Primary spine tumors: diagnosis and treatment.

BACKGROUND: Primary tumors are rare and those localized to a single location offer the potential for cure. To achieve this, early recognition of the primary tumor and proper workup and treatment are essential. METHODS: The authors reviewed the literature and best practices to provide recommendations on primary spine tumor treatment. Appropriate workup of primary spine tumors and treatment algorithms are also discussed. RESULTS: Patients suspected of a primary spine tumor should undergo fine-needle aspirate biopsy following consultation with the surgical team to ensure the biopsy tract is surgically resectable should the need arise. Once pathology is confirmed, metastatic workup should be performed to guide the level of treatment. If a localized lesion with poor radiation and chemotherapeutic response is diagnosed, then en bloc resection may be required for cure. If en bloc resection is not feasible or metastatic lesions are present, then radiation and medical oncology specialists must work in conjunction with the surgical team to determine the best treatment options. CONCLUSIONS: Patients with suspected primary tumors of the spine should be treated in a multidisciplinary fashion from the outset. With thoughtful management, these lesions offer the opportunity for surgical cure.

Association of Malnutrition with Surgical and Hospital Outcomes after Spine Surgery for Spinal Metastases: A National Surgical Quality Improvement Program Study of 1613 Patients.

Background: Malnutrition is a common condition that may exacerbate many medical and surgical pathologies. However, few have studied the impact of malnutrition on surgical outcomes for patients undergoing surgery for metastatic disease of the spine. This study aims to evaluate the impact of malnutrition on perioperative complications and healthcare resource utilization following surgical treatment of spinal metastases. Methods: We conducted a retrospective cohort study using the 2011-2019 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients with spinal metastases who underwent laminectomy, corpectomy, or posterior fusion for extradural spinal metastases were identified using the CPT, ICD-9-CM, and ICD-10-CM codes. The study population was divided into two cohorts: Nourished (preoperative serum albumin values ≥ 3.5 g/dL) and Malnourished (preoperative serum albumin values < 3.5 g/dL). We assessed patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), hospital LOS, discharge disposition, readmission, and reoperation. Multivariate logistic regression analyses were performed to identify the factors associated with a prolonged length of stay (LOS), AEs, non-routine discharge (NRD), and unplanned readmission. Results: Of the 1613 patients identified, 26.0% were Malnourished. Compared to Nourished patients, Malnourished patients were significantly more likely to be African American and have a lower BMI, but the age and sex were similar between the cohorts. The baseline comorbidity burden was significantly higher in the Malnourished cohort compared to the Nourished cohort. Compared to Nourished patients, Malnourished patients experienced significantly higher rates of one or more AEs (Nourished: 19.8% vs. Malnourished: 27.6%, p = 0.004) and serious AEs (Nourished: 15.2% vs. Malnourished: 22.6%, p < 0.001). Upon multivariate regression analysis, malnutrition was found to be an independent and associated with an extended LOS [aRR: 3.49, CI (1.97, 5.02), p < 0.001], NRD [saturated aOR: 1.76, CI (1.34, 2.32), p < 0.001], and unplanned readmission [saturated aOR: 1.42, CI (1.04, 1.95), p = 0.028]. Conclusions: Our study suggests that malnutrition increases the risk of postoperative complication, prolonged hospitalizations, non-routine discharges, and unplanned hospital readmissions. Further studies are necessary to identify the protocols that pre- and postoperatively optimize malnourished patients undergoing spinal surgery for metastatic spinal disease.

Current intraoperative devices to reduce visual loss after spine surgery.

Postoperative visual loss (POVL) after spine surgery performed with the patient prone is a rare but devastating postoperative complication. The incidence and the mechanisms of visual loss after surgery are difficult to determine. The 4 recognized causes of POVL are ischemic optic neuropathy (approximately 89%), central retinal artery occlusion (approximately 11%), cortical infarction, and external ocular injury. There are very limited guidelines or protocols on the perioperative practice for "prone-position" surgeries. However, new devices have been designed to prevent mechanical ocular compression during prone-position spine surgeries. The authors used PubMed to perform a literature search for devices used in prone-position spine surgeries. A total of 7 devices was found; the authors explored these devices' features, advantages, and disadvantages. The cause of POVL seems to be a multifactorial problem with unclear pathophysiological mechanisms. Therefore, ocular compression is a critical factor, and eliminating any obvious compression to the eye with these devices could possibly prevent this devastating perioperative complication.

Extended lateral parascapular approach for resection of a giant multi-compartment thoracic schwannoma.

BACKGROUND: Resection of giant thoracic schwannomas is challenging and usually requires a staged approach. The resection of the intraspinal component, usually via laminectomy, is done in one sitting and the intrathoracic component, via thoracotomy, follows at another. We describe the complete resection of a massive multi-compartmental thoracic schwannoma by an extended lateral parascapular approach. METHOD AND FINDINGS: The tumor, which presented with local pain and scapular displacement, had intrathoracic paraspinal (10 x 5 x 4 cm), posterolateral upper thoracic paramuscular (19 x 7 x 4 cm), foraminal, and epidural components. It was removed at a single sitting, via a posterior extended lateral parascapular approach that did not require staged procedures, multiple incisions, or repositioning of the patient. This operation included resection of the thoracic, foraminal, and intraspinal components and posterior stabilization with pedicle screws and rods. There were no postoperative neurological complications. CONCLUSIONS: The extended lateral parascapular approach allows complete resection of giant multi-compartment schwannomas of the thoracic spine that extend from the canal into the thoracic cavity. It also permits posterior stabilization through the same incision used for tumor removal.

Intraoperative Transpedicular Onyx Injection to Reduce Vascularity of a Thoracic Hemangiopericytoma After Unsuccessful Preoperative Endovascular Embolization: a Technical Report.

BACKGROUND AND IMPORTANCE: Hemangiopericytoma is a rare vascular tumor with central nervous system involvement representing only 1% of central nervous system tumors. They rarely affect the vertebral column. Complete surgical resection is the treatment of choice for hemangiopericytoma given their high rates of local recurrence. However, the high vascularity of such tumors with the risk of massive bleeding during surgery represents a significant challenge to surgeons. Therefore, preoperative endovascular embolization via the transarterial route has been advocated. CLINICAL PRESENTATION: In the current study, we present a case of a T12 hemangiopericytoma that was managed by a 2-stage surgical resection, with the use of intraoperative transpedicular onyx injection to reduce intraoperative blood loss following an unsuccessful trial of preoperative endovascular embolization. CONCLUSION: Preoperative endovascular embolization is not feasible in some cases due to the location of the segmental or radiculomedullary arteries in relation to tumor feeders and, rarely, small size of these arterial feeders. Percutaneous injection of onyx is an option. In this case report, we discuss direct intraoperative injection via a transpedicular route as a safe and effective method for decreasing the vascularity of some lesions and improving intraoperative blood loss.

Retropharyngeal abscess with secondary osteomyelitis and epidural abscess: proposed pathophysiological mechanism of an underrecognized complication of unstable craniocervical injuries: case report.

Because of the proximity of the oropharynx (a naturally contaminated region) to the spinal structures of the craniocervical junction, it is possible that small mucosal lacerations in the oropharynx caused by unstable traumatic craniocervical injuries may become contaminated and lead to secondary infection and osteomyelitis. In this report, the authors describe the case of a previously healthy and immunocompetent patient who developed a large retropharyngeal abscess with spinal osteomyelitis after a high-energy craniocervical injury. This unusual report of osteomyelitis with a delayed presentation after a high-energy traumatic injury of the craniocervical junction highlights the possibility of direct injury to a specific area in the oropharyngeal mucosa adjacent to the osteoligamentous structures of the craniocervical junction, an overall underrecognized complication of unstable craniocervical injuries.

Percutaneous vertebroplasty--a technique to treat refractory spinal pain in the setting of advanced metastatic cancer: a case series.

We present three cases of severe movement-related spinal pain in patients with advanced metastatic carcinomas successfully treated with percutaneous vertebroplasty (PV). These patients had multi-symptom burden and progressive metastasis. Their movement-related pain was incapacitating and refractory to a variety of more conservative interventions. PV is a minimally invasive technique to stabilize vertebral compression fractures, thereby decreasing spinal pain in this setting. Its use in the setting of advanced cancer with severe movement-related pain has not been previously clarified in the palliative care literature. In summary, PV is a technique with a favorable risk: benefit ratio even in the setting of advanced metastatic cancer. The keys to successful utilization of PV in this patient population are careful patient assessment and selection as outlined in the report, in addition to an experienced care team approach.

Metastatic sacral tumors.

Therapeutic approaches are still a matter of debate. Given the complexity of the sacral anatomy and the vicinity of major neural structures and vital organs, advantages of radical resection for local disease control must be weighed against the anticipated treatment morbidities and complications. It becomes imperative to establish a multidisciplinary team approach to provide the best environment for establishing individualized management plans.

Nail-gun injury of the cervical spine: simple technique for removal of a barbed nail.

Although nail-gun injuries are a common form of penetrating low-velocity injury, impalement with barbed nails has been underreported to date. Barbed nails are designed to resist dislodgment once embedded, and any attempt at removal may splay open the barbs along the path of entry, with the potential for significant soft-tissue and neurovascular injury. A 25-year-old man sustained a nail impalement of the cervical spine from accidental discharge of a nail gun. The patient was noted to be fully conscious with no neurological deficits. Cervical Zone 2 impalement was noted, with only the head of the nail visible. Angiography revealed the nail lying just anterior to the right vertebral artery (VA), with compression of the vessel. Preoperatively, analysis of a similar nail revealed that orientation of the head determined position of the barbs. A deep neck dissection was then performed to the lateral aspect of the C-3 body, using the nail as a guide. Prior to removal, the nail was turned 180° to change the position of the barbs, to prevent injury to the VA. Nail removal was uneventful. The authors present a simple technique for treatment of a nail-gun injury with a barbed nail. Prior to removal, radiographic analysis of the impaled nail must be performed to determine the presence of barbs. If possible, the surgeon should request a similar nail for analysis prior to surgery. Last, the treating surgeon must have knowledge of the barbs' position at all times during nail removal, to prevent damage to critical structures.

Reconstruction of the pelvis and lumbar-pelvic junction using 2 vascularized autologous bone grafts after en bloc resection for an iliosacral chondrosarcoma.

Primary pelvic sarcomas remain challenging and complex surgical problems with significant potential for postoperative impairment of ambulation, as well as bowel, bladder, and sexual function. En bloc resection with negative tumor margins represents the best chance of control or cure as current adjuvant therapies remain ineffective. Tumor involvement of the sacrum with extension to the greater sciatic notch and ipsilateral ilium requires an external hemipelvectomy and sagittal sacrectomy with sacrifice of the lower extremity to achieve en bloc resection, followed by lumbar-pelvic reconstruction. A patient with an iliosacral chondrosarcoma is presented to illustrate a novel lumbar-pelvic reconstruction technique, in which vascularized soft tissue and 2 vascularized bone grafts were harvested from the amputated lower extremity and transferred to the pelvis as composite flaps to restore pelvic ring integrity, augment lumbar-pelvic fusion, and close the soft-tissue defect. The biomechanical dynamics of this unique construct are discussed.

Percutaneous techniques in the treatment of spine tumors: what are the diagnostic and therapeutic indications and outcomes?

STUDY DESIGN: Systematic review of the literature. OBJECTIVE: Should cement augmentation procedures such as vertebroplasty and kyphoplasty be used in patients with painful compression fractures associated with metastatic spine disease? What is the role of embolization in the treatment of metastatic spine disease? SUMMARY OF BACKGROUND DATA: Vertebral augmentation is commonly employed in treating osteoporotic fractures and is now increasingly used in the management of pain in patients with spinal tumors. Intra-arterial and transcutaneous embolization techniques are also available in the management of spinal tumors. To date, the effectiveness and safety of these procedures have not been adequately demonstrated. METHODS: A review of the English literature was performed in Pub-Med. One search was performed using the following keywords: cancer, tumor, vertebroplasty, kyphoplasty, vertebral augmentation, outcome, safety, pain, and quality of life. A Second search was performed using the keywords: embolization, spinal, and tumors. Original studies reporting on at least 10 patients were included and systematically reviewed. The results were reviewed and discussed through consensus among a multidisciplinary panel of expert members of the Spine Oncology Study Group. Recommendations were made according to the Guyatt Guidelines. RESULTS: A total of 1665 abstracts were identified. Twenty-eight articles using vertebroplasty reported on 877 patients and 1599 treated levels. Medical and neurologic complications varied from 0% to 7.1% and 0% to 8.1%, respectively. Twelve articles using kyphoplasty reported on 333 patients and 481 treated levels. Medical complication rates varied from 0% to 0.5%, without any neurologic complications. Pain and functional outcomes were universally successful using either technique. Ten studies on embolization reported on 330 patients. There were 4 permanent complications (1.4%). Complete or partial embolization was possible in 97.5% with an estimated reduction of intraoperative blood loss of 2.3 L. CONCLUSION: There is strong recommendation and moderate evidence for vertebral augmentation as safe and effective in providing pain relief and improving functional outcome in patients with vertebral body fractures and axial pain due to metastatic disease. There is a strong recommendation and very low evidence for embolization techniques as safe and effective in decreasing intraoperative blood loss in hypervascular tumors.