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The evolution of surgical management for vertebral column tumors

JNSPG 75th Anniversary Invited Review Article

Jared Fridley and Ziya L. Gokaslan

T he treatment of vertebral column tumors has undergone significant transformation over the past several decades. Advances in surgical techniques, chemotherapy, radiation therapy, and the incorporation of technological innovations into the operating room have led to an overall shift in the management of patients with spine tumors, all with the goal of minimizing treatment-related morbidity. Perhaps the most significant changes have been the recent advances in spinal radiosurgery and cancer immunotherapy and the incorporation of patient and tumor-specific genomic

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Robert J. Jackson and Ziya L. Gokaslan

reviewed our experience with spinal—pelvic fixation in patients harboring lumbosacral tumors. Clinical Material and Methods Patient Population From July 1, 1994 to December 31, 1998, 802 spinal operations were performed in 621 patients by the surgeons of the neurosurgery service at The University of Texas M. D. Anderson Cancer Center. Thirteen of these patients required spinal—pelvic fixation for instability due to primary (eight cases) or metastatic (five cases) neoplasms. Previous treatment included spinal surgery in 77% (10) radiation therapy in 54% (seven

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Use of “MAPS” for determining the optimal surgical approach to metastatic disease of the thoracolumbar spine: anterior, posterior, or combined

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Daryl R. Fourney and Ziya L. Gokaslan

M etastases are by far the most common spinal neoplasms, and they represent a significant source of morbidity in cancer patients. 22 In the thoracolumbar spine, untreated neoplastic cord compression results in progressive paralysis, sensory loss, and sphincter dysfunction. 7 Severe axial pain may result from lytic VB collapse. 17 Effective cancer therapy must incorporate appropriate management of spinal metastases, both for the patient's quality of life and for oncological control. 60 In the last two decades, several developments have facilitated a

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Robert J. Jackson, Ziya L. Gokaslan and Shang-Chuin Arvinloh

affect the spine following breast, lung, and prostate, respectively. 23, 26 Additionally, RCC is the most common cancer in patients who present with a neurological deficit secondary to an undetected primary malignancy. 26 When RCC metastasizes to the spine, significant pain and neurological dysfunction often result. Although a few patients exhibit response to combined chemo- and immunotherapy, metastatic RCC remains highly resistant to systemic therapy and is generally radioresistant, thus making surgery the only remaining alternative. 2, 21, 22 Surgical treatment

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Kevin C. Yao, Stefano Boriani, Ziya L. Gokaslan and Narayan Sundaresan

Object

Spinal metastases are prevalent in the population of patients with cancer. Effective cancer therapy must incorporate treatment strategies for these lesions. Increasingly, surgery is being recognized as an effective treatment modality both for the patient's quality of life and potential oncological cure. En bloc spondylectomy is the surgical procedure of choice to obtain these goals. The purpose of this study was to examine critically the rationale, indications, and outcomes of en bloc spondylectomy for spinal metastases.

Methods

Outcomes in the authors' series of patients who underwent en bloc spondylectomy for spinal metastases are critically analyzed. The rationale and indications for this procedure are discussed. The Weinstein, Boriani, and Biagini surgical staging system for spinal tumors is described. A review of the literature is performed to examine further the rationale underlying this aggressive surgical approach to metastatic spinal disease.

Conclusions

En bloc spondylectomy is the treatment of choice for solitary and oligometastatic spinal metastases with biologically favorable histological findings. In appropriately selected patients, neurological outcome, pain control, and oncological control are significantly better after en bloc spondylectomy compared with radiation therapy. Oncological outcomes also exceed those of intralesional techniques. The Weinstein, Boriani, and Biagini surgical staging system provides a standard with which to plan surgical approaches and to compare surgical outcomes.

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Editorial

Metastatic spinal cord tumors

Mark N. Hadley

have influenced very favorably with spinal decompression, reconstruction, and fusion. There are also those whom we treat similarly—and we are stunned by their short survivals (the patients and families are too). How about those we treat who regain the ability to walk, live longer than otherwise suspected, and are terminally miserable? I will never forget a fellow I treated 10 years ago for metastatic esophageal carcinoma to the upper thoracic spine/cord. He had been receiving adjuvant therapy when he fell and became paraparetic (severe) due to a T-7 pathologic

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Daryl R. Fourney, Gregory N. Fuller and Ziya L. Gokaslan

rectal tone, and loss of the ankle jerk—was frequently found. When a significant portion of tumor is located anterior to the sacrum, as was the case in most of the patients in this survey, a palpable mass may be observed on pelvic and/or rectal examination. 15 TABLE 1 Summary of intraspinal extradural sacrococcygeal ependymomas reported in the literature * Authors & Year Age (yrs), Sex Clinical Presentation Metastases Surgery Postop Therapy Outcome Morantz, et al., 1979 31, F bladder dysfunction, pelvic mass

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Albert E. Telfeian, Gabriele P. Jasper, Adetokunbo A. Oyelese and Ziya L. Gokaslan

included but were not limited to physical therapy and epidural steroid injections. Patients were positioned prone on the Wilson frame or in the lateral decubitus position with the operating room table reversed and the flank over the break in the table. The choice of patient position was based on both the surgeon's and the patient's preference. The procedure was done under local analgesia and intravenous sedation (other practitioners do perform this procedure with general anesthesia); the level of anesthetic was titrated so that the patient was able to communicate with

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Risheng Xu, Daniel M. Sciubba, Ziya L. Gokaslan and Ali Bydon

ossification, is discontinuous with the adjacent laminae. This discontinuity is one of the most distinguishing characteristics separating CLF from OLF. At this time, there are no pharmacological therapies available to treat OLF; thus, the standard of treatment remains surgical in nature. In all cases, OLF requires decompression of the spinal cord via laminectomy and removal of the ossified ligamentum flavum. Recently, laminoplasty has been proposed as an alternative in treating OLF. 27–29 , 54 , 66 However, based on the largest and only retrospective study in which were

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En bloc resection of multilevel cervical chordoma with C-2 involvement

Case report and description of operative technique

Laurence D. Rhines, Daryl R. Fourney, Abdolreza Siadati, Ian Suk and Ziya L. Gokaslan

radiation therapy. Although there are several reports of en bloc excisions for thoracic and lumbar tumors, 5, 10, 12 the peculiar anatomical complexities of the cervical spine—including the intricate bone architecture, the encased VAs, and the need to preserve the cervical nerve roots—significantly increase the potential for intralesional margins. 3, 6 We present the case of a 54-year-old man who harbored a chordoma of the upper cervical spine (C2–4) with both a large retropharyngeal component and epidural extension. The method of en bloc removal of this lesion and