Blood loss in total en bloc spondylectomy for primary spinal bone tumours: a comparison of estimated blood loss versus actual blood loss in a single centre over 10 years.

Background: Total en bloc spondylectomy (TES) is a widely accepted surgical technique for primary spinal bone tumours but is frequently accompanied by substantial peri-operative blood loss. Prior studies have reported estimated blood loss (EBL) can reach up to 3,200 mL. The aim of this study is to estimate the blood loss during TES procedures performed in the last ten years at our tertiary referral centre and compare EBL with actual blood loss (ABL). Methods: We performed a retrospective review of all cases managed surgically with TES referred to our centre between 2005 and 2015. We recorded the oncological characteristics of each tumour and surgical management in terms of resection margins, operative duration and instrumentation. Data relating to peri-operative blood loss was also recorded including an estimation of total blood loss, the use of cell salvage where applicable and transfusion rates. Results: A total of 21 patients were found to meet our inclusion criteria. There were 11 men and 10 women, with a median age of 40 years. The mean total ABL was 3,310 mL. Total operation time ranged from 6.53 to 19.7 h. Compared to ABL, in 59% of cases EBL had been underestimated by an average of 78% by volume. The EBL of the remaining 41% cases had been overestimated by 43%. This was not statistically significant (P=0.373). Cell salvage was used in 62% patients with a mean blood loss of 2,845 mL (884-4,939 mL) and transfusion of 3.8 units (0-12 units) versus 4,069 mL (297-8,335 mL) and 9.3 units (0-18 units) in those not managed with cell salvage. There was no significant difference in ABL between the cell salvage and non-cell salvage groups. Conclusions: We report one of the largest case series in TES for primary bone tumours. EBL is not a reliable predictor for ABL. A large blood loss should be anticipated and use of cell salvage is recommended.

Spinal Tumour en Bloc Surgery: A Series of Abandoned Surgical Cases.

Select spinal tumors can be treated with en bloc spondylectomy (EBS) but the surgical complexity and relatively low frequency of eligible tumors render EBS an uncommon procedure. The expanded surgical access encompasses acceptance of relatively high morbidity as a trade-off against improved oncological results and survival. EBS durations can be long with dynamic changes affecting the risk-benefit ratio as the surgery proceeds.  We present a series of cases where we have elected to "abandon" EBS due to adverse findings or rising intraoperative risk along with our lessons learned.  A search of our surgical database for all "en bloc" spinal tumor procedures over a three-year period was performed and 27 operations were identified. Of these, four were abandoned. Two of the four surgeries were halted owing to adverse anatomical findings. One involved significant tumor growth from the interval imaging bringing into question disease control and the other displayed tumor adherence to the lung requiring significant dissection. The further two cases incurred significant blood loss and associated physiological complications of end-organ dysfunction.  Pre-operative embolization (POE), anesthetic monitoring, controlled hypotension, volume replacement, and transfusion optimize our chance of achieving the surgical plan. However, cardiovascular instability must be managed promptly and early warning signs of end-organ injury (lactate, renal output) should not be overlooked. In some situations abandoning the procedure may be in the best interests of the patient.

Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?

Background Despite a paucity of evidence or literature to support routine in-hospital post-operative radiographs (POXR) of anterior cervical discectomy and fusion (ACDF) surgery, it remains accepted practice. Most spinal surgeons consider it part of their standard post-operative routine for ACDF despite nearly always documenting a 'satisfactory intra-operative image' at the end of the operation. With an increasing financial pressure on NHS resources, our investigations should be clinically justified and evidence-based. Purpose To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging. Design A retrospective review of 101 consecutive ACDF patients of radiographs performed before discharge, associated length of inpatient stay, and any complications involved. Methods A retrospective review was performed of 101 ACDF patients who had single or multi-level instrumentation for degenerative spinal disease from a single neurosurgical centre from all surgeons. Seventy-eight had an in-hospital post-operative anteroposterior (AP) and lateral radiograph, 23 did not. In 95 of these, it was documented that there was 'satisfactory intra-operative imaging' before the closure of skin, six lacked documentation of this. All patients had intra-operative imaging of completed instrumentation on the radiology system. Any post-operative complications were noted, and the length of hospital stay (LOS) was recorded. Six patients underwent ACDF following trauma, therefore leaving 95 elective cases. Study parameters also included: number of levels operated on, whether or not a plate was used with a cage, hospital costings for 2-view imaging and additional days of inpatient stay.  Results There was one out of our 101 patients where the post-operative radiograph confirmed unsatisfactory placement of metalwork and warranted a return to surgery. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR's, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year. Conclusion In patients who undergo ACDF surgery with an uneventful post-operative course and have satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.

Can MRI be used as a safe and expedient option for calculating Spinal Instability Neoplastic Score for patients with metastatic spinal cord compression?

AIMS: The aim of this study was to assess the reliability of using MRI scans to calculate the Spinal Instability Neoplastic Score (SINS) in patients with metastatic spinal cord compression (MSCC). METHODS: A total of 100 patients were retrospectively included in the study. The SINS score was calculated from each patient's MRI and CT scans by two consultant musculoskeletal radiologists (reviewers 1 and 2) and one consultant spinal surgeon (reviewer 3). In order to avoid potential bias in the assessment, MRI scans were reviewed first. Bland-Altman analysis was used to identify the limits of agreement between the SINS scores from the MRI and CT scans for the three reviewers. RESULTS: The limit of agreement between the SINS score from the MRI and CT scans for the reviewers was -0.11 for reviewer 1 (95% CI 0.82 to -1.04), -0.12 for reviewer 2 (95% CI 1.24 to -1.48), and -0.37 for reviewer 3 (95% CI 2.35 to -3.09). The use of MRI tended to increase the score when compared with that using the CT scan. No patient having their score calculated from MRI scans would have been classified as stable rather than intermediate or unstable when calculated from CT scans, potentially leading to suboptimal care. CONCLUSION: We found that MRI scans can be used to calculate the SINS score reliably, compared with the score from CT scans. The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. This could be made easier by knowing the site of the primary tumour when calculating the score, or by using inverted T1-volumetric interpolated breath-hold examination MRI to assess the bone more reliably, similar to using CT. Cite this article: Bone Joint J 2021;103-B(5):971-975.

En Bloc Resection of Tumors of the Lumbar Spine: A Systematic Review of Outcomes and Complications.

BACKGROUND: The literature on total en bloc spondylectomy (TES) of bone tumors of the lumbar spine is sparse and heterogeneous. Therefore, the aim was to systematically pool the data from the published studies to quantitatively summarize the morbidity and mortality and to identify factors associated with favorable outcomes and complications. METHOD: A systematic literature search for studies with individual patient-level data was conducted using specific medical subject heading(MeSH) terms. The outcome measures assessed included complications, tumor recurrence, survival, and function. Individual patient data were pooled from all the studies and quantitatively analyzed to assess the association of different factors with outcomes and complications. RESULTS: Twelve studies were included in this review with a total of 145 TES cases. Of all patients, 50% had at least 1 reported complication post surgery and this was associated with advancing age (OR 1.04, P < 0.001), metastatic disease (OR 5.61, P < 0.001), and adjuvant chemo and/or radiotherapy (OR 20.3, P = 0.001). Intralesional excision (OR 5.2, P = 0.01) and primary malignant tumors (OR 3.3, P = 0.02) were associated with a high recurrence rate. However, the surgical approach was not associated with differences in survival (P = 0.874) or recurrence (P = 0.525) rates. L5 tumor resection was associated with excessive bleeding. Postoperatively, there was an overall improvement in the Frankel grades in most patients. CONCLUSION: TES is associated with high rates of complications especially in association with primary malignant and metastatic diseases. However, the number of publications on this topic remain scarce and heterogeneous. Hence, there is a need for standardization in the reporting of the outcomes and complications to help with decision-making and consenting for this procedure.

Should Denosumab or Radical Surgery Be Recommended for a Spinal Giant Cell Tumour in a Fertile Female?

Giant cell tumour (GCT) of the spine is a benign aggressive tumour with high recurrence rates. Patients can be asymptomatic due to the slow growth rate and present with localized pain or neurological dysfunction. Current management strategies include intralesional curettage, total en-bloc resection (TER) and denosumab therapy. Treatment strategies can be particularly challenging in women of childbearing age who wish to conceive, as the risks of tumour recurrence need to be balanced against the fetal complications associated with adjuvant denosumab therapy. This case report discusses the management options and controversies for women of childbearing age with GCT of the thoracic spine. Clinicians need to be aware of the complications associated with TER and denosumab treatment when managing GCTs of the spine in young females.

Experience of neuroprotective air injection during radiofrequency ablation (RFA) of spinal osteoid osteoma.

PURPOSE: To assess the usefulness of epidural air injection during the RFA treatment of spinal osteoid osteoma. METHODS: A retrospective review of 17 patients who underwent RFA for spinal osteoid osteoma between September 2006 and May 2017 was performed. All the procedures were performed by a single radiologist. We reviewed the perioperative CT studies to assess the distribution of air relative to the osteoid osteoma. The clinical outcome of each patient group was evaluated during routine follow-up. RESULTS: Seventeen patients were treated for spinal OO (male:female 13:4; mean age was 16, ranging from 4 to 42). The nidus size ranged from 5.8 to 17.2 mm (mean 11.2). In nine cases epidural air injection was performed. In three cases the neuroprotective air was deemed satisfactory with a clear layer of air between the osteoid osteoma and the dural sac being visualised. In six patients adherence between the cortical bone immediately adjacent to the osteoid osteoma and the dural sac in contact was observed. In 15 patients the procedure was successful in terms of pain relief. No neural damage or other complication was reported in either group. CONCLUSION: RFA is a safe treatment for spinal osteoid osteoma. Neuroprotective air injection does not appear to be necessary when performing the treatment in the spine. KEY POINTS: • Seventeen patients with spinal OO were treated with RFA, nine with air injection and eight without. Clinically successful treatment was achieved in 15 patients, with 2 subsequently undergoing surgery • In 6/9 cases the injected air failed to achieve separation between the osteoid osteoma and the thecal sac because of inflammatory adhesion • No complications were observed, regardless of whether neuroprotective air was instilled. Neuroprotective air injection appears unnecessary when treating spinal OO.

Multidisciplinary Oncoplastic Approach Reduces Infection in Chest Wall Resection and Reconstruction for Malignant Chest Wall Tumors.

BACKGROUND: Management of complex thoracic defects post tumor extipiration is challenging because of the nature of pathology, the radical approach, and the insertion of prosthetic material required for biomechanical stability. Wound complications pose a significant problem that can have detrimental effect on patient outcome. The authors outline an institutional experience of a multidisciplinary thoracic oncoplastic approach to improve outcomes. METHODS: Prospectively collected data from 71 consecutive patients treated with chest wall resection and reconstruction were analyzed (2009-2015). The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection were recorded. All patients were managed in a multidisciplinary approach to optimize perioperative surgical planning. RESULTS: Pathology included sarcoma (78%), locally advanced breast cancer (15%), and desmoids (6%), with age ranging from 17 to 82 years (median, 42 years) and preponderance of female patients (n = 44). Chest wall defects were located anterior and anterolateral (77.5%), posterior (8.4%), and apical axillary (10%) with skeletal defect size ranging from 56 to 600 cm(2) (mean, 154 cm(2)). Bony reconstruction was performed using polyprolene mesh, methyl methacrylate prosthesis, and titanium plates. Soft tissue reconstructions depended on size, location, and flap availability and were achieved using regional, distant, and free tissue flaps. The postoperative follow-up ranged from 5 to 70 months (median, 32 months). All flaps survived with good functional and aesthetic outcome, whereas 2 patients experienced surgical site infection (2.8%). CONCLUSIONS: Multidisciplinary thoracic oncoplastic maximizes outcome for patients with large resection of chest wall tumors with reduction in surgical site infection and wound complications particularly in association with rigid skeletal chest wall reconstruction.