Total L-5 spondylectomy and reconstruction of the lumbosacral junction

Technical note

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✓The authors describe a technique for total L-5 spondylectomy and reconstruction of the lumbosacral junction. The technique, which involves separately staged posterior and anterior procedures, is reported in two patients harboring neoplasms that involved the L-5 level. The first stage consisted of a posterior approach with removal of all posterior bone elements of L-5 and radical L4–5 and L5–S1 discectomies. Lumbosacral and lumbopelvic instrumentation included pedicle screws as well as iliac screws or a transiliac rod. The second stage consisted of an anterior approach with mobilization of vascular structures, completion of L4–5 and L5–S1 discectomies, and removal of the L-5 vertebral body. Anterior lumbosacral reconstruction included placement of a distractable cage and tension band between L-4 and S-1. Allograft bone was used for fusion in both stages. No significant complications were encountered. At more than 1 year of follow-up, both patients were independently ambulatory, without evidence of recurrent or metastatic disease, and adequate lumbosacral alignment was maintained. The authors conclude that this technique can be safely performed in appropriately selected patients with neoplasms involving L-5.

Abbreviations used in this paper:CT = computed tomography; GCT = giant cell tumor; MR = magnetic resonance; VB = vertebral body.

Article Information

Address reprint requests to: Gary L. Gallia, M.D., Ph.D., Department of Neurosurgery, The Johns Hopkins University School of Medicine, Meyer 8-161, 600 North Wolfe Street, Baltimore, Maryland 21287. email: ggallia1@jhmi.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Sagittal (A) and axial (B) Gd-enhanced T1-weighted preoperative MR images demonstrating a contrast-enhancing tumor involving the L-5 VB with extension into the pedicles bilaterally and the spinal canal.

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    Case 1. Illustrations of the anatomy visualized via the posterior approach of the complete L-5 spondylectomy. During this stage the posterior vertebral elements are removed en bloc following bilateral L-5 pediculotomies (A), and radical discectomies are performed at L4–5 and L5–S1 (B). Once the discectomies are completed, a Silastic sheet is placed ventral to the dura mater and nerve roots and dorsal to the tumor and VBs (C). In this case, posterior reconstruction was accomplished via bilateral contoured lumbar rods connecting pedicle screws at L-3, L-4, and S-1 and, via offsets, iliac screws.

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    Case 1. Intraoperative photographs demonstrating the posterior stage of the total L-5 spondylectomy. A: Photograph acquired after en bloc L-5 laminectomy, L4–5 and L5–S1 discectomies, and placement of a Silastic sheet anterior to the thecal sac and nerve roots and instrumentation. B and C: Photographs demonstrating the gross specimens of the posterior elements after en bloc removal.

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    Case 1. Illustrations of the anatomy visualized via the anterior approach of the complete L-5 spondylectomy. Left: The vascular structures are mobilized from the ventral aspect of the L-5 VB and the discectomies are completed allowing the VB to be removed en bloc. Right: The anterior lumbosacral reconstruction with a distractible cage and tension band. a.= artery; n. = nerve; v. = vein.

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    Case 1. Postoperative imaging studies. A: Sagittal CT scan with bone windows, demonstrating no residual elements at L-5. The plate and cage, packed with allograft and demineralized bone matrix, are seen anteriorly. B and C: Anteroposterior and lateral plain radiographs obtained 13 months after surgery.

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    Case 2. Preoperative imaging studies. Sagittal (A) and axial (B) Gd-enhanced T1-weighted MR images obtained after the tumor responded to systemic chemotherapy, demonstrating a heterogeneously enhancing soft-tissue mass involving the right transverse process, right L-5 pedicle, and the L-5 VB.

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    Case 2. Intraoperative photographs demonstrating the anterior stage of the total L-5 spondylectomy. A: Photograph obtained after L4–5 and L5–S1 discectomy completion, en bloc resection of the L-5 VB, and placement of a distractible cage between the L-4 VB and sacrum. B: Photograph acquired after placement of an anterior tension band under the iliac vessels. C: Photograph demonstrating the gross specimen of the L-5 VB after en bloc resection.

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    Case 2. Postoperative imaging studies. Anteroposterior (A) and lateral (B) plain radiographs obtained 17 months after surgery revealing the spinal alignment, anterior reconstruction, and posterior stabilization.

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