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Brian Shaw, Frederick L. Mansfield and Lawrence Borges

A s medical advances have extended the life expectancy of patients with cancer, there has been increased debate over optimal treatment of vertebral metastases. 1 Approximately 50% of patients with systemic cancer develop skeletal metastases, and the spine is the site most commonly involved. 7, 15 Within the spine, metastases arise predominantly in the thoracolumbar region, more specifically in the vertebral bodies and pedicles rather than in the posterior elements. 26 Hence, the main threat these tumors pose to the spinal cord and cauda equina is that of

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Wolfhard Caspar, Tobias Pitzen, Luca Papavero, Fred H. Geisler and Todd A. Johnson

40. Pasztor E , Lazar L , Benedek T , et al : Total body replacement with iliac bone graft and metal plate stabilization in lower cervical spine. Acta Neurochir 85 : 159 – 167 , 1987 Pasztor E, Lazar L, Benedek T, et al: Total body replacement with iliac bone graft and metal plate stabilization in lower cervical spine. Acta Neurochir 85: 159–167, 1987 41. Rao S , Davis R : Cervical spine metastases , in Clark CR (ed): The Cervical Spine , ed 3 . Philadelphia : Raven

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Daniel J. Miller, Frederick F. Lang, Garrett L. Walsh, Dima Abi-Said, David M. Wildrick and Ziya L. Gokaslan

, Gokaslan ZL : Occipitocervicothoracic fixation for spinal instability in patients with neoplastic processes. J Neurosurg (Spine 1) 91 : 81 – 89 , 1999 Jackson RJ, Gokaslan ZL: Occipitocervicothoracic fixation for spinal instability in patients with neoplastic processes. J Neurosurg (Spine 1) 91: 81–89, 1999 30. Jonsson B , Jonsson H , Karlstroem G , et al : Surgery of cervical spine metastases: a retrospective study. Eur Spine J 3 : 76 – 83 , 1994 Jonsson B, Jonsson H, Karlstroem G, et al

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Daryl R. Fourney, Dima Abi-Said, Frederick F. Lang, Ian E. McCutcheon and Ziya L. Gokaslan

posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 5 : 36 – 44 , 1996 Jonsson B, Sjostrom L, Olerud C, et al: Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J 5: 36–44, 1996 27. Kaplan EL , Meier P : Nonparametric estimation from incomplete observations. J Am Stat Assoc 53 : 457 – 481 , 1958 Kaplan EL, Meier P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53: 457–481, 1958 28. Kocialkowski A , Webb

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David Yen, Vikas Kuriachan, Jeff Yach and Andrew Howard

Object. The authors assessed the long-term results of anterior decompressive and vertebral body reconstructive surgery in which the Wellesley Wedge was applied in patients with metastatic spinal lesions over the life span of these individuals.

Methods. The authors performed a retrospective review of the outcome of 27 consecutively treated patients who underwent surgery for thoracic or lumbar spine metastases. Decompressive surgery was performed via an anterior thoracotomy and/or retroperitoneal approach depending on the level of the lesion. The spine was reconstructed using a U-shaped plate with an interposed methylmethacrylate strut known as the Wellesley Wedge.

Results. Thirty percent of patients suffered medical complications whereas 22% experienced postoperative improvement, as reflected by an improved Frankel grade. Used in patients with a variety of primary tumor types, a spectrum of ages and neurological status, and extensive preoperative osseous spinal involvement and deformity, the Wellesley Wedge resulted in spinal stability for the duration of patients' lives in 92%.

Conclusions. In this series the patient selection process for surgery was a challenge yet to be solved; however, considering the durability of the Wellesley Wedge itself, the authors will continue to use it in selected patients.

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Daryl R. Fourney, Julie E. York, Zvi R. Cohen, Dima Suki, Laurence D. Rhines and Ziya L. Gokaslan

, including three with atlantoaxial lesions, Rao, et al., 19 found a uniform recurrence of pain, despite some initial success. Nakamura, et al., 16 reported two patients harboring atlantoaxial metastases treated nonoperatively who died suddenly of respiratory arrest after a fall. Currently, there is general support for the surgical management of atlantoaxial metastases, especially in patients with painful instability or neurological deficits. 1, 13, 16–18, 24, 25 In a review of published reports on upper cervical spine metastases, the most frequent tumor location was at

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Jeremy C. Wang, Patrick Boland, Nandita Mitra, Yoshiya Yamada, Eric Lis, Michael Stubblefield and Mark H. Bilsky

Object. Patients with metastatic spine tumors often have multicolumn involvement and high-grade epidural compression, requiring circumferential decompression and instrumentation. Secondary medical and oncological issues add morbidity to combined approaches. The authors present their experience in using the single-stage posterolateral transpedicular approach (PTA) to decompress the spine circumferentially and to place instrumentation.

Methods. From September 1997 to February 2004, 140 patients with spine metastases underwent the PTA. Magnetic resonance imaging revealed high-grade spinal cord compression in 120 patients (86%) and lytic vertebral body destruction in all patients. Preoperatively 84 patients (60%) received radiotherapy directed to the involved level and 42 (30%) underwent tumor embolization. Following circumferential decompression, all patients underwent anterior reconstruction with polymethylmethacrylate and Steinmann pins, and posterior segmental fixation.

The median operative time was 5.1 hours, the median blood loss was 1500 ml, and the median hospital stay was 9 days. Ninety-six percent of the patients experienced postoperative pain improvement and improvement in or stabilization of neurological status. In 51 nonambulatory patients with poor Eastern Cooperative Oncology Group grades, 75% regained the ability to walk. One month postoperatively 90% of patients achieved good-to-excellent performance scores.

The overall median patient survival time was 7.7 months. Patients with colon and lung carcinomas had significantly shorter survival times. Major operative complications occurred in 20 patients (14.3%). Wound complications occurred in 16 patients (11.4%), but this was not correlated with preoperative radiation treatment.

Conclusions. The PTA allows circumferential epidural tumor decompression and the placement of anterior and posterior spinal column instrumention. Immediate spinal stability is achieved without the use of brace therapy. This technique achieved a high success rate for pain palliation, neurological preservation, and functional improvement, while avoiding the morbidity associated with combined approaches.

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Deborah L. Benzil, Mehran Saboori, Alon Y. Mogilner, Ronald Rocchio and Chitti R. Moorthy

S tereotactic radiosurgery of the spine is becoming an important tool in the neurosurgical armamentarium. Initial studies of the results of extracranial stereotactic radiosurgery demonstrated the accuracy and reproducibility of the various systems. 1, 2, 7, 14, 15, 18, 25, 26, 35, 38 More recently, larger case series have emerged. 11, 22, 32, 33 Rapid pain control has been achieved with stereotactic radiosurgery in patients with spine metastases. 11, 32 Radiologically demonstrated improvement has also been documented. 31 The scope of the neurological

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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

different there was a distinct trend toward longer survival in patients who underwent surgery and radiotherapy. Sundaresan, et al., 50 reported results obtained in 80 patients with solitary spinal metastases in whom grosstotal resection of tumor was performed using various procedures. The rate of local or regional disease recurrence for the entire series was 32%; however, in only one (17%) of six patients who underwent en bloc resection was a local recurrence demonstrated. In addition to patients with solitary spine metastases, an oncologically oriented surgical

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Mark H. Bilsky, Maxwell Boakye, Frederic Collignon, Dennis Kraus and Patrick Boland

tumors were RCC and breast carcinoma in six patients each. The primary tumors included six sarcomas of various histopathological compositions and two chordomas. The cervical spine was the first site of metastatic cancer in seven patients. The median interval between the diagnosis of the primary tumor and detection of the cervical spine metastases was 37 months (range 6–144 months). Twenty-five patients harbored other visceral and/or bone metastases at presentation. TABLE 1 Distribution of metastatic and primary tumors Tumors No. of Cases