Total En Bloc Spondylectomy for Spinal Tumors: Surgical Techniques and Related Basic Background

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The authors' group has developed a new surgical technique of spondylectomy (vertebrectomy) called “total en bloc spondylectomy” (TES). This technique is different from spondylectomy in that it involves en bloc removal of the lesion, that is, removal of the whole vertebra, body and lamina, as one compartment. The surgical technique of TES has been remarkably improved based on adequate knowledge and consideration of the surgical anatomy, physiology, and biomechanics of the spine and spinal cord. Review of the developmental process of this operation leads to recognition of the tips, pitfalls, and solutions.

Section snippets

Surgical indication for total en bloc spondylectomy

The TES technique was designed to achieve oncologic complete tumor resection en bloc, including the main and satellite microlesions in a vertebral compartment, so as to avoid local recurrence. The following pathologic findings are primary candidates: primary malignant tumor (stage I or II), aggressive benign tumor (stage III), and isolated metastasis with a long life expectancy (see surgical strategy; Figs. 1 and 2).18, 19

From the viewpoint of tumor growth (see surgical classification; Fig. 3),

Triple-Level Embolization

Preoperative embolization of bilateral segmental arteries at three levels (ie, embolization of bilateral segmental arteries of the tumor-laden level and two adjacent vertebrae [one cephalad and one caudal]) is tried within 48 hours before the operation (Fig. 4).18

Embolization is performed under local anesthesia in all cases. Arterial access is established using an intravascular sheath placed within the common femoral artery. After the aortic runoff, selective angiograms of segmental arteries

Surgical technique of total en bloc spondylectomy

The TES technique consists of two steps, including en bloc resection of the posterior element and en bloc resection of the anterior part to salvage the spinal cord. In some cases, a small part (the pedicle in most cases) becomes intralesional deliberately, but this must be permitted to salvage the spinal cord. The surgical approach is decided on the basis of the degree of tumor development or the affected spinal level(s).2, 3, 13, 15, 16, 17

Illustrative case presentation

A 40-year-old woman had thoracic metastasis from a sacrum chordoma. She had back pain and gait disturbance attributable to thoracic myelopathy. MRI of the thoracic spine showed that a vertebral tumor of T6 extended to the spinal canal in a craniocaudal direction, severely compressing the spinal cord and also expanding outside the vertebral body (see Fig. 6A left and right).

The patient underwent TES by means of a single posterior approach. The T5, T6, and T7 laminae were removed en bloc one by

Illustrative case presentation

A 38-year-old woman had a giant-cell tumor of the lumbar spine. She had severe lumbar pain. Images revealed that an L4 vertebral tumor largely expanded outside the vertebral body and had grown to the neighboring vertebrae (L3 and L5) (Fig. 12A left and right, B). The bilateral common iliac arteries were compressed and shifted to the anterior direction, and the vena cava inferior was also severely compressed so as to be flattened (see Fig. 12A left). The patient underwent TES by a

Postoperative management

Suction draining is preferred for 4 to 5 days after surgery, and the patient is allowed to start walking 1 week after surgery. The patient wears a thoracolumbosacral orthosis for 3 months until the bony union or incorporation of the artificial vertebral prosthesis is attained.

Preoperative triple-level embolization

Intraoperative bleeding is sometimes excessive in patients who have hypervascular spinal tumors in TES surgery. There is no doubt that preoperative embolization of the feeding artery at the affected vertebra is mandatory; nevertheless, this does not seem to be sufficient to stop the bleeding altogether. In a canine study, the authors found that when bilateral segmental arteries at three levels were ligated, blood flow of the middle vertebra was reduced to 25% of that of the control group27

Acknowledgment

The authors deeply thank all the doctors in the Department of Orthopaedic Surgery, Kanazawa University, who have contributed throughout this work.

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