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

T otal en bloc spondylectomies are rarely performed procedures, and they are particularly uncommon for the lower lumbar spine because of this area's unique anatomy. Only five such cases have been reported in the literature. 1, 14, 15 Although the surgery is technically demanding and carries a higher risk of neurological injury than other more commonly performed procedures, it offers the patient the best chance for a cure in certain circumstances. We present the case of a 64-year-old woman who harbored an isolated primary chondrosarcoma involving the L-4 VB

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Camilo A. Molina, Christopher F. Dibble, Sheng-fu Larry Lo, Timothy Witham, and Daniel M. Sciubba

technology for lumbar pedicle instrumentation. 11 A positive workflow and precision performance experience with this novel navigation system revealed the potential for more technically demanding surgical applications. Here, we describe the first use, to our knowledge, of ARMSS for guidance in unique osteotomy execution to achieve an en bloc wide marginal resection of an L1 chordoma through a posterior-only approach. FIG. 1. AR-HMD with an ITC ( A ) and translucent retinal display ( B ) enabling 2D and 3D navigational data overlaid in anatomically matching

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Paul E. Kaloostian, Patricia L. Zadnik, Ahmed J. Awad, Edward McCarthy, Jean-Paul Wolinsky, and Daniel M. Sciubba

-threatening consequences. These neuroendocrine tumors secrete highly potent catecholamines, such as norepinephrine and epinephrine, which trigger a wide range of vasoactive disturbances such as severe hypertension and tachycardia in the patient. 11 Elevated urinary levels of vanillylmandelic acid (236 g/24 hrs) and metanephrine (30,000 g/ng creatinine) are noted in these patients. 6 Diagnosis is established via history, laboratory values, and/or biopsy. 6 We describe the first case of en bloc resection of a spinal pheochromocytoma as a treatment for metabolic derangement and local

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Camilo A. Molina, Christopher P. Ames, Dean Chou, Laurence D. Rhines, Patrick C. Hsieh, Patricia L. Zadnik, Jean-Paul Wolinsky, Ziya L. Gokaslan, and Daniel M. Sciubba

C hordomas are tumors that originate from vestigial remnants of the notochord. 28 With the exception of plasmacytomas, chordomas are the most common primary malignancies of the spine. 24 The most commonly affected group is middle-aged adults. 28 Typically, the disease course is slow, with metastasis occurring late and death most often the result of local disease extension. 29 Management is often difficult, as chordomas are largely refractory to chemotherapy and conventional radiation therapy, making en bloc resection the ideal treatment modality. 4

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Dean Chou, Frank Acosta Jr., Jordan M. Cloyd, and Christopher P. Ames

A s a malignant tumor of the spinal column, chordoma is difficult to treat because of its local aggressiveness. It has been shown that en bloc resection of chordoma with wide margins, or even marginal margins, has a significantly better rate of control than intralesional resection. 3 , 5 , 8 , 10 Spondylectomy is ideal for resection of chordoma, but this can be difficult in the cervical spine because of the nerve roots and VAs involved. Multilevel chordomas pose even more challenges. Not only are multiple levels of nerve roots and the VAs involved, but

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Christopher S. Bailey, Charles G. Fisher, Michael C. Boyd, and Marcel F. S. Dvorak

spine because of its imposing anatomy, the enormity of the procedure, and the associated neurological morbidity. Relatively recent advances in medical imaging, biotechnology, and perioperative care have allowed more oncologically appropriate procedures to be performed in the mobile spinal regions with acceptable morbidity and mortality rates. 1 , 7 , 8 , 10 , 19–21 , 31 Because chordomas are malignant and will aggressively recur locally if intralesional resection alone is undertaken, wide or true en bloc resection is generally recommended. 1 , 7 , 8 , 10 , 20 , 21

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Daniel M. Sciubba, Rory J. Petteys, Sophia F. Shakur, Ziya L. Gokaslan, Edward F. McCarthy, Michael T. Collins, Matthew J. McGirt, Patrick C. Hsieh, Clarke S. Nelson, and Jean-Paul Wolinsky

report, we illustrate the presentation and treatment of a patient with a PMT of the spinal column. Because this patient presented with severe osteomalacia and multiple skeletal fractures due to the metabolic activity of her tumor, she underwent an en bloc spondylectomy to attain oncological and metabolic control. Pathological analysis of the spine lesion revealed a PMT, a rare type of tumor that causes tumor-induced osteomalacia. Since undergoing resection, the patient has experienced resolution of her osteomalacia. Although en bloc spondylectomy is generally reserved

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Tomio Sasaki, Makoto Taniguchi, Ichiro Suzuki, and Takaaki Kirino

carefully drilled off. Fig. 1. Left: Illustration of en bloc petrosectomy using a Gigli saw in the transpetrosal—transtentorial approach. A nick for the Gigli saw is made on the petrous ridge just behind the arcuate eminence, and petrosectomy is carried toward the imaginary line 5 mm superior to the upper margin of the external auditory canal. Two parallel solid line indicate the resection of the petrous bone. Right: Photographs of a cadaveric skull demonstrating en bloc petrosectomy using a Gigli saw. Abbreviations: a.e. = arcuate eminence and e

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Michelle J. Clarke, Patricia L. Zadnik, Mari L. Groves, Hormuzdiyar H. Dasenbrock, Daniel M. Sciubba, Wesley Hsu, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan, and Jean-Paul Wolinsky

E n bloc resection of primary tumors has consistently demonstrated a long-term disease-free survival benefit over palliative intralesional resections. 9–11 Originally conceived in 1982 by Roy-Camille for musculoskeletal tumors, 24 this approach has been applied to tumors throughout the body. In patients with bony metastasis from distant cancer, en bloc resection may also provide benefit. By including barrier tissues with a wide margin or total en bloc resection, local control may be improved. 11 In cases of a single bony spine metastasis, en bloc

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Benjamin D. Fox, Bartley D. Mitchell, Akash J. Patel, Katherine Relyea, Shankar P. Gopinath, Claudio Tatsui, and Bruce L. Ehni

using a modified bulb syringe that we connected to standard suction tubing to function as a vacuum retractor. This technique allows for rapid, safe, en bloc resection of large convexity meningiomas with minimal to no pressure on the surrounding brain. We present an illustrative case and then describe and discuss the technique. Case Illustration History and Examination This 82-year-old man with no significant medical history experienced new onset seizures in 2003. He was started on antiepileptic medications and MR imaging of his brain was obtained