Total en bloc Spondylectomy

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Total en bloc Spondylectomy

• If not for primary malignant tumors,
• for what else then?

Sohail Bajammal, MBChB, MSc, FRCS(C) October 29,
2008
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Above Knee Amputation
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Nakamura S., Kusuzaki K., Murata H. et al. More
than 10 years of follow-up of two patients after
total femur replacement for malignant bone tumor.
International Orthopaedics. 24(3)176-8, 2000.
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Evidence-Based PracticeHaynes et al. BMJ 2002
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Hierarchy of Evidence
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Primary Tumors of the Spine
Incidence 2.5 to 8.5 cases per 100,000 persons /
yr
Chi JH, Bydon A, Hsieh P, et al. Epidemiology and
Demographics for Primary Vertebral Tumors.
Neurosurgery Clinics of North America. 19(1)
1-4, 2008.
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Enneking Principles of Orthopaedic Oncology
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Enneking Principles of Orthopaedic Oncology

• Intralesional

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Enneking Principles of Orthopaedic Oncology

• Marginal

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Enneking Principles of Orthopaedic Oncology

• Wide

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Surgical Options

• Intralesional resection

• En bloc resection

• Removal of the tumor, with violation of the
  capsule and piecemeal removal of the growth, with
  margins defined by the tumor itself
• Acceptable for metastatic tumors and benign
  tumors
• Familiar approach
• Risk of recurrence

• Complete removal of the tumor without violation
  of its capsule, and with clearly defined normal
  tissue as margins
• Ideal for primary malignant locally aggressive
  tumors
• Technically demanding
• Less risk of recurrence

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Total en bloc Spondylectomy

• Stener (1971) chondrosarcoma
• Roy-Camille (1981-1990) popularized the
  procedure
• Tomita et al. and Fidler (1994) further
  popularized

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Decision Making

• Degree of difficulty
• Complications
• Feasibility of en bloc resection
• Patients preference
• Surgeons expertise

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Staging Systems

• WBB Staging System
• Tomita Classification System

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Weinstein JN, McLain RF. Primary tumors of the
spine. Spine 19871284351.

• 82 cases (31 benign 51 malignant)
• The mean follow-up 9.7 yr in benign and 3.8 yr
  in malignant lesions
• Five-year survival 86 for benign lesions
• Five-year survival in malignant lesions
• undergoing curettage nil
• undergoing incomplete resection 18.7
• undergoing complete excision 75

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Weinstein JN, McLain RF. Primary tumors of the
spine. Spine 19871284351.
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Boriani et al. En bloc resections of bone tumors
of the thoracolumbar spine. A preliminary report
on 29 patients. Spine. 21(16)1927-31, 1996.

• 29 patients
• 25 primary malignant aggressive benign
• 4 solitary metastases
• Surgical time was 3-21 hr (average, 12 hr)
• Surgical margin
• wide in 20, marginal in 8, intralesional in 1
• No local recurrence was found at follow-up
  evaluation after 6-134 mo (average, 30 mo)

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Tomita K, et al. Total en bloc spondylectomy a
new surgical technique for primary malignant
vertebral tumors. Spine 19972232433.
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Hasegawa K, et al. Margin-free spondylectomy for
extended malignant spine tumors surgical
technique and outcome of 13 cases. Spine.
32(1)142-8, 2007

• 3 chondrosarcoma, 3 giant cell tumor, 1
  osteosarcoma, 1 chordoma, and 5 metastases
• No local recurrence, except in 2 cases
  (chondrosarcoma with extirpation of 5 vertebrae,
  chordoma with multiple previous surgeries)
• Two cases of chondrosarcoma were disease-free 14
  13 years after surgery

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Hasegawa et al. Spine 2007
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Abe E, et al. Total spondylectomy for primary
tumor of the thoracolumbar spine. Spinal Cord.
38(3)146-52, 2000 Mar.

• 6 patients
• Approach
• Posterior in 3 (T1 osteosarcoma, L1 osteosarcoma
  and L1 chordoma)
• Combined single stage anterior and posterior (T6
  8 recurrent giant cell tumor, L4 chordoma and
  L5 giant cell tumor)
• Surgical Margins wide in 1, marginal in 4,
  intralesional in 1.

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Abe E, et al. Total spondylectomy for primary
tumor of the thoracolumbar spine. Spinal Cord.
38(3)146-52, 2000 Mar.

• Five patients were alive without evidence of
  tumor and one was alive with disease at follow-up
  evaluation after 2.0 4.8 years.
• Local recurrence was found in one case of T1
  osteosarcoma with an intralesional margin.

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Junming M, et al. Giant cell tumor of the
cervical spine a series of 22 cases and
outcomes. Spine. 33(3)280-8, 2008

• 22 patients
• 8 subtotal resection, 13 total spondylectomy, 1
  en bloc posterior element
• Postoperative radiation in 18 cases
• Local recurrence
• 5 of 7 cases (71.4) subtotal resection,
• 1 of 13 cases (7.7) total spondylectomy.
• 4 cases died within follow-up and all were
  recurrent cases.

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Melcher I, et al. Primary malignant bone tumors
and solitary metastases of the thoracolumbar
spine results by management with total en bloc
spondylectomy. European Spine Journal. 2007.

• 15 patients (3 primary malignant 12 solitary
  metastases)

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Tomita K, et al. Total en bloc spondylectomy for
spinal tumors improvement of the technique and
its associated basic background. Journal of
Orthopaedic Science. 11(1)3-12, 2006.

• From 1989 to 2003, 284 spinal tumors
• primary tumors in 86 patients
• metastasis in 198 patients
• TES was performed in 33 of the 86 patients with a
  primary tumor
• 17 patients with a malignant tumor
• 16 with aggressive benign tumors

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Tomita et al. Journal of Orthopaedic Science 2006

• The 5-year survival
• For the 17 patients with primary malignant tumors
  was 67
• For the16 patients with aggressive benign tumors
  (stages 2 and 3) was 100

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Liljenqvist U, et al. En bloc spondylectomy in
malignant tumors of the spine. European Spine
Journal. 17(4)600-9, 2008 Apr.

• 1997 and 2005, 21 consecutive patients
• 13 patients had primary malignant lesions
• 8 patients had solitary metastases
• Combined posteroanterior (n 19) or all
  posterior approach (n 2)
• Out of 11 patients with primary Ewing or
  osteosarcoma seven patients are alive without any
  evidence of disease.

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Liljenqvist et al. European Spine Journal 2008
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Liljenqvist et al. European Spine Journal 2008
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Major Risks of en bloc resection

• Mechanical and vascular spinal cord injury
• Injury to the major vascular structures
• Tumor margin violation during resection
• Significant operative blood loss because of
  epidural venous bleeding

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Adjuvant Therapy

• Unlike the popular Pitchell trial for metastatic
  tumors
• In primary malignant tumors of the spine,
  preoperative radiotherapy and/or chemotherapy to
  shrink the tumor mass

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Tomita et al. Journal of Orthopaedic Science 2006
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Thank You