Parasagittal resection of multilevel cervical chordoma with autograft duraplasty and unilateral vertebral artery ligation: A case report and literature review.

Chordomas are rare tumors and the recommended course of treatment typically entails surgical resection, which presents significant challenges owing to the anatomical location commonly involved and the inherent resistance of these lesions to radiation and chemotherapy. This case report details the experience of a 61-year-old male who underwent a parasagittal resection spanning from C1 to C4. A durotomy was executed to enable en bloc excision of the tumor. Subsequently, a duraplasty procedure was implemented, utilizing autologous muscle fascia grafting. A comprehensive analysis of the pertinent literature was conducted to underscore the key clinical aspects and outcomes related to this topic.

High dose image-guided, intensity modulated radiation therapy (IG-IMRT) for chordomas of the sacrum, mobile spine and skull base: preliminary outcomes.

PURPOSE: To report preliminary outcomes of high dose image-guided intensity modulated radiotherapy (IG-IMRT) in the treatment of chordomas of the sacrum, mobile spine and skull base. METHODS: Retrospective analysis of chordoma patients treated with surgery and/or radiotherapy (RT) in a single tertiary cancer center. Initial treatment was categorized as (A) Adjuvant or definitive high-dose RT (78 Gy/39fx or 24 Gy/1fx) vs (B) surgery-only or low dose RT. The primary endpoint was the cumulative incidence of local failure. RESULTS: A total of 31 patients were treated from 2010 through 2020. Median age was 55 years, tumor location was 64% sacrum, 13% lumbar, 16% cervical and 6% clivus. Median tumor volume was 148 cc (8.3 cm in largest diameter), 42% of patients received curative-intent surgery and 65% received primary RT (adjuvant or definitive). 5-year cumulative incidence of local failure was 48% in group A vs 83% in group B (p = 0.041). Tumor size > 330 cc was associated with local failure (SHR 2.2, 95% CI 1.12 to 7.45; p = 0.028). Eight patients developed distant metastases, with a median metastases-free survival of 56.1 months. 5-year survival for patients that received high dose RT was 72% vs 76% in patients that received no or low dose RT (p = 0.63). CONCLUSION: Our study suggests high-dose photon IG-IMRT improves local control in the initial management of chordomas. Health systems should promote reference centers with clinical expertise and technical capabilities to improve outcomes for this complex disease.

Control inadecuado del dolor agudo postoperatorio: prevalencia, prevención y consecuencias. Revisión de la situación en Latinoamérica / Inadequate management of acute postoperative pain: prevalence, prevention, and consequences. Review of the situation in Latin America

Resumen: Introducción: El dolor postoperatorio tiene un alto impacto, es una de las principales causas médicas de retraso en el alta hospitalaria. Asimismo, es causa frecuente de readmisión hospitalaria, retrasos en la recuperación y mayores costos para el sistema de salud y los pacientes. El objetivo del presente trabajo es conocer mejor la situación del dolor agudo postoperatorio en Latinoamérica mediante una revisión bibliográfica para poder establecer su prevalencia y evaluar su magnitud. Material y métodos: Se efectuó una búsqueda bibliográfica en SciELO y PubMed tratando de recopilar la información más detallada, precisa y actualizada. Resultados: En Latinoamérica la falta de políticas claras para la evaluación y el tratamiento del dolor postoperatorio, así como de formación, conduce a un control inadecuado del mismo con una prevalencia de dolor agudo postoperatorio moderado/severo superior a 40%. Conclusiones: El manejo del dolor agudo postoperatorio continúa siendo un problema en Latinoamérica. Muchos pacientes refieren dolor moderado o severo tras la cirugía, lo que puede conducir a dolor crónico. Se necesitan más estudios al respecto para poder establecer aún con mayor precisión la prevalencia del dolor agudo postoperatorio y los efectos derivados de su pobre control.

Abstract: Introduction: Postoperative pain has a profound impact. It is one of the main causes of delayed hospital discharge and it is associated with hospital readmission, recovery problems, and higher costs both for the healthcare system and the patients. The aim of this work is to shed light on the postoperative acute pain management in Latin America through a review of the literature, in order to have a better understanding of its prevalence and the extent of the problem. Material and methods: A bibliographical search was performed in SciELO and PubMed trying to gather the most precise, detailed and updated information. Results: In Latin America, the absence of clear policies for the evaluation and treatment of postoperative pain, as well as the lack of training, leads to its inadequate control with a prevalence of moderate/severe acute postoperative pain greater than 40%. Conclusions: Postoperative acute pain continues to be a problem in Latin America. Many patients still suffer moderate to severe pain after surgery, leading to a chronic or persistent painful condition. More studies are needed to get a clear picture of the prevalence of acute postoperative pain and the deleterious effects of an inadequate management.

Complications after partial, total or extended sacrectomy: a case series / Complicações depois de sacrectomia parcial, total ou estendida: série de casos / Complicaciones después de sacrectomía parcial, total o extendida: serie de casos

ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.

RESUMO Objetivo O objetivo deste estudo é fazer um levantamento das diferentes complicações da sacrectomia parcial, total ou estendida para tratamento de tumores da coluna vertebral. Métodos O estudo é uma análise descritiva de prontuários de uma série de 18 pacientes submetidos à sacrectomia entre 2010 e 2019 em um centro terciário especializado em cirurgias de neoplasia na coluna. As variáveis analisadas foram sexo, idade, tempo de internação, diagnóstico oncológico, padrão de fixação posterior, taxa de complicações e escalas de Frankel, ASA e ECOG. Resultados Dos 18 pacientes, 10 (55,5%) eram homens e 8 (44,5%) mulheres com média de idade de 48 anos. O tempo médio de internação foi de 23 dias. Dos 18 pacientes, 8 (44,5%) contraíram infecções pós-operatórias com necessidade de cirurgia. As complicações perioperatórias incluíram fistula liquórica (22,25%), instabilidade hemodinâmica com necessidade de medicação vasoativa no pós-operatório imediato (22,25%), deiscência da ferida operatória (11,1%), abdome obstrutivo agudo (11,1%), oclusão da artéria ilíaca externa esquerda (11,1%), óbito pós-operatório imediato por infarto agudo do miocárdio (11,1%) e óbito intraoperatório por instabilidade hemodinâmica (11,1%). Conclusões A sacrectomia parcial, total ou estendida é um procedimento complexo com alta taxa de mortalidade e morbidade, mesmo em centros especializados no tratamento de tumores na coluna. Nível de evidência IV; Série de casos.

RESUMEN Objetivo El objetivo de este estudio es evaluar las diferentes complicaciones de la sacrectomía parcial, total o extendida para el tratamiento de tumores vertebrales. Métodos El estudio es un análisis descriptivo de las historias clínicas de 18 pacientes sometidos a sacrectomía entre 2010 y 2019 en un centro terciario especializado en cirugías de neoplasia de columna. Las variables analizadas fueron sexo, edad, estancia hospitalaria, diagnóstico de cáncer, patrón de fijación posterior, tasa de complicaciones, escalas de Frankel, ASA y ECOG. Resultados De los 18 pacientes, 10 (55,5%) eran hombres y 8 (44,5%) mujeres con una edad promedio de 48 años. La estancia hospitalaria promedio fue de 23 días. De los 18 pacientes, 8 (44,5%) contrajeron infecciones posoperatorias que requirieron cirugía. Las complicaciones perioperatorias incluyeron fístula de líquido cefalorraquídeo (22,25%), inestabilidad hemodinámica que requirió medicación vasoactiva en el posoperatorio inmediato (22,25%), dehiscencia de la herida quirúrgica (11,1%), abdomen obstructivo agudo (11,1%), oclusión de la arteria ilíaca externa izquierda (11,1%), muerte posoperatoria inmediata por infarto agudo de miocardio (11,1%) y muerte intraoperatoria por inestabilidad hemodinámica (11,1%). Conclusiones La sacrectomía parcial, total o extendida es un procedimiento complejo con una alta tasa de mortalidad y morbilidad, incluso en centros especializados en el tratamiento de tumores de la columna. Nivel de evidencia IV; Series de casos

Risk Factors Associated with Postoperative Infection in Cancer Patients Undergoing Spine Surgery.

OBJECTIVES: To determine the rate of and main risk factors for postoperative infection in cancer patients who underwent spine surgery in the last 5 years in order to determine whether there is an association between postoperative infection and increased mortality during hospitalization. METHODS: All cancer patients who underwent surgical procedures between January 2015 and December 2019 at a single hospital specializing in spine cancer surgery were analyzed. The primary outcome of interest was postoperative infection. Bivariate logistic regression was used to estimate the odds ratio and 95% confidence interval for each variable in relation to the occurrence of infection. RESULTS: We evaluated 324 patients, including 176 men (54.3%) and 148 women (45.7%) with a mean age of 56 years. The incidence of postoperative infection was 20.37%. Of the 324 patients, 39 died during hospitalization (12%). CONCLUSIONS: Surgical time greater than 4 hours, surgical instrumented levels greater than 6, and an Eastern Cooperative Oncology Group of 3 or 4 were associated with an increased risk of postoperative infection, but these factors did not lead to an increase in mortality during hospitalization.

Risk Factors Associated with Postoperative Infection in Cancer Patients Undergoing Spine Surgery

OBJECTIVES: To determine the rate of and main risk factors for postoperative infection in cancer patients who underwent spine surgery in the last 5 years in order to determine whether there is an association between postoperative infection and increased mortality during hospitalization. METHODS: All cancer patients who underwent surgical procedures between January 2015 and December 2019 at a single hospital specializing in spine cancer surgery were analyzed. The primary outcome of interest was postoperative infection. Bivariate logistic regression was used to estimate the odds ratio and 95% confidence interval for each variable in relation to the occurrence of infection. RESULTS: We evaluated 324 patients, including 176 men (54.3%) and 148 women (45.7%) with a mean age of 56 years. The incidence of postoperative infection was 20.37%. Of the 324 patients, 39 died during hospitalization (12%). CONCLUSIONS: Surgical time greater than 4 hours, surgical instrumented levels greater than 6, and an Eastern Cooperative Oncology Group of 3 or 4 were associated with an increased risk of postoperative infection, but these factors did not lead to an increase in mortality during hospitalization.

SPINE METASTASIS OF INTRACRANIAL HEMANGIOPERICYTOMA: CASE REPORT OF TWO TREATMENTS.

OBJECTIVE: To report the use of two techniques (radiosurgery and en bloc vertebrectomy) on the same patient for the treatment of two metastases in different sites of the spine arising from intracranial hemangiopericytoma. Intracranial hemangiopericytomas are rare, comprising approximately 2.4% of meningeal tumors and <1% of all tumors of the central nervous system. Metastases to the spine are even rarer: The largest case series reported in the literature has 5 and 7 cases. METHODS: A 37-year-old man diagnosed with intracranial hemangiopericytoma was referred for a metastatic lesion in T12 and underwent en bloc resection using the Tomita technique. RESULTS: The disease evolved with a metastasis to T2 treated by radiosurgery with 1600 cGy. The patient died 1,706 days after the en bloc resection of T12 and 1324 days after the radiosurgery of T2, and no recurrence occurred in these locations due to progression of the systemic diseases (liver and central nervous system). CONCLUSION: This is the first case reported in the literature in which two different techniques were used to treat metastatic lesions in the spine from an intracranial hemangiopericytoma and is unique for its use of two treatments in the same patient. Level of evidence: V, case report.

OBJETIVO: Reportar o uso de duas técnicas (radiocirurgia e vertebrectomia em bloco) no mesmo paciente, para o tratamento de metástases de um hemangiopericitoma intracraniano em dois locais da coluna. Hemangiopericitomas intracranianos são raros, consistindo em cerca de 2,4% dos tumores da meninge e menos de 1% de todos os tumores do sistema nervoso central, e metástases para a coluna são ainda mais raras: as maiores séries de casos publicada tinham 5 e 7 casos. MÉTODOS: Um homem de 37 anos com diagnóstico de hemangiopericitoma intracraniano foi encaminhado para resecção em bloco de lesão metastática em T12 com a técnica de Tomita. RESULTADOS: A doença evoluiu com metástase em T2, tratada com radiocirurgia (dose de 1600 cGy). O paciente morreu 1.706 dias após a resecção em bloco de T12 e 1.324 dias após a radiocirurgia de T2, livre de recorrência nessas localizações, devido a progressão sistêmica da doença (para fígado e sistema nervoso central). CONCLUSÃO: Este é o primeiro caso na literatura no qual duas técnicas diferentes foram usadas pra tratar lesões metastáticas da coluna de hemangiopericitoma intracraniano, único pelo uso de duas técnicas de tratamento no mesmo paciente. Nível de evidência V, relato de caso.

Spine metastasis of intracranial hemangiopericytoma: case report of two treatments / Metástase na coluna de hemangiopericitoma intracraniano: relato de 2 tratamentos

ABSTRACT Objective: To report the use of two techniques (radiosurgery and en bloc vertebrectomy) on the same patient for the treatment of two metastases in different sites of the spine arising from intracranial hemangiopericytoma. Intracranial hemangiopericytomas are rare, comprising approximately 2.4% of meningeal tumors and <1% of all tumors of the central nervous system. Metastases to the spine are even rarer: The largest case series reported in the literature has 5 and 7 cases. Methods: A 37-year-old man diagnosed with intracranial hemangiopericytoma was referred for a metastatic lesion in T12 and underwent en bloc resection using the Tomita technique. Results: The disease evolved with a metastasis to T2 treated by radiosurgery with 1600 cGy. The patient died 1,706 days after the en bloc resection of T12 and 1324 days after the radiosurgery of T2, and no recurrence occurred in these locations due to progression of the systemic diseases (liver and central nervous system). Conclusion: This is the first case reported in the literature in which two different techniques were used to treat metastatic lesions in the spine from an intracranial hemangiopericytoma and is unique for its use of two treatments in the same patient. Level of evidence: V, case report

RESUMO Objetivo: Reportar o uso de duas técnicas (radiocirurgia e vertebrectomia em bloco) no mesmo paciente, para o tratamento de metástases de um hemangiopericitoma intracraniano em dois locais da coluna. Hemangiopericitomas intracranianos são raros, consistindo em cerca de 2,4% dos tumores da meninge e menos de 1% de todos os tumores do sistema nervoso central, e metástases para a coluna são ainda mais raras: as maiores séries de casos publicada tinham 5 e 7 casos. Métodos: Um homem de 37 anos com diagnóstico de hemangiopericitoma intracraniano foi encaminhado para resecção em bloco de lesão metastática em T12 com a técnica de Tomita. Resultados: A doença evoluiu com metástase em T2, tratada com radiocirurgia (dose de 1600 cGy). O paciente morreu 1.706 dias após a resecção em bloco de T12 e 1.324 dias após a radiocirurgia de T2, livre de recorrência nessas localizações, devido a progressão sistêmica da doença (para fígado e sistema nervoso central). Conclusão: Este é o primeiro caso na literatura no qual duas técnicas diferentes foram usadas pra tratar lesões metastáticas da coluna de hemangiopericitoma intracraniano, único pelo uso de duas técnicas de tratamento no mesmo paciente. Nível de evidência V, relato de caso.

Four-level en bloc vertebrectomy: a novel technique and literature review / Vertebrectomia em bloco em quatro níveis: nova técnica e revisão da literatura

ABSTRACT Objective: To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction. Methods: A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital. Results: The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient. Conclusion: The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

RESUMO Objetivo: Demonstrar uma nova técnica de reconstrução por vertebrectomia em bloco multinível. Métodos: Descrição de uma reconstrução pós-vertebrectomia em bloco multinível, em paciente tratado num hospital oncológico público universitário, com indicação de ressecção curativa de sarcoma de Ewing. Resultados: O procedimento proposto foi viável para a ressecção em bloco de quatro vértebras e a reconstrução foi aceitável e satisfatória em termos de estabilidade mecânica, sem causar dano neurológico ao paciente. Conclusão: O uso de aloenxerto com parafuso intramedular bloqueado é uma solução adequada para a reconstrução da coluna anterior e medial após vertebrectomias multiníveis. Além disso, a associação de quatro parafusos intramedulares dá estabilidade à reconstrução. Benefícios imediatos da técnica são o tempo de hospitalização mais curto e a redução da morbidade cirúrgica, em comparação com outras técnicas, comumente utilizadas. Nível de Evidência V, Estudo clínico de nova técnica cirúrgica e revisão da literatura.

SACRECTOMY ASSOCIATED WITH VERTEBRECTOMY: A NEW TECHNIQUE USING DOWEL GRAFTS FROM CADAVERS.

OBJECTIVE: The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver. STUDY DESIGN: Report of a case series with description of a new surgical technique. METHODS: The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used. RESULTS: In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively). CONCLUSION: The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

OBJETIVO: O propósito do estudo foi demonstrar, por meio de uma série de casos, uma nova técnica de sacrectomia com uso de enxerto encavilhado da crista ilíaca de cadáver. DESENHO DO ESTUDO: Relato de série de casos com descrição de uma nova técnica cirúrgica. MÉTODOS: A técnica usa quatro barras para sustentação da parte posterior da coluna e um enxerto encavilhado nas asas do ilíaco, com compressão da coluna e pelve sobre ele, para suporte da parte anterior da coluna. Foram operados três casos e em todos eles, realizou-se vertebrectomia. RESULTADOS: Nos dois primeiros casos, a técnica foi utilizada em duas etapas. A primeira etapa foi realizada por via anterior e acesso peritoneal, e a segunda etapa, por via posterior. No terceiro caso, o acesso retroperitoneal por via anterior significou que a técnica pôde ser realizada em apenas uma etapa, resultando em redução do tempo cirúrgico total (1250 x 1750 x 990 minutos, respectivamente). CONCLUSÃO: A nova técnica permite a fixação com estabilidade biomecânica, que é essencial para suportar a tensão na transição lombossacral e para a reabilitação precoce. Nível de evidência IV, série de casos.

Sacrectomy associated with vertebrectomy: a new technique using dowel grafts from cadavers / Sacrectomia associada à vertebrectomia: uma nova técnica com uso de enxerto de cadáver

ABSTRACT Objective: The purpose of this study was to demonstrate, in a case series, a new sacrectomy technique using an iliac crest dowel graft from a cadaver. Study design: Report of a case series with description of a new surgical technique. Methods: The technique uses four bars to support the posterior spine and a dowel graft in the iliac wings, with compression of the spine and pelvis above it, to support the anterior spine. Three cases were operated on, and in all of them, a vertebrectomy was used. Results: In the first two cases, the technique was performed as a two-stage surgery. The first stage was performed via the anterior and peritoneal access routes, and the second stage via the posterior access route. In the third case, retroperitoneal access via the anterior route meant that the technique could be performed in one stage, resulting in an overall reduction in surgical time (1250 vs. 1750 vs. 990 minutes, respectively). Conclusion: The new technique enables fixation with biomechanical stability, which is essential to support the stress in the lumbosacral transition and promote earlier rehabilitation. Level of evidence IV, case series.

RESUMO Objetivo: O propósito do estudo foi demonstrar, por meio de uma série de casos, uma nova técnica de sacrectomia com uso de enxerto encavilhado da crista ilíaca de cadáver. Desenho do estudo: Relato de série de casos com descrição de uma nova técnica cirúrgica. Métodos: A técnica usa quatro barras para sustentação da parte posterior da coluna e um enxerto encavilhado nas asas do ilíaco, com compressão da coluna e pelve sobre ele, para suporte da parte anterior da coluna. Foram operados três casos e em todos eles, realizou-se vertebrectomia. Resultados: Nos dois primeiros casos, a técnica foi utilizada em duas etapas. A primeira etapa foi realizada por via anterior e acesso peritoneal, e a segunda etapa, por via posterior. No terceiro caso, o acesso retroperitoneal por via anterior significou que a técnica pôde ser realizada em apenas uma etapa, resultando em redução do tempo cirúrgico total (1250 x 1750 x 990 minutos, respectivamente). Conclusão: A nova técnica permite a fixação com estabilidade biomecânica, que é essencial para suportar a tensão na transição lombossacral e para a reabilitação precoce. Nível de evidência IV, série de casos.

MINIMALLY INVASIVE EXTREME LATERAL APPROACH IN SPINAL LUMBAR METASTASIS.

INTRODUCTION: The extreme lateral approach has been widely used for the treatment of degenerative diseases. The objective of this study is to present a minimally invasive extreme lateral approach for the treatment of metastatic lesions in the lumbar spine without the use of the evoked potential exam (MEP). METHODS: Two patients with spinal metastases and indication for surgery via the anterior approach were treated in a cancer referral center in Brazil. They were placed in right lateral decubitus, and an oblique incision was made, exposing the psoas muscle. The anterior approach permitted the release of the psoas muscle from vertebral body and disc, without the need for MEP. CONCLUSIONS: When cancer cure is no longer possible, a minimally invasive extreme lateral approach to treat tumor metastases in the lumbar spine is a viable option, with short hospitalization time and low morbidity. The dislocation of the psoas muscle avoids the use of the transpsoas approach, which requires MEP equipment and a trained physician. Clinical studies are needed to extend these benefits to oncological patients who have treatment options for their primary disease. Level of Evidence IV; Case series.

INTRODUÇÃO: A técnica extremo-lateral já vem sendo amplamente usada no tratamento de doenças degenerativas fazendo com que o objetivo deste trabalho seja de apresentar a técnica extremo-lateral minimamente invasiva para o tratamento de metástases na coluna lombar, sem a necessidade do potencial evocado motor (MEP). MÉTODO: Dois pacientes com metástases em coluna com indicação para cirurgia pelo acesso anterior foram tratados em um centro de referência no Brasil. Eles foram posicionados em decúbito lateral direito e uma incisão oblíqua foi feita, expondo o músculo psoas. Pela via anterior, foi possível descolar as fibras do músculo psoas do corpo vertebral e disco, sem a ajuda do MEP. CONCLUSÃO: Quando a cura do câncer não é possível, o acesso extremo lateral por cirurgia minimamente invasiva é uma opção viável no tratamento de metástases tumorais na coluna lombar, com hospitalização curta e baixa morbidade. O descolamento do psoas evita o uso da via transpsoas, que exigiria a assistência com equipamento de MEP e profissional treinado para operá-lo. Estudos clínicos são necessários para que esses benefícios sejam estendidos a pacientes com câncer, para que ainda haja opção de tratamento para a doença primária. Nível de Evidência IV; Série de casos.

Minimally invasive extreme lateral approach in spinal lumbar metastasis / Via extremo lateral minimamente invasiva em casos de metastases lombares

ABSTRACT Introduction The extreme lateral approach has been widely used for the treatment of degenerative diseases. The objective of this study is to present a minimally invasive extreme lateral approach for the treatment of metastatic lesions in the lumbar spine without the use of the evoked potential exam (MEP). Methods Two patients with spinal metastases and indication for surgery via the anterior approach were treated in a cancer referral center in Brazil. They were placed in right lateral decubitus, and an oblique incision was made, exposing the psoas muscle. The anterior approach permitted the release of the psoas muscle from vertebral body and disc, without the need for MEP. Conclusions When cancer cure is no longer possible, a minimally invasive extreme lateral approach to treat tumor metastases in the lumbar spine is a viable option, with short hospitalization time and low morbidity. The dislocation of the psoas muscle avoids the use of the transpsoas approach, which requires MEP equipment and a trained physician. Clinical studies are needed to extend these benefits to oncological patients who have treatment options for their primary disease. Level of Evidence IV; Case series.

RESUMO Introdução A técnica extremo-lateral já vem sendo amplamente usada no tratamento de doenças degenerativas fazendo com que o objetivo deste trabalho seja de apresentar a técnica extremo-lateral minimamente invasiva para o tratamento de metástases na coluna lombar, sem a necessidade do potencial evocado motor (MEP). Método Dois pacientes com metástases em coluna com indicação para cirurgia pelo acesso anterior foram tratados em um centro de referência no Brasil. Eles foram posicionados em decúbito lateral direito e uma incisão oblíqua foi feita, expondo o músculo psoas. Pela via anterior, foi possível descolar as fibras do músculo psoas do corpo vertebral e disco, sem a ajuda do MEP. Conclusão Quando a cura do câncer não é possível, o acesso extremo lateral por cirurgia minimamente invasiva é uma opção viável no tratamento de metástases tumorais na coluna lombar, com hospitalização curta e baixa morbidade. O descolamento do psoas evita o uso da via transpsoas, que exigiria a assistência com equipamento de MEP e profissional treinado para operá-lo. Estudos clínicos são necessários para que esses benefícios sejam estendidos a pacientes com câncer, para que ainda haja opção de tratamento para a doença primária. Nível de Evidência IV; Série de casos.

En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series.

OBJECTIVES: The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines. METHODS: This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015. RESULTS: A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively. CONCLUSION: This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

FOUR-LEVEL EN BLOC VERTEBRECTOMY: A NOVEL TECHNIQUE AND LITERATURE REVIEW.

OBJECTIVE: To demonstrate a novel technique for multilevel en bloc post-vertebrectomy reconstruction. METHODS: A novel technique for en bloc multiple post-vertebrectomy reconstruction was used in a patient presenting for curative resection of Ewing's Sarcoma at the oncology center of a public university hospital. RESULTS: The procedure described was feasible for en bloc resection of the four vertebrae. The reconstruction was acceptable and satisfactory in terms of mechanical stability and was without any neurological sequelae in the patient. CONCLUSION: The use of an allograft with a locked intramedullary nail was an adequate solution for reconstructing the anterior and medial spines after multilevel vertebrectomy. In addition, the association of four intramedullary nails provided stability to the reconstruction. Immediate benefits of the technique compared to other commonly used techniques were shorter hospitalization times and reduced surgical morbidity. Level of Evidence V, Clinical study of a new surgical technique and a literature review.

OBJETIVO: Demonstrar uma nova técnica de reconstrução por vertebrectomia em bloco multinível. MÉTODOS: Descrição de uma reconstrução pós-vertebrectomia em bloco multinível, em paciente tratado num hospital oncológico público universitário, com indicação de ressecção curativa de sarcoma de Ewing. RESULTADOS: O procedimento proposto foi viável para a ressecção em bloco de quatro vértebras e a reconstrução foi aceitável e satisfatória em termos de estabilidade mecânica, sem causar dano neurológico ao paciente. CONCLUSÃO: O uso de aloenxerto com parafuso intramedular bloqueado é uma solução adequada para a reconstrução da coluna anterior e medial após vertebrectomias multiníveis. Além disso, a associação de quatro parafusos intramedulares dá estabilidade à reconstrução. Benefícios imediatos da técnica são o tempo de hospitalização mais curto e a redução da morbidade cirúrgica, em comparação com outras técnicas, comumente utilizadas. Nível de Evidência V, Estudo clínico de nova técnica cirúrgica e revisão da literatura.

En bloc vertebrectomy for the treatment of spinal lesions. Five years of experience in a single institution: a case series

OBJECTIVES: The objective of this study is to describe the experience of a Brazilian public university hospital regarding the treatment of metastatic or benign spine lesions with en bloc vertebrectomy of the thoracic and lumbar spines. METHODS: This study was a retrospective case series and included all medical records of patients with benign aggressive, primary malignant, or metastatic spine lesions who underwent en bloc vertebrectomy from 2010 to 2015. RESULTS: A total of 17 patients were included in the analysis. Most of them (71%) were indicated for surgery based on an oncologic resection for localized disease cure. Overall, 10 of the 17 patients (59%) underwent vertebrectomy via an isolated posterior approach using the technique described by Roy-Camille et al. and Tomita et al., while 7 patients (41%) underwent double approach surgeries. Of the 17 patients who underwent the en bloc resection, 8 are still alive and in the outpatient follow-up (47%), and almost all patients with metastatic lesions (8/9) died. The average survival time following the surgical procedure was 23.8 months. Considering the cases of metastatic lesions and the cases of localized disease (malignant or benign aggressive disease) separately, we observed an average survival time of 15 months and 47.6 months respectively. CONCLUSION: This study demonstrates and reinforces the reproducibility of the en bloc vertebrectomy technique described by Tomita et al.

Endovascular Treatment of Late Aortic Erosive Lesion by Pedicle Screw without Screw Removal: Case Report and Literature Review.

BACKGROUND: Aortic lesions are uncommon complications in spine surgery, but potentially fatal, because they can cause massive bleeding and hemodynamic instability. We report the endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal. METHODS: A breast cancer patient had a pathological fracture on T10, with spinal cord compression, and a pseudoaneurysm of the aorta in contact with an anterolateral pedicle screw. Endovascular surgery corrected the aortic lesion and allowed decompression, a week later, by posterior arthrodesis (T7-L1), with screw maintenance. RESULTS: There was no contrast leakage at thorax angiotomography in 2 years, and she died of meningeal carcinomatosis. CONCLUSION: Screw maintenance was safe in the endovascular treatment of aortic lesion by erosion.

Laminectomy without instrumentation for surgical treatment of metastatic spinal cord compression / Laminectomia sem instrumentação para tratamento cirúrgico da compressão medular metastática / Laminectomía sin instrumentación para tratamiento quirúrgico de la compresin metastásica de la médula espinal

OBJECTIVE: To analyze the development of mechanical complications as a result of spinal decompression or cauda equina in patients with metastatic tumors of the spine via laminectomy or laminoartrectomy without fixation. METHODS: We studied the medical records of all patients submitted to spine decompression with laminectomy without fixation. The decompression was indicated to treat cord compression or cauda equina caused by metastatic tumors. Patients were evaluated for the development of postoperative mechanical instability by comparing the preoperative radiological examinations with the latest one available in the medical record review.. In these images, we evaluated the emergence of new deformity in the sagittal or coronal planes and translational deformity. We consider new deformity, signs of deformity greater or equal to 5° in the coronal or sagittal planes and signs of increased vertebral translation greater than or equal to 3 mm. RESULTS: No patient developed radiological instability in the period evaluated with an average follow-up of 163.24 days (3-663). The complication rate in our sample was not higher than the previously reported in the literature. CONCLUSION: Isolated laminectomy at one or more levels is a safe procedure for the treatment of metastatic spinal cord compression where the spine is judged stable before surgery. .

OBJETIVO: Analisar o desenvolvimento de complicações mecânicas como resultado da descompressão medular ou da cauda equina de pacientes com doença metastática da coluna vertebral através de laminectomia ou laminoartrectomia sem fixação. MÉTODOS: Estudamos todos os prontuários de pacientes que foram submetidos à descompressão da coluna vertebral por laminectomia sem fixação. A descompressão foi indicada por compressão medular ou da cauda equina por tumores sólidos em doença metastática. Os pacientes foram avaliados quanto ao desenvolvimento de instabilidade mecânica pós-operatória através da comparação dos exames radiológicos pré-operatórios com o último exame disponível no prontuário. Nessas imagens, avaliamos o surgimento de deformidade nova no plano sagital ou coronal e deformidade translacional. Consideramos como deformidade nova, sinais de deformidade maior ou igual a 5º no plano coronal ou sagital e sinais de aumento da translação vertebral maior ou igual a 3 mm. RESULTADOS: Nenhum paciente evoluiu com instabilidade radiológica no período avaliado com tempo médio de seguimento de 163,24 dias (3-663). A taxa de complicações encontrada em nossa amostra não foi superior à encontrada na literatura. CONCLUSÃO: A laminectomia isolada em um ou mais níveis é um procedimento seguro para tratamento da compressão medular metastática quando há julgamento de que a coluna é estável no momento da indicação da cirurgia. .

OBJETIVO: Analizar el desarrollo de complicaciones mecánicas como consecuencia de la descompresión espinal o la cauda equina en los pacientes con enfermedad metastásica de la columna vertebral a través de una laminectomía o laminoartrectomia sin fijar. MÉTODOS: Se estudiaron las historias clínicas de todos los pacientes que fueron sometidos a laminectomía sin fijación. La descompresión se indicó por compresión de la médula o la cauda equina por metástasis de tumores sólidos. Los pacientes fueron evaluados para el desarrollo de la inestabilidad mecánica postoperatoria mediante la comparación de los exámenes radiológicos preoperatorios con última imagen disponible en el registro clínico. En estas imágenes, se evalúa la aparición de nueva deformidad en el plano coronal o sagital y deformidad traslacional. Consideramos nueva deformidad, los signos de una deformidad mayor o igual a 5° en el plano coronal o sagital y signos de aumento de la traslación vertebral superior o igual a 3 mm. RESULTADOS: Ningún paciente desarrolló inestabilidad radiológica en el período evaluado con un seguimiento promedio de 163,24 días (3-663). La tasa de complicaciones en nuestra muestra no era mayor que la encontrada en la literatura. CONCLUSIÓN: Laminectomía aislada en uno o más niveles es un procedimiento seguro para el tratamiento de compresión metastásica de la médula cuando se juzga que la columna es estable en el momento de la indicación quirúrgica. .

Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator.

OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties. METHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient. RESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases. CONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.

Interobserver agreement for the spine instability neoplastic score varies according to the experience of the evaluator

OBJECTIVES: To evaluate the interobserver agreement for the Neoplastic Spine Instability Score (SINS) among spine surgeons with or without experience in vertebral metastasis treatment and physicians in other specialties. METHODS: Case descriptions were produced based on the medical records of 40 patients with vertebral metastases. The descriptions were then published online. Physicians were invited to evaluate the descriptions by answering questions according to the Neoplastic Spine Instability Score (SINS). The agreement among physicians was calculated using the kappa coefficient. RESULTS: Seventeen physicians agreed to participate: three highly experienced spine surgeons, seven less-experienced spine surgeons, three surgeons of other specialties, and four general practitioners (n = 17). The agreement for the final SINS score among all participants was fair, and it varied according to the SINS component. The agreement was substantial for the spine location only. The agreement was higher among experienced surgeons. The agreement was nearly perfect for spinal location among the spine surgeons who were highly experienced in vertebral metastases. CONCLUSIONS: This study demonstrates that the experience of the evaluator has an impact on SINS scale classification. The interobserver agreement was only fair among physicians who were not spine surgeons and among spine surgeons who were not experienced in the treatment of vertebral metastases, which may limit the use of the SINS scale for the screening of unstable lesions by less-experienced evaluators.