Klinische Fälle
tumori

Wirbelsäulentumoren

Chirurgisches Management von Wirbelsäulentumoren — primäre Tumoren, Metastasen, En-bloc-Resektionen.

Fallserie

Chirurgisches Management von Wirbelsäulentumoren (Bukarest 2023)

55 Folien
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Surgical management of spine tumors

Ioan Branea

Bucuresti Octombrie 2023

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Spinal tumors

Locations on spine:

2 – 4% of all malign bone tumors

40 – 60% of all bone metastasis

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Benign - Osteoblastoma

- Osteoid osteoma

- Osteochondroma

- Eosinophilic granuloma

- Aneurysmatic bone cyst

Semimalign - Giant cell tumor

Malign - Osteosarcoma

- Chondrosarcoma

- Ewing sarcoma

- Lymphoma / Plasmocytoma

Spine tumors

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Benign bone tumors

Kelley 2007, 42 years register

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S1(latent), S2 (active), S3 (agressive)

Developed for limbs, translated to spine

Enneking (Staging), since 1980

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Vertebral body divided in 12 quadrants and 5 „rings“from paravertebral to dural

Weinstein-Boriani- Biagini, since 1991

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Operative indication

Pain

Presence or risk of neurological deterioration

Instability or deformity

Curative in solitary tumors

Diagnosis in unknown tumors

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local tumorinvasion

metastasis

age/general health state/prognosis

Operation planing

primary tumors (malign/benign)

secondary tumors (metastasis)

curative purpose

palliative purpose

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Tumor entity - primary tumor (benign/ malignant) - metastasis

- unknown histology (biopsy? / intraop. histol.?)

Localisation - vertebral body - posterior structures - staging

Involvement of vascular structures - resection? occlusion test?

Involvement of adjacent structures - radical resection possible?

Compression of the spinal cord ?

Aim of surgery - curative - palliative

Operation planing

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Biopsy mandatory

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Intralesional resection

piecemeal tumor removal

violation of tumor capsule

for metastatic tumors, some benign tumors

higher risk of recurrence

en bloc resection

complete removal without violation of tumor capsuleprimary malignant, locally aggressive tumorsless risk of recurrence

TOTAL EN BLOC: GOLD STANDARD

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Total En-bloc Vertebrectomy / Spinal Reconstruction

Gold standard in spinal tumor surgery

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Total en bloc spondylectomy - TES

00.00.2020

SRH Unternehmen – Max Mustermann

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Spinal Reconstruction

Mechanical Stability after En-bloc Vertebrectomy

Stable in the long run?

Shear forces?

Rotation forces?

Anterior support

Posterior tension band

Rotational stability by blocked facet joints

Fracture treatment

(posterior structures preserved)

En-bloc vertebrectomy

(posterior structures removed)

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Spinal Reconstruction

Shear forces / Rotational forces:

Compression at adjacent segments blocks the facet joints: fixed angle

Mechanical Stability after En-bloc Vertebrectomy

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Spinal Reconstruction

Shear forces / Rotational forces:

Cross-link connector: fixed angle

8y / 07-2004

Mechanical Stability after En-bloc Vertebrectomy

8y, m.

Osteoblastoma L3, status post curettage and filling with calcium sulfate.

Posterior-anterior-posterior en-bloc resection of L3

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Spinal Reconstruction

Shear forces / Rotational forces:

Cross-link connector: stable angle

12 yrs. follow-up after en-bloc resection of L3 in a 8 yrs. old boy

17y / 05-2013 / 9y pop.

20y / 05-2016 / 12y pop.

Mechanical Stability after En-bloc Vertebrectomy

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Spinal Reconstruction

Shear forces / Rotation forces:

Anterior plate: fixed angle

Mechanical Stability after En-bloc Vertebrectomy

30y, m.

Recurrence of a chordoma C2+3

Anterior-posterior tumor resection, C2 replacement

09-1998

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24 cases of total en bloc spondylectomy between 6/2011 - 6/2014, 5 surgeons

Tumor/ Localisations

malign (9)

benigne (7)

metastasis (8)

cervical (6), thoracic (14), lumbar (4)

Cancelous bone was added 6-12 months year after tumoresection (13)

TOTAL EN BLOC SPONDYLECTOMY: A REVIEW OF 24 CONSECUTIVE CASES

I. Branea, M. Ruf, G.Ostrowski, E.Salman, T. Pitzen

Kongress der Deutsche Wirbelsäulenchirurgische Gesellschaft, Frankfurt 2017

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Results and Complications

OP-Time: 3,75 Hrs. - 11,5, av. 7,5 Hrs.Days in hospital: average 25Bloodloss: average 2820 mlSurvival: 96% at 6, 92% at 36 Monate

Complicationrate: 46% Dural tear (4) LCR fistula (2) deep woundinfection (3) neurological deficit (2) Horner syndrome (2) ductus thor. lesion (2) rod/cage breakage (4) Tumor reccurence (3)

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70 patients operated between 01/ 2011 – 12/ 2018, mean age 56.9 years, 37 female. 16 benign, 54 malign tumors.

rate of patients having early postop complications was 65.8%.

the presence of complications was associated with prolonged hospital stay (p= 0.02).

Top 5 complications

Acute anemia (27.1%)

Hypokalemia (21.4%), hyponatremia (18.6%)

Paresis (8.6%)

Toxic hepatitis (8.6%)

arrhythmias (8.6%)

Intraoperative Blood Loss is Significantly Associated with early Complications in Cervical Spine Tumor Surgery

Iulian-Laurentiu Tiripa, Ute Heiler, Ioan Branea, Michael Ruf, Tobias Pitzen

Cervical spine research society, Paris 2021

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surgery related major complications

injury of the vertebral artery (1.3%)

lesion of the dural sac (2.6%)

early implant failure (2.6%)

no transvers lesion (0%)

surgery related minor complications

superficial wound infection (6.57%)

mean blood loss patients WITH complications : 933 ml

mean blood loss patients WITH complications : 364 ml

mortality in the first 2 weeks postop: 2.6%

Results

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Yes

No

Complication

Blood loss (ml)

p< 0.001

Results

age (p = 0.667)

ASA (p= 0,825)

tumor entity (malign/ benign) (p= 0.935)

Blood Loss is the Problem!

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Single metastasis in mamma carcinoma

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Single metastasis in mamma carcinoma, extracavitary en bloc resection

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31,M, Chondrosarcoma

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61, M, Chordoma

Fusionsmass added 6 months postop!

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16, m, Ewing sarcoma

nach 2 Jahren

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13, M, Haemangioma

frustrane Erst-OP mit PMMA und belassenem Tumor

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17, M, aneurysmat. bonecyst

Liquoransammlung

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09/2006

Spinal Reconstruction

Mechanical Stability after En-bloc Vertebrectomy

01/2007

66y, f.

Recurrence of a Chordoma C2-4, transoral resection, cage 10/2001

5y postop,:

Recurrence, mucosa dehiscence, infection, removal of the cage

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01/2007

09/2007

2y after new instrumentation

11/2009

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Spinal Reconstruction

Revision Cases (Anterior Approach)

Case 1:

59y, f. Chordoma T12

02/2004

03/2008

11/2011

03/2004: En-bloc vertebrectomy T12

10/2009: En-bloc vertebrectomy T8

11/2011: Tumor T4, resection and instrumentation to T2

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11/2011

10/2014: instrumentation failure at L1/2 with kyphosis (no recurrence of tumor)

10/2014

Mechanical overload due to the long lever arm?

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10/2014: posterior revision, instrumentation to L5

10/2014

12/2014

07/2016

11/2014: anterior revision, partial corpectomy L1+2, new cage T11 to L3

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Case2:

39y, m.

Malignant melanoma, metastasis T8/9, pulmonary metastases.

Status post posterior decompression, radiation 60gy

11/2006

12/2006

DVD vertebrectomy T8+9

Anterior support: cage filled with bone cement

Posterior instrumentation: T6-T11

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12/2006

03/2007

3m postop.:

patient is completely mobilized, minimal subsidence

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02/2011

4y postop.:

breakage of the rods, revision recommended

10/2011

4.5y postop.:

acute paraparesis

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10/2011

First surgery (emergency):

posterior revision with new instrumentation extended to T4 and L1, removal of the screws in T10

correction of kyphosis and translation

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10/2011

Second surgery (4d later):

Re-thoracotomy, removal of the cage, partial corpectomy T10

Insertion of a new cage, filled with bone cement in the center, autologous bone (rib) cranial and caudal

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03/2012

5m postop. 2:

No bony ingrowth, subsidence

Biological problem, due to radiation?

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12/2012

6y postop. 1, 1y postop. 2:

Rod breakage again, breakage of the lower edge of the cage

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12/2012

First surgery:

posterior revision with new instrumentation T4 to L1

fixation of an autologous bone graft (posterior iliac crest)

correction of kyphosis and translation

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12/2012

Second surgery (14d later):

Re-thoracotomy, removal of the broken cage, partial corpectomy T7

Insertion of a new cage, filled with bone cement in the center, autologous bone (anterior iliac crest) cranial and caudal

Adding von cancellous bone around the cage

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06/2017

10y postop. 1,

5y postop. 2,

4y postop. 3:

Breakage of one rod

Breakage of the posterior bone graft at the lower fixation

New instrumentation

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08/2017

12y postop. 1,

7y postop. 2,

6y postop. 3,

2y postop. 4:

01/2018

no recurrence of tumor,

Stable?

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Case 3: 54y, f.

Reccurence of giant cell tumor C3 (incomplete resection 12/2014) Involvement of the left vertebral artery. Paraparesis.

Previous disc herniation C6/7.

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Combined approach (transoral with mandibula/ tongue split, anterior high cervical, posterior):

Tumor resection, stabilisation with cage C1-5, instrumentation C1-T1 (11/2015)

6m postop.:

Perforation of the retropharyngeal mucosa, infection

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06/2016

Revision with a transoral (with mandibula/ tongue split) and,a high anterior approach:

Insertion of a new cage, cutis/subcutis flap, vascular anastomised

09/2017

06/2016

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Spinal Reconstruction

Current Concept

First step: Stabilisation with anterior spacer and posterior instrumentation according to the mechanical requirements

Advantage: good visualisation of potential recurrence

Second step: Addition of a autologous bone graft in long-term survivors without recurrence for long-lasting stability

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Radical excision of spinal tumors

Stable primary instrumentation

(anterior support, posterior instrumentation, cave shear and rotational forces)

Meticulous planning of surgery

(thoracic/ vascular surgeon, staged procedure)

Anticipate - cicatricial tissues

- postradiation adhesions

- osteoporotic bone (stress shielding)

- extensive bone defects

Consider Addition of autologous bone graft in long-term survivors without recurrence of tumor

Thorough preop workup (interventional radiology incl.)

Experienced anesthesiology and intensive care unit

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IS asociated with long operation time

massive bloodloss

high complication/revision rate

long hospital stayis NOT asociated with perioperative mortality

demands a CENTER with solid experience in tumorsurgery/ complications management

Radical excision of spinal tumors whenever indicated and technically feasible…

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