- Email: [email protected]
Two-level total en bloc lumbar spondylectomy with dural resection for metastatic renal cell carcinoma
70
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
Patients with active CS present a remarkable increase in cardiovascular risk, mainly due to dilated-hypertrophic cardiomyopathy1 with systolic dysfunction, which increases the risk for thrombo-embolic events in these patients.1 Also, there is an increase in the vascular risk secondary to atherosclerotic and lipid-related vascular damage,12 which may explain the brain infarction in our patient.12 4. Conclusions A 42-year-old, diabetic woman with CS of 5 years duration, secondary to an ectopic ACTH-producing lung tumor with a neurological profile secondary to a brain infarction in the left middle cerebral artery territory, is presented. A destructive lesion in the sphenoid sinus and sellar region was shown on CT and MRI. Plurihormonal pituitary adenoma, as well as pituitary apoplexy and features of a mucormycosis infection, were observed. Mucormycosis should be included in the differential diagnosis of lesions in the parasellar region and in CS. References 1. Onesti St, Wisniewski T, Post KD. Clinical versus subclinical pitutary apoplexy; presentation, surgical management, and outcome in 21 patients. Neurosurgery 1990;26:980–6.
2. Talmi YP, Goldschmied-Reouven A, Bakon M, et al. Rhino-orbital and rhino-orbito-cerebral mucormycosis. Otolaryngol Head Neck Surg 2002;127:22–31. 3. Iplikcioglu AC, Bek S, Bikmaz K, et al. Aspergillus pituitary abscess. Acta Neurochir (Wien) 2004;146:521–4. 4. Metellus P, Lerier O, Grisoli F. Abscess-like formation concomitant with pituitary adenoma in Cushing’s disease: a case report and pathological consideration. Br J Neurosurg 2002;16:373–5. 5. Rotman-Pikierly P, Patromnas N, Papanicoloau DA. Pituitary apoplexy induced by corticotrophin-releasing hormone in a patient with Cushing’s disease. Clin Endocrinol 2003;58:545–9. 6. Scanagatta P, Montresor E, Pergher S, et al. Cushing’s syndrome induced by bronchopulmonary carcinoid tumours: a review of 98 cases and our experience of two cases. Chir Ital 2004;56:63–70. 7. Calli C, Savas R, Parildar M, et al. Isolated pontine infarction due to rhinocerebral mucormycosis. Neuroradiology 1999;41:179–81. 8. Keane JR. Pituitary apoplexy presenting with epistaxis. J Clin Neuroophthalmol 1984;4:7–8. 9. Oliveira V, Costa A. Cerebral hematoma caused by mucormycosis. Rev Neurol 2001;33:951–93. 10. Urculo E, Aranzadi MJ, Villanua J. Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation. Brief report of special case. Acta Neurochir (Wien) 2005;147:341–2. 11. Taylor HC, McLean S, Monheim K. Resolution of Cushing’s disease followed by secondary adrenal insufficiency after anticoagulantassociated pituitary hemorrhage; report of cases and review of the literature. Endocr Pract 2003;9:147–51. 12. Mancini T, Kola B, Mantero F, et al. High cardiovascular risk in patients with Cushing’s syndrome according to 1999 WHO/ISH guidelines. Clin Endocrinol (Oxf) 2004;61:768–77.
doi:10.1016/j.jocn.2006.01.023
Two-level total en bloc lumbar spondylectomy with dural resection for metastatic renal cell carcinoma Henry E. Aryan a
a,b,*
, Frank L. Acosta a, Christopher P. Ames
a,b,*
Department of Neurological Surgery, University of California at San Francisco (UCSF), 400 Parnassus Avenue, A868, San Francisco, CA 94143-0350, USA b UCSF Spine Center, San Francisco, California, USA Received 29 November 2005; accepted 25 January 2006
Abstract Only five reports of multilevel spondylectomy for tumor have been reported in the literature, mostly in the thoracic spine. We report a successful two-level spondylectomy with en bloc dural resection in a patient with metastatic renal carcinoma to the L3 and L4 vertebrae. 2006 Elsevier Ltd. All rights reserved. Keywords: Spondylectomy; Lumbar spine; En bloc; Dural resection; Reconstruction; Tumor
*
Corresponding authors. Present address: UC San Diego, 200 W. Arbor Drive, Suite 8893, San Diego, CA 92103-8893, USA. Tel.: +415 3532979/ 8582203621; fax: +928 222 1700. E-mail addresses: [email protected], [email protected] (H.E. Aryan), [email protected] (C.P. Ames).
1. Introduction The vertebral column is the most common destination for skeletal metastases.1 En bloc spondylectomy has been
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
71
Fig. 1. Operative specimen comprising the L3 and L4 vertebral bodies with tumor.
proven effective to decrease local spread of spinal tumors. Furthermore, it has been shown that patients have the best outcome after total en bloc spondylectomy rather than radiation therapy alone.2 The total en bloc spondylectomy procedure, initially developed by Tomita et al.,3 has since been expanded to include multiple vertebrae for metastases to more than one level. These rare procedures are more commonly required in the thoracic spine. Only five cases of en bloc spondylectomy have been reported at the lower three lumbar vertebrae.2 Surgeries at this level are rare because of the unique anatomy of the lumbar spine. We present a patient with renal cell carcinoma spinal metastasis.1 We employed the anterior-posterior total spondylectomy
Fig. 2. Intra-operative photograph, posterior view, demonstrating spondylectomy, dural repair, and rod/screw construct.
procedure because it allows for an extralesional, marginal resection of the tumor and the involved vertebra. This patient had tumor affecting both the L3 and L4 vertebrae. 2. Case report The patient is a 60-year-old man with a history of renal cell carcinoma diagnosed 2 years prior to presentation. He presented with back pain and was initially found to have an L4 vertebral metastasis and was treated with a
Fig. 3. Anteroposterior (a) and lateral (b) post-operative imaging demonstrates intact segmental fixation with pedicle screws and anterior interbody expandable cage placement.
72
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
transpedicular partial corpectomy and vertebroplasty followed by radiosurgery 1 year prior to presentation. Follow-up imaging showed recurrent metastatic tumor growth involving the L3 and L4 vertebra. The spondylectomy was conducted in two stages. In the first stage, via a posterior approach, bilateral laminectomies were performed at L2 and L5, exposing the dura rostral and caudal to L3 and L4, respectively. The bilateral pedicles of L3 and L4 were then divided using an osteotome. En bloc resection of the paraspinous muscles of L4, tumor-infiltrated dura, and the entire posterior elements and neural arch of L3 and L4 was then performed. The dura was repaired with a patch graft. In the second stage, we performed an anterior L3 and L4 vertebrectomy with transection of the anterior longitudinal ligament and removal of the L2–3 and L4–5 discs. A single specimen of the L3 and L4 vertebral tumor was then removed (Fig. 1). Interbody fusion was then carried out using an expandable cage and lateral fixation with a screw/rod construct (Fig. 2). The patient initially had weakness of bilateral ilipsoas and right quadriceps muscles, which had improved to near-normal strength at 6 months. Postoperative imaging demonstrated intact segmental fixation with pedicle screws and anterior interbody expandable cage placement (Fig. 3a,b).
3. Discussion Metastases are the most common spinal column tumors. Approximately 18,000 new cases are diagnosed in North America each year, with up to 10% of cancer patients developing symptomatic secondary spinal lesions with multiple levels of involvement present in 40–70% of symptomatic cancer patients.4 Although the majority of symptomatic spinal metastases occur at the thoracic and cervical level, it has been demonstrated that the distribution of extradural metastasis is related to the size of the vertebrae, therefore a majority of nonsymptomatic spinal metastases occur in the larger vertebra of the lumbar spine.4 Although an aggressive treatment, total en bloc spondylectomy has proven beneficial in some patients with respect to increased survival rate, increased motility, and decreased pain, and also as an adjunct to radiation therapy.5 In spinal metastasis, a recent study demonstrated that each vertebra acts as a separate compartment surrounded by an anatomical barrier to neoplastic cells,2 thus suggesting that en bloc procedures may be beneficial. Total spondylectomy is, therefore, indicated for patients with primary spinal tumors or with isolated, solitary metastatic
doi:10.1016/j.jocn.2006.01.021
spinal disease when the primary tumor has been completely resected.2 Total spondylectomy was initially performed as a series of piecemeal resections. These small extractions led to significant tumor cell contamination and made it difficult to determine healthy tissue from neoplastic tissue. The posterior approach alone is not recommended for the lower lumbar vertebra because of the proximity of nerve roots, ureters, iliac vessels, and the iliopsoas muscle. The preferred method employs the two-stage anterior-posterior approach, with the second stage often performed the same day or within a few days of the first. With this method, there is less of a chance of injury to large vessels, the thecal sac, or cord or cauda equina.2 En bloc resection has been shown to improve median survival times and results in 5year survival rates of greater than 15%.5–8
4. Conclusion Although a highly invasive and aggressive procedure, the two-stage multilevel total spondylectomy can have favorable results in curative or palliative patient care. Utilizing the anterior-posterior approach, the one-level lumbar en bloc spondylectomy can be successfully expanded to two levels and is a useful approach to the treatment of select tumors of the lumbar spine.
References 1. Wetzel FT, Phillips FM. Management of metastatic disease of the spine. Orthop Clin North Am 2000;31:611–21. 2. Marmor E, Rhines LD, Weinberg JS, et al. Total en bloc lumbar spondylectomy. case report. J Neurosurg 2001;95 (Suppl.2):264–9. 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. Perrin RG. Metastatic tumors of the axial spine. Curr Opin Oncol 1992;4:525–32. 5. Yao KC, Boriani S, Gokaslan ZL, et al. En bloc spondylectomy for spinal metastases: a review of techniques. Neurosurg Focus 2003;15:E6. 6. Sakaura H, Hosono N, Mukai Y, et al. Outcome of total en bloc spondylectomy for solitary metastasis of the thoracolumbar spine. J Spinal Disord Tech 2004;17:297–300. 7. Abe E, Kobayashi T, Murai H, et al. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord 2001;14:237–46. 8. Heary RF, Vaccaro AR, Benevenia J, et al. ‘‘En-bloc’’ vertebrectomy in the mobile lumbar spine. Surg Neurol 1998;50:548–56.
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
Patients with active CS present a remarkable increase in cardiovascular risk, mainly due to dilated-hypertrophic cardiomyopathy1 with systolic dysfunction, which increases the risk for thrombo-embolic events in these patients.1 Also, there is an increase in the vascular risk secondary to atherosclerotic and lipid-related vascular damage,12 which may explain the brain infarction in our patient.12 4. Conclusions A 42-year-old, diabetic woman with CS of 5 years duration, secondary to an ectopic ACTH-producing lung tumor with a neurological profile secondary to a brain infarction in the left middle cerebral artery territory, is presented. A destructive lesion in the sphenoid sinus and sellar region was shown on CT and MRI. Plurihormonal pituitary adenoma, as well as pituitary apoplexy and features of a mucormycosis infection, were observed. Mucormycosis should be included in the differential diagnosis of lesions in the parasellar region and in CS. References 1. Onesti St, Wisniewski T, Post KD. Clinical versus subclinical pitutary apoplexy; presentation, surgical management, and outcome in 21 patients. Neurosurgery 1990;26:980–6.
2. Talmi YP, Goldschmied-Reouven A, Bakon M, et al. Rhino-orbital and rhino-orbito-cerebral mucormycosis. Otolaryngol Head Neck Surg 2002;127:22–31. 3. Iplikcioglu AC, Bek S, Bikmaz K, et al. Aspergillus pituitary abscess. Acta Neurochir (Wien) 2004;146:521–4. 4. Metellus P, Lerier O, Grisoli F. Abscess-like formation concomitant with pituitary adenoma in Cushing’s disease: a case report and pathological consideration. Br J Neurosurg 2002;16:373–5. 5. Rotman-Pikierly P, Patromnas N, Papanicoloau DA. Pituitary apoplexy induced by corticotrophin-releasing hormone in a patient with Cushing’s disease. Clin Endocrinol 2003;58:545–9. 6. Scanagatta P, Montresor E, Pergher S, et al. Cushing’s syndrome induced by bronchopulmonary carcinoid tumours: a review of 98 cases and our experience of two cases. Chir Ital 2004;56:63–70. 7. Calli C, Savas R, Parildar M, et al. Isolated pontine infarction due to rhinocerebral mucormycosis. Neuroradiology 1999;41:179–81. 8. Keane JR. Pituitary apoplexy presenting with epistaxis. J Clin Neuroophthalmol 1984;4:7–8. 9. Oliveira V, Costa A. Cerebral hematoma caused by mucormycosis. Rev Neurol 2001;33:951–93. 10. Urculo E, Aranzadi MJ, Villanua J. Aspergillus granuloma of the cavernous sinus: magnetic resonance imaging with pathologic correlation. Brief report of special case. Acta Neurochir (Wien) 2005;147:341–2. 11. Taylor HC, McLean S, Monheim K. Resolution of Cushing’s disease followed by secondary adrenal insufficiency after anticoagulantassociated pituitary hemorrhage; report of cases and review of the literature. Endocr Pract 2003;9:147–51. 12. Mancini T, Kola B, Mantero F, et al. High cardiovascular risk in patients with Cushing’s syndrome according to 1999 WHO/ISH guidelines. Clin Endocrinol (Oxf) 2004;61:768–77.
doi:10.1016/j.jocn.2006.01.023
Two-level total en bloc lumbar spondylectomy with dural resection for metastatic renal cell carcinoma Henry E. Aryan a
a,b,*
, Frank L. Acosta a, Christopher P. Ames
a,b,*
Department of Neurological Surgery, University of California at San Francisco (UCSF), 400 Parnassus Avenue, A868, San Francisco, CA 94143-0350, USA b UCSF Spine Center, San Francisco, California, USA Received 29 November 2005; accepted 25 January 2006
Abstract Only five reports of multilevel spondylectomy for tumor have been reported in the literature, mostly in the thoracic spine. We report a successful two-level spondylectomy with en bloc dural resection in a patient with metastatic renal carcinoma to the L3 and L4 vertebrae. 2006 Elsevier Ltd. All rights reserved. Keywords: Spondylectomy; Lumbar spine; En bloc; Dural resection; Reconstruction; Tumor
*
Corresponding authors. Present address: UC San Diego, 200 W. Arbor Drive, Suite 8893, San Diego, CA 92103-8893, USA. Tel.: +415 3532979/ 8582203621; fax: +928 222 1700. E-mail addresses: [email protected], [email protected] (H.E. Aryan), [email protected] (C.P. Ames).
1. Introduction The vertebral column is the most common destination for skeletal metastases.1 En bloc spondylectomy has been
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
71
Fig. 1. Operative specimen comprising the L3 and L4 vertebral bodies with tumor.
proven effective to decrease local spread of spinal tumors. Furthermore, it has been shown that patients have the best outcome after total en bloc spondylectomy rather than radiation therapy alone.2 The total en bloc spondylectomy procedure, initially developed by Tomita et al.,3 has since been expanded to include multiple vertebrae for metastases to more than one level. These rare procedures are more commonly required in the thoracic spine. Only five cases of en bloc spondylectomy have been reported at the lower three lumbar vertebrae.2 Surgeries at this level are rare because of the unique anatomy of the lumbar spine. We present a patient with renal cell carcinoma spinal metastasis.1 We employed the anterior-posterior total spondylectomy
Fig. 2. Intra-operative photograph, posterior view, demonstrating spondylectomy, dural repair, and rod/screw construct.
procedure because it allows for an extralesional, marginal resection of the tumor and the involved vertebra. This patient had tumor affecting both the L3 and L4 vertebrae. 2. Case report The patient is a 60-year-old man with a history of renal cell carcinoma diagnosed 2 years prior to presentation. He presented with back pain and was initially found to have an L4 vertebral metastasis and was treated with a
Fig. 3. Anteroposterior (a) and lateral (b) post-operative imaging demonstrates intact segmental fixation with pedicle screws and anterior interbody expandable cage placement.
72
Case Reports / Journal of Clinical Neuroscience 15 (2008) 70–72
transpedicular partial corpectomy and vertebroplasty followed by radiosurgery 1 year prior to presentation. Follow-up imaging showed recurrent metastatic tumor growth involving the L3 and L4 vertebra. The spondylectomy was conducted in two stages. In the first stage, via a posterior approach, bilateral laminectomies were performed at L2 and L5, exposing the dura rostral and caudal to L3 and L4, respectively. The bilateral pedicles of L3 and L4 were then divided using an osteotome. En bloc resection of the paraspinous muscles of L4, tumor-infiltrated dura, and the entire posterior elements and neural arch of L3 and L4 was then performed. The dura was repaired with a patch graft. In the second stage, we performed an anterior L3 and L4 vertebrectomy with transection of the anterior longitudinal ligament and removal of the L2–3 and L4–5 discs. A single specimen of the L3 and L4 vertebral tumor was then removed (Fig. 1). Interbody fusion was then carried out using an expandable cage and lateral fixation with a screw/rod construct (Fig. 2). The patient initially had weakness of bilateral ilipsoas and right quadriceps muscles, which had improved to near-normal strength at 6 months. Postoperative imaging demonstrated intact segmental fixation with pedicle screws and anterior interbody expandable cage placement (Fig. 3a,b).
3. Discussion Metastases are the most common spinal column tumors. Approximately 18,000 new cases are diagnosed in North America each year, with up to 10% of cancer patients developing symptomatic secondary spinal lesions with multiple levels of involvement present in 40–70% of symptomatic cancer patients.4 Although the majority of symptomatic spinal metastases occur at the thoracic and cervical level, it has been demonstrated that the distribution of extradural metastasis is related to the size of the vertebrae, therefore a majority of nonsymptomatic spinal metastases occur in the larger vertebra of the lumbar spine.4 Although an aggressive treatment, total en bloc spondylectomy has proven beneficial in some patients with respect to increased survival rate, increased motility, and decreased pain, and also as an adjunct to radiation therapy.5 In spinal metastasis, a recent study demonstrated that each vertebra acts as a separate compartment surrounded by an anatomical barrier to neoplastic cells,2 thus suggesting that en bloc procedures may be beneficial. Total spondylectomy is, therefore, indicated for patients with primary spinal tumors or with isolated, solitary metastatic
doi:10.1016/j.jocn.2006.01.021
spinal disease when the primary tumor has been completely resected.2 Total spondylectomy was initially performed as a series of piecemeal resections. These small extractions led to significant tumor cell contamination and made it difficult to determine healthy tissue from neoplastic tissue. The posterior approach alone is not recommended for the lower lumbar vertebra because of the proximity of nerve roots, ureters, iliac vessels, and the iliopsoas muscle. The preferred method employs the two-stage anterior-posterior approach, with the second stage often performed the same day or within a few days of the first. With this method, there is less of a chance of injury to large vessels, the thecal sac, or cord or cauda equina.2 En bloc resection has been shown to improve median survival times and results in 5year survival rates of greater than 15%.5–8
4. Conclusion Although a highly invasive and aggressive procedure, the two-stage multilevel total spondylectomy can have favorable results in curative or palliative patient care. Utilizing the anterior-posterior approach, the one-level lumbar en bloc spondylectomy can be successfully expanded to two levels and is a useful approach to the treatment of select tumors of the lumbar spine.
References 1. Wetzel FT, Phillips FM. Management of metastatic disease of the spine. Orthop Clin North Am 2000;31:611–21. 2. Marmor E, Rhines LD, Weinberg JS, et al. Total en bloc lumbar spondylectomy. case report. J Neurosurg 2001;95 (Suppl.2):264–9. 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. Perrin RG. Metastatic tumors of the axial spine. Curr Opin Oncol 1992;4:525–32. 5. Yao KC, Boriani S, Gokaslan ZL, et al. En bloc spondylectomy for spinal metastases: a review of techniques. Neurosurg Focus 2003;15:E6. 6. Sakaura H, Hosono N, Mukai Y, et al. Outcome of total en bloc spondylectomy for solitary metastasis of the thoracolumbar spine. J Spinal Disord Tech 2004;17:297–300. 7. Abe E, Kobayashi T, Murai H, et al. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord 2001;14:237–46. 8. Heary RF, Vaccaro AR, Benevenia J, et al. ‘‘En-bloc’’ vertebrectomy in the mobile lumbar spine. Surg Neurol 1998;50:548–56.