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Two-level en bloc spondylectomy for osteosarcoma at the cervicothoracic junction
Journal of Clinical Neuroscience 16 (2009) 698–700
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical Note
Two-level en bloc spondylectomy for osteosarcoma at the cervicothoracic junction Dean Chou *, Vincent Wang Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, Box 0112, San Francisco, California 94143-0112, USA
a r t i c l e
i n f o
Article history: Received 27 May 2008 Accepted 9 June 2008
Keywords: Osteosarcoma En bloc Cervicothoracic junction Spondylectomy Two-level spondylectomy
a b s t r a c t En bloc resection of osteosarcoma is critical for a chance at curing the disease. In the spine, a spondylectomy should be performed to optimize the chances of survival. Involvement of two contiguous segments in the spinal column poses technical challenges, and performing a spondylectomy at the cervicothoracic junction adds another set of clinical concerns. We present a 22-year-old female with a two-level vertebral involvement at the cervicothoracic junction who underwent a two-level en bloc spondylectomy for osteosarcoma, and we describe our technique. Ó 2008 Elsevier Ltd. All rights reserved.
1. Introduction Surgical margins are important in the treatment of osteosarcoma, and chemotherapy and en bloc resection combined are ideal for a chance at long-term survival.1,2 Spondylectomy is the ideal surgical technique for complete tumor removal with an attempt at a cure for such malignant tumors.3 A two-level spondylectomy at the cervicothoracic junction poses particular challenges, not only because of the need to remove two vertebral segments at once, but also because of the unique biomechanical properties at this transition zone. We describe our technique of performing a two-level en bloc spondylectomy at the cervicothoracic junction. 2. Case report 2.1. Case description and surgical technique A 22-year-old female presented to her primary care physician with upper thoracic pain. She underwent a CT scan of the chest, which demonstrated a 2nd and 3rd rib lesion. Thoracoscopic biopsy by cardiothoracic surgery of this lesion demonstrated osteosarcoma. Chemotherapy with VP-16 and ifosfamide was begun. She subsequently underwent a chest wall resection by the cardiothoracic team at the 2nd and 3rd ribs with a gross total resection of the lesion. At follow-up she received serial imaging and bone scans. At the 6-month post-operative bone scan, an area of increased uptake at T1 and T2 was noted (Fig. 1A). A CT scan of the chest demonstrated some pericardial calcification and sclerotic bone * Corresponding author. Tel.: +1 415 353 9095; fax: +1 415 353 3907. E-mail address: [email protected] (D. Chou). 0967-5868/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2008.06.016
affecting the T1 and T2 vertebral bodies (Fig. 1B). MRI showed enhancement in both the T1 and T2 vertebral bodies (Fig. 1C). Her case was reviewed by the tumor board, and it was felt that a total en bloc resection of this lesion was indicated, given her age and lack of systemic disease. Her pericardial calcification was suspicious for osteosarcoma, and the cardiothoracic surgeons felt it was important to remove this. We planned a combined procedure with them for access to the upper thoracic spine. We planned a two-stage operation with the posterior stage first and the anterior stage second. Given the destabilizing nature of a two-level spondylectomy at the cervicothoracic junction, we first performed an instrumented spinal fusion posteriorly from C5 to T5 with allograft. During this first stage of the operation, we also performed an en bloc resection of the posterior elements by pedicle amputation. A single cut through the pedicle was made with an osteotome. The right T2 nerve was ligated. The right T1 nerve was encased in tumor and abnormally small. As we manipulated the posterior elements, we could not separate the T1 nerve. Because we did not want to violate the tumor and the nerve was so atretic, we ligated the T1 nerve. Post-operatively, the patient awoke with 4 /5 strength in her right hand. For the second stage, our cardiac surgery colleagues performed the median sternotomy to remove the pericardial mass, and we subsequently approached the spine in a left transcervical fashion. We removed the discs of C7-T1 and T2-3 and removed the posterior longitudinal ligaments. The vertebral bodies of T1 and T2 were inseparable because of tumor growth. We then removed the soft tissue surrounding T1 and T2, and both vertebral bodies were removed en bloc (Fig. 2). The anterior column was reconstructed with an expandable titanium cage, and arthrodesis was performed with allograft (Fig. 3). At two-year follow-up, the patient has local
D. Chou, V. Wang / Journal of Clinical Neuroscience 16 (2009) 698–700
699
Fig. 1. (A) A bone scan showing increased uptake at T1-2, (B) Axial CT scan showing the sclerotic lesion within the vertebral body, (C) Axial T1-weighted contrast enhanced MRI demonstrating osteosarcoma affecting both T1 and T2.
Fig. 2. Gross specimen with both T1 and T2 together, removed en bloc. This figure is available in colour at www.sciencedirect.com.
control of her disease, and she uses her right hand normally with 4+/5 strength. 3. Discussion Spondylectomies can be technically difficult, and multi-level spondylectomies can be even more challenging. In a recently pub-
lished en bloc spondylectomy series, which included multi-level spondylectomy, six were intralesional resections, which by definition does not make them ‘‘en bloc” resections.4 Hasegawa et al. recently reported their series of 13 patients, in which two patients underwent two-level spondylectomy in the thoracic spine.5 Neither of these patients, however, underwent the spondylectomy at the cervicothoracic junction.5 Murakami et al. reported a case of a multi-level spondylectomy at the cervicothoracic junction; however, this case involved complete spinal cord resection at the level.6 Kawahara et al. reported on a three-level spondylectomy at the thoracolumbar junction from an entirely posterior approach with ligation of the lower thoracic and high lumbar nerve roots.7 In our case, we felt that a two-level spondylectomy was important in order to give the patient the best chance at disease-free survival. One difficulty was the involvement of the T1 nerve root on the right side. The patient was right-handed, and we tried to preserve the T1 nerve root, but the tumor had so encased the root that we had to sacrifice it. Because the left-sided posterior elements did not contain tumor, we were able to separate them from the vertebral bodies using a small osteotome, preserving the left-sided nerve roots without difficulty. The vertebral bodies were separated from the posterior aspect of the spine by osteotomies through the pedicles at T1 and T2 bilaterally. There was a planned transgression of the tumor on the right side, but we felt that a single cut through the pedicle with tumor was still oncologically more sound than piecemeal resection of the posterior elements. After these osteotomies are performed and the posterior elements are removed, the only structures holding the vertebral bodies in place were the C7-T1 disc, the T2-3 disc, the anterior and posterior longitudinal ligaments, and the soft tissue surrounding the vertebral bodies. Once we cut the discs at C7-T1 and T2-3
700
D. Chou, V. Wang / Journal of Clinical Neuroscience 16 (2009) 698–700
Fig. 3. (A) Anterior-posterior, and (B) lateral radiographs showing final reconstruction of the spine.
and separated the anterior and posterior longitudinal ligaments, we separated the soft tissue with monopolar cautery and curette dissection. This allowed us to lift the two bodies out en bloc. We felt the technically most difficult portion of this operation was the amputation of the pedicles at T1-2 without disruption of the posterior elements. To assist with visualization, we performed laminectomies above T1 and below T3. We palpated the pediclevertebral body junction, and docked our osteotome at this point to perform our cuts. Monopolar cautery was used to release the transverse processes from the ribs. For the anterior portion, complete discetomies and removal of the posterior longitudinal ligament was performed in the standard fashion. 4. Conclusion A two-level en bloc spondylectomy at the cervicothoracic junction can be performed by separation of the posterior elements from the anterior elements. The most technically challenging aspect of this operation is en bloc removal of the posterior elements; however, with meticulous dissection and palpation of the pedicles,
the pedicle-vertebral body interface can be separated with small osteotomes.
References 1. Sundaresan N, Rosen G, Huvos AG, et al. Combined treatment of osteosarcoma of the spine. Neurosurgery 1988;23:714–9. 2. Talac R, Yaszemski MJ, Currier BL, et al. Relationship between surgical margins and local recurrence in sarcomas of the spine. Clin Orthop Relat Res 2002;397:127–32. 3. Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine 1997;22:324–33. 4. Liljenqvist U, Lerner T, Halm H, et al. En bloc spondylectomy in malignant tumors of the spine. Eur Spine J 2008;17:600–9. 5. Hasegawa K, Homma T, Hirano T, et al. Margin-free spondylectomy for extended malignant spine tumors: surgical technique and outcome of 13 cases. Spine 2007;32:142–8. 6. Murakami H, Tomita K, Kawahara N, et al. Complete segmental resection of the spine, including the spinal cord, for telangiectatic osteosarcoma: a report of 2 cases. Spine 2006;31:E117–22. 7. Kawahara N, Tomita K, Fujita T, et al. Osteosarcoma of the thoracolumbar spine: total en bloc spondylectomy. A case report. J Bone Joint Surg Am 1997;79: 453–8.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical Note
Two-level en bloc spondylectomy for osteosarcoma at the cervicothoracic junction Dean Chou *, Vincent Wang Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, Box 0112, San Francisco, California 94143-0112, USA
a r t i c l e
i n f o
Article history: Received 27 May 2008 Accepted 9 June 2008
Keywords: Osteosarcoma En bloc Cervicothoracic junction Spondylectomy Two-level spondylectomy
a b s t r a c t En bloc resection of osteosarcoma is critical for a chance at curing the disease. In the spine, a spondylectomy should be performed to optimize the chances of survival. Involvement of two contiguous segments in the spinal column poses technical challenges, and performing a spondylectomy at the cervicothoracic junction adds another set of clinical concerns. We present a 22-year-old female with a two-level vertebral involvement at the cervicothoracic junction who underwent a two-level en bloc spondylectomy for osteosarcoma, and we describe our technique. Ó 2008 Elsevier Ltd. All rights reserved.
1. Introduction Surgical margins are important in the treatment of osteosarcoma, and chemotherapy and en bloc resection combined are ideal for a chance at long-term survival.1,2 Spondylectomy is the ideal surgical technique for complete tumor removal with an attempt at a cure for such malignant tumors.3 A two-level spondylectomy at the cervicothoracic junction poses particular challenges, not only because of the need to remove two vertebral segments at once, but also because of the unique biomechanical properties at this transition zone. We describe our technique of performing a two-level en bloc spondylectomy at the cervicothoracic junction. 2. Case report 2.1. Case description and surgical technique A 22-year-old female presented to her primary care physician with upper thoracic pain. She underwent a CT scan of the chest, which demonstrated a 2nd and 3rd rib lesion. Thoracoscopic biopsy by cardiothoracic surgery of this lesion demonstrated osteosarcoma. Chemotherapy with VP-16 and ifosfamide was begun. She subsequently underwent a chest wall resection by the cardiothoracic team at the 2nd and 3rd ribs with a gross total resection of the lesion. At follow-up she received serial imaging and bone scans. At the 6-month post-operative bone scan, an area of increased uptake at T1 and T2 was noted (Fig. 1A). A CT scan of the chest demonstrated some pericardial calcification and sclerotic bone * Corresponding author. Tel.: +1 415 353 9095; fax: +1 415 353 3907. E-mail address: [email protected] (D. Chou). 0967-5868/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2008.06.016
affecting the T1 and T2 vertebral bodies (Fig. 1B). MRI showed enhancement in both the T1 and T2 vertebral bodies (Fig. 1C). Her case was reviewed by the tumor board, and it was felt that a total en bloc resection of this lesion was indicated, given her age and lack of systemic disease. Her pericardial calcification was suspicious for osteosarcoma, and the cardiothoracic surgeons felt it was important to remove this. We planned a combined procedure with them for access to the upper thoracic spine. We planned a two-stage operation with the posterior stage first and the anterior stage second. Given the destabilizing nature of a two-level spondylectomy at the cervicothoracic junction, we first performed an instrumented spinal fusion posteriorly from C5 to T5 with allograft. During this first stage of the operation, we also performed an en bloc resection of the posterior elements by pedicle amputation. A single cut through the pedicle was made with an osteotome. The right T2 nerve was ligated. The right T1 nerve was encased in tumor and abnormally small. As we manipulated the posterior elements, we could not separate the T1 nerve. Because we did not want to violate the tumor and the nerve was so atretic, we ligated the T1 nerve. Post-operatively, the patient awoke with 4 /5 strength in her right hand. For the second stage, our cardiac surgery colleagues performed the median sternotomy to remove the pericardial mass, and we subsequently approached the spine in a left transcervical fashion. We removed the discs of C7-T1 and T2-3 and removed the posterior longitudinal ligaments. The vertebral bodies of T1 and T2 were inseparable because of tumor growth. We then removed the soft tissue surrounding T1 and T2, and both vertebral bodies were removed en bloc (Fig. 2). The anterior column was reconstructed with an expandable titanium cage, and arthrodesis was performed with allograft (Fig. 3). At two-year follow-up, the patient has local
D. Chou, V. Wang / Journal of Clinical Neuroscience 16 (2009) 698–700
699
Fig. 1. (A) A bone scan showing increased uptake at T1-2, (B) Axial CT scan showing the sclerotic lesion within the vertebral body, (C) Axial T1-weighted contrast enhanced MRI demonstrating osteosarcoma affecting both T1 and T2.
Fig. 2. Gross specimen with both T1 and T2 together, removed en bloc. This figure is available in colour at www.sciencedirect.com.
control of her disease, and she uses her right hand normally with 4+/5 strength. 3. Discussion Spondylectomies can be technically difficult, and multi-level spondylectomies can be even more challenging. In a recently pub-
lished en bloc spondylectomy series, which included multi-level spondylectomy, six were intralesional resections, which by definition does not make them ‘‘en bloc” resections.4 Hasegawa et al. recently reported their series of 13 patients, in which two patients underwent two-level spondylectomy in the thoracic spine.5 Neither of these patients, however, underwent the spondylectomy at the cervicothoracic junction.5 Murakami et al. reported a case of a multi-level spondylectomy at the cervicothoracic junction; however, this case involved complete spinal cord resection at the level.6 Kawahara et al. reported on a three-level spondylectomy at the thoracolumbar junction from an entirely posterior approach with ligation of the lower thoracic and high lumbar nerve roots.7 In our case, we felt that a two-level spondylectomy was important in order to give the patient the best chance at disease-free survival. One difficulty was the involvement of the T1 nerve root on the right side. The patient was right-handed, and we tried to preserve the T1 nerve root, but the tumor had so encased the root that we had to sacrifice it. Because the left-sided posterior elements did not contain tumor, we were able to separate them from the vertebral bodies using a small osteotome, preserving the left-sided nerve roots without difficulty. The vertebral bodies were separated from the posterior aspect of the spine by osteotomies through the pedicles at T1 and T2 bilaterally. There was a planned transgression of the tumor on the right side, but we felt that a single cut through the pedicle with tumor was still oncologically more sound than piecemeal resection of the posterior elements. After these osteotomies are performed and the posterior elements are removed, the only structures holding the vertebral bodies in place were the C7-T1 disc, the T2-3 disc, the anterior and posterior longitudinal ligaments, and the soft tissue surrounding the vertebral bodies. Once we cut the discs at C7-T1 and T2-3
700
D. Chou, V. Wang / Journal of Clinical Neuroscience 16 (2009) 698–700
Fig. 3. (A) Anterior-posterior, and (B) lateral radiographs showing final reconstruction of the spine.
and separated the anterior and posterior longitudinal ligaments, we separated the soft tissue with monopolar cautery and curette dissection. This allowed us to lift the two bodies out en bloc. We felt the technically most difficult portion of this operation was the amputation of the pedicles at T1-2 without disruption of the posterior elements. To assist with visualization, we performed laminectomies above T1 and below T3. We palpated the pediclevertebral body junction, and docked our osteotome at this point to perform our cuts. Monopolar cautery was used to release the transverse processes from the ribs. For the anterior portion, complete discetomies and removal of the posterior longitudinal ligament was performed in the standard fashion. 4. Conclusion A two-level en bloc spondylectomy at the cervicothoracic junction can be performed by separation of the posterior elements from the anterior elements. The most technically challenging aspect of this operation is en bloc removal of the posterior elements; however, with meticulous dissection and palpation of the pedicles,
the pedicle-vertebral body interface can be separated with small osteotomes.
References 1. Sundaresan N, Rosen G, Huvos AG, et al. Combined treatment of osteosarcoma of the spine. Neurosurgery 1988;23:714–9. 2. Talac R, Yaszemski MJ, Currier BL, et al. Relationship between surgical margins and local recurrence in sarcomas of the spine. Clin Orthop Relat Res 2002;397:127–32. 3. Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine 1997;22:324–33. 4. Liljenqvist U, Lerner T, Halm H, et al. En bloc spondylectomy in malignant tumors of the spine. Eur Spine J 2008;17:600–9. 5. Hasegawa K, Homma T, Hirano T, et al. Margin-free spondylectomy for extended malignant spine tumors: surgical technique and outcome of 13 cases. Spine 2007;32:142–8. 6. Murakami H, Tomita K, Kawahara N, et al. Complete segmental resection of the spine, including the spinal cord, for telangiectatic osteosarcoma: a report of 2 cases. Spine 2006;31:E117–22. 7. Kawahara N, Tomita K, Fujita T, et al. Osteosarcoma of the thoracolumbar spine: total en bloc spondylectomy. A case report. J Bone Joint Surg Am 1997;79: 453–8.