palsy Bisphosphonate þ target therapy e
Bisphosphonate þI131
PE, preoperative embolization; OT, operative time; BL, blood loss; Pre-, preoperation; Post-, postoperation; VAS, visual analogue scale; FU, follow-up; P, posterior; VLIFT, VLIFT artificial vertebra; AIBS, autogenous iliac bone strut; PS, pedicle screws; CSF, cerebrospinal fluid; DOD, died of disease; TC, titanium cage; RT, radiotherapy; NED, no evidence of disease; CT, chemotherapy; AWD, alive with disease.
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Figure 1. Case 6. Thyroid cancer at L4 in a 60-year-old woman. (A) Sagittal computed tomographic scan demonstrated vertebral body collapse of L4. (B) Axial computed tomographic scan demonstrated the tumor with spinal canal compromise because of osteolytic destruction. Sagittal (C) and axial (D) T2-weighted magnetic resonance imaging showed the tumor involving the L4 vertebral body. (E) The vertebral body was removed around the thecal sac. (F) Spinal reconstruction with an anterior cage and
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posterior pedicle screw instruments was performed. Specimen of the diseased vertebra after TES (G) and radiograph of the resected specimen (H) showed complete removal of the L4. Anteroposterior (I) and lateral (J) radiographs showed a stable construct at 2 years postoperatively. T2-weighted sagittal magnetic resonance imaging (K) and T1-weighted contrast axial magnetic resonance imaging (L) demonstrated no recurrence of the disease. (continues)
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Figure 1. (continued)
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Complications Two (22.2%) of the patients experienced an intraoperative dural tear and postoperative cerebrospinal fluid leak. An intraoperative watertight seal of the dura mater and a postoperative lumbar drain were performed in all patients. The leak resolved within 1 week in all patients. All the unilateral L4 nerve roots were stretched when the vertebral body was rolled out from one side of the dural sac. Six (66.7%) of the patients showed no significant deterioration in neurologic function after surgery. However, transient motor weakness, resulting from nerve root traction and extensive dissection of the lumbosacral plexus nerves, was detected in 3 (33.3%) patients. The symptoms were significantly alleviated in 4 weeks. Two patients had local recurrence. Cage subsidence was observed in 3 patients, but no implant failures or related clinical symptoms were found. Long-Term Outcomes The mean follow-up time was 41.2 months (range 24e65 months). All the patients received systemic adjuvant therapy according to the type of pathology, including bisphosphonates, radiotherapy, chemotherapy, endocrine therapy, target therapy, and I131 (Table 3). Eight (88.9%) of the patients had normal motor function and were able to go back to work at 6 months of follow-up, and only 1 (11.1%) had preserved motor function with mild weakness. Visual analogue scale scores for pain were significantly improved after surgery. During the follow-up period, 5 patients (55.5%) showed no evidence of disease at the latest follow-up. Three patients (33.3%) died of metastasis and systemic failure. One patient (case 5) developed new metastases and was alive with disease at the last follow-up. KaplaneMeier survival curve is showed in Figure 2.
DISCUSSION The unique anatomical features of the spine make radical resection rarely possible for surgical management of spinal tumors in spinal oncology. Even though traditional curettage or piecemeal excision may achieve complete resection of tumors, these methods may result in a high risk of tumor cell contamination to the surrounding structures and residual tumors. Studies have shown that TES with negative surgical margins is often the treatment of choice for malignant spinal tumors and invasive benign primary spinal tumors, as it improves long-term tumor control and increases the survival rate.3,4,7,8 Several surgical techniques of TES for thoracolumbar spinal tumors have been developed.2-5,10,12,27 The most representative approach is the posterior-only surgical technique.2-5 Classically, TES usually is performed through a combined anterior-posterior approach for lower lumbar spinal tumors.1,6,7,10,11 Even though it is technically challenging for surgeons to complete TES of lower lumbar spinal tumors through a posterior-only approach, we still believe in the feasibility of this surgical technique. Therefore, we spend a long time to obtain as much surgical details as possible by anatomic studies. Dimensions of the vertebral body and nerve roots were measured to find the optimal anatomical sites when taking out the tumor.
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Figure 2. KaplaneMeier survival curve.
Two surgical approaches to achieve complete resection of lower lumbar spinal tumors have been reported in the literature, a predominant number of which are case reports and short case series.11-16,28 Only a few cases of lower lumbar spinal tumors treated successfully by total en bloc resection through combined approaches have been reported.10-19,21 Roy-Camille et al.10 had suggested that a 2-staged operation was required when a complete resection of the lumbar vertebra was to be done, and that a single posterior approach would be almost impossible due to the anatomical complexity, such as the psoas and iliac muscle insertions on the vertebral body, as well as the adjacent nerve roots. Hsieh et al.6 reported that the operation could be performed in a posterior-only approach for tumors between T3 and L1. In Kawahara et al.’s9 cadaveric studies, they found that the posterior approach for TES could be achieved for lesions located from T1 to L2 and possibly to L4 if the anterior vessels had been safely mobilized. Conventionally, we would recommend the combined anterior and posterior approach for a complete removal of lower lumbar spine vertebrae because of anatomical reasons such as the close relationship between the lower lumbar spine and the main blood vessels, as well as obstruction from the iliac wings in exposing the L4 vertebral bodies posteriorly. However, our cadaveric anatomic studies demonstrated that we could successfully achieve total en bloc resection for certain patients with L4 or L5 spinal tumor through a posterior-only approach. With the support of these vast experiences, we performed a TES of L4 and reconstruction of the lumbar spine in a posterior-only approach without severe complications. To our knowledge, this is the first clinical case series report focusing on the feasibility of TES for the fourth lumbar spinal tumors through a posterior-only approach. Classically, after resection of the posterior elements and identification of the intervertebral discs, 2 T-saws should be inserted at the proximal and distal cutting levels of the involved vertebra to perform the discectomy.1-3,5-7,9,12,29 Because L4 are nearly situated
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at the point of lumbar lordosis with deep location, it is difficult to manipulate the T-saws. Therefore, in our series we cut the intervertebral discs by a 2-step dissection with T-saws and osteotome by learning from Huang’s experience on the modified TES technique.30 TES by a posterior-only approach of the L4 vertebra is particularly a surgical challenge. The key to this surgical method is how to roll out the vertebra around the dural tube from one side of the thecal sac without injuring or sacrificing the nerve roots. Abe et al.11 stated that the size of a resected vertebral body was large enough to injure the nerve roots or lumbar nerve plexus when it is rolled out around the dural tube between the nerve roots without cutting them, and that serious neurologic deficits would result from sacrifice of the L3, L4, and L5 nerve roots. Anatomically, the L4 vertebra is one of the largest vertebrae in the whole vertebral column, which is nearly situated at the point of greatest lumbar lordosis. When spondylectomy is performed via a posterior approach, the nerve roots make it difficult to rotate the vertebral body out from one side of the thecal sac and obscure cage placement as well. To overcome these obstacles, surgical exposure should be wide enough to include the tip of the transverse process during this procedure. The nerve roots should be mobilized to the lumbosacral plexus nerves. When placing the titanium mesh cage or expandable cage, the radian of rods should be less than the lumbar curve. This will reduce the lumbar lordosis and contribute to cage placement. Postoperative neurologic function decline of the lower extremities was noted in 3 patients, all of whom were male. We believe that one of the reasons is that the vertebral bodies of men are larger than those of women. Symptoms of proximal muscle weakness might have been caused by mechanical traction of the nerve roots and paraspinal psoas muscle dissection. The symptoms were significantly alleviated in 4 weeks and fully resolved within 6 months after surgery. Our experiences showed that it was
REFERENCES 1. Tomita K, Kawahara N, Baba H, Tsuchiya H, Nagata S, Toribatake Y. Total en bloc spondylectomy for solitary spinal metastases. Int Orthop. 1994;18:291-298. 2. Tomita K, Kawahara N, Baba H, Tsuchiya H, Fujita T, Toribatake Y. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine (Phila Pa 1976). 1997;22:324-333. 3. Tomita K, Kawahara N, Murakami H, Demura S. Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background. J Orthop Sci. 2006;11:3-12. 4. Kawahara N, Tomita K, Murakami H, Demura S. Total en bloc spondylectomy for spinal tumors: surgical techniques and related basic background. Orthop Clin North Am. 2009;40:47-63. 5. Yao KC, Boriani S, Gokaslan ZL, Sundaresan N. En bloc spondylectomy for spinal metastases: a review of techniques. Neurosurg Focus. 2003;15:E6.
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nearly inevitable to stretch the nerve roots when pulling out of the vertebral body. In this series, there was wide margin resection in 5 patients, marginal resection in 2, and intralesional resection in 2 patients because of significant tumor extension into the pedicles. We applied intraoperative chemotherapy in all cases with distilled water and high concentrated cisplatinum to deal with contaminated cells. Previous studies indicated that this method could possibly eradicate the contaminated tumor cells.3,31 During the follow-up, however, 2 patients experienced local recurrence because of potential contamination. This study has several limitations, and some key points need to be considered when performing this procedure. First, comparing the combined anterior and posterior approaches, this technique does not dominate when surgeons dissect blindly the aortic and iliac bifurcation away from the spine. The dissection is extremely high risk, and any perforation into those large vessels is likely lifethreatening. Second, to safely rotate a vertebral body away from one side of the thecal sac, there needs to be wide exposure of the spinal canal and nerve roots in the region of the spondylectomy and space laterally. Third, it is important to note that TES of L4 through a posterior-only approach can only be attempted if the tumor is confined to the vertebral body or at least one pedicle is free of tumor. Finally, this procedure needs a multidisciplinary support including general surgery, vascular surgery, internal medicine, and critical care medicine. CONCLUSIONS TES for the fourth lumbar spine is technically feasible via a posterior-only approach. It is a technically demanding procedure that requires a thorough understanding of the anatomy of the lower lumbar spine and an experienced surgical group. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.
6. Hsieh PC, Li KW, Sciubba DM, Suk I, Wolinsky JP, Gokaslan ZL. Posterior-only approach for total en bloc spondylectomy for malignant primary spinal neoplasms: anatomic considerations and operative nuances. Neurosurgery. 2009;65:173-181. 7. Yamazaki T, McLoughlin GS, Patel S, Rhines LD, Fourney DR. Feasibility and safety of en bloc resection for primary spine tumors: a systematic review by the Spine Oncology Study Group. Spine (Phila Pa 1976). 2009;34:S31-38. 8. Kato S, Murakami H, Demura S, Yoshioka K, Kawahara N, Tomita K, et al. More than 10-year follow-up after total en bloc spondylectomy for spinal tumors. Ann Surg Oncol. 2014;21:1330-1336. 9. Kawahara N, Tomita K, Baba H, Toribatake Y, Fujita T, Mizuno K, et al. Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors. Spine (Phila Pa 1976). 1996;21:1401-1407. 10. Roy-Camille R, Mazel CH, Saillant G, Sundaresan N, Schmidek HH, Schiller AL, et al. Treatment of malignant tumor of the spine with posterior instrumentation. In: Sundaresan N,
Schmidek HH, Schiller AL, Rosenthal DI, eds. Tumors of the Spine. Philadelphia: WB Saunders; 1990:473-487. 11. Abe E, Sato K, Tazawa H, Chiba M, Okuyama K. Total spondylectomy for primary tumor of the thoracolumbar spine. Spinal Cord. 2000;38:146-152. 12. Kawahara N, Tomita K, Murakami H, Demura S, Yoshioka K, Kato S. Total en bloc spondylectomy of the lower lumbar spine: a surgical techniques of combined posterior-anterior approach. Spine (Phila Pa 1976). 2011;36:74-82. 13. Abe E, Kobayashi T, Murai H, Suzuki T, Chiba M, Okuyama K. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord. 2001;14:237-246. 14. Bosma JJ, Pigott TJ, Pennie BH, Jaffray DC. En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases. J Neurosurg. 2001;94:284-291. 15. Gallia GL, Sciubba DM, Bydon A, Suk I, Wolinsky JP, Gokaslan ZL, et al. Total L5 spondylectomy and reconstruction of the lumbosacral
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junction. Technical note. J Neurosurg Spine. 2007;7: 103-111.
neurologic deficits. Clin Orthop Relat Res. 1987;218: 201-216.
16. Wenger M, Teuscher J, Markwalder R, Markwalder TM. Total spondylectomy and circular reconstruction for L5 vertebral body chordoma using a telescopic lordotic cage. Acta Orthop. 2006; 77:825-829.
23. Boriani S, Weinstein JN, Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine (Phila Pa 1976). 1997;22:1036-1044.
17. Santiago-Dieppa DR, Hwang LS, Bydon A, Gokaslan ZL, McCarthy EF, Witham TF. L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature. Evid Based Spine Care J. 2014;5:151-157. 18. Marmor E, Rhines LD, Weinberg JS, Gokaslan ZL. Total en bloc lumbar spondylectomy. Case report. J Neurosurg. 2001;95:264-269. 19. Heary RF, Vaccaro AR, Benevenia J, Cotler JM. "En-bloc" vertebrectomy in the mobile lumbar spine. Surg Neurol. 1998;50:548-556. 20. Boriani S, De Iure F, Bandiera S, Campanacci L, Biagini R, Di Fiore M, et al. Chondrosarcoma of the mobile spine: report on 22 cases. Spine (Phila Pa 1976). 2000;25:804-812. 21. Sciubba DM, De la Garza Ramos R, Goodwin CR, Xu R, Bydon A, Witham TF, et al. Total en bloc spondylectomy for locally aggressive and primary malignant tumors of the lumbar spine. Eur Spine J. 2016;25:4080-4087. 22. Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete
24. Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35:E1221-1229. 25. Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2001;26: 298-306. 26. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 2005;30:2186-2191. 27. Hu Y, Xia Q, Ji J, Miao J. One-stage combined posterior and anterior approaches for excising thoracolumbar and lumbar tumors: surgical and oncological outcomes. Spine (Phila Pa 1976). 2010;35: 590-595.
29. Melcher I, Disch AC, Khodadadyan-Klostermann C, Tohtz S, Smolny M, Stöckle U, et al. Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy. Eur Spine J. 2007;16: 1193-1202. 30. Huang L, Chen K, Ye JC, Tang Y, Yang R, Wang P, et al. Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach. Eur Spine J. 2013;22: 556-564. 31. Abdel-Wanis ME, Tsuchiya H, Kawahara N, Tomita K. Efficacy of cytotoxic agents for prevention of tumor growth after tumor contamination and blocks inoculation: an in vivo comparative study of cisplatin and distilled water, providone iodine, hydrogen peroxide and saline in athymic mice. J Musculoskelet Res. 2005; 9:145-152. Conflict of interest statement: This study was supported by Science and Technology Commission of Shanghai Municipality (Grant 15411963400). Received 14 February 2018; accepted 29 June 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.06.251 Journal homepage: www.WORLDNEUROSURGERY.org
28. Hunt T, Shen FH, Arlet V. Expandable cage placement via a posterolateral approach in lumbar spine reconstructions. Technical note. J Neurosurg Spine. 2006;5:271-274.
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Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Fourth Lumbar Spine in a Posterior-Only Approach Wending Huang1,2, Haifeng Wei3, Weiluo Cai1, Wei Xu3, Xinghai Yang3, Tielong Liu3, Zhipeng Wu3, Quan Huang3, Wangjun Yan1, Jianru Xiao3
BACKGROUND: Total en bloc spondylectomy (TES) significantly decreases the rate of local recurrence and provides long-term survival in patients with malignant tumor of the spine. This procedure can be performed through a posterior-only approach. However, TES for lower lumbar spine through a posterior-only approach is technically challenging.
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METHODS: We retrospectively reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES in a posterior-only approach from June 2012 to December 2015. This series included 5 female and 4 male patients, with a mean age of 54.1 years. Endpoints included length of surgery, estimated blood loss, visual analogue scale for pain, instrumentation failure, perioperative complications, local control rate, and overall survival.
3 patients, but no implant failures or related clinical symptoms were found. CONCLUSIONS: TES for the fourth lumbar spine in a posterior-only approach is feasible. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.
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RESULTS: All patients underwent TES and circumferential reconstruction of the involved level. Average operative time and estimated blood loss were 282 minutes and 2421 mL, respectively. The mean follow-up time was 41.2 months. We encountered nerve roots stretches in all patients during the surgeries. Three patients experienced acute lower-extremity neurologic dysfunction, but the symptoms were significantly alleviated in 4 weeks postoperatively and fully resolved within 6 months. Five patients showed no evidence of disease at the latest followup. Three patients died of metastasis and systemic failure. One patient developed new metastases and was alive with disease. Titanium mesh cage subsidence was observed in
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INTRODUCTION
S
urgical management of tumors in the spine has evolved significantly over the last 4 decades with the advent of advanced spinal tumor classification, staging, and surgical techniques. Total en bloc spondylectomy (TES), an approach coined by Tomita et al.1,2 in 1990s that has been perfected and standardized by his team ever since, has become one of the most popular techniques for the management of spinal tumor and a widespread term in the literature on this field.3-6 The operative time, intraoperative blood loss, and perioperative complications have been remarkably decreased with this procedure. More importantly, studies have shown that the long-term clinical outcomes after TES are favorable and encouraging.7,8 Clinical and anatomic studies have concluded the indications for TES include malignant primary spinal tumors, benign aggressive primary spinal tumors, and solitary metastatic spinal disease.3,4,6 A posterior-only approach is the most often preferred technique, which can be achieved for lesions located from T1 to L3.6,9 However, for tumors at lower lumbar spine, due to the close relationship between the spine and main blood vessels, together
Key words Lumbar spine - Metastatic tumors - Outcomes - Surgical approach - Total en bloc spondylectomy
Hospital, Navy Military Medical University, Shanghai; and 3Spine Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Navy Military Medical University, Shanghai, China
Abbreviations and Acronyms TES: Total en bloc spondylectomy
Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.06.251
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To whom correspondence should be addressed: Wangjun Yan, M.D.; Jianru Xiao, M.D. [E-mail: [email protected]; [email protected]] Wending Huang, Haifeng Wei, and Weiluo Cai contributed equally to this work.
Journal homepage: www.WORLDNEUROSURGERY.org From the 1Spine Tumor Center, Department of Musculoskeletal Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai; 2Department of Orthopaedics, Hongkou Medicine Center, Changhai
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with the obstruction caused by the bilateral iliopsoases and the iliac wings when exposing the L4 or L5 vertebral bodies, a posterior-only approach can be extremely challenging.10-12 Therefore, it is usually deemed that combined anterior and posterior approaches should be performed for TES of these neoplasms.11-21 The aims of this study were to report our experience and results of TES for patients with solitary metastatic tumors of the fourth lumbar spine in a posterior-only approach and to assess the feasibility and safety of this surgical technique. PATIENTS AND METHODS
Tomita score25 and revised Tokuhashi score26 were assessed preoperatively. Visual analogue scale for back and leg pain also was obtained. Spinal angiography and selective embolization of the feeding arteries and segmental arteries above and below the diseased vertebra were performed on the day before the operation. All the data were shown in Table 2. Surgical Procedure Step 1. The patient was placed prone on the operating table. A posture mat was used to lift the lumbar spine. A vertical midline incision was made over the spinous process. The length of the incision should extend 2e3 spinal levels above and below the lesion. The paraspinal muscles were dissected subperiosteally from the spinous process, lamina, and transverse process. Then, the paraspinal soft tissues were retracted laterally by retractor. To maintain spinal stability after removal of the vertebra, instrumented fixation was performed at least 2 levels above and below the involved vertebra (Video 1).
Patient Sample This study was approved by our institutional review board. We reviewed 9 patients with solitary metastatic tumors of the fourth lumbar spine who underwent TES at our institutions from June 2012 to December 2015. The series included 5 women and 4 men. The mean age at the time of admission was 54.1 years (range 39e65 years). We Video available at collected data on patient demographics, primary WORLDNEUROSURGERY.org Step 2. The supraspinous and interspinous ligaments cancer, date of diagnosis of the spinal metastatic were dissected and removed with a scalpel. A wide disease, treatment history, clinical images, surgery, laminectomy was then performed at the adjacent and follow-up. levels above and below the lesion to expose the spinal canal. The superior and inferior articular processes of the immediate neighPreoperative Evaluation boring vertebra were osteotomized and removed, respectively. All patients in our series were evaluated meticulously by our group After the dissection and removal of the soft tissues attached to the after admission. All patients underwent lumbar radiography, articular processes and laminas, the nerve root canals were fully computed tomography with 3-dimensional reconstruction of the exposed to avoid iatrogenic nerve injury. spine, and magnetic resonance imaging, positron-emission toA curved malleable T-saw guide was passed around the medial mography/computed tomography, or single-photon emission aspect of the pedicles and then through the intervertebral foramen computed tomography bone scan. Neurologic function was 22 in a cephalocaudal direction. Threadwire saws were then passed assessed according to the modified Frankel grading system through the foramen in the wire guide and tightened/wrapped (Table 1). All tumors were evaluated according to Weinstein, around the pedicles so as not to damage the thecal sac and nerve Boriani, and Biagini surgical staging systems.23 Tumor-related roots. The bilateral pedicles were then cut with a reciprocating instability is assessed preoperatively by Spinal Instability motion of the wire saws. The entire posterior elements of the Neoplastic Score system, which classifies patients as stable, involved vertebra were then removed in an en bloc fashion. After potentially unstable, and unstable based on the total score.24 the removal of the posterior elements, the cut surfaces of the pedicles were sealed with bone wax to reduce bleeding and minimize contamination of the tumor. Once the posterior eleTable 1. Modified Frankel Grading System ments were removed, the dural sac was dissected from the posterior longitudinal ligament with the help of an operative Grade Neurologic Function microscope (Video 2). A
Complete motor loss and sensory loss
B
Preserved sensation only, voluntary motor function absent
C
Preserved motor less than fair grade (nonfunctional for any useful purpose)
D1
Preserved motor at lowest functional grade (3þ/5þ) and/or with bowel or bladder paralysis with normal or reduced voluntary motor function
D2
Preserved motor at mid-functional grade (3þ to 4þ/5þ) and/or with neurogenic bowel or bladder dysfunction
D3
Preserved motor at high-functional grade (4þ to 5þ) and normal voluntary bowel or bladder function
E
Complete motor loss and sensory function normal (may still have abnormal reflexes)
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Step 3. If the tumor had violated the epidural space and venous plexus, the thecal sac also was dissected from the capsule of the tumor. Because the tumor could invade and compress the outer layer of the dura mater, meticulous attention was taken to guarantee the integrity of the capsule and the thecal sac. Once the dural mater was freed up circumferentially, a nerve retractor could be used for gentle traction so that an unobstructed access was provided for the dissection of the vertebral body. The bilateral nerve roots of L3 and L4 were mobilized to the lumbosacral plexus nerves. Then, the segmental vessels were identified before blunt dissection of the paraspinal tissues of the vertebral body. The segmental vessels should be ligated if they were injured. The psoas muscles were dissected from the anterolateral wall of L4 by using lance-shaped dissectors along the
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WBB, WeinsteineBorianieBiagini; SINS, Spine Instability Neoplastic Score (stable: 0～6 points; potentially unstable: 7～12 points; unstable: 13～18 points); M, male; RT, radiotherapy; F, female; CT, chemotherapy.
I131 Wide/marginal excision 1 year 13 1e2 years 9 5e8, BeD 56/M 9
Thyroid cancer
Type 2
4
CT Wide/marginal excision 1 year 12 >2 years
CT Wide/marginal excision 1 year 15 >2 years
9
3
8
Type 2
5e6, BeC
5e8, BeD
Brest cancer 39/F
49/M
7
8
Renal cell carcinoma
Type 1
2
I131 Wide/marginal excision 1 year 14 >2 years 12 6e8, BeD 60/F 6
Thyroid cancer
Type 2
2
CT
1 year >2 years
CT
Marginal excision
Wide/marginal excision
6 months 10
15
1e2 years 5 9
12
Type 4
6e9, BeC
4e8, BeD
52/F 5
Brest cancer
50/F 4
Nonesmall cell lung cancer
Type 2
2
RT 1y >2 years
Immune therapy Marginal excision
Wide/marginal excision
6 months 9
13
1e2 years 5
3
9
8 5e6, BeC
Type 2 5e8, BeD
53/F 3
Endometrial cancer
65/M 2
Hepatocellular carcinoma
Type 1
Wide/marginal excision 1 year 15 >2 years 2 9 5e9, BeD 63/M 1
Prostate cancer
Type 4
Surgical Strategy Case
Pathology
SINS
Predicted Prognosis Revised Tokuhashi Score Predicted Prognosis WBB Staging
Tomita Classification
Tomita Score
RT þ endocrine
TES FOR TUMORS OF THE FOURTH LUMBAR SPINE
Age/ Sex
Table 2. Baseline Characteristics of Patients with Solitary Metastatic Tumor of the Fourth Lumbar Spine
Adjuvant Therapy Before Surgery
WENDING HUANG ET AL.
lateral wall to the ventral vertebral body. Then, the dissection was extended rostally and caudally by exposing the intervertebral discs above and below the vertebra. Once the dissection was completed, a malleable baffle was placed around the vertebral body after filling with gauze to protect the paraspinal structures and maintain the exposure. Then, 2 T-saws were placed in the L3eL4 and L4eL5 disk spaces, respectively. A titanium rod contoured to the lumbar lordosis was temporarily placed to ensure spinal stability. Complete discectomy was divided into 2 steps. The first step was to cut the intervertebral disc to a level about two-thirds anteriorly to posteriorly gradually with a T-saw. Then an osteotome was used to cut the rest of the disc in a posterior to anterior direction. In recent cases, an osteotome was used to cut the discs and anterior longitudinal ligament without support of the T-saw. After complete discectomy, the affected vertebra was detached from the spinal column. Nerve root retractors were used to protect the dura mater and mobilize the nerve roots. The freed vertebra was pushed ventrally and rotated around the thecal sac. Once the tumor excised, it was subjected to radiographic examination to confirm radiographic margins (Video 3). Step 4. After completion of en bloc spondylectomy, circumferential reconstruction of L4 vertebra was performed. Anterior reconstruction was done with a titanium mesh cage (DePuy Synthes Companies, Zuchwil, Switzerland) or VLIFT expandable cage (Stryker, Kalamazoo, Michigan, USA) filled with autogenous bone, allograft bone, or bone cement. Once the titanium mesh cage was placed, the posterior instrumentation was slightly compressed to allow for the cage to properly seat between the vertebral endplates. Finally, a drain was placed and the wound was closed by layers (Video 4). Postoperative Management and Follow-up Rehabilitation management is recommended and performed for every patient in the first 3 months after the operation. The aim is to improve patients’ quality of life, physical function, and mood. Adjuvant therapies are added depending on the type of pathology. Follow-up was by outpatient evaluation every 3 months during the first year and semiannually thereafter. Statistical Analysis Data analysis was performed in SPSS, version 19.0 (IBM Corp., Armonk, New York, USA). The KaplaneMeier method was used to estimate postoperative survival and survival curves were analyzed and depicted. RESULTS General Data Patients' surgical and follow-up data are summarized in Table 3. All patients underwent TES through a posterior-only approach as well as circumferential reconstruction of the involved level (Figure 1). The mean operation time was 282 minutes (range, 245 ～320 minutes). The average estimated blood loss was 2421 mL, with a range of 1900e3000 mL. Surgical margins were classified as wide in 5 patients, marginal in 2 patients, and intralesional in 2 patients due to significant tumor extension into the pedicles.
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Table 3. Surgical Data and Outcomes of Patients Who Underwent En Bloc Spondylectomy Modified Frankel OT, Case PE Approach minutes BL, mL
Reconstruction
Pre- Post-1 day Post-6 months
VAS Complications
Adjuvant Therapy
FU, Pre- Post-6 months months/Status
No
P
245
1900
VLIFT with AIBS, L2eL3, L5eS1 PS
E
D2
E
Transient nerve root palsy CSF leak
Endocrine
5
0
43/DOD
2
Yes
P
280
3000
TC with bone cement, L2eL3, L5eS1 PS
D2
C
E
Transient nerve root palsy CSF leak, recurrence
Bisphosphonate þ RT
7
2
24/DOD
3
No
P
270
3000
TC with allogenic bone, L2eL3, L5eS1 PS
D3
D3
E
Case substance
Bisphosphonate þ RT
8
0
65/NED
4
Yes
P
255
1940
TC with bone cement, L2eL3, L5eS1 PS
D3
D3
E
Recurrence
Bisphosphonate þ RT
6
0
42/DOD
5
Yes
P
265
2100
TC with bone cement, L2eL3, L5eS1 PS
D3
D3
D3
Cage substance
Bisphosphonate þ CT
5
2
54/AWD
6
Yes
P
290
3000
VLIFT with allogenic bone, D3 L2eL3, L5eS1 PS
D3
E
e
Bisphosphonate þI131
3
0
32/NED
7
Yes
P
300
2050
TC with allogenic bone, L2eL3, L5eS1 PS
E
E
E
Cage substance
Bisphosphonate þ endocrine
4
1
58/NED
8
Yes
P
320
2500
TC with allogenic bone, L2eL3, L5eS1 PS
E
D3
E
6
2
28/NED
9
No
P
310
2300
VLIFT with allogenic bone, D3 L2eL3, L5eS1 PS
D3
E
8
0
25/NED
Transient nerve root palsy Bisphosphonate þ target therapy e
Bisphosphonate þI131
PE, preoperative embolization; OT, operative time; BL, blood loss; Pre-, preoperation; Post-, postoperation; VAS, visual analogue scale; FU, follow-up; P, posterior; VLIFT, VLIFT artificial vertebra; AIBS, autogenous iliac bone strut; PS, pedicle screws; CSF, cerebrospinal fluid; DOD, died of disease; TC, titanium cage; RT, radiotherapy; NED, no evidence of disease; CT, chemotherapy; AWD, alive with disease.
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Figure 1. Case 6. Thyroid cancer at L4 in a 60-year-old woman. (A) Sagittal computed tomographic scan demonstrated vertebral body collapse of L4. (B) Axial computed tomographic scan demonstrated the tumor with spinal canal compromise because of osteolytic destruction. Sagittal (C) and axial (D) T2-weighted magnetic resonance imaging showed the tumor involving the L4 vertebral body. (E) The vertebral body was removed around the thecal sac. (F) Spinal reconstruction with an anterior cage and
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posterior pedicle screw instruments was performed. Specimen of the diseased vertebra after TES (G) and radiograph of the resected specimen (H) showed complete removal of the L4. Anteroposterior (I) and lateral (J) radiographs showed a stable construct at 2 years postoperatively. T2-weighted sagittal magnetic resonance imaging (K) and T1-weighted contrast axial magnetic resonance imaging (L) demonstrated no recurrence of the disease. (continues)
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Figure 1. (continued)
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Complications Two (22.2%) of the patients experienced an intraoperative dural tear and postoperative cerebrospinal fluid leak. An intraoperative watertight seal of the dura mater and a postoperative lumbar drain were performed in all patients. The leak resolved within 1 week in all patients. All the unilateral L4 nerve roots were stretched when the vertebral body was rolled out from one side of the dural sac. Six (66.7%) of the patients showed no significant deterioration in neurologic function after surgery. However, transient motor weakness, resulting from nerve root traction and extensive dissection of the lumbosacral plexus nerves, was detected in 3 (33.3%) patients. The symptoms were significantly alleviated in 4 weeks. Two patients had local recurrence. Cage subsidence was observed in 3 patients, but no implant failures or related clinical symptoms were found. Long-Term Outcomes The mean follow-up time was 41.2 months (range 24e65 months). All the patients received systemic adjuvant therapy according to the type of pathology, including bisphosphonates, radiotherapy, chemotherapy, endocrine therapy, target therapy, and I131 (Table 3). Eight (88.9%) of the patients had normal motor function and were able to go back to work at 6 months of follow-up, and only 1 (11.1%) had preserved motor function with mild weakness. Visual analogue scale scores for pain were significantly improved after surgery. During the follow-up period, 5 patients (55.5%) showed no evidence of disease at the latest follow-up. Three patients (33.3%) died of metastasis and systemic failure. One patient (case 5) developed new metastases and was alive with disease at the last follow-up. KaplaneMeier survival curve is showed in Figure 2.
DISCUSSION The unique anatomical features of the spine make radical resection rarely possible for surgical management of spinal tumors in spinal oncology. Even though traditional curettage or piecemeal excision may achieve complete resection of tumors, these methods may result in a high risk of tumor cell contamination to the surrounding structures and residual tumors. Studies have shown that TES with negative surgical margins is often the treatment of choice for malignant spinal tumors and invasive benign primary spinal tumors, as it improves long-term tumor control and increases the survival rate.3,4,7,8 Several surgical techniques of TES for thoracolumbar spinal tumors have been developed.2-5,10,12,27 The most representative approach is the posterior-only surgical technique.2-5 Classically, TES usually is performed through a combined anterior-posterior approach for lower lumbar spinal tumors.1,6,7,10,11 Even though it is technically challenging for surgeons to complete TES of lower lumbar spinal tumors through a posterior-only approach, we still believe in the feasibility of this surgical technique. Therefore, we spend a long time to obtain as much surgical details as possible by anatomic studies. Dimensions of the vertebral body and nerve roots were measured to find the optimal anatomical sites when taking out the tumor.
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Figure 2. KaplaneMeier survival curve.
Two surgical approaches to achieve complete resection of lower lumbar spinal tumors have been reported in the literature, a predominant number of which are case reports and short case series.11-16,28 Only a few cases of lower lumbar spinal tumors treated successfully by total en bloc resection through combined approaches have been reported.10-19,21 Roy-Camille et al.10 had suggested that a 2-staged operation was required when a complete resection of the lumbar vertebra was to be done, and that a single posterior approach would be almost impossible due to the anatomical complexity, such as the psoas and iliac muscle insertions on the vertebral body, as well as the adjacent nerve roots. Hsieh et al.6 reported that the operation could be performed in a posterior-only approach for tumors between T3 and L1. In Kawahara et al.’s9 cadaveric studies, they found that the posterior approach for TES could be achieved for lesions located from T1 to L2 and possibly to L4 if the anterior vessels had been safely mobilized. Conventionally, we would recommend the combined anterior and posterior approach for a complete removal of lower lumbar spine vertebrae because of anatomical reasons such as the close relationship between the lower lumbar spine and the main blood vessels, as well as obstruction from the iliac wings in exposing the L4 vertebral bodies posteriorly. However, our cadaveric anatomic studies demonstrated that we could successfully achieve total en bloc resection for certain patients with L4 or L5 spinal tumor through a posterior-only approach. With the support of these vast experiences, we performed a TES of L4 and reconstruction of the lumbar spine in a posterior-only approach without severe complications. To our knowledge, this is the first clinical case series report focusing on the feasibility of TES for the fourth lumbar spinal tumors through a posterior-only approach. Classically, after resection of the posterior elements and identification of the intervertebral discs, 2 T-saws should be inserted at the proximal and distal cutting levels of the involved vertebra to perform the discectomy.1-3,5-7,9,12,29 Because L4 are nearly situated
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at the point of lumbar lordosis with deep location, it is difficult to manipulate the T-saws. Therefore, in our series we cut the intervertebral discs by a 2-step dissection with T-saws and osteotome by learning from Huang’s experience on the modified TES technique.30 TES by a posterior-only approach of the L4 vertebra is particularly a surgical challenge. The key to this surgical method is how to roll out the vertebra around the dural tube from one side of the thecal sac without injuring or sacrificing the nerve roots. Abe et al.11 stated that the size of a resected vertebral body was large enough to injure the nerve roots or lumbar nerve plexus when it is rolled out around the dural tube between the nerve roots without cutting them, and that serious neurologic deficits would result from sacrifice of the L3, L4, and L5 nerve roots. Anatomically, the L4 vertebra is one of the largest vertebrae in the whole vertebral column, which is nearly situated at the point of greatest lumbar lordosis. When spondylectomy is performed via a posterior approach, the nerve roots make it difficult to rotate the vertebral body out from one side of the thecal sac and obscure cage placement as well. To overcome these obstacles, surgical exposure should be wide enough to include the tip of the transverse process during this procedure. The nerve roots should be mobilized to the lumbosacral plexus nerves. When placing the titanium mesh cage or expandable cage, the radian of rods should be less than the lumbar curve. This will reduce the lumbar lordosis and contribute to cage placement. Postoperative neurologic function decline of the lower extremities was noted in 3 patients, all of whom were male. We believe that one of the reasons is that the vertebral bodies of men are larger than those of women. Symptoms of proximal muscle weakness might have been caused by mechanical traction of the nerve roots and paraspinal psoas muscle dissection. The symptoms were significantly alleviated in 4 weeks and fully resolved within 6 months after surgery. Our experiences showed that it was
REFERENCES 1. Tomita K, Kawahara N, Baba H, Tsuchiya H, Nagata S, Toribatake Y. Total en bloc spondylectomy for solitary spinal metastases. Int Orthop. 1994;18:291-298. 2. Tomita K, Kawahara N, Baba H, Tsuchiya H, Fujita T, Toribatake Y. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine (Phila Pa 1976). 1997;22:324-333. 3. Tomita K, Kawahara N, Murakami H, Demura S. Total en bloc spondylectomy for spinal tumors: improvement of the technique and its associated basic background. J Orthop Sci. 2006;11:3-12. 4. Kawahara N, Tomita K, Murakami H, Demura S. Total en bloc spondylectomy for spinal tumors: surgical techniques and related basic background. Orthop Clin North Am. 2009;40:47-63. 5. Yao KC, Boriani S, Gokaslan ZL, Sundaresan N. En bloc spondylectomy for spinal metastases: a review of techniques. Neurosurg Focus. 2003;15:E6.
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nearly inevitable to stretch the nerve roots when pulling out of the vertebral body. In this series, there was wide margin resection in 5 patients, marginal resection in 2, and intralesional resection in 2 patients because of significant tumor extension into the pedicles. We applied intraoperative chemotherapy in all cases with distilled water and high concentrated cisplatinum to deal with contaminated cells. Previous studies indicated that this method could possibly eradicate the contaminated tumor cells.3,31 During the follow-up, however, 2 patients experienced local recurrence because of potential contamination. This study has several limitations, and some key points need to be considered when performing this procedure. First, comparing the combined anterior and posterior approaches, this technique does not dominate when surgeons dissect blindly the aortic and iliac bifurcation away from the spine. The dissection is extremely high risk, and any perforation into those large vessels is likely lifethreatening. Second, to safely rotate a vertebral body away from one side of the thecal sac, there needs to be wide exposure of the spinal canal and nerve roots in the region of the spondylectomy and space laterally. Third, it is important to note that TES of L4 through a posterior-only approach can only be attempted if the tumor is confined to the vertebral body or at least one pedicle is free of tumor. Finally, this procedure needs a multidisciplinary support including general surgery, vascular surgery, internal medicine, and critical care medicine. CONCLUSIONS TES for the fourth lumbar spine is technically feasible via a posterior-only approach. It is a technically demanding procedure that requires a thorough understanding of the anatomy of the lower lumbar spine and an experienced surgical group. Although the surgery is challenging, long-term oncologic and neurologic outcomes are satisfying.
6. Hsieh PC, Li KW, Sciubba DM, Suk I, Wolinsky JP, Gokaslan ZL. Posterior-only approach for total en bloc spondylectomy for malignant primary spinal neoplasms: anatomic considerations and operative nuances. Neurosurgery. 2009;65:173-181. 7. Yamazaki T, McLoughlin GS, Patel S, Rhines LD, Fourney DR. Feasibility and safety of en bloc resection for primary spine tumors: a systematic review by the Spine Oncology Study Group. Spine (Phila Pa 1976). 2009;34:S31-38. 8. Kato S, Murakami H, Demura S, Yoshioka K, Kawahara N, Tomita K, et al. More than 10-year follow-up after total en bloc spondylectomy for spinal tumors. Ann Surg Oncol. 2014;21:1330-1336. 9. Kawahara N, Tomita K, Baba H, Toribatake Y, Fujita T, Mizuno K, et al. Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors. Spine (Phila Pa 1976). 1996;21:1401-1407. 10. Roy-Camille R, Mazel CH, Saillant G, Sundaresan N, Schmidek HH, Schiller AL, et al. Treatment of malignant tumor of the spine with posterior instrumentation. In: Sundaresan N,
Schmidek HH, Schiller AL, Rosenthal DI, eds. Tumors of the Spine. Philadelphia: WB Saunders; 1990:473-487. 11. Abe E, Sato K, Tazawa H, Chiba M, Okuyama K. Total spondylectomy for primary tumor of the thoracolumbar spine. Spinal Cord. 2000;38:146-152. 12. Kawahara N, Tomita K, Murakami H, Demura S, Yoshioka K, Kato S. Total en bloc spondylectomy of the lower lumbar spine: a surgical techniques of combined posterior-anterior approach. Spine (Phila Pa 1976). 2011;36:74-82. 13. Abe E, Kobayashi T, Murai H, Suzuki T, Chiba M, Okuyama K. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord. 2001;14:237-246. 14. Bosma JJ, Pigott TJ, Pennie BH, Jaffray DC. En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases. J Neurosurg. 2001;94:284-291. 15. Gallia GL, Sciubba DM, Bydon A, Suk I, Wolinsky JP, Gokaslan ZL, et al. Total L5 spondylectomy and reconstruction of the lumbosacral
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17. Santiago-Dieppa DR, Hwang LS, Bydon A, Gokaslan ZL, McCarthy EF, Witham TF. L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature. Evid Based Spine Care J. 2014;5:151-157. 18. Marmor E, Rhines LD, Weinberg JS, Gokaslan ZL. Total en bloc lumbar spondylectomy. Case report. J Neurosurg. 2001;95:264-269. 19. Heary RF, Vaccaro AR, Benevenia J, Cotler JM. "En-bloc" vertebrectomy in the mobile lumbar spine. Surg Neurol. 1998;50:548-556. 20. Boriani S, De Iure F, Bandiera S, Campanacci L, Biagini R, Di Fiore M, et al. Chondrosarcoma of the mobile spine: report on 22 cases. Spine (Phila Pa 1976). 2000;25:804-812. 21. Sciubba DM, De la Garza Ramos R, Goodwin CR, Xu R, Bydon A, Witham TF, et al. Total en bloc spondylectomy for locally aggressive and primary malignant tumors of the lumbar spine. Eur Spine J. 2016;25:4080-4087. 22. Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete
24. Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35:E1221-1229. 25. Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2001;26: 298-306. 26. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 2005;30:2186-2191. 27. Hu Y, Xia Q, Ji J, Miao J. One-stage combined posterior and anterior approaches for excising thoracolumbar and lumbar tumors: surgical and oncological outcomes. Spine (Phila Pa 1976). 2010;35: 590-595.
29. Melcher I, Disch AC, Khodadadyan-Klostermann C, Tohtz S, Smolny M, Stöckle U, et al. Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy. Eur Spine J. 2007;16: 1193-1202. 30. Huang L, Chen K, Ye JC, Tang Y, Yang R, Wang P, et al. Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach. Eur Spine J. 2013;22: 556-564. 31. Abdel-Wanis ME, Tsuchiya H, Kawahara N, Tomita K. Efficacy of cytotoxic agents for prevention of tumor growth after tumor contamination and blocks inoculation: an in vivo comparative study of cisplatin and distilled water, providone iodine, hydrogen peroxide and saline in athymic mice. J Musculoskelet Res. 2005; 9:145-152. Conflict of interest statement: This study was supported by Science and Technology Commission of Shanghai Municipality (Grant 15411963400). Received 14 February 2018; accepted 29 June 2018 Citation: World Neurosurg. (2018). https://doi.org/10.1016/j.wneu.2018.06.251 Journal homepage: www.WORLDNEUROSURGERY.org
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