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Gasbarrini A, Pasini S, Fu Z, Ghermandi R, Pipola V, Gargiulo M, Innocenti M, Boriani S. EnBloc Resection of a Chordoma of the Thoracic Spine by "L"-Shaped Osteotomy for Spinal Canal Preservation. J Clin Med 2025; 14:349. [PMID: 39860358 PMCID: PMC11766227 DOI: 10.3390/jcm14020349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 11/27/2024] [Accepted: 01/02/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: EnBloc resections of bone tumors of the spine are very demanding as the target to achieve a tumor-free margin specimen (sometimes impossible due to the extracompartimental tumor extension) is sometimes conflicting with the integrity of neurological functions and spine stability. Methods: The surgical treatment of a huge multi-level chordoma of the thoracic spine with unusual extension is reported. Anteriorly, the tumor widely invaded the mediastinum and displaced the aorta; on the left side, it expanded in the subpleuric region; posteriorly, it was uncommonly distant 13 mm from the posterior wall. Results: EnBloc resection is largely performed for primary bone tumors of the spine and many reports have been published concerning brilliant solutions to difficult issues of surgical anatomy. One of the major challenges is still the compatibility between oncological and functional requirements. Conclusions: Oncological staging, careful imaging analysis, a multidisciplinary surgical team, and utilization of the most recent technologies like navigation and robotics have made an oncologically appropriate EnBloc resection of a multi-level chordoma of the thoracic spine possible without affecting the continuity of the spinal canal and without any involvement of its content by an original "L"-shaped osteotomy.
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Affiliation(s)
- Alessandro Gasbarrini
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy
| | - Stefano Pasini
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Zhaozong Fu
- Department of Spine Surgery, Jiangmen Central Hospital, Jiangmen 529030, China;
| | - Riccardo Ghermandi
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Valerio Pipola
- Spine Surgery Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (A.G.); (R.G.); (V.P.)
| | - Mauro Gargiulo
- Vascular Surgery Department, IRCCS Policlinico di Sant’Orsola, 40138 Bologna, Italy;
| | - Marco Innocenti
- Orthoplasty Department, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Stefano Boriani
- Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy;
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Xue S, Xu N, Liu S, Yan M, Tian Y, Hung K, Liu Z, Wang S. Using additive manufacturing for craniocervical reconstruction in traditionally challenging cases. Neurosurg Rev 2024; 47:871. [PMID: 39586929 DOI: 10.1007/s10143-024-03104-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 10/28/2024] [Accepted: 11/11/2024] [Indexed: 11/27/2024]
Abstract
Retrospective case series. The aim of this study was to evaluate the clinical outcomes and effectiveness of using 3D printed implants in upper cervical spine and occipitocervical junction surgery. C2 primary tumor patients who required axial en bloc resection and other patients who required partial bone decompression using customized 3D printed implants or fixation devices for surgery were included. Evaluate the stability and surgical outcomes of 3D printed implants through perioperative and follow-up period. Five tumor patients underwent reconstruction using customized 3D printed artificial vertebral bodies, while another five patients with atlantoaxial joint dislocation underwent reduction and decompression using customized 3D printed internal fixation devices. The postoperative imaging results showed that the 3D printed structures had good immediate stability and had no signs of displacement or subsidence. Follow up showed that all five cases of vertebral body reconstruction had achieved fusion. Only one patient died one month after surgery due to infection and respiratory difficulties. Other patients showed excellent improvement in neurological function in follow up. The use of 3D printed implants in surgery involving the occipitocervical area is a feasible and reliable alternative choice. It is a valuable attempt for complex atlantoaxial dislocation that cannot be treated with conventional instruments. 3D printed implants can improve the safety and accuracy of surgery, provide good immediate stability, have a low incidence of subsidence, fewer related complications during the follow-up period.
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Affiliation(s)
- Shilin Xue
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Peking University Health Science Center, Beijing, China
| | - Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Shanshan Liu
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
| | - Ming Yan
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Yinglun Tian
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Kanlin Hung
- Peking University Health Science Center, Beijing, China
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China.
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
| | - Shenglin Wang
- Department of Orthopaedics, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, China.
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
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Tavares Junior MCM, Morale V, Soares LDS, Teixeira WGJ, Narazaki DK. Parasagittal resection of multilevel cervical chordoma with autograft duraplasty and unilateral vertebral artery ligation: A case report and literature review. Radiol Case Rep 2024; 19:1181-1189. [PMID: 38259708 PMCID: PMC10801135 DOI: 10.1016/j.radcr.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Chordomas are rare tumors and the recommended course of treatment typically entails surgical resection, which presents significant challenges owing to the anatomical location commonly involved and the inherent resistance of these lesions to radiation and chemotherapy. This case report details the experience of a 61-year-old male who underwent a parasagittal resection spanning from C1 to C4. A durotomy was executed to enable en bloc excision of the tumor. Subsequently, a duraplasty procedure was implemented, utilizing autologous muscle fascia grafting. A comprehensive analysis of the pertinent literature was conducted to underscore the key clinical aspects and outcomes related to this topic.
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Affiliation(s)
| | - Victor Morale
- Cancer Institute of Sao Paulo State – Oncologic Orthopedic Spinal Surgery Division, University of Sao Paulo, Sao Paulo, Brazil
| | - Lucas de Sousa Soares
- Cancer Institute of Sao Paulo State – Oncologic Orthopedic Spinal Surgery Division, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Douglas Kenji Narazaki
- Cancer Institute of Sao Paulo State – Oncologic Orthopedic Spinal Surgery Division, University of Sao Paulo, Sao Paulo, Brazil
- DWO Medicos Associados, Sao Paulo, Brazil
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Iwai C, Nozawa S, Fushimi K, Yamada K, Akiyama H. Surgical Management of Intraosseous Neurofibroma in Cervical Spine: A Case Report. JBJS Case Connect 2024; 14:01709767-202403000-00029. [PMID: 38341863 DOI: 10.2106/jbjs.cc.23.00480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
CASE A 30-year-old man had cervical radiculomyelopathy and neck pain caused by a massive intraosseous neurofibroma (IONF) originating from the C6 vertebrae. We performed posterior tumor resection with spinal instrumentation and fusion from C3 to T2 and a follow-up resection procedure of the remaining C6 anterior tumor, sacrificing the affected vertebral artery (VA), which accordingly required bypass surgery at 2 months recovery. Reconstruction using a titanium mesh cage was successfully performed. There were no local recurrences at 2 years postoperatively. CONCLUSIONS Total tumor resection split into 2 stages with sacrifice of the affected VA is a feasible option for treatment of IONF.
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Affiliation(s)
- Chizuo Iwai
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Satoshi Nozawa
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazunari Fushimi
- Department of Orthopaedic Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Kazunari Yamada
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Haruhiko Akiyama
- Department of Orthopaedic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
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Haddad M, Rimawi L, Hussein M, Al-Mollah M, Maani W. A case report of Sustained triumph: 15-year recurrence-free survival following surgical resection of a cervical chordoma in a 15-year-old girl. Ann Med Surg (Lond) 2024; 86:565-570. [PMID: 38222716 PMCID: PMC10783405 DOI: 10.1097/ms9.0000000000001545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/17/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction and importance Chordoma of the cervical spine is a rare condition associated with poor long-term outcomes. This is mainly attributed to its pathological involvement of vital structures such as the cervical roots and vertebral artery (VA). Although the most appropriate management in these cases is total en bloc excision, attaining complete resection is relatively challenging due to the vicinity of the critical anatomical structures mentioned above. Case description A 15-year-old female with middle cervical spine chordoma was treated by a multidisciplinary team involving neurosurgery and head and neck surgeons utilizing anterior and posterior approaches followed by high-beam X-ray radiotherapy. Histopathological examination matched the description of a chordoma. Fifteen years after the initial excision, the patient maintained her normal neurological function without local recurrence or metastasis. Clinical discussion The patient underwent surgery in two stages. A posterior approach for C3, C4, and C5 laminectomies was performed in the first stage, with the second stage involving head and neck surgery for complete resection of the tumor. The patient also underwent radiotherapy 3 months after surgery for a total duration of 1 month. The patient is currently 30 years old with no evidence of chordoma recurrence. Conclusion Patients afflicted with cervical chordomas often find themselves undergoing multiple operations due to high recurrence rates. Fortunately, the utilization of en bloc resection coupled with adjuvant radiotherapy presents a hopeful treatment modality that can serve to substantially reduce recurrence rates, increase survival rates, and ultimately enhance the quality of life.
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Affiliation(s)
| | | | | | - Mustafa Al-Mollah
- Department of Neurosurgery, Jordan University Hospital Amman, Jordan
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Jeon JW, Kang KW, Kim WK, Yang S, Kang BJ. Cervical spine reconstruction after total vertebrectomy using customized three-dimensional-printed implants in dogs. J Vet Sci 2024; 25:e2. [PMID: 38311317 PMCID: PMC10839172 DOI: 10.4142/jvs.23241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Sufficient surgical resection is necessary for effective tumor control, but is usually limited for vertebral tumors, especially in the cervical spine in small animal neurosurgery. OBJECTIVE To evaluate the primary stability and safety of customized three-dimensional (3D)-printed implants for cervical spine reconstruction after total vertebrectomy. METHODS Customized guides and implants were designed based on computed tomography (CT) imaging of five beagle cadavers and were 3D-printed. They were used to reconstruct C5 after total vertebrectomy. Postoperative CT images were obtained to evaluate the safety and accuracy of screw positioning. After harvesting 10 vertebral specimens (C3-C7) from intact (group A) and implanted spines (group B), implant stability was analyzed using a 4-point bending test comparing with groups A and C (reconstituted with plate and pins/polymethylmethacrylate after testing in Group A). RESULTS All customized implants were applied without gross neurovascular damage. In addition, 90% of the screws were in a safe area, with 7.5% in grade 1 (< 1.3 mm) and 2.5% in grade 2 (> 1.3 mm). The mean entry point and angular deviations were 0.81 ± 0.43 mm and 6.50 ± 5.11°, respectively. Groups B and C significantly decreased the range of motion (ROM) in C3-C7 compared with intact spines (p = 0.033, and 0.018). Both groups reduced overall ROM and neutral zone in C4-C6, but only group B showed significance (p = 0.005, and 0.027). CONCLUSION Customized 3D-printed implants could safely and accurately replace a cervical vertebra in dog cadavers while providing primary stability.
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Affiliation(s)
- Ji-Won Jeon
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Kyu-Won Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
| | - Woo-Keyoung Kim
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul 08826, Korea
| | - Sook Yang
- CUSMEDI Co., Ltd., Suwon 16675, Korea
| | - Byung-Jae Kang
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, Seoul 08826, Korea
- BK21 FOUR Future Veterinary Medicine Leading Education and Research Center, Seoul National University, Seoul 08826, Korea.
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Berjano P, Baroncini A, Cecchinato R, Langella F, Boriani S. En-bloc resection of a chordoma in L3 by a combined open posterior and less invasive retroperitoneal approach: technical description and case report. Arch Orthop Trauma Surg 2023; 143:801-808. [PMID: 34562120 DOI: 10.1007/s00402-021-04177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To fulfill oncological criteria, extensive open anterior and posterior approaches are usually performed in the lumbar spine to obtain an appropriate en-bloc spondylectomy. It is commonly accepted that the price of a tumor-free margin includes such extensive incisions and soft-tissue damage, with consequent relevant blood loss and possible postoperative complications as delayed wound healing. In this article, a case of chordoma in L3 is presented, submitted to an oncologically appropriate en-bloc resection performed by an open posterior approach combined with a mini-retroperitoneal approach. The successful oncologic procedure was combined with a short and uneventful postoperative course. MATERIALS AND METHODS The authors present the surgical technique and the possible challenges of minimally invasive anterior oncologic surgery as a contribution to a limited literature. RESULTS Up to date, palliative care of single metastases has been the main setting in which anterior, minimally invasive surgery has been performed in the lumbar spine. The authors explained how, in selected cases, this approach can be performed in combination with an open posterior access for an oncologically appropriate treatment of a primary malignant tumor. CONCLUSION Anterior, minimally invasive surgery can have a role in selected patients with primary malignant tumors of the lumbar spine. The surgical team should have extensive training both in oncologic and minimally invasive surgery.
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Affiliation(s)
- Pedro Berjano
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Alice Baroncini
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Department of Orthopaedics, RWTH Uniklinik Aachen, Aachen, Germany.
| | - Riccardo Cecchinato
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Francesco Langella
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Stefano Boriani
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
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Pinter ZW, Moore EJ, Rose PS, Nassr AN, Currier BL. En bloc resection of a high cervical chordoma followed by reconstruction with a free vascularized fibular graft: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22305. [PMID: 36536523 PMCID: PMC9764371 DOI: 10.3171/case22305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/12/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Wide excision of chordoma provides better local control than intralesional resection or definitive radiotherapy. The en bloc excision of high cervical chordomas is a challenging endeavor because of the complex anatomy of this region and limited reconstructive options. OBSERVATIONS This is the first case report to describe reconstruction with a free vascularized fibular graft following the en bloc excision of a chordoma involving C1-3. LESSONS This report demonstrates the durability of this construct at 10-year follow-up and is the first case report demonstrating satisfactory long-term oncological outcomes after a true margin-negative resection of a high cervical chordoma.
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Affiliation(s)
| | - Eric J. Moore
- Department of Otorhinolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Peter S. Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Ahmad N. Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota; and
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Hu P, Du S, Wei F, Zhai S, Zhou H, Liu X, Liu Z. Reconstruction after resection of C2 vertebral tumors: A comparative study of 3D-printed vertebral body versus titanium mesh. Front Oncol 2022; 12:1065303. [PMID: 36601475 PMCID: PMC9806260 DOI: 10.3389/fonc.2022.1065303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Surgical resection of C2 vertebral tumors is challenging owing to the complex anatomy of C2 vertebrae and the challenges to surgical exposure. Various surgical approaches are available, but some are associated with excessively high risks of complications. An additional challenge is reconstruction of the upper cervical spine following surgery. In the last decade, additive-manufacturing personalized artificial vertebral bodies (AVBs) have been introduced for the repair of large, irregular bony defects; however, their use and efficacy in upper cervical surgery have not been well addressed. Therefore, in this study, we compared instrumented fixation status between patients who underwent conventional titanium mesh reconstruction and those who underwent the same resection but with personalized AVBs. Methods We performed a retrospective comparative study and recruited a single-institution cohort of patients with C2 vertebral tumors. Clinical data and imaging findings were reviewed. Through data processing and comparative analysis, we described and discussed the feasibility and safety of surgical resection and the outcomes of hardware implants. The primary outcome of this study was instrumented fixation status. Results The 31 recruited patients were divided into two groups. There were 13 patients in group A who underwent conventional titanium mesh reconstruction and 18 group B patients who underwent personalized AVBs. All patients underwent staged posterior and anterior surgical procedures. In the cohort, 9.7% achieved total en bloc resection of the tumor, while gross total resection was achieved in the remaining 90.3%. The perioperative complication and mortality rates were 45.2% and 6.5%, respectively. The occurrence of perioperative complications was related to the choice of anterior approach (p < 0.05). Group A had a higher complication rate than group B (p < 0.05). Four patients (4/13, 30.8%) developed hardware problems during the follow-up period; however, this rate was marginally higher than that of group B (1/18, 5.6%). Conclusions Total resection of C2 vertebral tumors was associated with a high risk of perioperative complications. The staged posterior and retropharyngeal approaches are better surgical strategies for C2 tumors. Personalized AVBs can provide a reliable reconstruction outcome, yet minor pitfalls remain that call for further modification.
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Affiliation(s)
- Panpan Hu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Suiyong Du
- Department of Spine Surgery, 521 Hospital of Norinco Group, Xi’an, China
| | - Feng Wei
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,*Correspondence: Feng Wei,
| | - Shuheng Zhai
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Hua Zhou
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Zhongjun Liu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
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Jabbar R, Jankowski J, Pawełczyk A, Szmyd B, Solek J, Pierzak O, Wojdyn M, Radek M. Cervical Paraspinal Chordoma: A Literature Review with a Novel Case Report. J Clin Med 2022; 11:jcm11144117. [PMID: 35887879 PMCID: PMC9325254 DOI: 10.3390/jcm11144117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023] Open
Abstract
Chordomas are rare malignant neoplasms, accounting for 1–4% of all primary bone tumors. Most spinal chordomas occur in the sacrococcygeal region and the base of the skull; however, 6% of chordomas are observed in the cervical spine. In these cases, the lesion is mainly located in the midline. These tumors slowly grow before becoming symptomatic and encase the surrounding vascular and nerve structures. Patients with advanced chordoma have a poor prognosis due to local recurrence with infiltration and destruction of adjacent bone and tissues. Systemic chemotherapy options have not been fully effective in these tumors, especially for recurrent chordomas. Thus, new combinations of currently available targeted molecular and biological therapies with radiotherapy have been proposed as potential treatment modalities. Here, the present paper describes the case of a 41-year-old male with a C2–C4 chordoma located paravertebrally, who underwent surgical resection with a debulking procedure for a cervical chordoma. Computed tomography angiography revealed a paraspinal mass with bone remodeling and the MRI showed a paravertebral mass penetrating to the spinal canal with a widening of the intervertebral C2–C3 foramen. Initially, the tumor was diagnosed as schwannoma based on its localization and imaging features; however, the histopathology specimen confirmed the diagnosis of chordoma. This case study highlights the effectivity of radical surgical resection as a mainstay treatment for chordomas, discusses neuroimaging, diagnosis, and the use of currently available targeted therapies and forthcoming treatment strategies, as alternative treatment options for chordoma.
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Affiliation(s)
- Redwan Jabbar
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Jakub Jankowski
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Agnieszka Pawełczyk
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Bartosz Szmyd
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Julia Solek
- Department of Pathology, Chair of Oncology, Medical University of Lodz, 92-213 Lodz, Poland;
| | - Olaf Pierzak
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Maciej Wojdyn
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
| | - Maciej Radek
- Department of Neurosurgery, Spine and Peripheral Nerve Surgery, Medical University of Lodz, 90-549 Lodz, Poland; (R.J.); (J.J.); (A.P.); (B.S.); (O.P.); (M.W.)
- Correspondence:
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Molina-Martínez RP, Medina-Illueca VD, Betancourt-Quiroz C, Vega-Moreno DA, Moral-Naranjo AA, Vicuña-González RM, Llamas-Ceras ML, Reyes-Rodríguez VA, Hernández-Reséndiz RE, la Torre AID, García-González U. 360-surgery for a giant cervical chordoma with involvement of the right vertebral artery. Surg Neurol Int 2021; 12:604. [PMID: 34992921 PMCID: PMC8720446 DOI: 10.25259/sni_1075_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/16/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Chordomas are malignant tumors that arise from the remnants of the notochord. Complete en bloc radical resection with postoperative radiation therapy is currently considered the gold standard. Here, we performed a 360-staged approach to manage a C3-C4 chordoma that involved the right vertebral artery. CASE DESCRIPTION A 40-year-old woman presented with a C3-C4 chordoma that invaded the right vertebral artery. She responded well to a circumferential approach including resection and stabilization. CONCLUSION A 40-year-old woman with a C3-C4 spinal chordoma was optimally managed with a combined anterior/posterior surgical approach including decompression/fusion.
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Affiliation(s)
| | | | - Carlos Betancourt-Quiroz
- Department of Neurosurgery, Hospital Central Sur de Alta Especialidad PEMEX, Tlalpan, Ciudad de México, México
| | | | | | - Rosa María Vicuña-González
- Department of Pathology, Hospital Central Sur de Alta Especialidad PEMEX, Tlalpan, Ciudad de México, México
| | | | | | | | - Abraham Ibarra-de la Torre
- Department of Neurosurgery, Hospital Central Sur de Alta Especialidad PEMEX, Tlalpan, Ciudad de México, México
| | - Ulises García-González
- Department of Neurosurgery, Hospital Central Sur de Alta Especialidad PEMEX, Tlalpan, Ciudad de México, México
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Pennington Z, Westbroek EM, Lo SFL, Sciubba DM. Surgical Approaches to Tumors of the Occipito-Cervical, Subaxial Cervical, and Cervicothoracic Spine: An Algorithm for Standard versus Extended Anterior Cervical Access. World Neurosurg 2021; 156:e41-e56. [PMID: 34508912 DOI: 10.1016/j.wneu.2021.08.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To propose a surgical approach algorithm for the tumors of the cervicothoracic spine. METHODS All patients operated for vertebral column tumors involving the occipito-cervicothoracic spine were reviewed. Oncologic characteristics and surgical approach were gathered. Approach was classified by the use of staging and trajectory (posterior, transnasal, transoral, transmandibular, transcervical, transsternal). Angle of attack was defined for the occipitocervical junction tumor as the angle inscribed by the inferior mandibular plane and line connecting the superior tumor pole and mandibular angle. For lesions extending below the thoracic inlet, angle of attack was that inscribed by the plane of the thoracic inlet and the line connecting the jugular notch and inferior tumor pole. RESULTS In total, 115 patients were included (mean age 56.7 years, 64 [56%] male, average size 26.5 cm3, 39 [34%] primary tumors). Sixty-nine (60%) of patients had single-stage procedures (57 [49.6%] posterior-only, 12 [10.4%] anterior-only), 35 (30.4%) had 2-stage procedures, and 11 (9.6%) had 3- or 4-stage approaches. Lesions requiring a combined transmandibular-transcervical approach all involved the C2 and C3 levels and had a significantly steeper angle of attack (42.5 ± 9.5 vs. 6.1 ± 13.3°; P = 0.01) and greater superior tumor extent above the inferior plane of the mandible (3.69 ± 2.18 vs. 0.33 ± 0.78; P = 0.002). Lateral tumor extent, tumor size, nor inferior angle of attack differed significantly between approach groups. CONCLUSIONS Here, we present a preliminary decision-making algorithm for the management of vertebral column tumors of the cervicothoracic spine. Based on this single-center experience, we suggest which patients, assessed via a combination of tumor histology and regional anatomy, may benefit from extended anterior surgical access.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, New York, USA.
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Silva JDS, Silva LECTD, Silva FGSE, Tavares RH, Barros AGCD. LABIOMANDIBULAR GLOSSOTOMY APPROACH FOR CRANIOCERVICAL PATHOLOGIES - SPINE RECONSTRUCTION. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212002224171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 – C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.
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Affiliation(s)
- Jackson Daniel Sousa Silva
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Brazil; Instituto da Coluna Vertebral do Rio de Janeiro, Brazil
| | | | | | - Renato Henrique Tavares
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Brazil; Instituto da Coluna Vertebral do Rio de Janeiro, Brazil
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He LM, Ma X, Chen C, Zhang HY. Treatment of cervical spine metastasis with minimally invasive cervical spondylectomy: A case report and literature review. World J Clin Cases 2021; 9:644-650. [PMID: 33553403 PMCID: PMC7829725 DOI: 10.12998/wjcc.v9.i3.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/18/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cervical spondylectomy for the treatment of cervical tumors is traumatic, causes bleeding, and is risky. This study reports on the experience with minimally invasive cervical spondylectomy for a cervical metastasis and reviewed the literature on cervical spondylectomy. The purpose was to reduce the risk and trauma of spondylectomy.
CASE SUMMARY A 60-year-old woman presented with cervical pain and radiating pain in the left upper limb for more than 2 mo. Preoperative diagnosis was C4 metastasis of thyroid cancer. Preoperative visual analogue scale score was 5. American Spinal Cord Injury Association (ASIA) grade was E. Tomita classification was 7. Weinstein-Boriani-Biagini (WBB) classification was A-D, 3-9. Tomita score was 5. Modified Tokuhashi score was 9. Spinal instability neoplastic score (SINS) was 13. The patient underwent minimally invasive cervical spondylectomy on September 28, 2017. The operative time was 200 min; the estimated blood loss was 1200 mL. The operation was successful, without complications. The postoperative visual analogue scale score was 0. The patient remained classified as ASIA grade E at the last follow-up. She accepted regular iodine-131 therapy postoperatively. The serum thyroglobulin (Tg) level of this patient was 299.02 ng/mL at 1 mo after the operation and was 13.57 ng/mL at the last follow-up. There was no local recurrence at the 25-mo follow-up, according to images, single-photon emission computed tomography, and serum Tg levels. Obvious ossification and solid fusion of C3-C5 were found at the last follow-up.
CONCLUSION Minimally invasive cervical spondylectomy with tubular retractor could minimize soft tissue trauma, intraoperative traction injury, and paraspinal muscle injury, accelerating postoperative recovery. This technique requires a rich experience in cervical spine surgery with tubular retractors, so that surgeons can visualize the anatomical structure in a small field.
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Affiliation(s)
- Li-Ming He
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Xun Ma
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Chen Chen
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Hong-Yi Zhang
- Department of Orthopedics, Bethune Hospital Affiliated to Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
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15
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He S, Yang X, Yang J, Ye C, Liu W, Wei H, Xiao J. Customized "Whole-Cervical-Vertebral-Body" Reconstruction After Modified Subtotal Spondylectomy of C2-C7 Spinal Tumor Via Piezoelectric Surgery. Oper Neurosurg (Hagerstown) 2020; 17:580-587. [PMID: 31089696 DOI: 10.1093/ons/opz077] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/25/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Radical resection is the first-line option in managing cervical primary chondrosarcoma. Favorable anterior reconstruction is challenging after multilevel total spondylectomy in the cervical spine. OBJECTIVE To illustrate the application of piezoelectric surgery and three-dimensional (3D) printing techniques in spine surgery. METHODS A 27-yr-old patient was referred to our center with complaints of nocturnal neck pain and right upper extremity weakness. A 2-stage radical tumor resection was conducted using piezoelectric surgery with pathologically tumor-free margins. A 3D-printed titanium microporous prosthesis (3D-PTMP) was designed to reconstruct the anterior column of the cervical spine between C1 and T1 for stability. RESULTS The whole intraoperative blood loss was 2300 mL over the 2 procedures. The patient had an uneventful recovery, regaining ambulatory status 3 wk after the 2 operations without ventilator support or other severe complications. By the final 14-mo follow-up, the patient had achieved marked pain relief and favorable neurological improvement; a postoperative computed tomography scan indicated a good position of the 3D-printed construct between the endplates with no sign of tumor recurrence or implant subsidence. CONCLUSION The applications of piezosurgery in total spondylectomy and in 3D-PTMP in reconstruction can be a favorable alternative for managing multilevel cervical spinal tumors. Further studies are warranted to validate this surgical strategy.
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Affiliation(s)
- Shaohui He
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xinghai Yang
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jian Yang
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Chen Ye
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Weibo Liu
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China.,Department of Spine Surgery, Central Hospital of Qingdao, Shandong Province, China
| | - Haifeng Wei
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jianru Xiao
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Glukhov DA, Zorin VI, Yu. MA. Surgery of cervical spine tumors in the close vicinity to the vertebral artery: literature review. HIRURGIÂ POZVONOČNIKA (SPINE SURGERY) 2020. [DOI: 10.14531/ss2020.3.91-99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- D. A. Glukhov
- St.Petersburg Research Institute of Phthisiopulmonology
| | - V. I. Zorin
- St.Petersburg Research Institute of Phthisiopulmonology;
North-Western State Medical University n.a. I.I. Mechnikov
| | - Mushkin A. Yu.
- St. Petersburg Research Institute of Phthisiopulmonology
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17
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Zhang Y, Ai F, Fu S, Li K, Xia H, Wu Z, Ma X. [An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1149-1157. [PMID: 32929909 DOI: 10.7507/1002-1892.202001014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objective To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness. Methods The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C 0, 1, 3 cases of C 2, 1 case of C 1, 2, 1 case of C 2, 3, and 1 case of C 0-2. Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation. Results The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 ( t=7.638, P=0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score ( t=1.549, P=0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases. Conclusion Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.
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Affiliation(s)
- Yu Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - Fuzhi Ai
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - Suochao Fu
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - Keke Li
- Department of Spinal Surgery, Huaxin Orthopaedic Hospital, Guangzhou Guangdong, 510100, P.R.China
| | - Hong Xia
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - Zenghui Wu
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
| | - Xiangyang Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China
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18
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A Novel Reconstruction Using a Combined Anterior and Posterior Approach After Axis Tumor Spondylectomy. Clin Spine Surg 2020; 33:E299-E306. [PMID: 32604195 DOI: 10.1097/bsd.0000000000001039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVE To describe a novel reconstruction strategy using a T-shaped titanium mesh cage with posterior cervical screw-rod fixation after total spondylectomy of axis tumors. SUMMARY OF BACKGROUND DATA Instability of the upper cervical spine because of tumors in axis (C2) often results in devastating complications. Surgical resection and reconstruction after spondylectomy of C2 remain a technical challenge because of the intricate anatomies, vital adjacent tissues, and the unique spinal biomechanics in this special region. MATERIALS AND METHODS The novel reconstruction mode included the construction of the anterior aspect conducted with a specially made titanium mesh cage and the posterior cervical fixation only. Patients who received total C2 tumors spondylectomy and reconstruction with this novel mode in our center between January 2009 and December 2017 were retrospectively analyzed to evaluate the efficacy of this novel reconstruction method. RESULTS A total of 24 patients with C2 tumor received total spondylectomy and the new mode of local reconstruction. The neurological deficits recovered well and local pain relieved significantly (P<0.001) during the mean follow-up time of 22 months. Perioperative complications were rare and controllable. No internal fixation failure occurred. The mobility of the occipital-cervical junction was largely preserved in all patients. CONCLUSIONS This novel reconstruction mode using an anterior "T-shaped" mesh cage with posterior screw-rod fixation provides satisfactory stability and motion of occipital-cervical junction with limited complications, and therefore may prove to be an ideal option for management of C2 tumors. LEVEL OF EVIDENCE Level IV.
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19
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Westbroek EM, Pennington Z, Ehresman J, Ahmed AK, Gailloud P, Sciubba DM. Vertebral Artery Sacrifice versus Skeletonization in the Setting of Cervical Spine Tumor Resection: Case Series. World Neurosurg 2020; 139:e601-e607. [PMID: 32330623 DOI: 10.1016/j.wneu.2020.04.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tumors of the cervical spine often encase 1 or both vertebral arteries (VA), presenting the treating surgeon with the dilemma of whether to sacrifice or skeletonize the artery. We propose an algorithm for VA management in surgeries for cervical neoplasms METHODS: A retrospective review was carried out of 67 patients undergoing resection of cervical spine tumors with VA involvement. Patients were categorized by tumor origin (primary vs. metastatic) and degree of circumferential VA involvement: 1) abutment only; 2) <180° circumferential involvement; 3) >180° circumferential involvement without complete encasement; or 4) complete encasement. RESULTS Twelve patients (18%) underwent VA sacrifice, whereas 55 (82%) underwent VA skeletonization. Compared with 11/30 patients with primary tumors (37%), only 1/37 patients (3%) with metastatic disease underwent VA sacrifice (P < 0.01). This patient had invasion of the V2 arterial wall, requiring VA sacrifice. Odds of VA sacrifice also increased with increasing circumferential involvement (P < 0.01). No patients with simple abutment or 0°-180° circumferential involvement underwent sacrifice, whereas 6 of 10 (60%) with 180°-359° involvement and 6 of 29 (21%) with complete encasement underwent VA sacrifice. Of the 27 patients with ≥180° involvement, the reasons for preserving the VA were metastatic disease at the time of treatment (n = 18), a compromised contralateral VA (n = 7), vertebrobasilar junction aplasia (n = 1), and presence of a radiculomedullary artery at the affected level (n = 1). CONCLUSIONS Primary tumor disease and >180° of circumferential VA involvement should be considered as indications for intraoperative sacrifice of the VA pending preoperative angiographic evaluation for contraindications.
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Affiliation(s)
- Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeff Ehresman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Wei F, Li Z, Liu Z, Liu X, Jiang L, Yu M, Xu N, Wu F, Dang L, Zhou H, Li Z, Cai H. Upper cervical spine reconstruction using customized 3D-printed vertebral body in 9 patients with primary tumors involving C2. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:332. [PMID: 32355776 PMCID: PMC7186708 DOI: 10.21037/atm.2020.03.32] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Reconstruction following resection of the primary tumors of the upper cervical spine is challenging, and conventional internal implants develop complications in this region. 3D printing, also known as additive manufacturing, can produce patient-specific porous implants in a particular shape for bone defect reconstruction. This study aimed to describe the clinical outcomes of upper cervical spine reconstruction using customized 3D-printed vertebral body in 9 patients with primary tumors involving C2. Methods Patients with primary tumors involving C2 who were treated in our institution between July 2014 and November 2018 were enrolled. A two-stage intralesional spondylectomy was performed using the posterior-anterior approach. Anterior reconstruction was accomplished using a customized 3D-printed vertebral body, which was fabricated by successive layering of melted titanium alloy powder using electron beam melting. No bone graft was used. Results Nine patients (2 males and 7 females) were included in the study with a mean age of 31.4 years (12 to 59 years). Seven patients demonstrated tumors located in C2 and 2 showed involvement of C2 and C3. During a mean follow-up of 28.6 months (range, 12–42 months), 1 patient died of systemic metastasis and 1 had local tumor recurrence, the other 7 patients were alive and functional in their daily living until the last follow-up without evidence of disease. The 3D-printed vertebral bodies were all stable with no sign of displacement or subsidence, evidence of implant osseointegration was observed on the imaging studies. For the posterior instrumentation systems, no screw loosening or rod breakage was found. Conclusions Spinal reconstruction in the upper cervical region using customized 3D-printed vertebral body is reliable. The tailored shape matching with the contact surfaces and the porous structure conductive to osseointegration provide both short- and long-term stability to the implant.
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Affiliation(s)
- Feng Wei
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Zhehuang Li
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Miao Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Nanfang Xu
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Fengliang Wu
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Lei Dang
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Hua Zhou
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Zihe Li
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Hong Cai
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
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Wang X, Eichbaum E, Jian F, Chou D. Two-Stage En Bloc Resection of Multilevel Cervical Chordomas With Vertebral Artery Preservation: Operative Technique. Oper Neurosurg (Hagerstown) 2019; 14:538-545. [PMID: 28961805 DOI: 10.1093/ons/opx178] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 07/08/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND En bloc excision of cervical chordoma is a technically complex procedure, due to the involvement and closeness of the tumor to the spinal cord, cervical nerve roots, and vertebral arteries. Studies have previously shown that en bloc excision of chordomas with negative margins improves local control and prolongs disease-free survival compared with intralesional excision. True en bloc spondylectomy in the cervical spine is not feasible since bilateral vertebral artery sacrifice is not possible. However, for lateralized tumors, en bloc excision of chordoma can be performed with unilateral vertebral artery preservation by parasagittal osteotomy. OBJECTIVE To describe the operative technique of performing en bloc excision of cervical chordoma via parasagittal osteotomy. METHODS Four patients underwent en bloc excision of multilevel cervical chordomas via parasagittal osteotomy between 2008 and 2016. These 4 cases of chordoma were at the upper-cervical, mid-cervical, and cervicothoracic regions. We analyzed the tumor location, oncological staging, surgical technique, and perioperative complications. RESULTS All 4 patients underwent en bloc excision of chordoma with expandable cage reconstruction and posterior instrumentation. Cervical nerve roots were sacrificed in 2 patients, and vertebral artery ligation was performed in 3 patients. Complications include new neurologic deficit, implant failure, and pharyngeal erosion after radiation. No tumor recurrence was seen. CONCLUSION Parasagittal osteotomy is a useful alternative to en bloc spondylectomy in the treatment of lateralized multilevel cervical chordoma, preserving one vertebral artery while still achieving an en bloc resection.
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Affiliation(s)
- Xingwen Wang
- Department of Neurological Surgery, Xuanwu Hospital, Capital Medical Univer-sity, Beijing, China
| | - Eldan Eichbaum
- Washington Hospital Healthcare System, Fremont, California
| | - Fengzeng Jian
- Department of Neurological Surgery, Xuanwu Hospital, Capital Medical Univer-sity, Beijing, China
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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Baba S, Matsumoto Y, Kawaguchi K, Iida K, Saiwai H, Okada S, Matsunobu A, Shioyama Y, Nakashima Y. Post-carbon-ion radiotherapy vertebral pathological fractures in upper cervical primary malignant spinal tumors treated by occipito-cervical fusion. Arch Orthop Trauma Surg 2019; 139:1525-1531. [PMID: 30944982 DOI: 10.1007/s00402-019-03183-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe the characteristic features of post-carbon-ion radiotherapy (CIRT) vertebral pathological fractures (VPFs) in upper cervical primary malignant spinal tumors (PMSTs) treated by occipito-cervical (OC) fusion. METHODS OC fusion was performed for three consecutive patients with post-CIRT VPFs. The clinical results and imaging findings, including bone single-photon emission computed tomography (SPECT)/CT were prospectively collected. RESULTS No surgery-related wound complication and surgical site infection were noted. One patient experienced re-fracture and displacement of dens with the loosening of occipital screws and was treated by posterior revision surgery. At the final follow-up, all patients were alive without evidence of disease, and the solid OC fusion was confirmed. Bone SPECT/CT clearly revealed the effect of CIRT on bone turnover in the irradiated field. CONCLUSION The OC fusion with autologous bone grafts was a reliable option for the treatment of post-CIRT VPCs in the patients with upper cervical PMSTs. In addition, evaluation of the bone turnover at the irradiated field by bone SPECT/CT would help surgeons select an effective plan of care, such as fusion level and postoperative care.
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Affiliation(s)
- Satoshi Baba
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Yoshihiro Matsumoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
| | - Kenichi Kawaguchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Keiichiro Iida
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Hirokazu Saiwai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | - Seiji Okada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
| | | | | | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan
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Turgut M, Yücesoy K. Obstructive sleep apnea secondary to cervical spine chordoma. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rustagi T, Mashaly H, Mendel E. Posterior occiput-cervical fixation for metastasis to upper cervical spine. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2019; 10:119-126. [PMID: 31402832 PMCID: PMC6652252 DOI: 10.4103/jcvjs.jcvjs_29_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Metastasis to craniocervical area may result in instability manifesting as disabling pain, cranial nerve dysfunction, paralysis, or even death. Stabilization is required to prevent complications. Nonoperative treatment modalities are ineffective in providing stability and adequate pain relief. We present our experience of diagnosis, presentation, and surgical management for metastatic tumors to the upper cervical spine (UCS). Methods: Single-center single-surgeon database of consecutively operated posterior occiput-cervical fusion for metastasis to UCS was reviewed from 2007 to 2016. Demographics, clinical, and surgical data were collected through chart review. Pain scores based on Visual Analog Scale (VAS) and other radiological data were noted. Kaplan–Meier curve was used for survival analysis. Clinical outcomes and complications were recorded. Results: A total of 29 patients (17 females/12 males) had the mean age of 56.7 ± 13.5 (24–82). Predominant metastasis included from the breast in 9 (31.03%) cases, followed by renal in 5, melanoma in 4, and 3 each from lung and colon. Axis was involved in 24 cases (C2 body in 21, pedicle in 8 cases). Atlas was involved in 9 cases (lateral mass in 8 cases and arch in 3 cases) and occiput was involved in three cases. Average Spinal Instability Neoplastic Score was 10 ± 2.3 (7–14). Mild cord compression was seen in 7 cases. Fusion extended from occiput to C4 fusion (n = 23), C5 (n = 5), and C6 (n = 1). Average blood loss was 364.8 ± 252.1 ml and operative time was 235 ± 51.9 min. Average length of stay was 7 ± 2.8 days (3–15). VAS improved from 8.3 ± 1.5 to 1 ± 1.1 (P < 0.001). C2 angulation corrected from 2.1° ±5.3° (0°–17°) to 0.5° ±1.2° (P = 0.045). Three patients each developed cardiopulmonary complications and deep infection. The average survival was 14.5 ± 15.1 (0.15–50) months. Conclusion: C2 body is the most common site of metastasis. Occiput-cervical fusion for unstable upper cervical metastasis offers a good palliative treatment for pain relief and improved quality of life.
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Affiliation(s)
- Tarush Rustagi
- Ohio State University Wexner Medical Center, Columbus, OH, USA.,Indian Spinal Injuries Centre, New Delhi, India
| | - Hazem Mashaly
- Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Ehud Mendel
- Ohio State University Wexner Medical Center, Columbus, OH, USA
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Kong G, Ji W, Lin J, Liu Q, Huang Z, Zhu Q. The Anatomic Study of Intracranial Structures Related to Clival Screw Placement. World Neurosurg 2019; 126:e1005-e1011. [PMID: 30877008 DOI: 10.1016/j.wneu.2019.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND A clival plate and screw fitted to the craniovertebral junction (CVJ) were developed in our previous studies. However, the anatomy of intracranial structures related to clival screw placement has not been studied. OBJECTIVE To measure the intracranial anatomic parameters delineating the basilar plexus and vertebrobasilar artery (VBA) course and to determine the relationship between brainstem and clivus for safer screw placement. METHODS Morphometric analysis of the VBA was conducted on 95 patients (48 men, 47 women) by CT angiography (CTA) and of the basilar plexus and brainstem on 80 patients (44 men, 36 women) by magnetic resonance imaging (MRI) The narrowest distance between the VBA and the intracranial clivus and the distance between the VBA and the median line of the skull were measured on the axial plane at different parts. The relative positions of point I (intersection of vertebral artery and basilar artery) and the pharyngeal tubercle were analyzed. The distance between the clivus and the brainstem was measured at different levels. RESULTS As the VBA ascended the distances to the intracranial clivus and the midline decreased. In 83.3% cases, point I was above the pharyngeal tubercle, and in only 9.5% cases was it located on the vertical line drawn from pharyngeal tubercle. The smallest safe space between the intracranial clivus and the brainstem was 7.46 mm at the lower part. CONCLUSION Appropriate screw size at the lower clivus and the pharyngeal tubercle may help avoiding inadvertent injury to the brainstem and the VBA. Preoperative CTA and MRI of the CVJ are suggested to guide the surgeon in this regard.
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Affiliation(s)
- Ganggang Kong
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Orthopaedic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| | - Junyu Lin
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qi Liu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zucheng Huang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Younus A, Kelly A, Lekgwara P. Axial chordoma of the cervical spine managed by a trans-mandibular trans-oral approach. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
STUDY DESIGN Systematic review and meta-analysis of observational studies. OBJECTIVE The aim of the study is to evaluate different treatment modalities in the management of sacrococcygeal chordoma. SUMMARY OF BACKGROUND DATA Chordomas are primary malignant bone tumors associated with considerable morbidity and mortality. METHODS We searched MEDLINE, EMBASE, Cochrane Central-Register of Controlled Trials, and Scopus from inception to July 2015. Eligible studies included patients with sacrococcygeal chordoma treated exclusively with surgery, radiotherapy, or both. Two reviewers independently assessed the eligibility of potential studies, risk of bias, and extracted data. Outcomes of interest were all-cause mortality, progression-free survival, and metastases. We analyzed further surgical outcomes by resection margin. All outcomes were assessed at 60 months and more than 60 months following intervention. RESULTS We included 33 noncomparative studies reporting on 501 patients (mean age 57 years). Overall mortality rate was (16%) after surgical resection with adjuvant radiotherapy and (28%) after surgical resection, and (43%) after radiotherapy (P = 0.28). All-cause mortality following wide surgical resection was (32%) compared to (40%) after marginal resection (P = 0.51). Overall progression-free survival rate was (58%) after surgical resection with adjuvant radiotherapy and (55%) after surgery (P = 0.92). However, at more than 60 months follow-up, progression-free survival rates were significantly higher (P = 0.024) following surgical resection with adjuvant radiotherapy (74%) in comparison to surgery (55%) and radiotherapy (36%). Overall progression-free survival rates were nonsignificantly higher after wide surgical resection (66%) than marginal resection (33%) (P = 0.16). However, at 60 months follow-up, progression-free survival rates were significantly higher following wide surgical resection (73%) than marginal resection (33%) (P = 0.047). CONCLUSION Sacrococcygeal chordoma is a difficult to treat disease entity. Until comparative studies become available, wide surgical resection and multidisciplinary management are the recommended approaches to improve patient outcomes. LEVEL OF EVIDENCE 3.
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Boriani S. En bloc resection in the spine: a procedure of surgical oncology. JOURNAL OF SPINE SURGERY 2018; 4:668-676. [PMID: 30547137 DOI: 10.21037/jss.2018.09.02] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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One-Stage Wedge Osteotomy Through Posterolateral Approach for Cervical Postlaminectomy Kyphosis with Anterior Fusion. World Neurosurg 2018; 119:45-51. [PMID: 30064029 DOI: 10.1016/j.wneu.2018.07.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Osteotomy through anterior exposure is challenging with severe complications for upper cervical kyphosis (CK), especially for cases with previous anterior fusion. A novel technique comprising 1-stage osteotomy via a posterolateral-only approach is introduced for treatment of CK secondary to C2-4 laminectomy for neurofibroma removal and subsequent anterior fusion. METHODS A 42-year-old man presented with progressive numbness and weakness of upper and lower limbs. As an adolescent, he underwent posterior laminectomy and neurofibroma excision without effective fixation and anterior C2-4 vertebra fusion 6 years later. Sagittal computed tomography indicated that Cobb angle between C2 and C6 was 68° with complete fusion between C2 and C4 vertebral bodies. Secondary CK was diagnosed based on medical history and radiographic findings, and modified Japanese Orthopaedic Association scale score was 10. Piezosurgery was used for osteotomy by shortening the vertebral height through posterolateral approach after cervical pedicle screw placement. Occipitocervical fusion was performed with compression between C2 and C4. RESULTS Cobb angle was adjusted to 8° postoperatively. Modified Japanese Orthopaedic Association score increased to 14 with obvious muscle strength improvement. The 6-month postoperative x-ray indicated good position of C2-4 vertebrae and occipitocervical fixation system. No neurologic complications or local recurrence was found at final follow-up at 8 months. The patient returned to work in his full capacity. CONCLUSIONS Preliminary outcomes reveal wedge osteotomy via piezosurgery through a posterolateral-only approach is feasible and effective in revision surgery for upper CK with previous anterior fusion.
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Aoun SG, Elguindy M, Barrie U, El Ahmadieh TY, Plitt A, Moreno JR, Truelson JM, Bagley CA. Four-Level Vertebrectomy for En Bloc Resection of a Cervical Chordoma. World Neurosurg 2018; 118:316-323. [PMID: 30059783 DOI: 10.1016/j.wneu.2018.07.153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chordomas are locally aggressive tumors that can involve multiple levels of the spine and are difficult to resect. We present our technique for 4-level en bloc cervical spondylectomy for a locally aggressive chordoma. CASE DESCRIPTION A 37-year-old woman presented with a 6-month history of dysphagia and a large indurated cervical mass. Imaging showed an enhancing lesion involving C3-6. Needle biopsy confirmed the diagnosis of chordoma. En bloc resection was chosen to maximize her chances of disease-free survival. A 360° approach was deemed necessary. We posteriorly disconnected the vertebral bodies and skeletonized the bilateral vertebral arteries and nerve roots. The interspinous and yellow ligaments and the spinous processes were spared to maintain a solid posterior tension band, as previously described approaches that had sacrificed these elements had a high rate of instrumentation failure. After posterior instrumentation, a wide anterior approach enabled us to resect the tumor attached to the vertebral bodies of C3-6 as 1 specimen. A 4-level corpectomy cage and plate were used for anterior instrumentation. The patient tolerated the surgery well. She needed a temporary gastrostomy, and she had a right C5 palsy that progressively recovered. Follow-up imaging showed no tumor recurrence and good bony fusion. CONCLUSIONS En bloc resection as part of a multidisciplinary team approach remains the mainstay of spinal chordoma treatment. Modern instrumentation and careful dissection can provide good results even in locally advanced cases.
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Affiliation(s)
- Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Mahmoud Elguindy
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Aaron Plitt
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jessica R Moreno
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John M Truelson
- Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Nisson PL, Berger GK, James WS, Hurlbert RJ. Surgical Techniques and Associated Outcomes of Primary Chondrosarcoma of the Spine. World Neurosurg 2018; 119:e32-e45. [PMID: 30026140 DOI: 10.1016/j.wneu.2018.06.189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/22/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Only a few case reports and case series exist reporting on primary chondrosarcomas of the spine. The objective of this study was to gain a better understanding of this patient population and surgical techniques used for treatment. METHODS A systematic literature search was performed in January 2018 querying several scientific databases, per PRISMA guidelines. Surgery type was categorized into en bloc, piecemeal excision, or non-en bloc or piecemeal excision. RESULTS In total, 34 records and 3 patients were included in the systematic review, yielding 87 patients with primary chondrosarcoma of the spine. The mean age was 41.5 years, with the tumor most commonly arising in adult patients (90.8%, 79/87); most were male (66.7%, 58/87). Those who underwent piecemeal excision had the highest death rate (56.7%, P ≤ 0.001) and highest rate of recurrence (63.3%, P ≤ 0.001) compared with en bloc and non-en bloc or piecemeal excision. The calculated reduced relative risk (RR) comparing en bloc with the other surgical techniques for recurrence and mortality was 78.8% (RR, 0.21; P ≤ 0.001) and 80.7% (RR, 0.19; P≤ 0.001), respectively. Survival analysis showed patients with a piecemeal excision had 9.4 times hazards ratio for death compared with en bloc (P = 0.001). CONCLUSIONS CS is a rare lesion that most commonly presents in adult male patients. En bloc surgical resection was associated with a significant decrease in recurrence, mortality, and increased survival compared with the other surgical techniques. In addition, any surgical technique that involved entering the tumor capsule showed a significantly greater risk for recurrence and death.
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Affiliation(s)
- Peyton L Nisson
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Garrett K Berger
- College of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - R John Hurlbert
- Division of Neurosurgery, Banner University of Arizona Medical Center Tucson, Tucson, Arizona, USA.
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Tu J, Li W, Shu S, Zhang Y, Hua W, Li S, Yang S, Yang C. Total spondylectomy of recurrent giant cell tumors in the cervical spine: Two case reports and review of literature. Medicine (Baltimore) 2018; 97:e10799. [PMID: 29768375 PMCID: PMC5976291 DOI: 10.1097/md.0000000000010799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Spinal Giant Cell Tumors (SGCTs) are rare, aggressive, and benign tumors. Their presence in the cervical spine is even more exceptional. There are few reports of cervical GCT in the literature, especially recurrent cases. The treatment are challenging to clinically because radical resection is extremely difficult. PATIENT CONCERNS In this study, we present the cases of a 25-year-old man and a 41-year-old woman who suffered from recurrent cervical GCT. INTERVENTIONS They underwent extensive total spondylectomy of C3-5 and C2-4, respectively, by a combined anterior and posterior approach. OUTCOMES Both patients had a satisfactory prognosis after 2 years followe-up, and extensive total spondylectomy provided good disease-free survival rates. Extensive total spondylectomy of cervical recurrent giant cell tumor was successfully achieved combined anterior and posterior approach. LESSONS This surgical technique can be an effective option for this pathological condition, which is difficult to manage using other conventional treatment options including repeated curettage and radiotherapy. However, there are insufficient data on long-term subjective outcomes in this type of patient, and larger series studies are needed to determine the efficacy of this approach, especially compared with piecemeal resection techniques.
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Affiliation(s)
- Ji Tu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wentian Li
- Wuhan Institute of Biological Products Co., Ltd., Wuhan, Hubei, People's Republic of China
| | - Shenglei Shu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan. China
| | - Yukun Zhang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenbin Hua
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuai Li
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuhua Yang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cao Yang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Fourney DR. Expert's comment concerning Grand Rounds case entitled "Posterolateral cervical transpedicular corpectomy for the surgical management of metastatic tumor" by M.H. Pham et al. (Eur Spine J; 2018: DOI 10.1007/s00586-018-5466-7). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:833-834. [PMID: 29388092 DOI: 10.1007/s00586-018-5492-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 01/20/2018] [Indexed: 06/07/2023]
Affiliation(s)
- Daryl R Fourney
- Division of Neurosurgery, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
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Xiao J, He S, Jiao J, Wan W, Xu W, Zhang D, Liu W, Zhong N, Liu T, Wei H, Yang X. Single-stage multi-level construct design incorporating ribs and chest wall reconstruction after en bloc resection of spinal tumour. INTERNATIONAL ORTHOPAEDICS 2018; 42:559-565. [PMID: 29404670 DOI: 10.1007/s00264-018-3816-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/26/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE Multi-level reconstruction incorporating the chest wall and ribs is technically demanding after multi-segmental total en bloc spondylectomy (TES) of thoracic spinal tumours. Few surgical techniques are reported for effective reconstruction. A novel and straightforward technical reconstruction through posterior-lateral approach was presented to solve the extensive chest wall defect and prevent occurrences of severe respiratory dysfunctions after performing TES. The preliminary outcomes of surgery were reviewed. METHODS Multi-level TES was performed for five patients with primary or recurrent thoracic spinal malignancies through posterior-lateral approach. The involved ribs and chest wall were removed to achieve tumour-free margin. Then titanium mesh with allograft bone and pedicle screw-rod system were adopted for the circumferential spinal reconstruction routinely. Titanium rods were modified accordingly to attach to the screw-rod system proximally, and the distal end of rods was dynamically inserted into the ribs. RESULTS The mean surgery time was 6.7 hours (range 5-8), with the average blood loss of 3260 ml (range 2300-4500). No severe neurological complications were reported while three patients had complaints of slight numbness of chest skin (no. 1, 3, and 5). No severe respiratory complications occurred during peri-operative period. No implant failure and no local recurrence or distant metastases were observed with an average follow-up of 12.5 months. CONCLUSIONS The single-stage reconstructions incorporating spine and chest wall are straightforward and easy to perform. The preliminary outcomes of co-reconstructions are promising and favourable. More studies and longer follow-up are required to validate this technique.
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Affiliation(s)
- Jianru Xiao
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Shaohui He
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Jian Jiao
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Wei Wan
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Wei Xu
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Dan Zhang
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Weibo Liu
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
- Department of spine surgery, Central Hospital of Qingdao, 127 Siliu South Road, Qingdao, Shandong Province, 266042, China
| | - Nanzhe Zhong
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Tielong Liu
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Haifeng Wei
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Xinghai Yang
- Spinal Tumor Center, Department of Orthopaedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
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An Approach to Primary Tumors of the Upper Cervical Spine With Spondylectomy Using a Combined Approach: Our Experience With 19 Cases. Spine (Phila Pa 1976) 2018; 43:81-88. [PMID: 26020844 DOI: 10.1097/brs.0000000000001007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To examine the link between major complications, surgical techniques, and perioperative care in the intralesional spondylectomy of the upper cervical spine. SUMMARY OF BACKGROUND DATA Spondylectomy has been demonstrated to prolong cancer-free survival in many patients with locally aggressive spinal tumors. However, the challenging nature of this surgical procedure and the potential for severe complications often limit its application in the upper cervical spine. METHODS Nineteen patients with primary upper cervical tumors were treated with spondylectomy from March 2005 to August 2009, using either the anterior-posterior or posterior-anterior approach. Anterior procedures were transmandibular, transoral, or high retropharyngeal. Anterior reconstructions were performed in plates with iliac crest strut grafts, plates with mesh cages, and Harms mesh cages alone. Occipitocervical fixation was performed with Halo-vest application for postoperative immobilization. RESULTS Vertebral artery injuries occurred unilaterally in 5 cases intraoperatively: 4 occurred in the anterior approach of anterior-posterior procedures. Fusion was achieved in 9 patients with intact internal instrumentation. Fusion with the anterior construct in a tilted position occurred in 3 patients, all of whom underwent anterior-posterior procedures with Halo-vest immobilization for less than 1 month. Nonunion occurred in 3 cases after the posterior-anterior procedure because of anterior bone graft absorption. Prolonged Halo-vest immobilization maintained postoperative stability. Failure of internal instrumentation occurred in 3 cases. Anterior construct dislocation and severe tilting occurred in 2 cases after the anterior-posterior procedure. Five patients had a local recurrence. All recurrent lesions were malignant tumors and occurred in regions where surgical exposure was inadequate with incomplete excision. CONCLUSION The order of the surgical approach is a critical determinant of complications, fusion rates, choice of surgical technique, and reconstruction methods. The postoperative use of a Halo-vest is recommended. Local recurrence is associated with tumor malignancy and inadequate excision margin. LEVEL OF EVIDENCE 4.
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A Case of C5 Vertebral Chordoma in a 73-Year-Old Patient with More Than 8 Years of Follow-Up after Total Piecemeal Spondylectomy. Case Rep Orthop 2017; 2017:3284131. [PMID: 29138702 PMCID: PMC5613465 DOI: 10.1155/2017/3284131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/28/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022] Open
Abstract
Chordoma arising from the cervical spine is rare and the traditional long-term prognosis is typically poor. Total en bloc spondylectomy with a wide margin is generally accepted to be the most appropriate management for thoracic and lumbar malignant tumors. However, this method is still challenging for the cervical spine because of the proximity of the tumor to the vertebral arteries and neural elements. Here, we report a 73-year-old man with a C5 vertebral chordoma treated with total piecemeal spondylectomy. Histological examination revealed pathognomonic physaliphorous cells with mucus-filled cytoplasm in the tumor, and the ratio of Ki-67-positive cells within the tumor was high (19.0%), showing active proliferation rate. Local recurrences were found at 9 months, 4 years and 2 months, and 6 years after the initial surgery. All the recurrences were encapsulated and isolated and treated with an additional en bloc resection successfully at each stage. Eight years after the initial total piecemeal spondylectomy, the patient maintained his intact neurological status without local recurrence or metastasis. The prognosis of cervical chordoma depends on the patient's age, surgical procedures, and histological features. In this report, we present that piecemeal spondylectomy is an alternative management for aged patients with cervical chordoma, even for those with high MIB-1 index.
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Zheng Y, Wang J, Liao S, Zhang D, Zhang J, Ma L, Xia H. Biomechanical evaluation of a novel integrated artificial axis: A finite element study. Medicine (Baltimore) 2017; 96:e8597. [PMID: 29381931 PMCID: PMC5708930 DOI: 10.1097/md.0000000000008597] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Various modified instruments are used for the anterior reconstruction of the tumor lesion affecting the second cervical vertebra, but there have been no reports regarding individual integrated artificial axis (IAA) prosthesis fabricated by selective laser melting. In the present work, a new type of IAA prosthesis has been designed with a 3-dimensional (3D) finite element model of normal occiput-the fourth cervical vertebra being established to assess its biomechanics. For easy comparison, another 3D finite element model is also established for the T-shaped Harms cage and an additional posterior fixation was performed on each model. The models are tested under a preliminary loading of 40 N to simulate cervical physical action including flexion, extension, lateral bending, and rotation. Under various loads from 4 different directions, the maximum stress and displacement of the IAA are less than those of the modified T-shaped Harms cage. Except for flexion, the maximum stress of the third cervical vertebra endplate of the IAA is smaller than that of the modified T-shaped Harms cage. The new prosthesis with axis is a good choice for upper cervical operation, which not only can greatly increase the operation stability of the upper cervical segment but also could significantly reduce the risk of fixation failure due to Harms cage subsidence.
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Affiliation(s)
- Yongqiang Zheng
- Southern Medical University, Guangzhou
- Department of Orthopedics, Jinjiang Municipal Hospital, Jinjiang
| | - Jianhua Wang
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command
| | - Suixiang Liao
- Department of Orthopedics, Panyu Central Hospital, Guangzhou, P. R. China
| | - Dongsheng Zhang
- Southern Medical University, Guangzhou
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command
| | - Jinshan Zhang
- Department of Orthopedics, Jinjiang Municipal Hospital, Jinjiang
| | - Limin Ma
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command
| | - Hong Xia
- Southern Medical University, Guangzhou
- Hospital of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command
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Marginal En Bloc Resection of C2-C3 Chordoma with Bilateral Vertebral Artery Preservation and Mesh Cage Reconstruction with Review of Previously Published Cases. World Neurosurg 2017; 108:993.e1-993.e7. [PMID: 28889042 DOI: 10.1016/j.wneu.2017.08.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/26/2017] [Accepted: 08/28/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Chordomas arise from remnants of the notochord and occur throughout the neuroaxis. En bloc resection of chordomas can prove especially challenging in the upper cervical spine secondary to the unique structural anatomy and intimate relationship to the vertebral arteries and spinal cord. CASE DESCRIPTION We describe the resection of a C2-C3 chordoma in a 55-year-old woman in 2-stage fashion with preservation of the vertebral arteries. First, a posterior instrumented fusion and removal of the posterior elements was performed, followed by an anterior transmandibular en bloc resection with cage reconstruction with kick-plate support achievable with off-the-shelf products. CONCLUSIONS Chordomas in the upper cervical spine pose a surgical challenge but are amenable to en bloc resection. With careful planning and intraoperative adaptability, the surgeon can achieve a suitable reconstruction with off-the-shelf products.
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Hyun SJ, Kim JW, Kim KJ, Jahng TA, Roh SW, Ra YS, Kim HJ, Rhim SC. Long-Term Results Following Surgical Resection of Chordomas in the Craniocervical Junction and the Upper Cervical Spine: Review of 12 Consecutive Cases. Oper Neurosurg (Hagerstown) 2017; 14:112-120. [DOI: 10.1093/ons/opx082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/21/2017] [Indexed: 01/22/2023] Open
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Wang J, Lu Y, Xia H, Yin Q. A unique procedure of joined transoral and retropharyngeal high cervical approach (JTRC) without mandibulectomy for treating upper cervical neoplasm involving both C2 and C3. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:1090-1095. [PMID: 27757681 DOI: 10.1007/s00586-016-4798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 08/04/2016] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate a unique procedure of joined transoral and retropharyngeal high cervical approach (JTRC) without mandibulectomy for treating upper cervical neoplasm involving both C2 and C3. METHOD A 23-year-old male patient had neoplasma involving C2 and C3 that caused pathologic fracture of C2 and bony destruction of C3. The neoplasm excision and cervical spine reconstruction were performed through JTRC approach without splitting up the mandible. In this approach, there were two surgery windows that could be applied in turns by closing or opening the mouth to gain an ideal exposure. By rotating the mandible, we could gain maximized exposure for either surgery windows. In addition, there was an overlay zone between transoral approach and high cervical retropharyngeal approach that could eliminate the blind area behind the mandible. RESULTS All the procedures were successfully performed; the surgical incisions healed without infection. By operating alternatively between the two surgery windows, we have successfully performed neoplasm excision and cervical spine reconstruction involving both C2 and C3. Pathologic results showed metastatic renal cell cancer to the resected cervical tumor and confirmed the patient's diagnosis of tuberous sclerosis (Bourneville disease). A 3-month postoperative cervical spine radiography and CT scan demonstrated a favorable placement of the bone implant as well as a favorable instrumentation. CONCLUSION The JTRC approach could provide good surgical exposure for treating disorders involving both upper and lower cervical spine without splitting up the mandible.
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Affiliation(s)
- Jianhua Wang
- Department of Orthopaedic, General Hospital of Military Army in Guangzhou Command (LiuHuaQiao Hospital of GuangZhou), Guangzhou, 510010, China.
| | - Yang Lu
- Department of Radiology, University of Illinois Hospital & Health Sciences System, Chicago, IL, 60612, USA
| | - Hong Xia
- Department of Orthopaedic, General Hospital of Military Army in Guangzhou Command (LiuHuaQiao Hospital of GuangZhou), Guangzhou, 510010, China
| | - Qingshui Yin
- Department of Orthopaedic, General Hospital of Military Army in Guangzhou Command (LiuHuaQiao Hospital of GuangZhou), Guangzhou, 510010, China
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Xiao JR, Huang WD, Yang XH, Yan WJ, Song DW, Wei HF, Liu TL, Wu ZP, Yang C. En Bloc Resection of Primary Malignant Bone Tumor in the Cervical Spine Based on 3-Dimensional Printing Technology. Orthop Surg 2017; 8:171-8. [PMID: 27384725 DOI: 10.1111/os.12234] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 02/07/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the feasibility and safety of en bloc resection of cervical primary malignant bone tumors by a combined anterior and posterior approach based on a three-dimensional (3-D) printing model. METHODS Five patients with primary malignant bone tumors of the cervical spine underwent en bloc resection via a one-stage combined anteroposterior approach in our hospital from March 2013 to June 2014. They comprised three men and two women of mean age 47.2 years (range, 26-67 years). Three of the tumors were chondrosarcomas and two chordomas. Preoperative 3-D printing models were created by 3-D printing technology. Sagittal en bloc resections were planned based on these models and successfully performed. A 360° reconstruction was performed by spinal instrumentation in all cases. Surgical margins, perioperative complications, local control rate and survival rate were assessed. RESULTS All patients underwent en bloc excision via a combined posterior and anterior approach in one stage. Mean operative time and estimated blood loss were 465 minutes and 1290 mL, respectively. Mean follow-up was 21 months. Wide surgical margins were achieved in two patients and marginal resection in three; these three patients underwent postoperative adjuvant radiation therapy. One vertebral artery was ligated and sacrificed in each of three patients. Nerve root involved by tumor was sacrificed in three patients with preoperative upper extremity weakness. One patient (Case 3) had significant transient radiculopathy with paresis postoperatively. Another (Case 4) with C 4 and C 5 chordoma had respiratory difficulties and pneumonia after surgery postoperatively. He recovered completely after 2 weeks' management with a tracheotomy tube and antibiotics in the intensive care unit. No cerebrovascular complications and wound infection were observed. No local recurrence or instrumentation failure were detected during follow-up. CONCLUSION Though technically challenging, it is feasible and safe to perform en bloc resection of cervical primary bone tumors. This is the most effective means of managing cervical spine tumors. Preoperative 3-D printing modelling enables better anatomical understanding of the relationship between the tumor and cervical spine and can assist in planning the surgical procedure.
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Affiliation(s)
- Jian-Ru Xiao
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wen-Ding Huang
- Department of Orthopaedics, 411th Hospital of the People's Liberation Army, Shanghai, China
| | - Xing-Hai Yang
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Wang-Jun Yan
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Dian-Wen Song
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Hai-Feng Wei
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Tie-Long Liu
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Peng Wu
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Cheng Yang
- Department of Orthopaedic Oncology, Spine Tumor Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Surgeon’s perception of margins in spinal en bloc resection surgeries: how reliable is it? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:868-873. [DOI: 10.1007/s00586-017-4967-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 12/01/2016] [Accepted: 01/18/2017] [Indexed: 11/27/2022]
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Yang J, Jia Q, Peng D, Wan W, Zhong N, Lou Y, Cai X, Wu Z, Zhao C, Yang X, Xiao J. Surgical treatment of upper cervical spine metastases: a retrospective study of 39 cases. World J Surg Oncol 2017; 15:21. [PMID: 28088217 PMCID: PMC5237490 DOI: 10.1186/s12957-016-1085-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/22/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The surgical treatment of upper cervical spine metastases are controversial up to now. By summarizing and analyzing the clinical data of the upper cervical spine involved metastases treated surgically in our center, we mainly aimed to investigate the surgical decisions and outcomes so as to provide more references for the clinical treatment of this special and complex spine metastasis. METHODS We evaluated the patients' pre- and post-operative neck pain and neurologic function with paired t test, followed by the statistics of the selection of surgical approaches, ways of reconstruction, and related complications. Moreover, the Kaplan-Meier survival analysis was adopted to analyze the patients' survival according to different growth group (rapid, moderate, and slow). RESULTS There were 39 patients with atlantoaxial metastases in this study. The most common symptom (94.87%) was occipital-cervical pain, which relieved greatly after surgical interventions (p < 0.01). The metastases mainly resulted from lung cancer and nasopharyngeal cancer with an incidence of 38.46 and 10.26%, respectively. As to different growth group, the rapid-growth tumors accounted for 69.23% in all atlantoaxial metastases. Tumor resection and stabilization were performed mainly via the combined anterior and posterior approach (66.67%). The 1-, 2-, and 3-year overall survival rate at the last follow-up was 58.5, 40, and 28.3%, respectively, with a median survival time of 18 months. The rate of complications associated with the surgical intervention was 12.82% (5/39), which is lower than that of the previous reports and generally controllable. CONCLUSIONS Relatively radical interventions with surgery for upper cervical spine metastases offered satisfactory outcomes with a low mortality. Together with adjuvant therapy, surgical treatment benefits patients with atlantoaxial metastases by relieving regional pain, restoring or improving the neurologic function, stabilizing the quality of life, and prolonging the survival time of such patients.
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Affiliation(s)
- Jian Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Qi Jia
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Dongyu Peng
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Wei Wan
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Nanzhe Zhong
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yan Lou
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Xiaopan Cai
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Zhipeng Wu
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Chenglong Zhao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Xinghai Yang
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Jianru Xiao
- Department of Orthopedic Oncology, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
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Pham M, Awad M. Outcomes following surgical management of cervical chordoma: A review of published case reports and case series. Asian J Neurosurg 2017; 12:389-397. [PMID: 28761513 PMCID: PMC5532920 DOI: 10.4103/1793-5482.185066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aim: This review aimed to summarize the clinical outcomes in relation to tumor resection margins of cervical chordomas. Methods: Studies that described any surgical intervention for cervical chordoma were identified. Cervical chordomas with cranial or spinal extension, purely retropharyngeal chordomas or where resection type was not reported, were excluded from the study. Results: Seventy-six articles were obtained and these reported a total of 195 patients. Seventy-six percent cervical chordoma patients had intralesional resection with adjuvant radiotherapy. Ninety-two percent chordoma recurrences and all chordoma metastases occurred in patients with intralesional resection. En bloc surgeries were longer (900 min vs. 619 min) and staged surgeries. Intralesional surgeries (2899 ml vs. 2661 ml) had greater intraoperative blood loss. Vertebral artery and nerve root sacrifice were greater in en bloc patients (35%, 39%) compared to intralesional patients (17%, 10%). Postoperative complications were more common in en bloc (54%) than in intralesional patients (11%). Conclusions: En bloc resection cervical chordomas are associated with less recurrence and no metastasis compared to intralesional resection. En bloc is possible through wide exposure of the vertebrae via a multidisciplinary team approach and utilization of particular surgical equipment. The higher rate of complications associated with en bloc surgeries may be acceptable, particularly when there is a chance of cure of disease.
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Affiliation(s)
- My Pham
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
| | - Mohammed Awad
- Department of Neurosurgery, The Royal Melbourne Hospital, Victoria 3050, Australia
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Boriani S, Gasbarrini A, Bandiera S, Ghermandi R, Lador R. En Bloc Resections in the Spine: The Experience of 220 Patients During 25 Years. World Neurosurg 2016; 98:217-229. [PMID: 27794510 DOI: 10.1016/j.wneu.2016.10.086] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/15/2016] [Accepted: 10/18/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE En bloc resections aim at surgically removing a tumor in a single, intact piece. Approach must be planned for the complete removal of the tumor without violation of its margins. The shared knowledge of the morbidity, mortality, risk assessment for local disease recurrence, complications, and death, related to spine tumors excised en bloc could improve the treating physician's apprehension of the diseases and decision making process before, during, and after surgical treatment. The purpose of this study was to review and report the experience gained during 25 years in one of the world's biggest spine oncologic centers. METHODS A retrospective study of prospective collected data of 1681 patients affected by spine tumors, of whom 220 had en bloc resections performed. RESULTS Most tumors were primary-165 cases (43 benign and 122 malignant); metastases occurred in 55 patients. A total of 60 patients died from the disease and 33 local recurrences were recorded. A total of 153 complications were observed in 100 of 216 patients (46.2%); 64 of these patients (30%) suffered 1 complication, whereas the rest had 2 or more. All complications were categorized according to temporal distribution and severity. These were further divided into 7 groups according to the type of complication. There were 105 major and 48 minor complications. Seven patients (4.6%) died as a result of complications. There were 33 local recurrences (15.28%) recorded. Contaminated cases, surgical margins of the resected tumor-intralesional, marginal, and malignant tumors-were statistically significant independent risk factors for local recurrence of the tumor. Contamination, local recurrence, neoadjuvant radiotherapy, number of levels resected, and metastatic tumors compared with primary malignant tumor were shown to be independent risk factors for a patient's death. CONCLUSIONS Treatment of spinal aggressive benign and malignant bone tumors with en bloc resection is beneficial in terms of better local control and prognosis, although it is a highly demanding and risky procedure. Margins are the key point of this procedure, thus a careful preoperative oncologic and surgical staging is necessary to define the optimal surgical approach. The adverse event profile of these surgeries is high. Therefore, it should be performed by experienced and multidisciplinary teams in specialized high volume centers.
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Affiliation(s)
- Stefano Boriani
- Department of Oncologic and Degenerative Spine Surgery, Unit of Oncologic Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, Unit of Oncologic Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Stefano Bandiera
- Department of Oncologic and Degenerative Spine Surgery, Unit of Oncologic Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Riccardo Ghermandi
- Department of Oncologic and Degenerative Spine Surgery, Unit of Oncologic Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Ran Lador
- Unit of Spine Surgery, Tel-Aviv Medical Center, Tel-Aviv, Israel.
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Ji W, Tong J, Huang Z, Zheng M, Wu X, Chen J, Zhu Q. Stabilization of the Craniovertebral Junction with Clivus Plate Constructs: Biomechanical Comparison with Conventional Technique. World Neurosurg 2016; 94:42-49. [DOI: 10.1016/j.wneu.2016.06.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 01/22/2023]
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Boriani S, Gasbarrini A, Bandiera S, Ghermandi R, Lador R. Predictors for surgical complications of en bloc resections in the spine: review of 220 cases treated by the same team. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:3932-3941. [PMID: 26972427 DOI: 10.1007/s00586-016-4463-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/06/2016] [Accepted: 02/07/2016] [Indexed: 01/14/2023]
Abstract
PURPOSE Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries. METHODS A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team. RESULTS A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection. CONCLUSION The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection.
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Affiliation(s)
- Stefano Boriani
- Department of Oncologic and Degenerative Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Stefano Bandiera
- Department of Oncologic and Degenerative Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Riccardo Ghermandi
- Department of Oncologic and Degenerative Spine Surgery, Rizzoli Institute, Bologna, Italy
| | - Ran Lador
- Spine Surgery Unit, Tel-Aviv Medical Center, 6 Weizman St., 64239, Tel-Aviv, Israel.
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Anterior Spinal Reconstruction to the Clivus Using an Expandable Cage After C2 Chordoma Resection Via a Labiomandibular Glossotomy Approach: A Technical Report. World Neurosurg 2016; 90:372-379. [PMID: 26968445 DOI: 10.1016/j.wneu.2016.02.115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/26/2016] [Accepted: 02/27/2016] [Indexed: 01/20/2023]
Abstract
INTRODUCTION En bloc resection of high-cervical chordomas is a technically challenging procedure associated with significant morbidity. Two key components of this procedure include the approach and the method of spinal reconstruction. A limited number of reported cases of en bloc resection of high-cervical chordomas have been reported in the literature. CASE PRESENTATION We report a novel case using an expandable cage to reconstruct the anterior spinal column above C2 with fixation to the clivus. We also report a novel anterior approach to the high-cervical spine via a midline labiomandibular glossotomy. We detail the management of complications related to 2 instances of wound dehiscence and hardware exposure requiring two additional operations. The final surgical procedure involved explantation of the anterior cervical plate and use of a vascularized radial graft to close the posterior pharyngeal defect and protect the hardware. At 26-month follow-up, the patient remained disease free without any neurologic deficit. DISCUSSION We report the novel use of the midline labiomandibular glossotomy for surgical approach and reconstruction of the anterior column to the clivus with an expandable cage. The unique features of this operative strategy allowed the surgical team to tailor the construct intraoperatively, resulting in solid arthrodesis without significant neurologic sequelae. CONCLUSIONS Labiomandibular glossotomy for approach to high anterior cervical chordomas followed by craniospinal reconstruction to the clivus with an expandable cage represents a novel technique for managing high cervical chordomas.
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Charest-Morin R, Dea N, Fisher CG. Health-Related Quality of Life After Spine Surgery for Primary Bone Tumour. Curr Treat Options Oncol 2016; 17:9. [PMID: 26820288 DOI: 10.1007/s11864-015-0383-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OPINION STATEMENT Treatment of primary bone tumours (PBT) of the spine is complex, often involving numerous surgical and oncology disciplines. Surgical en bloc resection with oncologically appropriate margins is the modality of choice when treating malignant PBT. En bloc resection with wide or marginal margins appears to offer better local and systemic control of the disease. This type of surgical resection can also be considered when treating benign aggressive tumours such as aneurysmal bone cyst, giant cell tumour and osteoblastoma. Although these surgeries respect oncologic principles, significant morbidity and mortality are associated. Adverse event collection is highly variable in the literature and mostly from retrospective studies. Wound complication, neurologic deficit and significant blood loss are encountered with surgical resection of PBT of the mobile spine and especially, the sacrum. The adverse event profile of these surgeries is high even in experienced quaternary referral centres. Therefore, primary spinal tumour resection is best performed in experienced centre with adequate multidisciplinary support. Furthermore, prospective and systematic adverse event data collection should be developed to ensure accurate data. The impact of such extensive and potentially impairment producing procedures on health-related quality of life (HRQOL) is another critically valuable piece of information in the era of shared treatment decision making. At the present time, there is paucity of published data regarding HRQOL following these surgeries. Nonetheless, in theory, it seems that health-related quality of life after surgery for PBT is acceptable given the curative intent of the treatment. However, a decision-making process should be tailored to each patient and his or her expectations. Comprehensive discussions should be held preoperatively with the patient, family and other related allied health professionals if the informed consent and decision-making process is to be optimal.
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Affiliation(s)
- Raphaële Charest-Morin
- Department of Orthopaedics, Centre Hospitalier Universitaire de Québec, 1401 18e rue, Local B-2408, Quebec, Quebec, Canada, G1J 1Z4.
| | - Nicolas Dea
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier Universitaire de Sherbrooke, 3001, 12th Avenue North, Local 5110, Sherbrooke, QC, Canada, J1H 5 N4.
| | - Charles G Fisher
- Division of Spine, Department of Orthopaedics, The Combined Neurosurgical and Orthopaedic Spine Program at Vancouver Coastal Health, Blusson Spinal Cord Centre, 6th Floor, 818 West 10th Avenue, Vancouver, BC, Canada, V5Z 1M9.
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Reconstruction of the Upper Cervical Spine Using a Personalized 3D-Printed Vertebral Body in an Adolescent With Ewing Sarcoma. Spine (Phila Pa 1976) 2016; 41:E50-4. [PMID: 26335676 DOI: 10.1097/brs.0000000000001179] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To describe a three-dimensional (3D) printed axial vertebral body used in upper cervical spine reconstruction after a C2 Ewing sarcoma resection in an adolescent boy. SUMMARY OF BACKGROUND DATA Ewing sarcoma is a malignant musculoskeletal neoplasm with a peak incidence in adolescents. Cervical spine as the primary site of the tumor has been related to a worse prognosis. Tumor resection is particularly challenging in the atlantoaxial region due to complexity of the anatomy, necessity for extensive resection according to oncological principles, and a lack of specialized implants for reconstruction. 3D printing refers to a process where 3D objects are created through successive layering of material under computer control. Although this technology potentially enables accurate fabrication of patient-specific orthopedic implants, literature on its utilization in this regard is rare. METHODS A 12-year-old boy with a C2 Ewing sarcoma underwent a staged spondylectomy. Wide resection of the posterior elements was first performed. Two weeks later, a high anterior retropharyngeal approach was taken to remove the remains of the C2 vertebra. A customized artificial vertebral body fabricated according to a computer model using titanium alloy powder was inserted to replace the defect between C1 and C3. The microstructure of the implant was optimized for better biomechanical stability and enhanced bone healing. RESULTS Patient had an uneventful recovery and began to ambulate on postoperative day 7. Adjuvant treatment commenced 3 weeks after the surgery. He was tumor-free at the 1-year follow-up. Computed tomography studies revealed evidence of implant osseointegration and no subsidence or displacement of the construct. CONCLUSION This is a case example on the concept of personalized precision medicine in a surgical setting and demonstrates how 3D-printed, patient-specific implants may bring individualized solutions to rare problems wherein restoration of the specific anatomy of each patient is a key prognostic factor.
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