Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis

Abstract

We have developed a new surgical technique, 'total en bloc spondylectomy' (TES), to treat a solitary metastasis in the thoracic or lumbar vertebra. This operation is designed as a local cure for the metastatic site and involves the radical resection of the affected vertebra with a wide margin. The spondylec tomy consists of two steps: en bloc laminectomy with posterior spinal instru ments for stabilisation (first step) and en bloc corporectomy and replacement using a vertebral prosthesis (second step) . TES makes it possible to remove the affected vertebra extracompartmentally with its tumour barrier and accomplishes circumferential decompression of the spinal cord. Before clinical practice, we constructed experimental models using cats to examine spinal cord blood flow (SCBF) after ligation of the nerve roots and circumspinal decompression. The changes of SCBF were negligible, so it was proved that TES on one vertebra has little effect on spinal cord circulation. This method was used in 24 patients. Fourteen of the 18 patients with neurological deficits improved remarkably, and the 23 evaluable cases experienced pain relief. Impending paralysis was pre vented in all six patients by this surgical intervention. There has been no recurrence of the local tumour after surgery. After a median follow up period of 14. 1 months, 12 patients have survived. These data suggest that TES may have a significant clinical value in the treatment of spinal metastasis.

Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy

“…The authors of this study furthermore demonstrated median survival time after en bloc spondylectomy of more than 30 months and nearly 20% surviving more than 5 years. These findings underscore the results reported by Tomita et al who demonstrated median survival times in patients after en bloc resection of 38 months [33][34][35].…”

“…Based on these promising results, Tomita et al were the first to extend the surgical oncological concept of en bloc spondylectomy also to the treatment strategy of solitary spinal metastases of selected patients with specific tumor entities [33][34][35]. According to these studies, there is general consensus that indication for en bloc spondylectomy requires careful patient selection for which the following criteria might be helpful: (1) no underlying tumor type, which is considered to be a systemic disease, (2) tumor types that are known to be biologically favorable and to have a prolonged course (e.g., renal cell or mamma carcinoma), (3) radical treatment of the original/primary tumor, (4) long period between treatment of primary tumor and diagnosis of solitary metastatic disease, and (5) cation of isolated/solitary metastatic disease in CT scans, bone scan and/or PET.…”

“…Nevertheless, TES is reported to additionally improve local control and long-term outcome in patients who otherwise were treated with palliative excision surgery or radiochemotherapy [34]. Furthermore, Tomita et al have developed a prognostic scoring system for spinal metastases [33][34][35] by revealing a relationship between grades of malignancy and the extent of visceral and further bone metastases on the one hand and long-term local controls as well as disease-free survival on the other. Based on the prognostic score and expected survival periods, treatment goals could be defined and the appropriate oncological surgical strategy, ranging from simple spinal cord decompression to en bloc spondylectomy, can be selected.…”

En bloc spondylectomy reconstructions in a biomechanical in-vitro study

“…The previously described techniques were modified [7,32,37,58,59], prognostic surgical scores [56,57,60,61] were established considering the underlying tumor biology, the number/presence of extraspinal metastases and an estimation of life expectancy. With the results of these scores and the tremendous advance in spine surgery technique the indication from primary spinal tumors is now extended to selected cases of solitary spinal metastases with biologically favorable tumor entities [1,54,62,70]. Thanks to advances in tumor screening and diagnostics, the number of patients who may benefit from this extensive surgical treatment continues to increase.…”

Total en-bloc spondylectomy for correcting congenital kyphosis

“…This is the ®rst report of congenital kyphosis corrected using a total en-bloc spondylectomy. 7,8 Case report…”