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Doniel Drazin, Neil Bhamb, Lutfi T. Al-Khouja, Ari D. Kappel, Terrence T. Kim, J. Patrick Johnson and Earl Brien

OBJECTIVE

The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors.

METHODS

The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type.

RESULTS

Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type.

CONCLUSIONS

Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

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Rani Nasser, Doniel Drazin, Jonathan Nakhla, Lutfi Al-Khouja, Earl Brien, Eli M. Baron, Terrence T. Kim, J. Patrick Johnson and Reza Yassari

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.