Factors associated with increased length of stay and risk of complications in 336 patients submitted to spine surgery. The role of a validated capture system (SAVES v2) as a first-line tool to properly face the problem.

PURPOSE: In this study, we analyzed the use of a validated capture system (Spinal Adverse Events Severity system, SAVES V2) as a first non-technical skill to properly face the relevant problem of surgical complications (SCs) and adverse events (AEs) in spinal surgery. METHODS: We retrospectively collected AEs occurring in a tertiary referral center for spine surgery from January 2017 to January 2018 and classified them according to SAVES V2 system. We compared this collection of AEs with a prospective collection performed without any classification system. Univariate and multivariate logistic regression models were used to determined odds ratio (ORs) for selected potential risk factors of AEs and prolonged length of stay. RESULTS: Overall a higher number of AEs was retrospectively recorded using SAVES system compared to the prospective recording without the use of any capture system (97/336 vs 210/336, p < 0.001). The length of stay (LOS) increased in the group of complicated patients for all the procedures examined. In the non-oncological group, LOS was significantly higher for complicated patients compared to uncomplicated patients (F = 44.11, p = 0.0000). Similar results have been obtained in the oncological group of patients. In the multivariate regression model surgical time and postoperative AEs emerged as risk factors for prolonged LOS, while only the presence of previous surgeries was confirmed as risk factor for AEs. CONCLUSION: Considering that the rate of AEs and SCs in spinal surgery is still high despite the improvement of technical skills, we suggest the use of SAVES V2 capture system as a first-line tool to face the problem.

Minimally invasive treatment of pedicle stress fracture in a young athlete: A case report.

INTRODUCTION: Pedicle stress fractures are an uncommon type of non-union often associated with contralateral neural arch interruption in young, active patients. Patients present with long-lasting low back pain, and the diagnosis is usually delayed. Treatment is generally conservative. Few cases treated surgically are described in the literature, with a high degree of treatment heterogeneity and no consensus on optimal treatment. PRESENTATION OF CASE: A 24-year-old male, following a sports-related trauma, developed persistent lower back pain. Imaging revealed a right L3 pedicle stress fracture with left lamina and pars interarticularis interruption. A minimally invasive percutaneous approach targeting the pedicle fracture was chosen. The procedure aimed to alleviate pain and promote non-union healing, without addressing the contralateral defect. The patient quickly recovered, achieving significant pain relief, and starting a tailored physical therapy program. At the 4-month follow-up, the pedicle fracture healed with callus formation. The patient returned to sports practice. DISCUSSION: Pedicle stress fractures may result from biomechanical force redistribution. Diagnosis is challenging, necessitating advanced imaging, including bone scintigraphy, MRI, and CT scans. Conservative management with rest, restriction with a brace, and focused rehabilitation usually achieves good results. When conservative management fails, surgery should be considered. Surgical options include direct repair, bone grafting, and screw fixation of the pedicle and contralateral pars defect. CONCLUSION: Minimally invasive surgery can achieve good clinical and functional results while avoiding blood loss and soft tissue trauma. Treating only the stress fracture is sufficient to promote bone healing, in contrast to more complex procedures.

Carbon Fiber-Reinforced PolyEtherEtherKetone (CFR-PEEK) Instrumentation in Degenerative Disease of Lumbar Spine: A Pilot Study.

CFR-PEEK is gaining popularity in spinal oncological applications due to its reduction of imaging artifacts and radiation scattering compared with titanium, which allows for better oncological follow-up and efficacy of radiotherapy. We evaluated the use of these materials for the treatment of lumbar degenerative diseases (DDs) and considered the biomechanical potential of the carbon fiber in relation to its modulus of elasticity being similar to that of bone. Twenty-eight patients with DDs were treated using CRF-PEEK instrumentation. The clinical and radiographic outcomes were collected at a 12-month FU. Spinal fusion was evaluated in the CT scans using Brantigan scores, while the clinical outcomes were evaluated using VAS, SF-12, and EQ-5D scores. Out of the patients evaluated at the 12-month FU, 89% showed complete or almost certain fusion (Brantigan score D and E) and presented a significant improvement in all clinical parameters; the patients also presented VAS scores ranging from 6.81 ± 2.01 to 0.85 ± 1.32, EQ-5D scores ranging from 53.4 ± 19.3 to 85.0 ± 13.7, SF-12 physical component scores (PCSs) ranging from 29.35 ± 7.04 to 51.36 ± 9.75, and SF-12 mental component scores (MCSs) ranging from 39.89 ± 11.70 to 53.24 ± 9.24. No mechanical complications related to the implant were detected, and the patients reported a better tolerance of the instrumentation compared with titanium. No other series of patients affected by DD that was stabilized using carbon fiber implants have been reported in the literature. The results of this pilot study indicate the efficacy and safety of these implants and support their use also for spinal degenerative diseases.

Indications and Limits of Surgery for Spinal Metastases Derived from Lung Cancer: A Single-Center Experience.

Lung cancer is the second most frequently diagnosed cancer in the world, and surgery is an integral part of the treatment for spinal metastases. The aims of this retrospective study were to assess the overall survival of surgically treated patients affected by lung cancer spinal metastases and identify any factors related to a better survival rate. We recruited 56 consecutive patients (34 male and 22 female) surgically treated for metastatic lung cancer in the spine from 2009 to 2019. Surgical indications were based on a previously published and validated flow chart following a multidisciplinary evaluation. We assessed the localization of vertebral metastases, the presence of other bone or visceral metastases, neurological status according to the Frankel score, ambulatory autonomy, and general status, measured with the Karnofsky performance scale. The expected prognosis was retrospectively assessed according to the revised Tokuhashi score. The median survival was 8.1 months, with over a third of patients surviving more than 1 year. We observed a global improvement in all clinical parameters after surgical treatment. The Tokuhashi predictive score did not correlate with survival after surgery. The results of this study suggest that the surgical treatment of symptomatic spinal metastases from lung cancer can improve quality of life, even in patients with a shorter life expectancy, by controlling pain and improving autonomy.

Could Spinal Epidural Lipomatosis Be the Hallmark of Metabolic Syndrome on the Spine? A Literature Review with Emphasis on Etiology.

Spinal epidural lipomatosis is defined by an excessive amount of epidural fat in the spinal canal, usually in the lumbosacral tract: a well-known cause of lumbar pain and spinal stenosis with a possible wide range of neurological symptoms. Recent research data reveal that, nowadays, obesity has become the main cause of spinal epidural lipomatosis. Moreover, this condition was recently recognized as a previously unknown manifestation of metabolic syndrome. Radiological studies (CT and MRI) are the only tools that are able to diagnose the disease non-invasively. Indeed, radiologists play a key role in disease recognition, with subsequent possible implications on patients' systemic health assessments. Despite its clinical importance, the condition is still underreported and neglected. The current literature review summarizes all the main etiologies of spinal epidural lipomatosis, particularly regarding its linkage with metabolic syndrome. An overview of disease characteristics from diagnosis to treatment strategies is also provided.

Clear Cell Renal Cell Carcinoma Spinal Metastases: Which Factors Matter to the Overall Survival? A 10-Year Experience of a High-Volume Tumor Spine Center.

Clear cell renal cell carcinoma (ccRCC) usually spreads in the spinal region causing instability or spinal cord compression leading to neurological deficits. Therefore, surgical treatment is required for improving the outcome of patients. The aim of this study is to identify which prognostic factors could affect overall survival in patients affected by ccRCC. Methods: Retrospective cohort study of patients with ccRCC spinal metastases, surgically treated from November 2009 to April 2019. Demographic and clinical data were collected. The Kaplan−Meier method was used to estimate overall survival, and the log-rank test was used to evaluate differences in survival among potentially prognostic factors. Results: A total of 69 patients were surgically treated and followed up for a median period of 65 months. The average age at the time of surgery was 62.6 years old. The median overall survival (OS) was 34.7 months (95% CI 20.8−51.9) and 5-year OS was 31.2% (95% CI 19.2−44.1). A high Tokuhashi score (p = 0.0217), the presence of visceral metastases (p < 0.001), other bone metastases (p = 0.02012) and the kind of surgical treatment (p = 0.0395) are the main prognostic factors that influence the OS. Moreover, 3-year progression-free survival (PFS) was analyzed: the median PFS was 53.1 months and the % 3-year PFS was 62.9% (45.2−76.3). In the multivariate analysis, only pre-operative radiation therapy had a significant impact on 3-year PFS (95% CI 0.929−12.994, p = 0.0643). Conclusion: The results of this study suggest that the absence of visceral metastases and an aggressive surgery as en-bloc, when feasible, could prolong the survival rate and improve quality of life for patients.

Custom-Made 3D-Printed Implants for Anterior Column Reconstruction in the Upper Cervical Spine after Intralesional Extracapsular Excision-Report of 2 Cases and Literature Review.

The use of three-dimensional (3D)-printed custom-made implants is spreading in the orthopedics field for the reconstruction of bone losses or for joint replacement, thanks to their unparalleled versatility. In particular, this novel technology opens new perspectives to formulate custom-made fixation strategies for the upper cervical region, sacrum and pelvis, where reconstruction is challenging. We report and analyze the literature concerning upper cervical reconstruction with 3D-printed personalized implants after tumor surgery, and discuss two cases of patients where this technology was used to reconstruct the anterior column after extracapsular debulking of C2 recurrent chordoma at our institution.

Complications and Risk Factors in En Bloc Resection of Spinal Tumors: A Retrospective Analysis on 298 Patients Treated in a Single Institution.

En bloc resection consists in the surgical removal of a vertebral tumor in a single piece with a sufficient margin, to improve survival and reduce recurrence rate. This procedure is technically demanding and correlates with a high complication rate. The purpose of this study is to investigate the risk factors for complications in en bloc resection and evaluate if benefits overcome the risks in term of overall survival. We retrospectively analyzed prospectively collected data of patients treated with en bloc resection between 1980 and 2021. Complications were classified according to SAVES-V2. Overall Survival was estimated using Kaplan-Meier method. A total of 149 patients out of 298 (50%) suffered from at least one complication. Moreover, 220 adverse events were collected (67 intraoperative, 82 early post-operative, 71 late post-operative), 54% of these were classified as grade 3 (in a severity scale from 1 to 6). Ten years overall survival was 67% (95% CI 59-74). The occurrence of relapses was associated to an increased risk of mortality with OR 3.4 (95% CI 2.1-5.5), while complications did not affect the overall survival. Despite a high complication rate, en bloc resection allows for a better control of disease and should be performed in selected patients by specialized surgeons.

Primary Tumors of the Sacrum: Imaging Findings.

The diagnosis of sacral neoplasms is often delayed because they tend to remain clinically silent for a long time. Imaging is useful at all stages of the management of sacral bone tumors, i.e., from the detection of the neoplasm to the long-term follow-up. Radiographs are recommended as the modality of choice to begin the imaging workup of a patient with known or suspected sacral pathology. More sensitive examinations, such as Computerized Tomography (CT), magnetic resonance (MRI), or scintigraphy, are often necessary. The morphological features of the lesions on CT and MRI help orientate the diagnosis. Although some imaging characteristics are helpful to limit the differential diagnosis, an imaging-guided biopsy is often ultimately required to establish a specific diagnosis. Imaging is of paramount importance even in the long-term follow-up, in order to assess any residual tumor when surgical resection remains incomplete, to assess the efficacy of adjuvant chemotherapy and radiotherapy, and to detect recurrence.

MRI Features and Clinical Significance of Spinal Epidural Lipomatosis: All You Should Know.

Spinal epidural lipomatosis (SEL) is defined as the abnormal accumulation of unencapsulated adipose tissue in the spinal epidural space. SEL can be asymptomatic or can cause a wide range of symptoms, the most common of which is neurogenic claudication. Several other neurological manifestations may also occur, above all myelopathy and radicular symptoms. The spinal level most frequently involved in patients with SEL is the lumbar one, followed by the thoracic one. Imaging plays a key role in the disease assessment. MRI is considered the most effective and sensitive modality for diagnosing and staging SEL. Anyway, also CT scan can diagnose SEL. The diagnosis may be incidental (in mild-moderate disease) or may be taken into account in cases with neurological symptoms (in moderate-severe disease). There are some recognized risk factors for SEL, the most common of which are exogenous steroid use and obesity. Recent studies have found an association between SEL and obesity, hyperlipidemia and liver fat deposition. As a matter of fact, SEL can be considered the spinal hallmark of metabolic syndrome. Risk factors control represents the initial treatment strategy in patients with SEL (e.g. weight loss, steroid therapy suspension). Surgical decompression may be required when conservative treatment fails or when the patient develops acute/severe neurological symptoms.

Autologous mesenchymal stem cells in the treatment of spinal aneurysmal bone cyst.

PURPOSE: We retrospectively analyzed a cohort of patients treated at our Centre with bone marrow concentrated (BMC) injection for aneurysmal bone cyst (ABC) of the spine, in order to propose this treatment as a valid alternative for the management of ABCs. METHODS: Fourteen patients (6 male, 8 female) were treated between June 2014 to December 2019 with BMC injection for ABC of the spine. The mean age was 15.5 years. The mean follow up was 37.4 months (range 12-60 months). The dimension of the cyst and the degree of ossification were measured by Computed Tomography (CT) scans before the treatment and during follow-up visits. RESULTS: Six patients received a single dose of BMC, five patients received two doses and in three patients three doses of BMC were administered. The mean ossification of the cyst (expressed in Hounsfield units) increased statistically from 43.48 ± 2.36 HU to 161.71 ± 23.48 HU during follow-up time and the ossification was associated to an improvement of the clinical outcomes. The mean ossification over time was significantly higher in patients treated with a single injection compared to patients treated with multiple injections. No significant difference in ossification was found between cervical and non-cervical localization of the cyst. Moreover, the initial size of the cyst was not statistically associated with the degree of ossification during follow-up CONCLUSIONS: Results of this paper reinforce our previous evidence on the use of BMC as a valid alternative for spinal ABC management when SAE treatment is contraindicated or ineffective.

Pyogenic and Non-pyogenic Spinal Infections: Diagnosis and Treatment.

Spinal Infection (SI) is an infection of vertebral bodies, intervening disc, and/or adjoining para-spinal tissue. It represents less than 10% of all skeletal infections. There are numerous factors that predispose to developing a SI. Due to the low specificity of signs, delayed diagnosis is common. Hence, SI may be associated with poor outcomes. Diagnosis of SI must be supported by clinicopathological and radiological findings. MRI is a reliable modality of choice. Treatment options vary according to the site of the infection, disease progression, neurology, presence of instability, and general condition of the subject. Conservative treatment (orthosis/ bed-rest + antibiotics) is recommended during the early course with no/ lesser degree of neurological involvement and to medically unfit patients. Nevertheless, when conservative measures alone fail, surgical interventions must be considered. The use of concomitant antimicrobial drugs intravenously during initial duration followed by oral administration is a necessity. Controversies exist regarding the optimal duration of antimicrobial therapy, yet never given less than six weeks. Heterogeneity in clinical picture and associated co-morbidities with a range of treatment modalities are available; however, a common applicable guideline for SI does not exist. Managing SI must be tailored on a case-to-case basis.

Histological examination of a retrieved custom-made 3D-printed titanium vertebra : Do the fine details obtained by additive manufacturing really promote osteointegration?

PURPOSE: In the present report it is described the design, the manufacturing and the successful surgical implant of one of the first 3D custom titanium vertebra realized with Additive Manufacturing technique and its use for the spinal reconstruction after en-bloc resection for primary osteogenic sarcoma. METHODS: Clinical case presentation and the design of the 3D custom titanium vertebra was reported. It was also described the complex procedures adopted to evaluate the retrieved device from the histological point of view, as a tumor relapse hit the patient, one year after the reconstruction procedure. RESULTS: The histological evaluation confirmed that the resection technique exerts an important role in promoting bone formation: vertebral body osteotomies favored the reconstruction procedure and maximized the contact area between host bone/vertebral prosthesis thus favoring the bone tissue penetration and device colonization. CONCLUSION: The sharing of these results is very important as they represent the starting point for improving the knowledge starting from the evidence obtained in a challenging clinical condition and with post-operative treatments that could be never reproduced in preclinical model.

Primary sclerosing epithelioid fibrosarcoma of the spine: a single-institution experience.

AIMS: To present our experience on spinal sclerosing epithelioid fibrosarcoma (SEF) and review the existing literature pertaining to SEF of the spine. METHODS AND RESULTS: Six cases of spinal SEF were reviewed, and a literature search of all primary SEFs of the spine was performed. All tumours occurred in adults (median age, 41 years) and were located all along the spine, the lumbar vertebrae being the most commonly involved. All patients presented with pain that they had experienced for months. The mean tumour size at diagnosis was 52 mm. Five tumours showed a spectrum of microscopic features consistent with pure SEF, and one showed a hybrid morphology with areas of low-grade fibromyxoid sarcoma. All were diffusely and strongly positive for mucin 4. Two cases were initially misdiagnosed as epithelioid haemangioendothelioma and aggressive chondroblastoma. Fluorescence in-situ hybridisation showed rearrangements of either FUS or EWSR1 in four cases. Reverse transcription polymerase chain reaction showed the presence of FUS-CREB3L1 and EWSR1-CREB3L1 fusion transcripts in two cases and one case, respectively. Of five patients with follow-up data available, two developed one or more local recurrences and three patients had metastatic disease. Distant metastases were mainly to other osseous locations, followed by lungs and lymph nodes. At last follow-up, three patients had died of disease and one was alive with multiple metastases. CONCLUSIONS: SEF is an aggressive sarcoma that can involve the spine. It is important to recognise the spine as the primary location of SEF, in order to avoid misdiagnosis as more common primary spinal neoplasms, which can impact on therapeutic approaches.

Sublaminar bands in oncological spine surgery: illustrative cases.

BACKGROUND: Sublaminar bands have been used in addition to pedicle screw placement in the correction of idiopathic scoliosis forming a so-called hybrid construct. OBSERVATIONS: In this article, the authors present several cases that demonstrate the potential applications of sublaminar bands in oncological spine surgery. The potential applications are divided into three categories: (1) as an additional tool in salvage procedures, (2) to correct kyphosis in pathological fractures, and (3) for bone graft anchoring to the spine. LESSONS: The cases presented in this article demonstrate the potential beneficial effects of the sublaminar bands in addition to pedicle screw placement.

Surgery Versus Radiofrequency Ablation in the Management of Spinal Osteoid Osteomas: A Spine Oncology Referral Center Comparison Analysis of 138 Cases.

BACKGROUND: Osteoid osteomas (OOs) are benign bone forming tumors that, usually, occur in the extremities, with about 10% of them arising in the spine more commonly in the posterior elements. The aim of this study is to evaluate the long-term results of patients suffering from spinal OO treated with surgery and radiofrequency ablation. METHODS: This was a retrospective comparison analysis of data prospectively collected from 2 cohorts of consecutive patients diagnosed with OO of the spine treated at the same Institute from November 2002 to February 2019. The first cohort included patients submitted to an intralesional extracapsular excision of the lesion (surgery group); the second cohort included patients submitted to radiofrequency ablation (RFA group). RESULTS: The surgery group showed a local recurrence rate of 1.7% versus a recurrence rate of 12.5% in the RFA group with a statistically significant difference in the disease-free survival at longest follow-up (P = 0.012). No statistically significant differences were observed in local recurrence rate stratified for level and site of lesion. No complications were observed in both groups at the time of first procedure. CONCLUSIONS: Surgery and RFA are both safe and effective interventional procedures for the management of spinal OO, although RFA is associated with a greater recurrence rate. Treatment should be tailored according to the relationship of lesions with neural structures and to advantages and disadvantages of each technique.

Composite PEEK/carbon fiber rods in the treatment for bone tumors of the cervical spine: a case series.

INTRODUCTION: Radiotherapy (RT) is frequently applied as an adjuvant therapy during spinal tumors treatment. Metallic implants can interfere with RT planning and execution, as it is known that metallic implants produce a backscattering effect that can limit RT accuracy and their presence can be associated with unwanted dose increase. PEEK/carbon fiber implants are designed to reduce these problems but their application in the cervical spine is limited, due to the reduced number and types of implants, the screw dimensions and the absence of lateral mass screws. We propose a hybrid system made of carbon rods and screws coupled with subliminal polyester bands with titanium clamps. We designed this hybrid construct to enclose the cervical region in the area of instrumentation without limiting the application of postoperative radiotherapy. MATERIALS AND METHODS: Six patients in which the hybrid hardware was implanted were retrospectively examined. Data on demographics, intraoperative and postoperative events, tumor details and staging and cervical alignment were collected pre- and postoperatively. RESULTS: No intraoperative complications occurred. En bloc resection was performed in two patients, while the remaining four received an intralesional resection. Three out of six patients received postoperative RT, without any alteration in its planning and administration. DISCUSSION AND CONCLUSIONS: Hybrid implants made of composite PEEK/carbon fiber screws and rods and sublaminar bands are a helpful solution for spinal reconstruction in the cervical and cervico-thoracic regions after spine tumor surgery. The implants do not produce artifacts at postoperative images, easing the planning and execution of postoperative radiotherapy.

Breast cancer spinal metastases: Prognostic factors affecting survival after surgery. A retrospective study.

Breast cancer spinal metastases (BCSM) are common and require proper treatment that leads to an improvement of the quality of life and contributes to the quod vitam prognosis. Surgical treatment is often required for intractable pain, spinal cord compression or spinal instability. The aim of this retrospective study is to identify which prognostic factors could affect postoperative overall survival in patients affected by BCSM. We report a retrospective cohort study of patients with BCSM, surgically treated from September 2009 to May 2018. Demographic and clinical data were collected. Kaplan-Meier method was used to estimate overall survival, and the log-rank test was used to compare survival curves. A total of 77 patients were studied. The median age at the time of surgery was 54 years. The median follow-up was 49 months. The 3-year and 5-year overall survival rates were 61% (95%CI: 47.5-72.1) and 43.3% (95%CI: 28.8-57.1). Metastatic bone disease (p = 0.0196), preoperative neurological impairment (p = 0.0029), Karnofsky status <70 (p = 0.0241) reduce survival. With multivariate analysis, the effect of Karnofsky score loses statistical significance. The presence of concurrent bone metastases and a preoperative neurological deficit are independent prognostic factors. Therapeutic choices are based on a multidisciplinary assessment that takes into consideration several factors, including an accurate study of prognostic factors.

Composite peek/carbon fiber pre-shaped rods and sublaminar bands for posterior stabilization of cervico-thoracic junction: A novel technique.

The combination of surgery plus radiotherapy is a valid treatment option when en bloc resection with wide margins is not feasible. The aim of this paper is to show a novel technique for fixation of cervico-thoracic junction with carbon fiber reinforced peek pre-shaped rods with sublaminar bands in order to guarantee cervical spine stability and particle therapy efficacy. A 42 years-old man with a Sclerosing Epithelioid Fibrosarcoma (SEF) arising from C7, involving the right latero-cervical region from C5 to the apex of the right lung, underwent an en bloc resection with a double approach (anterior plus posterior). Fixation of cervical spine was achieved with composite PEEK/carbon fiber rods connected to C4 and T2 laminae with sublaminar bands. After surgery, the patient received 9 cycles of chemotherapy (cisplatin, etoposide and adriamycin) and proton therapy. At 2 years follow-up, no local recurrence was detected with implant stability demonstrating no mechanical failure. The main issues related to this case were: planning en bloc resection able to achieve an Enneking appropriate margin; incorporate in the decision making process the functional loss related to the sacrifice of neurological structures infiltrated by the tumor; establish a therapeutic strategy that included, in addition to surgery, adjuvant chemotherapy and radiotherapy for improving local and systemic control; stabilize with implants that do not interfere with accelerated particle radiotherapy.

Function Preservation or Oncological Appropriateness in Spinal Bone Tumors?: A Case Series of Segmental Resection of the Spinal Canal Content (Spinal Amputation).

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To evaluate (1) if the segmental resection of the content of the spinal canal could provide an Enneking appropriate tumor-free margin for local control of primary bone tumors surrounding and invading the canal and (2) the safety profile of the segmental resection of the neurostructures. SUMMARY OF BACKGROUND DATA: Treatment outcomes of primary malignant and benign aggressive bone tumors of the spine have been dramatically changed by the application of the musculoskeletal oncologic principles described by Enneking. However, the efficacy of spinal oncology surgery might be limited by unique features of spinal anatomy. METHODS: Database search was conducted with the following inclusion criteria: en bloc resection, segmental inclusion of the spinal canal content in the surgical specimen, histologically proven diagnosis, minimum follow-up of 2 years. Exclusion criteria were piecemeal excision of the tumor (debulking) and diagnosis other than primary bone tumors (metastasis, or local extension of extraosseous tumors). RESULTS: A consecutive cohort of eight patients (three men, five women) was available for review. Two patients died within 3 months from the surgery for systemic disease progression or sequelae of the surgery. En bloc resection with segmental spinal canal content inclusion was able to achieve local control of the disease in four out of remaining six cases (66.7%) at an average follow-up of 68.7 months (range 12-174 mo). Three patients in whom local control was achieved are free from disease at an average follow-up of 98.7 months (range 38-174), and one died for systemic disease progression (after 38 mo). Seven out of 8 patients (87.5%) experienced overall 16 complications. CONCLUSION: En bloc resection including the spinal canal content (spinal amputation) to achieve a tumor-free margin might be considered to perform an Enneking appropriate treatment for motivated patients. LEVEL OF EVIDENCE: 4.