User Tools

Site Tools


en_bloc_spondylectomy

En bloc spondylectomy

The rationale of en bloc spondylectomy is to allow a resection of the tumor in one piece together with a layer of healthy tissue (marginal or wide resection) and thus to reduce local recurrence rate and to improve long-term survival of the patients 1) 2) 3)

History

The first case of a total en bloc spondylectomy was published by Bertil Stener in 1971 in a case of chondrosarcoma of T6–T8 in a 49-year-old farmer 4).

Raymond Roy-Camille further standardized and popularized the technique 5) 6) 7) 8).

Larger series were published by Tomita et al. 9) and Fidler in 1994 10).

While Tomita’s technique was an all posterior procedure, Fidler preferred a combined simultaneous posteroanterior approach. Fidler’s series consisted of ten patients with mainly Giant cell tumors, whereas Tomita et al. reported on 20 patients with solitary spine metastases. In a later publication Tomita et al. reported on five patients with primary malignant tumors of the spine 11).

Further authors adopted and modified these techniques and published their results with series of between seven and 29 patients 12) 13) 14) 15) 16).

Surgical Technique

Videos

Case series

2016

To describe the specific surgical details and report the lessons learned with a series of patients suffering from spinal tumours that underwent total en bloc spondylectomy (TES).

A retrospective case series review is presented, together with an analysis of the clinical and technical variables, as well as the outcomes.

A total of 10 patients underwent TES (2000-2016) for primary (osteosarcoma, chondrosarcoma, fibrosarcoma and chordoma) and secondary spinal tumours (lung, breast, thyroid, oesophagus, and meningioma metastases). According to the Tomita classification, 2 patients had intra-compartmental tumours, and the rest presented as extra-compartmental. All patients experienced an improvement in their pain level after surgery. Nine patients preserved ambulation post-operatively and one patient developed paraplegia. Six patients needed subsequent operations for wound debridement, tumour recurrence, or revision of the fixation. Other complications included pneumothorax, pleural effusion and venous thrombosis. Four patients remain alive (4 months to 15 years follow-up). The rest died due to primary tumour progression (6.5 months to 12 years). A detailed description of the surgical steps, tips, and pitfalls is provided. Modifications of the technique and adjuncts to resection are commented on. Observation of some considerations (selection of candidates, careful blunt vertebral dissection, strict blood loss control, careful handling of the spinal cord, and maintenance of the radical resection concept at all stages) is key for a successful operative performance.

TES is a paradigmatic operation, in which the concept of radical resection provides functional effectiveness and improves survival in selected patients suffering from spinal tumours. Our preliminary experience allows us to highlight some specific and relevant features, especially those favouring a simpler and safer operation 17).


Aim of a study was to analyse the results of 21 patients with malignant lesions of the spine, all treated with en bloc excision in a combined posteroanterior (n = 19) or all posterior approach (n = 2). Twenty-one consecutive patients, operated between 1997 and 2005, were included into this retrospective study. Thirteen patients had primary malignant lesions, eight patients had solitary metastases, all located in the thoracolumbar spine. There were 16 single level, three two-level, one three-level and one four-level spondylectomy. The patients were followed clinically and radiographically (including CT studies) with an average follow-up of 4 years. Out of 11 patients with primary Ewing or osteosarcoma seven patients are alive without any evidence of disease. One patient died after 5 years from other causes and three are alive with evidence of disease. Latter had either a poor histologic response to the preoperative chemotherapy (n = 2) or an intralesional resection (n = 1). All three patients with solitary spinal metastases of Ewing or osteosarcoma died of the disease. Five patients with solitary metastases of mainly hypernephroma are alive. In total, six resections were intralesional, mainly due to large intraspinal tumor masses, with two patients having had previous surgery. In the remaining cases, wide (n = 10) or marginal (n = 5) resection was accomplished. There were one pseudarthrosis requiring extension of the fusion and two cases with local recurrences and repeated excisional surgery. At follow-up CT studies, all cages were fused. Health related quality of life analysis (SF-36) revealed only slightly decreased physical component and normal mental component scores compared to normals in those patients with no evidence of disease. En bloc spondylectomy enables wide or marginal resection of malignant lesions of the spine in most cases with acceptable morbidity. Intralesional resection, poor histologic response, and solitary spinal metastases of Ewing and osteosarcoma are associated with a poor prognosis 18).

1)
Boriani S, Weinstein J, Biagini R. Primary bone tumors of the spine. Spine. 1997;22:1036–1044. doi: 10.1097/00007632-199705010-00020.
2)
Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop. 1980;204:9–24.
3) , 14)
Fisher C, Keynan O, Boyd M, et al. The surgical management of primary tumors of the spine. Spine. 2005;30:1899–1908. doi: 10.1097/01.brs.0000174114.90657.74.
4)
Stener B. Total spondylectomy in chondrosarcoma arising from the seventh thoracic vertebra. J Bone Joint Surg Br. 1971 May;53(2):288-95. PubMed PMID: 4931082.
5)
Roy-Camille R, Mazel Ch, Sailant G, Lapresle Ph, et al. Treatment of malignant tumors of the spine with posterior instrumentation. In: Sundaresan N, Schmidek HH, Schiller AL, et al., editors. Tumors of the spine: diagnosis and clinical management. Philadelphia: Saunders; 1990. pp. 473–487.
6)
Roy-Camille R, Mazel Ch. Vertebrectomy through an enlarged posterior approach for tumors and malunions. In: Bridwell KH, Wald RL, editors. The text book of spinal surgery. Philadelphia: Lippincott; 1991. pp. 1245–1256.
7)
Roy-Camille R, Saillant G, Bisserie M, Judet T, Hautefort E, Mamoudy P. Total excision of thoracic vertebrae. Rev Chir Orthop Reparatrice Appar Mot. 1981;67:421–430.
8)
Roy-Camille R, Saillant G, Mazel Ch, Monpierre H. Total vertebrectomy as treatment of malignant tumors of the spine. Chir Organi Mov. 1990;75:94–96.
9)
Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy for solitary spinal metatases. Int Orthop. 1994;18:291–298. doi: 10.1007/BF00180229.
10)
Fidler MW. Radical resection of vertebral body tumours. J Bone Joint Surg. 1994;76-B:765–772.
11)
Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy. Spine. 1997;22:324–333. doi: 10.1097/00007632-199702010-00018.
12)
Boriani S, Biagini R, DeLure F. En bloc resections of bone tumors of the thoracolumbar spine. Spine. 1996;21:1927–1931. doi: 10.1097/00007632-199608150-00020.
13)
Boriani S, Chevally F, Weinstein J. Chordoma of the spine above the sacrum. Spine. 1996;21:1569–1577. doi: 10.1097/00007632-199607010-00017.
15)
Krepler P, Windhager R, Bretschneider W, et al. Total vertebrectomy for primary malignant tumours of the spine. J Bone Joint Surg. 2002;84-B:712–715. doi: 10.1302/0301-620X.84B5.12684.
16)
Mazel Ch, Grunenwald D, Laudrin P, Marmorat J. Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases. Spine. 2003;28:782–792. doi: 10.1097/00007632-200304150-00010.
17)
Delgado-López PD, Rodríguez-Salazar A, Martín-Velasco V, Castilla-Díez JM, Martín-Alonso J, Galacho-Harriero A, Gil-Polo C, Araus-Galdós E. [Total en bloc spondylectomy for spinal tumours: Technical aspects and surgical details]. Neurocirugia (Astur). 2016 Sep 14. pii: S1130-1473(16)30055-0. doi: 10.1016/j.neucir.2016.07.002. [Epub ahead of print] Spanish. PubMed PMID: 27639666.
18)
Liljenqvist U, Lerner T, Halm H, Buerger H, Gosheger G, Winkelmann W. En bloc spondylectomy in malignant tumors of the spine. Eur Spine J. 2008 Apr;17(4):600-9. doi: 10.1007/s00586-008-0599-8. Epub 2008 Jan 24. PubMed PMID: 18214553; PubMed Central PMCID: PMC2295282.
en_bloc_spondylectomy.txt · Last modified: 2019/03/19 19:39 by administrador