Total en bloc lumbar spondylectomy

Case report

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✓ The authors describe a technique for total en bloc spondylectomy that can be used for lesions involving the lumbar spine. The technique involves a combined anterior—posterior approach and takes into account the unique anatomy of the lumbar spine. This technique allows for the en bloc resection of lumbar vertebral tumors, thus optimizing outcome while minimizing the risk of neurological injury. The technique is described in detail with the aid of neuroimaging studies, photographs of gross pathological specimens, and illustrations, and a discussion of other authors' experiences is provided for comparison.

Article Information

Address reprint requests to: Ziya L. Gokaslan, M.D., Department of Neurosurgery, Box 442, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030–4095. email: zgokasla@mdanderson.org

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative imaging studies. Axial (upper left) and sagittal (upper right) MR images of the tumor extensively involving the L-4 vertebra with epidural extension and compression of the neural elements. Although there appears to be tumor invasion of the aortic surface, none was found intraoperatively. Preoperative CT scan with bone windows (lower) demonstrating the destructive lesion involving more than half of the VB on the left.

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    Illustration of the anatomy as visualized from the posterior approach. During this part of the procedure, the posterior vertebral elements are removed en bloc, exposing the dura mater and involved nerve roots. A partial discectomy is also performed during this part of the operation. Inset: Illustration of patient positioning for the posterior-approach stage of the procedure, showing skin incisions involved. M = muscle.

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    Illustration of anatomy as visualized from the anterolateral approach. During this part of the procedure, the discectomy is completed, and the ligamentous attachments of the VB are divided to allow for the en bloc removal of the anterior part of the involved vertebra. Inset: Illustration of patient positioning for the anterolateral approach part of the procedure, showing the skin incision involved. A = artery; v = vein.

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    Illustration (posterior view) showing the posterior instrumentation, in which pedicle screws were used, and the anterior reconstruction of the L-4 VB with part of a chest tube and methylmethacrylate.

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    A: Intraoperative photograph obtained during the posterior—approach procedure after the posterior vertebral elements have been removed. Note the exposed thecal sac and preserved L-4 nerve roots bilaterally (arrows). B: Intraoperative photograph acquired during the posterior—approach procedure after placement of the Silastic sheet anterior to the thecal sac and nerve roots (arrows). The Silastic sheet serves as an important landmark during the anterolateral aspect of the procedure. C: Photograph showing gross specimen of posterior elements after they have been removed en bloc. D: Intraoperative photograph obtained during the anterolateral part of the procedure. Note the anterior view of the thecal sac dura mater as well as the bilaterally preserved L-4 nerve roots (arrows). E: Photograph of the gross anterior part of L-4 VB containing tumor after en bloc resection. F: Photograph of the gross view of both anterior and posterior elements of the L-4 vertebra, demonstrating the total en bloc spondylectomy.

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    Postoperative anteroposterior (left) and lateral (right) plain radiographs. Pictured are posterior (L3–5) segmental fixation with pedicle screws and anterior reconstruction with methylmethacrylate in which the chest tube technique was used. (Magnetic resonance images confirmed that the apparent ventral protrusion of the graft in the lateral view was an artifact caused by poor visualization of the anterior border of L-5 from underpenetration of the x-ray film; data not shown.)

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