Federico De Iure

Aneurysmal Bone Cyst of the Mobile Spine: Report on 41 Cases

Study Design. Forty-one cases of aneurysmal bone cyst of the mobile spine were retrospectively reviewed. Objectives. To evaluate the role of surgical and nonsurgical treatment of aneurysmal bone cyst of the spine. Summary of Background Data. Ten to 30% of aneurysmal bone cysts arise from the mobile spine, frequently occurring in pediatric patients. The course of the disease depends on the aggressiveness of the tumor, as well as the treatment. Intralesional surgery seems to be an effective treatment, as well as radiotherapy and embolization. Methods. All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical staging of these cases. Thirty-two patients underwent curettage (14 of them followed by radiotherapy), four were submitted to selective arterial embolization, three received radiotherapy alone, and two underwent en bloc excision. Results. All patients were found alive and disease free at final follow-up evaluation. Two recurrences followed one incomplete curettage and one embolization. The combination of curettage and radiotherapy, although effective, showed the greatest incidence of late axial deformity. Selective arterial embolization was curative in three of four cases and did not affect the possibility of surgery in case of local recurrence. Conclusions. If confirmed on larger series, selective arterial embolization seems to be the first treatment option for spine aneurysmal bone cyst, because of the low cost-to-benefit ratio. Diagnosis must be certain, based on pathognomonic radiographic pattern or on histologic study.— In case of neurologic involvement, pathologic fracture, technical impossibility of performing embolization, or local recurrence after at least two embolization procedures, complete intralesional excision would be the therapy of choice.

Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases.

Study Design Twenty‐one cases of chordoma arising in the mobile spine were retrospectively reviewed. Objectives All the cases were submitted to oncologic and surgical staging to correlate treatment and outcome. Summary of Background Data Excluding plasmacytomas, chordoma is the most frequent primary malignant tumor of the spine, occurring mainly in elderly men. The course of the disease is slow, metastases occur late, and death can result from complications related to local extension of the disease. Complete excision of the tumor according to oncologic criteria can be hampered by extension of the tumor and by anatomic constraints in the mobile spine. Methods All charts, radiographs, and images were reviewed. The composite information provided by this review allowed for oncologic and surgical of these cases. Treatment was defined according to Ennekings criteria. All the patients were followed for determination of their status clinically and radiographically. Results Ten patients died (1 to 137 months after treatment, mean 65 months); four patients are alive with the disease; only seven patients (33%) are symptom free at the final follow‐up (39 to 112 months after treatment, mean 65 months). Conventional radiation therapy was not effective in eradicating the tumor, even if associated with palliative or debulking surgery: of 15 cases, 12 were associated with recurrence or progression. Intralesional surgery also was not effective (two recurrences in two cases, 18 to 41 months later). En bloc excision of the lesion, sometimes combined with radiation therapy as an adjuvant, obtained the best results (four patients disease free at 39 to 112 months, mean 77 months). Conclusions En bloc excision‐even if marginal‐is the treatment of choice of chordomas of the spine. Early diagnosis and careful surgical staging and planning are necessary. Megavoltage radiation can be administered as an adjuvant.

En bloc resections for primary spinal tumors in 20 years of experience: effectiveness and safety

BACKGROUND CONTEXT Many studies have demonstrated that en bloc surgical resection of primary spinal tumors with adequate margins results in improved local disease control and survival compared with intralesional excision. Nevertheless, the use of this procedure is under debate because most of the current evidence is provided by small and heterogeneous series of cases. PURPOSE To validate the application of en bloc resection for the treatment of aggressive benign and primary malignant spinal tumors. STUDY DESIGN This is a prospective cohort study. PATIENT SAMPLE From August 1990 to March 2010, 103 consecutive patients affected by primary spinal tumors were enrolled in the study. All patients were submitted to the same clinical and imaging workup. OUTCOME MEASURES Analysis of local recurrence (LR) and tumor-related mortality, reliability of preoperative surgical planning, and morbidity and mortality. In addition, the effects of possible predictors of these events were studied. METHODS The parameters for the effectiveness and safety of en bloc resections performed on primary spinal tumors were considered as primary end points of this study, and two research questions were formulated. The analysis of the procedure effectiveness considered the identification of possible predictors of LR and tumor-related mortality. Information about safety is collected so as to clarify the possibility to respect the preoperative planning and to identify possible predictors of morbidity and mortality. Data from clinical and imaging examination were collected in a database and were used to answer the proposed research questions. RESULTS All patients were followed for a minimum of 24 months or until death. At the final assessment, 69 patients resulted with no evidence of disease with a mean follow-up of 100 months. Among the 103 patients, tumor recurred in 22 cases with a mean follow-up period of 39 months after surgery. A Cox regression multivariate analysis shows that marginal and intralesional resections are independent predictors of LR (hazard ratio [HR] 9.45, 95% confidence interval [CI] 1.06-84.47 and HR 38.62, 95% CI 4.67-319.21, respectively, compared with wide resection) and tumor-related mortality (in particular, HR 17.10, 95% CI 3.80-77.04 for intralesional resection compared with the wide one). The same analysis demonstrates that en bloc resection performed in recurrent cases or patients previously submitted to open biopsy (nonintact cases) have a LR risk higher than intact cases (HR 3.45, 95% CI 1.38-8.63). The success rate of en bloc resections in achieving adequate margins is 82.4%, and Weinstein-Boriani-Biagini surgical staging can also predict the margins in a high percentage of cases (75.7%). Complications occurred in 41.7% of patients with a higher rate observed in the nonintact group and for surgery with a double-approach or multisegmental resections. The mortality rate related to surgery complications was 1.9%, whereas tumor-related mortality was 15.5%. CONCLUSIONS Statistical analysis of the long-term results referred to 103 patients affected by aggressive benign and malignant primary spine tumors indicates that an en bloc resection is associated with a high rate of complications. Nevertheless, it decreases the risk of LR and tumor-related mortality. En bloc resection is a highly demanding procedure but can be performed to an acceptable degree of safety.

Minimally Invasive Posterior Stabilization Improved Ambulation and Pain Scores in Patients with Plasmacytomas and/or Metastases of the Spine

Background. The incidence of spine metastasis is expected to increase as the population ages, and so is the number of palliative spinal procedures. Minimally invasive procedures are attractive options in that they offer the theoretical advantage of less morbidity. Purpose. The purpose of our study was to evaluate whether minimally invasive posterior spinal instrumentation provided significant pain relief and improved function. Study Design. We compared pre- and postoperative pain scores as well as ambulatory status in a population of patients suffering from oncologic conditions in the spine. Patient Sample. A consecutive series of patients with spine tumors treated minimally invasively with stabilization were reviewed. Outcome Measures. Visual analog pain scale as well as pre- and postoperative ambulatory status were used as outcome measures. Methods. Twenty-four patients who underwent minimally invasive posterior spinal instrumentation for metastasis were retrospectively reviewed. Results. Seven (29%) patients were unable to ambulate secondary to pain and instability prior to surgery. All patients were ambulating within 2 to 3 days after having surgery (P = 0.01). The mean visual analog scale value for the preoperative patients was 2.8, and the mean postoperative value was 1.0 (P = 0.001). Conclusion. Minimally invasive posterior spinal instrumentation significantly improved pain and ambulatory status in this series.

Minimal Invasive Percutaneous Fixation of Thoracic and Lumbar Spine Fractures

We studied 122 patients with 163 fractures of the thoracic and lumbar spine undergoing the surgical treatment by percutaneous transpedicular fixation and stabilization with minimally invasive technique. Patient followup ranged from 6 to 72 months (mean 38 months), and the patients were assessed by clinical and radiographic evaluation. The results show that percutaneous transpedicular fixation and stabilization with minimally invasive technique is an adequate and satisfactory procedure to be used in specific type of the thoracolumbar and lumbar spine fractures.

Complications in minimally invasive percutaneous fixation of thoracic and lumbar spine fractures.

Minimally invasive stabilization of thoracic and lumbar fractures without neurologic involvement is becoming a more frequent alternative to open fusion and conservative treatment. The authors analyzed the complication rate and limits of this technique in a consecutive series of 99 patients (127 thoracolumbar vertebral fractures) who underwent this technique between May 2005 and November 2009. Eighty-three patients had only spine injuries, whereas 16 had polytrauma injuries (mean Injury Severity Score, 25.2). In these 16 patients, percutaneous fixation was performed as a damage control procedure. The most frequent construct was monosegmental: 1 level above and 1 level below the fractured vertebra. In the remaining 21 patients, multilevel construction was performed for multiple injuries. Complications were analyzed according to the period of onset (intra- and postoperative) and the severity (major and minor). Twelve (12%) complications were recorded: 4 (4%) were intraoperative, 6 (6%) were early postoperative, and 2 (2%) were late postoperative; 4 (4%) were minor and 8 (8%) were major. Mean follow-up was 52 months (range; 36-90 months). All patients except 1 were considered healed after 6-month follow-up. The failed patient had an initial kyphosis greater than 20°, and a posterior open reduction and fusion would have been more appropriate. Minimally invasive stabilization of selected spine injuries is a safe technique with a low complication rate. The main goal of this approach is a fast recovery time, so any complication leading to an extended length of stay should be considered severe. An adequate learning curve is important to minimize complications.

Diagnosis and planning in the management of musculoskeletal tumors: surgical perspective.

The evaluation of musculoskeletal tumors requires a close interaction between the orthopedic oncologist, radiologist, and the pathologist. Successful outcome can be achieved in a considerable number of patients by following the appropriate diagnostic strategies and staging studies. The aim of this article is to outline the presentation, imaging, and staging of the primary and metastatic bone and soft tissue tumors. Some of the image-guided interventions for these tumors are also presented.

Traumatic lumbosacral lateral dislocation without fracture

Study designA unique case of lumbosacral lateral dislocation without fracture is reported.ObjectiveTo report on the diagnosis and treatment of a traumatic L5-S1 lateral dislocation in a polytrauma 34-year-old male with L5 nerve root paralysis.MethodInterbody fusion following decompression, posterior reduction and interbody grafting combined with posterior plating was performed.ResultsAt an early stage the patient was able to return to work and walk without supports. At the 12-month follow-up evaluation no back pain was referred and fusion was achieved.ConclusionsLateral pure dislocation of the lumbosacral joint is very rare and can be easily misdiagnosed. A careful evaluation of the AP standard X-ray can lead to diagnosis and can be confirmed by CT scan. Prompt reduction and fusion is the treatment of choice to allow a quick functional recovery.

Cervical osteoid osteoma progression to osteoblastoma

A 16-year-old boy presented with 6 months of moderate neck pain, more severe at night, and temporarily relief by nonsteroidal anti-inflammatory drugs. Radiographs were normal. Magnetic resonance imaging showed edema in C6 vertebral body and surrounding C5–C6 posterior element (Fig. 1). Computed tomography (CT) scan findings were consistent with osteoid osteoma located on the right pedicle of C6 (Fig. 2). Intralesional excision was proposed to the patient and parents who did not accept. One year later, the patient reported a worsening cervical pain no longer responsive to analgesics with root irritation in the right arm. A new CT scan showed considerable expansion of the lesion involving C6 right pedicle and articular process surrounding the C6 nerve root and vertebral artery, highly

Lumbale Vertebrektomie bei Wirbeltumoren

GOAL OF SURGERY Wide en-bloc resection of bone tumors confined to the vertebral body or involving one pedicle only. INDICATIONS Aggressive benign or malignant tumors confined to the vertebral body. CONTRAINDICATIONS Pseudotumoral lesions like aneurysmal bone cyst. Radiosensitive tumors like plasmocytoma. Involvement of both pedicles. POSITIONING AND ANAESTHESIA First prone, then 45o oblique supine position. SURGICAL TECHNIQUE Lumbar vertebrectomy through an anterior and posterior approach. Reconstruction with posterior instrumentation and anterior bone grafting plus internal fixation. POSTOPERATIVE MANAGEMENT Mobilization on the first postoperative day. After 2 weeks standing and walking with a brace. Unprotected weight bearing after consolidation of reconstruction. POSSIBLE COMPLICATIONS Laceration of lumbar vessels. Injury to ureter. Opening of abdominal cavity Injury to nerve root. CSF fistula. RESULTS In 4 patients an en bloc resection was done and in 3 an intralesional excision. No intraoperative death occurred but in 1 patient the lumbar vessels were injured and successfully repaired. No recurrence of tumor after an average of 13 months (6 to 21 months). No mechanical failures of mechanical reconstruction. All patients had radiographic signs of fusion.SummaryGoal of SurgeryWide en-bloc resection of bone tumors confined to the vertebral body or involving one pedicle only.IndicationsAggressive benign or malignant tumors confined to the vertebral body.ContraindicationsPseudotumoral lesions like aneurysmal bone cyst.Radiosensitive tumors like plasmocytoma.Involvement of both pedicles.Positioning and AnaesthesiaFirst prone, then 45o oblique supine position.Surgical TechniqueLumbar vertebrectomy through an anterior and posterior approach.Reconstruction with posterior instrumentation and anterior bone grafting plus internal fixation.Postoperative ManagementMobilization on the first postoperative day. After 2 weeks standing and walking with a brace. Unprotected weight bearing after consolidation of reconstruction.Possible ComplicationsLaceration of lumbar vessels.Injury to ureter.Opening of abdominal cavityInjury to nerve root.CSF fistula.ResultsIn 4 patients an en bloc resection was done and in 3 an intralesional excision. No intraoperative death occurred but in 1 patient the lumbar vessels were injured and successfully repaired. No recurrence of tumor after an average of 13 months (6 to 21 months). No mechanical failures of mechanical reconstruction. All patients had radiographic signs of fusion.