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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

Surgery for the resection of vertebral column tumors has undergone a remarkable evolution over the past several decades. Multiple advancements in surgical techniques, spinal instrumentation, technology, radiation therapy, and medical therapy have led to improved patient survival, function, and decreased morbidity. In this review, the authors discuss major changes in each of these areas in further detail.

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Ziya L. Gokaslan

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Robert J. Jackson and Ziya L. Gokaslan

Object. Primary and metastatic neoplasms of the lumbosacral junction frequently pose a complex problem for the surgical management and stabilization of the spine because of the anatomical and biomechanical factors of this transition zone between spine and pelvis. The authors have used a modification of the Galveston technique, originally described by Allen and Ferguson in the treatment of scoliosis, to achieve rigid spinal—pelvic fixation in patients with lumbosacral neoplasms. The authors retrospectively reviewed their experience, with particular attention to method, pain relief, and neurological status.

Methods. From July 1994 through December 1998, 13 patients at the authors' institution have required spinal—pelvic fixation secondary to instability caused by primary (eight cases) or metastatic (five cases) neoplasms. Previous treatment included spinal surgery in 10 (77%), radiation therapy in seven (54%), and/or chemotherapy in six (46%). Following tumor resection, fixation was achieved by intraoperative placement of contoured titanium rods bilaterally into the ilium. These rods were attached to the lumbar spine with pedicle screws and subsequently crosslinked. Arthrodesis was performed.

In the follow-up period of 3 to 50 months (average 20 months), nine (69%) of 13 patients were still alive. There were no cases of surgery-related death. Seven weeks postoperatively instrumentation failure occurred in one patient and was corrected by performing double L-rod spinal—pelvic fixation. Two patients experienced neurological dysfunction (ankle weakness and neurogenic bladder) that was thought to be related to tumor resection rather than the fixation procedure. Neurological status improved in four patients and remained unchanged in seven patients. Ambulatory status improved in 62% (eight patients), remained unchanged in 23% (three patients), and worsened in 15% (two patients). Spinal pain, as measured by a visual analog pain scale and determined by medication consumption was significantly reduced in 85% (11 cases).

Conclusions. In selected patients with primary or metastatic lumbosacral tumors, resection followed by modified Galveston L-rod spinal—pelvic fixation is an effective means of achieving stabilization that can provide significant pain relief and preserve ambulatory capacity.

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Carlos A. Bagley and Ziya L. Gokaslan

Cauda equina syndrome (CES) is defined as the constellation of symptoms that includes low-back pain, sciatica, saddle anesthesia, decreased rectal tone and perineal reflexes, bowel and bladder dysfunction, and variable amounts of lower-extremity weakness. There are several causes of this syndrome including trauma, central disc protrusion, hemorrhage, and neoplastic invasion. In this manuscript the authors reviewed CES in the setting of both primary and secondary neoplasms. They examined the various primary tumor types in this region as well as those representative of metastatic spread. Both surgical and nonsurgical management in this setting were studied.

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Robert J. Jackson and Ziya L. Gokaslan

Object. Occipitocervicothoracic (OCT) fixation and fusion is an infrequently performed procedure to treat patients with severe spinal instability. Only three cases have been reported in the literature. The authors have retrospectively reviewed their experience with performing OCT fixation in patients with neoplastic processes, paying particular attention to method, pain relief, and neurological status.

Methods. From July 1994 through July 1998, 13 of 552 patients who underwent a total of 722 spinal operations at the M. D. Anderson Cancer Center have required OCT fixation for spinal instability caused by neoplastic processes (12 of 13 patients) or rheumatoid arthritis (one of 13 patients). Fixation was achieved by attaching two intraoperatively contoured titanium rods to the occiput via burr holes and Luque wires or cables; to the cervical spinous processes with Wisconsin wires; and to the thoracic spine with a combination of transverse process and pedicle hooks. Crosslinks were used to attain additional stability. In all patients but one arthrodesis was performed using allograft.

At a follow-up duration of 1 to 45 months (mean 14 months), six of the 12 patients with neoplasms remained alive, whereas the other six patients had died of malignant primary disease. There were no deaths related to the surgical procedure. Postoperatively, one patient experienced respiratory insufficiency, and two patients required revision of rotational or free myocutaneous flaps. All patients who presented with spine-based pain experienced a reduction in pain, as measured by a visual analog scale for pain. All patients who were neurologically intact preoperatively remained so; seven of seven patients with neurological impairment improved; and six of seven patients improved one Frankel grade. There were no occurrences of instrumentation failure or hardware-related complications. In one patient a revision of the instrumentation was required 13.5 months following the initial surgery for progression of malignant fibrous histiosarcoma.

Conclusions. In selected patients, OCT fixation is an effective means of attaining stabilization that can provide pain relief and neurological preservation or improvement.

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Patrick C. Hsieh and Ziya L. Gokaslan

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Daryl R. Fourney and Ziya L. Gokaslan

Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. The value of adjuvant treatment is uncertain, and resection remains the primary mode of treatment. Chordomas are difficult to excise completely, but recent improvements in imaging and surgical techniques have allowed surgeons to perform more frequently en bloc sacral resections with wide surgical margins. The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.

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Ziya L. Gokaslan, Albert E. Telfeian and Michael Y. Wang

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

Object. Renal cell carcinoma (RCC) is an aggressive malignancy that frequently metastasizes. When RCC metastasizes to the spine, significant pain and neurological dysfunction often follow. Because systemic therapy and radiotherapy have a limited effect in controlling spinal disease, surgery is frequently required; however, there are very few published series specifically addressing the role and benefits of the surgical treatment for this disease. The authors conducted a retrospective study to review their experience with the surgical treatment of metastatic RCC of the spine, paying particular attention to methodology and patient neurological status, pain relief, and survival.

Methods. Between January 1993 and April 1999, 79 patients (63 men and 16 women patients; average age 55 years, range 16–82 years) underwent 107 spinal operations for metastatic RCC. Indications for surgery included disabling pain (94 [88%] of 107 procedures) and/or neurological dysfunction (55 [51%] of 107 procedures). The anatomical location and extent of tumor determined the choice of an anterior, posterior, or combined surgical approach. Internal fixation was performed in all but three patients. Preoperative embolization was required in approximately one half of the patients. Radiotherapy was performed in 40 patients prior to surgery, and immuno- and chemotherapy were administered in 70 patients either pre- or postoperatively. After an average follow-up duration of 15 months, 57 patients had died. Kaplan—Meier analysis revealed a median postoperative survival of 12.3 months. Significant pain reduction, as indicated by a visual analog pain scale, was achieved in 84 (89%) of the 94 cases presenting with disabling pain. Neurological improvement was seen in 36 (65%) of the 55 patients. The major morbidity and 30-day mortality rates were 15% (16 of 107 procedures) and 2% (two of 107 procedures), respectively.

Conclusions. In selected patients with metastatic RCC of the spine, resection followed by stabilization can provide pain relief and neurological preservation or improvement.

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Doniel Drazin, Ziya L. Gokaslan and J. Patrick Johnson