Osteoma osteoide raquídeo recidivante en forma de osteoblastoma agresivo / Spinal osteoid osteoma recurring as an aggressive osteoblastoma

Presentamos el caso de un osteoma osteoide recurrente en forma de un osteoblastoma agresivo en columna lumbar. Un varón de 15 años acudió a nuestro servicio con una escoliosis dolorosa. El TC y la RM mostraron una tumoración formadora de hueso esclerótico de 7 mm compatible con un osteoma osteoide. Se realizó una ablación percutánea guiada por radiofrecuencia con remisión completa de la sintomatología. Seis meses después, dicha sintomatología recurrió. Se realizaron TC y RM que mostraron un crecimiento del nidus en la lámina L4 derecha, con un diámetro de 15 mm. Se realizó una resección marginal. La histología mostró un osteoblastoma epiteloide. Un años después, se realizaron nuevos estudios de imagen que mostraron una nueva recurrencia del tumor con rasgos agresivos e invasión del canal espinal. Se le realizó una cirugía de resección en bloque con estabilización de la columna lumbar. La histología confirmó el diagnóstico de osteoblastoma epiteloide

We report an uncommon case of osteoid osteoma recurring as an aggressive osteoblastoma of the spine. A 15-years-old male consulted in our department with long-term painful scoliosis. The CT-scans and MRI revealed a sclerotic bone forming tumor of 7 mm diameter consistent with a osteoid osteoma. A percutaneous radiofrequency ablation was performed with complete resolution of the symptoms. After 6 months, the symptoms recurred. A new CT and a MRI showed a growth of the nidus on the right L4 lamina, with a size of 15 mm. Therefore, a marginal resection by laminectomy of L4 was performed. Pathology confirmed an epithelioid osteoblastoma. A year later, subsequent imaging studies showed a new recurrence with aggressive features and invasion of the spinal canal. The patient then underwent an "in block surgery" needing concurrent stabilization of the spine. Histopathology confirmed the diagnosis of epithelioid osteblastoma

How good are the outcomes of instrumented debulking operations for symptomatic spinal metastases and how long do they stand? A subgroup analysis in the global spine tumor study group database.

BACKGROUND: The benefits of surgery for symptomatic spinal metastases have been demonstrated, largely based on series of patients undergoing debulking and instrumentation operations. However, as cancer treatments improve and overall survival lengths increase, the incidence of recurrent spinal cord compression after debulking may increase. The aim of the current paper is to document the postoperative evolution of neurological function, pain, and quality of life following debulking and instrumentation in the Global Spine Tumor Study Group (GSTSG) database. METHODS: The GSTSG database is a prospective multicenter data repository of consecutive patients that underwent surgery for a symptomatic spinal metastasis. For the present analysis, patients were selected from the database that underwent decompressive debulking surgery with instrumentation. Preoperative tumor type, Tomita and Tokuhashi scores, EQ-5D, Frankel, Karnofsky, and postoperative complications, survival, EQ-5D, Frankel, Karnofsky, and pain numeric rating scores (NRS) at 3, 6, 12, and 24 months were analyzed. RESULTS: A total of 914 patients underwent decompressive debulking surgery with instrumentation and had documented follow-up until death or until 2 years post surgery. Median preoperative Karnofsky performance index was 70. A total of 656 patients (71.8%) had visceral metastases and 490 (53.6%) had extraspinal bone metastases. Tomita scores were evenly distributed above (49.1%) and below or equal to 5 (50.9%), and Tokuhashi scores almost evenly distributed below or equal to 8 (46.3%) and above 8 (53.7%). Overall, 12-month survival after surgery was 56.3%. The surgery resulted in EQ-5D health status improvement and NRS pain reduction that was maintained throughout follow-up. Frankel scores improved at first follow-up in 25.0% of patients, but by 12 months neurological deterioration was observed in 18.8%. CONCLUSION: We found that palliative debulking and instrumentation surgeries were performed throughout all Tomita and Tokuhashi categories. These surgeries reduced pain scores and improved quality of life up to 2 years after surgery. After initial improvement, a proportion of patients experienced neurological deterioration by 1 year, but the majority of patients remained stable.

Spinal osteoid osteoma recurring as an aggressive osteoblastoma. / Osteoma osteoide raquídeo recidivante en forma de osteoblastoma agresivo.

We report an uncommon case of osteoid osteoma recurring as an aggressive osteoblastoma of the spine. A 15-years-old male consulted in our department with long-term painful scoliosis. The CT-scans and MRI revealed a sclerotic bone forming tumor of 7mm diameter consistent with a osteoid osteoma. A percutaneous radiofrequency ablation was performed with complete resolution of the symptoms. After 6 months, the symptoms recurred. A new CT and a MRI showed a growth of the nidus on the right L4 lamina, with a size of 15mm. Therefore, a marginal resection by laminectomy of L4 was performed. Pathology confirmed an epithelioid osteoblastoma. A year later, subsequent imaging studies showed a new recurrence with aggressive features and invasion of the spinal canal. The patient then underwent an "in block surgery" needing concurrent stabilization of the spine. Histopathology confirmed the diagnosis of epithelioid osteblastoma.

A novel risk calculator to predict outcome after surgery for symptomatic spinal metastases; use of a large prospective patient database to personalise surgical management.

AIM: Surgery for spinal metastases can improve symptoms, but sometimes complications can negate the benefits. Operations may have different indications, complexities and risks, and the choice for an individual is a tailor-made personalised decision. Previous prognostic scoring systems are becoming out of date and inaccurate. We designed a risk calculator to estimate survival after surgery, to inform clinicians and patients when making management decisions. METHODS: A prospective cohort study was performed, including 1430 patients with spinal metastases who underwent surgery. Of them, 1264 patients from 20 centres were used for model development using a Cox frailty model. Calibration slope, D-statistic and C-index were used for model validation based on 166 patients. Follow-up was to death or minimum of 2 years after surgery. Pre-operative indices (examination findings, pain, Karnofsky physical functioning score, and radiology) were assessed. RESULTS: An algorithm to predict survival was constructed including the tumour type, ambulatory status, analgesic use, American Society of Anesthesiologists score, number of spinal metastases, previous radiotherapy or chemotherapy, presence of visceral metastases, cervical or thoracic spine involvement, as predictors. An Internet-based risk calculator was developed based on this algorithm, with similar or improved accuracy compared to other validated prognostic scoring systems (C-index, 0.68; 95% confidence interval, 0.63--0.73, and calibration slope, 1.00; 95% confidence interval, 0.68--1.32). CONCLUSION: A large, prospective, surgical series of patients with symptomatic spinal metastases was used to create a validated risk calculator that can help clinicians to inform patients about the most appropriate treatment plan. The calculator is available at www.spinemet.com.

Loss of Local Tumor Control After Index Surgery for Spinal Metastases: A Prospective Cohort Study.

BACKGROUND: As survival after treatment for symptomatic spinal metastases increases, the incidence of local tumor recurrence also may increase. However, data regarding incidence and timing of recurrence or duration of survival after second surgeries are not readily available and may help to inform clinicians when to perform second surgeries. OBJECTIVE: To identify features associated with loss of local control (LLC) at a previously treated or new spinal level. METHODS: Clinical and surgical data were collected from a prospective cohort of 1421 patients who had surgery for symptomatic spinal metastases. Patients undergoing repeat spinal surgery for symptomatic LLC at the same or a different level were identified and analyzed. RESULTS: In total, 3.0% patients underwent repeat surgery for symptomatic LLC after a median interval of 184 days from the first surgery; median survival was 6.1 months after second surgery. Factors associated with second surgery for LLC were the primary tumor type, number of spinal levels, Tomita staging, Tokuhashi and Karnofsky scores, anterior surgical approach, more aggressive surgical resection, and postoperative radiotherapy. In total, 1.5% patients were admitted for surgery for a different spinal level than the index operation after median 338 days from the first operation. CONCLUSIONS: The likelihood for repeat surgery due to LLC cannot be accurately predicted at the time of initial presentation. Factors associated with second surgery for LLC relate to less aggressive tumor biology and better survival. Most patients had a reasonable duration of survival after second surgery.

Comparación de resultados de osteotomías de Smith-Petersen, osteotomías de sustracción pedicular y vertebrectomía en el tratamiento de desequilibrio sagital / Comparação de resultados de osteotomias de Smith-Petersen, osteotomias de subtração pedicular e vertebrectomias no tratamento do desequilíbrio sagital / Comparison of Smith-Petersen, pedicle subtraction osteotomy and vertebral column resection for the correction of sagittal imbalance

OBJETIVO: Comparar los resultados clínicos y radiológicos de pacientes sometidos a osteotomías de Smith-Petersen (SPO), de sustracción pedicular (PSO) y vertebrectomías (VCR) en pacientes con desequilibrio sagital. MÉTODOS: Estudio observacional y retrospectivo. Se compararon 42 pacientes sometidos a 3 SPO (n=14), 1 PSO (n=16) y 1 VCR (n=12) por desequilibrio sagital fijo en el periodo de 2003-2011. La muestra constó de 71,4% de hombres y la edad promedio fue 43 años (17-74). El tiempo de seguimiento promedio fue 5 años. Se registraron las complicaciones, los resultados del cuestionario SRS-22, el ángulo de cifosis y eje sagital vertical (SVA) en el preoperatorio y a los 2 años postoperatorios. RESULTADOS: El tiempo quirúrgico (min.) fue menor en SPO respecto a PSO y VCR (420±347 vs. 578±459 vs. 533±435) (p<0,00). El sangrado intraoperatorio (cc) fue menor en SPO respecto a PSO y VCR (1341±804 vs. 2364±1459 vs, 2134±1335) (p<0,03). Del total, 38% presentaron complicaciones. No se observaron diferencias en el promedio de corrección en la cifosis segmentaria, pero sí en la corrección del SVA, siendo menor SPO. En el SRS-22, en los tres grupos se presentaron cambios significativos en todos los dominios respecto al preoperatorio, sin diferencias significativas entre grupos. CONCLUSIONES: No se encontraron diferencias en las complicaciones, aunque fueron de mayor gravedad en PSO y VCR. No había diferencias en la corrección de la cifosis segmentaria, pero PSO y VCR obtuvieron mejores resultados en la modificación del SVA. No había diferencias en la calidad de vida.

OBJETIVO: Comparar os resultados clínicos e radiológicos de pacientes submetidos a osteotomias de Smith-Petersen (SPO), de subtração pedicular (PSO) e vertebrectomias (VCR) em pacientes com desequilíbrio sagital fixo. MÉTODOS: Estudo retrospectivo observacional. Foram comparados 42 pacientes submetidos a 3 SPO (n = 14), 1 PSO (n = 16) e 1 VCR (n = 12) por desequilíbrio sagital no período 2003-2011. A amostra é constituída por 71,4% do sexo masculino e a média de idade é de 43 anos (17-74). O tempo médio de acompanhamento foi de 5 anos. Registraram-se as complicações, os resultados do questionário SRS-22, ângulos de cifose e SVA no pré-operatório e no pós-operatório, aos 2 anos. RESULTADOS: O tempo de cirurgia (minutos) foi menor em SPO comparado com PSO e VCR (420 ± 347 vs. 578 ± 459 vs. 533 ± 435) (p < 0,00). As perdas sanguíneas intraoperatórias (cc) foram menores em SPO quando comparadas com SPO PSO e VCR (1341 ± 804 vs. 2364 ± 1.459 vs. 2134 ± 1335) (p < 0,03). Do total, 38% apresentaram complicações. Não houve diferenças na correção média da cifose segmentar, mas sim na correção SVA, sendo menor SPO. No SRS-22, os três grupos apresentaram mudanças significativas em todas as áreas, em comparação com o pré-operatório, sem diferenças significativas entre os grupos. CONCLUSÕES: Não houve diferenças nas complicações, embora tenham sido mais graves em PSO e VCR. Não se verificaram diferenças na correção da cifose segmentar, mas PSO e VCR obtiveram melhores resultados na modificação do SVA. Não havia diferenças na qualidade de vida.

OBJECTIVE: To compare the clinical and radiological results of Smith-Petersen osteotomy (SPO), Pedicle Subtraction Osteotomy (PSO) and Vertebral Column Resection (VCR) on sagittal imbalance. METHODS: Retrospective cohort study. We compared 42 patients submitted to 3 SPO (n=14), 1 PSO (n=16) and 1 VCR (n=12) for fixed sagittal imbalance in the period 2003 to 2011. The sample consisted of 71.4% males, and the mean age was 43 years (17-74). The mean follow-up was 5 years. The complications, results of the SRS-22 questionnaire, sagittal Cobb angle and sagittal vertical axis (SVA) prior to surgery and 2 years after surgery were recorded. RESULTS: Mean operating time (min) was lower in SPO vs PSO and VCR (420 ± 347 vs. 578 ± 459 vs. 533 ± 435) (p<0.00). Average blood loss (cc) was lower in SPO vs PSO and VCR (1341 ± 804 vs. 2364 ± 1.459 vs. 2134 ± 1335) (p<0.03). The overall rate of complications was 38%. There were no differences in the mean segmental kyphosis correction achieved, but in the correction of SVA differences were observed, with SPO being lower. In SRS-22, the three groups showed significant differences in all areas, compared with the preoperative results, where there were no differences between the groups. CONCLUSIONS: there were no differences in complications, although these were more severe in PSO and VCR. No differences were found in correction of segmental kyphosis, but PSO and VSR achieved better results in terms of modifying the SVA. There was no difference in quality of life.

Expansive laminoplasty as a method for managing cervical multilevel spondylotic myelopathy.

STUDY DESIGN: This study evaluated 12 patients with multilevel cervical spondylotic myelopathy who underwent Kurokawa's procedure using hydroxyapatite spacers and performed with T-saw thread wire. OBJECTIVES: To assess the efficacy and safety of Kurokawa's laminoplasty for patients with multilevel cervical spondylotic myelopathy using the T-saw, and to determine the radiographic and clinical factors that correlate with the prognosis. SUMMARY OF BACKGROUND DATA: Spinous process-splitting laminoplasty as an alternative or a combined method with an anterior approach was evaluated for the management of multilevel stenosis of the cervical spine. METHODS: This study involved 12 patients (10 men and 2 women) with multilevel spondylotic myelopathy managed with expansive laminoplasty using the T-saw to open the spinous process. The mean age of the patients was 56 years. The mean postoperative follow-up period was 2 years. Magnetic resonance imaging and computed tomography scan were performed for all the patients. Clinical status and mobility after surgery also were evaluated. The average duration of symptoms was 3 years (range, 3 months to 5 years). RESULTS: Nine patients had five levels of decompression (C3-C7), and three patients had four levels of decompression: C3-C6 (2 patients) and C4-C7 (1 patient). The mean duration of surgery was 3 hours. No cases of postoperative kyphosis, instability, or neurologic deficit were found. All the patients had a decrease of at least one level. The mean Nurick Functional Disability Score improved from 2.8 (range, 2-4) before surgery to 1.2 (range 1-3) after surgery. Verification of the canal expansion was measured using the increase of the spinal canal-vertebral body ratio at each level from C3 to C7 in nine patients, from C3 to C6 in two patients, and from C4 to C7 in one patient. After surgery, it was possible to make a comparison by measuring the osseous canal directly with computed tomography scans and high-resolution magnetic resonance imaging. The levels of myelomalacia assessed by magnetic resonance imaging in all the patients was 2.5 before surgery, and less than one level (range, 0-2) thereafter, the posterior movement of the spinal cord in all the patients at level C5 being 1.2 mm. At the latest follow-up evaluation, cervical motion assessed by plain radiographs in flexion and extension, both before and after surgery, decreased 29% (range, 25-32%). CONCLUSIONS: Laminoplasty with the T-saw technique appears to be a good method for managing multilevel cervical spondylotic myelopathy. This method is associated with a low rate of complications that also allows marked functional improvement in most patients. It can be used as a complement to anterior surgery.