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Daryl R. Fourney, Dima Abi-Said, Laurence D. Rhines, Garrett L. Walsh, Frederick F. Lang, Ian E. McCutcheon and Ziya L. Gokaslan

Patient Population and Data Collection Between July 1, 1994 and March 31, 2000, a total of 1128 spinal operations were performed in 846 patients at The University of Texas M. D. Anderson Cancer Center. After patients with Pancoast tumors (the subject of a previous report 33 ) were excluded, there were 28 patients who underwent a simultaneous anterior—posterior approach to the thoracic or lumbar spine for the treatment of neoplastic disease. Two patients with paravertebral lesions without spinal invasion were excluded; the remaining 26 patients made up the study

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Kazuhiro Hasegawa, Akira Ogose, Hiroto Kobayashi, Tetsuro Morita and Yasuharu Hirata

simultaneous anterior—posterior approach, which is followed by spinal reconstruction. Illustrative Case This 59-year-old man was referred for consultation after an abnormal shadow was observed on his chest x-ray film ( Fig. 1 ). The patient experienced occasional right-sided chest pain that had not been treated. On presentation he experienced tenderness over his right upper-back area with slight intercostal radiating pain. Sensory and motor deficits of his trunk and lower extremities were not apparent. Vesicorectal functions and reflexes were normal. Magnetic resonance

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Lissa Peeling, Evan Frangou, Stephen Hentschel, Ziya L. Gokaslan and Daryl R. Fourney

approaches, true simultaneous anterior-posterior approaches provide the most direct visualization of ventral pathology as well as adjacent neurovascular and visceral structures. Two surgical teams can work simultaneously through separate incisions. This approach is ideal for cases in which large paraspinal tumors must be excised along with vertebral lesions involving the anterior and posterior spinal columns. The simultaneous, combined anterior-posterior exposure 1 , 7 , 12 , 16 has not gained popularity, perhaps because of the difficulty of placing pedicle screws while

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Narayan Sundaresan, Alfred A. Steinberger, Frank Moore, Ved Parkash Sachdev, George Krol, Laura Hough and Kevin Kelliher

. Although a single approach may suffice in most patients, radiographic studies frequently demonstrate three-column involvement or marked instability of the spine. In such patients, a purely posterior or anterior approach does not provide sufficient access for tumor resection or correction of the instability. Thus, combined anterior—posterior approaches may be required. Although this concept is not new, and has been advocated in several small series in the literature, 8, 25 no large series have analyzed long-term outcome and morbidity. Therefore, we have performed a

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Jark J. D. Bosma, Timothy J. D. Pigott, Bruce H. Pennie and David C. Jaffray

resection. 4 Heary, et al., 13 favor a single anterior—posterior approach and have described this two-stage procedure in detail. At the end of the first stage cotton patties are placed ventral to the dura and nerve roots, which appears to be a particularly useful step to identify these structures in the second stage. A left retroperitoneal approach is then undertaken with the patient in right lateral decubitus position, and this is very similar to the approach we used in Case 2. Heary, et al., believe that this approach is safer for the great vessels, but they noted

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Narayan Sundaresan, Alfred A. Steinberger, Frank Moore, Ved Parkash Sachdev, George Krol, Laura Hough and Kevin Kelliher

Spinal instrumentation currently allows gross-total resection and reconstruction in cases of malignancies at all levels of the spine. The authors analyzed the results in 110 patients who underwent surgery for primary and metastatic spinal tumors over a 5 year period (1989–1993) at a single institution. Major primary sites of tumor included breast (14 cases), chordoma (14 cases), lung (12 cases), kidney (11 cases), sarcoma (13 cases), plasmacytoma (10 cases), and others (36 cases). Prior to surgery, 55 patients (50%) had received prior treatment. Forty eight patients (44%) were nonambulatory, and severe paraparesis was present in 20 patients. Fifty three patients (48%) underwent combined anterior-posterior resection and instrumentation, 33 (30%) underwent anterior resection with instrumentation, 18 (16%) underwent anterior or posterior resection alone, and the remaining six patients (5%) underwent posterior resection and instrumentation. Major indications for anterior-posterior resection included three-column involvement, high-grade instability, involvement of contiguous vertebral bodies, and solitary metastases. Postoperatively, 90 patients improved neurologically. The overall median survival was 16 months, with 46% of patients surviving 2 years. Fifty-three patients (48%) suffered postoperative complications. Despite the high incidence of complications, the majority of patients reported improvement in their quality of life at follow-up review. Our findings suggest that half of all patients with spinal malignancies require combined anterior-posterior surgery for adequate tumor removal and stabilization.

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Nancy E. Epstein, Renee Hollingsworth, Dominic Nardi and Johnathan Singer

Object. The authors conducted a study to determine how to avoid emergency postoperative reintubation and its associated morbidity in patients who have undergone multilevel anterior—posterior cervical spine surgery.

Methods. In a group effort between the departments of anesthesia and neurosurgery, a protocol was developed to avoid having to reintubate patients postoperatively. As a preventative measure, patients remained intubated overnight; on the 1st postoperative day or thereafter, based on direct fiberoptic visualization of reactive tracheal swelling, an anesthesiologist extubated the patients. Fifty-eight patients underwent multilevel anterior corpectomy with fusion (ACF; with 41 receiving plates and 17 not receiving plates), posterior wiring and fusion (PWF), and application of a halo. On average, ACF involved three levels, whereas PWF included 6.5 levels. Surgery typically lasted 10 hours, and an average 2.6 U of blood was required.

Forty patients were successfully extubated on the 1st, five on the 2nd, three on the 3rd, two on the 4th, two on the 5th, and three on the 7th postoperative day. Three elective tracheostomies were performed on the 7th postoperative day. Risk factors associated with delayed extubation or tracheostomy in 18 patients included: operative time longer than 10 hours (12 patients), obesity greater than 220 lbs (12 patients), transfusion of more than 4 U of blood (10 patients), ACF reoperations (nine patients), ACF including C-2 (seven patients), four-level ACF (five patients), and asthma (five patients). In the only case in which emergency reintubation was required, three risk factors were present.

Conclusions. Emergency reintubation following anterior—posterior cervical surgery and fusion can be avoided by maintaining intubation overnight and subsequently having an anesthesiologist remove the tube after healing is fiberoptically confirmed. Familiarity with major risk factors contributing to airway compromise, combined with this protocol, should minimize the significant morbidity associated with reintubation following multilevel anterior—posterior cervical fusion.

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Eric Marmor, Laurence D. Rhines, Jeffrey S. Weinberg and Ziya L. Gokaslan

sophisticated spinal instrumentation, however, the patient was not permitted to stand for 11 months after the procedure. Subsequently, other teams have described techniques for total en bloc spondylectomies. 1, 3, 8, 13, 15, 16 Lubicky, et al., 7 and Savini, et al., 10 have reported using a combined anterior—posterior approach for piecemeal total spondylectomies in patients with giant cell tumors. In 1988, Magerl and Coscia 8 reported performing nine total spondylectomies via a posterior approach, but in their technique piecemeal resection of the VB was also required

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Novel use of a threadwire saw for high sacral amputation

Technical note and description of operative technique

Robert J. Bohinski, Ehud Mendel and Laurence D. Rhines

above these foramina (supraforaminal). 14, 15 The level of sacral resection depends on the rostrocaudal extent of sacral involvement and the size of the tumor. Anterior, posterior, and combined approaches have been described in the treatment of these lesions. 6, 7, 9, 13 In general, large sacral chordomas and other primary sacral malignant tumors require a combined anterior—posterior approach. The complexity and risk of these procedures increases substantially as the tumor invades more rostral sacral levels, and the rarity of cases amenable to high sacral amputation

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Alecio C. E. S. Barcelos and Ricardo V. Botelho

telescoping of the involved vertebrae is a combined anterior-posterior approach with corpectomy, anterior support implant, and further posterior instrumentation. 24 , 36 These procedures usually require 2 surgical teams, involve longer operating times and greater risk of surgical complications related to the anterior approach, and commonly entail longer postoperative care before discharge. We report on 2 patients with high thoracic fracture-dislocations with telescoping (T-2 and T-4) ( Figs. 1A , 1B , and 2 left ) who were treated in the subacute phase with total