Comparison of subtotal vertebral resection with reconstruction and percutaneous vertebroplasty for treatment of metastasis in the lumbar spine.

Purpose: Tumor metastasis in the spine can cause pain and fractures, leading to deformities, and deficits in movement, sensation, and bowel/bladder function. Percutaneous vertebroplasty (PVP) and subtotal vertebral resection with reconstruction (SVR) are suitable treatments, but their relative clinical efficacy is uncertain. The purpose of this retrospective cohort study was to compare the management and clinical effect of SVR for lumbar metastatic tumor with PVP.Methods: Sixty-seven patients (mean age: 58.6 years) with metastases in the lumbar spine received SVR or PVP at our institution between 2010 and 2013. Thirty-three patients received SVR via a posterior approach, in which vertebrae were resected, with the anterior and lateral walls retained using polymethylmethacrylate (PMMA), followed by reconstruction and pedicle screw fixation. Thirty-four patients received PVP via the vertebral pedicle. Patients were followed for 3-26 months.Results: None of the patients experienced serious complications after surgery, and all patients experienced significant amelioration of pain. Twelve patients (8 in the PVP group and 4 in the SVR group) died during the follow-up, and the survival time was significantly longer in the SVR group. Two patients in the SVR group and 7 patients in the PVP groups experienced recurrence during follow-up, but the groups had no significant difference in local recurrence. Both treatments significantly reduced scores for pain on a visual analog scale (pain-VAS) and disability (Oswestry Disability Index [ODI]), and increased performance status (Karnofsky Performance Status [KPS]). Compared with the PVP group, the SVR group had better ODI score at 1 month and 3 months after surgery and a higher KPS score at 1 month after surgery. The two groups had no significant difference in pain-VAS scores during follow-up.Conclusions: SVR is a reliable treatment for lumbar metastatic tumor and provides good survival rate and satisfying follow-up results.

Langerhans cell histiocytosis at L5 vertebra treated with en bloc vertebral resection: a case report.

BACKGROUND: Langerhans cell histiocytosis (LCH) in adult lumbar spine is extremely rare, and optimal treatments remain unclear. In literature, only a few cases of lumbar spine LCH were treated using surgery but en bloc vertebral resection has not been used. CASE PRESENTATION: A 50-year-old man presented with unbearable radiating pain at his right leg. Radiological studies revealed a solitary osteolytic lesion, which was moderately enhanced on contrast MR imaging and hyper-metabolic on PET/CT, at the right L5 vertebral body and arch. In biopsy, Langerhans cells were observed, but findings were insufficient to establish a diagnosis of LCH. A modified L5 en bloc vertebral resection via anterior and posterior approaches was performed to remove the right 2/3 portion of the L5 vertebra. The left 1/3 vertebral body and left pedicle of L5, which were not affected, were kept in situ to allow short instrumentation and reconstruction. His leg pain disappeared after the surgery, and a precise diagnosis of LCH was established after a throughout histological study of the removed vertebra. The patient further accepted 1 cycle of low-dose radiotherapy postoperatively. At 18-month follow-up, the lumbosacral spine was fused and no local reoccurrence was noticed. CONCLUSIONS: For lumbar spine LCH, surgery should be considered if there are neurological symptoms or histological diagnosis is indefinite in biopsy. En bloc vertebral resection can be used to alleviate neurological symptoms and prevent local reoccurrence.

Thoracolumbar and Lumbar Posterior Vertebral Resection for the Treatment of Rigid Congenital Spinal Deformities in Pediatric Patients: A Long-Term Follow-up Study.

Objective: We sought to determine whether a posterior vertebral resection on congenital deformities of thoracolumbar and lumbar vertebrae leads to more complications and provides less correction. Methods: Twenty-three patients underwent a posterior vertebral resection for a rigid congenital spinal deformity, which included scoliosis (13 patients), kyphoscoliosis (6 patients), and pure kyphosis (4 patients). The surgeries involved removing 1 to 2 vertebrae using multiaxial pedicle screws in all but 2 of the patients. All surgeries were performed under intraoperative spinal cord monitoring. Thoracic curve, lumbar lordosis, focal kyphosis, shift, and sagittal vertical axis were collected at baseline and during the last follow-up (taking place after at least 3 years) and were then statistically analyzed. Results: The major curve correction was about 55% in cases of scoliosis, with focal kyphosis improving from 54.3 ± 19.1 degrees to 21.3 ± 15 degrees. Two patients experienced intraoperative neuromonitoring changes, with data returning to baseline without any surgical intervention. Sensory or motor palsy after the surgery was not reported in patients.Despite improving sagittal or coronal deformities, 8 patients experienced excessive sagittal decompensation during follow-up, 1 of whom underwent revision surgery. Sagittal decompensation was by far the most common complication. Larger kyphoscoliosis or focal kyphosis angles were preoperative risk factors for postoperative sagittal imbalance (P value < 0.05). Conclusions: Using a lumbar or thoracolumbar posterior vertebral resection enables surgeons to correct rigid curves in the pediatric population without major risk to nerve roots. The primary complications would be sagittal decompensation and the likelihood of undercorrection, which requires mindful addressing during the preoperative planning stages.

Ultrasonic osteotome versus high-speed burr in cervical anterior vertebral subtotal resection: A retrospective study of 81 cases.

AIM: This study aimed to investigate the safety and effectiveness of ultrasonic osteotome in cervical anterior vertebral subtotal resection. METHODS: Retrospective clinical data were collated for 81 patients with cervical spondylotic myelopathy who required cervical anterior vertebral subtotal resection. RESULTS: Group A (n=40) was treated with an ultrasonic osteotome and group B (n=41) with a high-speed burr. Vertebrectomy time, intraoperative blood loss, surgical complications, Japanese Orthopedic Association (JOA) scores and JOA score improvement were compared. Group A showed significantly shorter vertebrectomy time and significantly less intraoperative blood loss (P<0.05). In group A, dysphagia occurred in one patient, and superior laryngeal nerve injury in one. Urinary tract infection occurred in one patient in group B. JOA score in both groups significantly increased 3 days after surgery (P<0.05), and at last follow-up compared with 3 days after surgery (P<0.05). CONCLUSION: Ultrasonic osteotome was a safe and effective tool for subtotal anterior cervical vertebral resection.

Partial Vertebrectomies without Instrumented Stabilization During En Bloc Resection of Primary Bronchogenic Carcinomas Invading the Spine: Feasibility Study and Results on Spine Balance.

OBJECTIVE: It is unknown whether spinal instrumentation is required to prevent deformity after partial vertebrectomy in the treatment of primary bronchogenic carcinomas invading the spine (PBCIS). In this study, we focus on the postoperative spine deformity in patients who underwent operation for partial vertebrectomies without instrumentation during en bloc PBCIS resection. Our objective was to determine whether deformity depends on the type of vertebral resection and if any vertebral resection threshold can be observed to justify additional spinal instrumentation. METHODS: This is a retrospective study, including all patients with PBCIS operated without spinal instrumentation from 2009 to 2018. Partial vertebrectomies were classified into categories A, B, and C depending on vertebral resection. Patients had long-term radiologic follow-up to assess the spine deformity evolution. RESULTS: Eighteen patients were included. The median follow-up was 27 months. Four patients underwent a secondary posterior instrumentation surgical procedure due to progressive spinal deformity. A low-risk group of deformation was characterized as type A resection and type B resection on less than 3 vertebrae. CONCLUSIONS: There are no validated criteria to justify a systematic spinal instrumentation when performing a partial vertebrectomy during en bloc resection of PBCIS. Performed alone without spine instrumentation, both type A and type B resections on less than 3 resected vertebrae were not subject to sagittal and coronal deformity even after a long follow-up, emphasizing that a systematic stabilization is not needed in this low-risk group. These results could help to reduce the perioperative morbidity of these procedures that are usually long and complex.

Surgical Treatment of Angular Pott's Kyphosis with Posterior Approach, Pedicular Wedge Osteotomy and Canal Widening.

BACKGROUND: It has been observed that the correction of severe posttuberculous angular kyphosis is still a challenge, mainly because of the neurologic risk. METHODS: Nine patients were reviewed after surgery (mean follow-up 18 months). There were 2 thoracic, 4 thoraco-lumbar and 3 lumbar kyphosis. The mean age at surgery was 23. Clinical results were evaluated by the Oswestry Disability Index (ODI) and by the neurologic evaluation. Preoperative, postoperative and final follow-up X-rays were assessed. The surgery included a posterior approach with cord release and correction by transpedicular wedge osteotomy and widening of the spinal canal. RESULTS: Average kyphotic angulation was 72° before surgery, 10° after surgery and 12° at follow-up. Three out of four patients with neural deficit showed improvement. Neurologic complications included a transitory quadriceps paralysis, likely by foraminal compression of the root. CONCLUSION: A posterior transpedicular wedge osteotomy allows a substantial correction of the kyphosis, more by deflexion than by elongation, with limited neurologic risks. However it is mandatory to widely enlarge the spinal canal on the levels adjacent to the osteotomy, in order to allow the dura to expand backwards.

Complications of posterior vertebral resection for spinal deformity.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the incidence and risk factors of complications following posterior vertebral resection (PVR) for spinal deformity. METHODS: A review of 233 patients treated with PVR at one institution over a nine-year period (1997 to 2005) was performed. The average age was 33.5 years. Complications were assessed in terms of surgical techniques (posterior vertebral column resection [PVCR] and decancellation osteotomy) and etiologies of deformity. RESULTS: Local kyphosis was corrected from 51.4° to 2.7°, thoracic scoliosis 63.9° to 24.5° (62.6% correction), and thoracolumbar or lumbar scoliosis 50.1° to 17.1° (67.6%). The overall incidence of complications was 40.3%. There was no significant difference between PVCR and decancellation osteotomy in the incidence of complications. There were more complications in the older patients (>35 years) than the younger (p < 0.05). Hig her than 3,000 ml of blood loss and 200 minutes of operation time increased the incidence of complications, with significant difference (p < 0.05). More than 5 levels of fusion significantly increased the total number of complications and postoperative neurologic deficit (p < 0.05). Most of the postoperative paraplegia cases had preoperative neurologic deficit. Preoperative kyphosis, especially in tuberculous sequela, had hig her incidences of complications and postoperative neurologic deficit (p < 0.05). More than 40° of kyphosis correction had the tendency to increase complications and postoperative neurologic deficit without statistical significance (p > 0.05). There was 1 mortality case by heart failure. Revision surgery was performed in 15 patients for metal failure or progressing curve. CONCLUSIONS: The overall incidence of complications of PVR was 40.3%. Older age, abundant blood loss, preoperative kyphosis, and long fusion were risk factors for complications.