Total cervical spondylectomy for primary osteogenic sarcoma

Case report and description of operative technique

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✓ The authors describe a technique for total spondylectomy for lesions involving the cervical spine. The method involves separately staged anterior and posterior approaches and befits the unique anatomy of the cervical spine. The procedure is described in detail, with the aid of radiographs, intraoperative photographs, and illustrations. Unlike in the thoracic and lumbar spine—for which methods of total en bloc spondylectomy have previously been described—a strictly en bloc resection is not possible in the cervical spine because of the need to preserve the vertebral arteries and the nerve roots supplying the upper limbs. Although the resection described in this case is by definition intralesional, it is oncologically sound, given the development of effective neoadjuvent chemotherapeutic regimens for osteosarcoma.

Article Information

Address reprint requests to: Ziya L. Gokaslan, M.D., Department of Neurosurgery, Johns Hopkins University, 600 North Wolfe Street, Meyer 7–109, Baltimore, Maryland 21287. email: zgokasl1@jhmi.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial (left) and sagittal (right) Gd-enhanced T1-weighted MR images obtained after response to neoadjuvant chemotherapy, demonstrating osteosarcoma of C-6 involving the VB, both pedicles, and extension into the surrounding soft tissues. The adjacent VBs are also involved.

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    Illustrations of the anatomy as visualized via the posterior approach. Left: Laminectomies from C-5 to C-7 and bilateral facetectomies at C5–6 and C6–7 were performed. Osseous dissection exposed the VAs and nerve roots bilaterally. A transpedicular C-6 partial vertebrectomy was performed and a Synmesh cage was placed into the vertebrectomy defect to prevent anterior column collapse prior to the anterior-approach stage. Inset: Illustration of the posterior skin incision. Depicted in green is the bone to be removed. Right: Posterior segmental instrumentation consisting of lateral mass screws (C-3 to C-5), pedicle screws (T-1 to T-3), rods, and crosslinks. a = artery.

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    Illustration of the anatomy as visualized from the anterior approach. Left: Tumor extended anteriorly from the C-6 VB to the C-5 and C-7 levels. Careful dissection along the lateral aspects of the VBs by using the high-speed drill exposed the VAs bilaterally at C-6 and C-7. The temporary cage, placed via the posterolateral approach, remains in place. Inset: Illustration of the skin incision. Right: Illustration of the complete resection and reconstruction as viewed from the anterior approach. At left, the remaining portions of the C-6 VB with the cage, the C5–6 and C6–7 intervertebral discs, as well as the C-5 and C-7 VBs were all resected in toto. At right, a Synmesh cage, filled with allograft and Grafton, was placed to span the C5–7 vertebrectomy defect. A cervical plate was placed from C-4 to T-1. m = muscle; n = nerve; v = vein.

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    Intraoperative photographs demonstrating the posterior stage of total C-6 spondylectomy. A: Laminectomies from C-5 to C-7 and bilateral facetectomies at C5–6 and C6–7 were performed, with wide exposure of the thecal sac and exiting nerve roots. The lateral mass screws and pedicle screws are in place. B: The C-6 pedicles were removed using the high-speed drill. C: Bone was removed to free the VAs (arrows) from the transverse foramina bilaterally. D: Posterior segmental fixation is shown. The Synmesh cage, which was placed into the C-6 vertebrectomy defect prior to placement of the rods, is obscured by the neural elements. E: Another view demonstrating the Synmesh cage.

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    Intraoperative photographs demonstrating the anterior stage of total C-6 vertebrectomy. A: The initial view after the anterior exposure revealing gross tumor involving the C-6 VB and extending rostrally and caudally. The temporary Synmesh cage is visible. B: Pathological specimen of the C-6 VB, the cage, the adjacent intervertebral discs, and the C-5 and C-7 VBs. C: The view through the C5–7 vertebrectomy defect, prior to the anterior reconstruction, demonstrating the decompressed thecal sac and the widely exposed C-6 and C-7 nerve roots.

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    Anteroposterior (left) and lateral (right) postoperative plain radiographs revealing the spinal alignment, anterior reconstruction, and posterior stabilization. Note the absence of osseous elements at C-6.

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    Axial plain computerized tomography scan obtained through bone windows, demonstrating no residual osseous elements at C-6. The plate and cage, packed with bone chips, are seen anteriorly, and the rods are seen posteriorly.

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    Recently obtained anteroposterior (left) and lateral (right) plain radiographs revealing an intact construct and normal spinal alignment.

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