Jianru Xiao

Preoperative scoring systems and prognostic factors for patients with spinal metastases from hepatocellular carcinoma.

Study Design. A retrospective study had been conducted to compare the existing preoperative scoring systems and to find useful prognostic factors for patients with spinal metastases from hepatocellular carcinoma (HCC). Objective. To evaluate different preoperative scoring systems and prognostic factors for patients with spinal metastases from HCC. Summary of Background Data. Different scoring systems for metastatic spinal tumor have been designed for prognostic evaluation. However, these scoring systems were formulated from many different types of tumors, so that their efficacy for a certain type of cancer needs to be validated. Furthermore, some serologic test results may enhance the accuracy of the scoring system. Methods. We conducted a retrospective study to evaluate 4 prognostic scoring systems and factors in a series of 41 cases with spinal metastases from HCC in a single center. These scoring systems include Tokuhashi revised score, Tomita score, Bauer score, and a revised van der Linden score by the authors. Serologic test items including serum albumin, aspartate aminotransferase, alanine transaminase, and lactate dehydrogenase (LDH) were also evaluated. Results. The revised Tokuhashi scoring system provided statistically significant differences in survival time between different groups (P = 0.012), while the Tomita and Bauer systems did not show statistically significant differences (P = 0.918 and P = 0.754, respectively). Significantly improved survival was found in patients with good performance status and no visceral metastases (Group C, P = 0.008) in revised van der Linden scores. Univariate and multivariate analyses showed serum albumin and LDH were independent prognostic factors for survival time. Conclusion. Revised Tokuhashi scoring system is practicable and highly predictive, while serum albumin and LDH also have prognostic value in patients with spinal metastases from HCC, especially those without visceral metastases. More accurate prognosis may be obtained if the scoring systems include clinical and laboratory data in future.

Aneurysmal bone cyst secondary to giant cell tumor of the mobile spine: a report of 11 cases.

Study Design. A retrospective analysis was performed. Objective. To analyze the characteristics of aneurysmal bone cyst arising from giant cell tumor of the mobile spine and to discuss the outcome of corresponding surgical and nonsurgical treatment. Summary of Background Data. Giant cell tumors are generally benign neoplasms that exhibit aggressive behavior with a tendency to recur locally. Aneurysmal bone cysts are benign, highly vascular osseous lesions. Although both of them have been described separately in previous literatures, few reports have described aneurysmal bone cyst secondary to giant cell tumor of the mobile spine. Methods. Between January 2004 and December 2009, 11 patients were identified with an aneurysmal bone cyst arising from giant cell tumor of the mobile spine. Four patients underwent subtotal tumor resection followed by radiotherapy, and the other 7 patients underwent total tumor resection. Patients with lesions located below T6 were treated with selective arterial embolization before surgery. Clinical data and the efficacy of surgery were analyzed via chart review Results. Of the eleven patients identified for inclusion in this study, the average age was 33 months (range ∇ 14–65 months). The mean length of follow-up was 31 months. Seven patients kept disease-free during the follow-ups. The remaining four patients recurred and one died of local re-recurrence and lung metastasis. Conclusion. Unlike primary aneurysmal bone cyst, secondary aneurysmal bone cyst arising from giant cell tumor of the mobile spine has a more aggressive tendency to recurrence locally. Complete resection with systematic radiotherapy should be undertaken for the treatment of aneurysmal bone cyst secondary to giant cell tumor of the mobile spine, which is associated with a good prognosis for local tumor control. As complete or as radical an operation as possible should be performed at first presentation. The best chance for the patient is the first chance. Selective preoperative embolization is advised to minimize intraoperative blood loss.

Surgery and prognostic factors of patients with epidural spinal cord compression caused by hepatocellular carcinoma metastases: retrospective study of 36 patients in a single center.

Study Design. A retrospective study of 36 patients with metastatic hepatocellular carcinoma (HCC) of the mobile spine was performed by survival analysis. Objective. To discuss the factors that may affect outcomes of patients with HCC spinal metastases. Summary of Background Data. HCC is a rare tumor in Western countries. However, HCC is common in Far East (Taiwan, Korea, mainland China), where the hepatitis B virus is epidemic. As the mean survival time of patients with HCC has largely increased in recent years, it is now more common to encounter a patient with epidural spinal cord compression caused by HCC spinal metastases in clinic. Methods. The univariate and multivariate analyses of various clinical factors were performed to identify independent variables that could predict prognosis. The survival rate was estimated by the Kaplan-Meier method, and differences were analyzed by the log-rank test. Factors with P values of 0.1 or less were subjected to multivariate analysis for survival rate by multivariate Cox proportional hazards analysis. Results. A total of 36 patients with metastatic HCC of the mobile spine were included in the study. Age (⩽45 yr/>45 yr), duration of preoperative symptoms (<6 mo/≥6 mo), preoperative Frankel score (A–C/D–E), Tomita score (5–7/8–10), and bisphosphonate treatment were suggested as the potential prognostic factors through univariate analysis. However, as they were submitted to the multivariate Cox regression model, only Tomita score was found as an independent prognostic factor. Conclusion. Tomita score no more than 7 is a favorable prognostic factor for HCC metastases in the mobile spine. Level of Evidence: 4

Chondrosarcomas of the cervical and cervicothoracic spine: surgical management and long-term clinical outcome.

Study Design A retrospective review study. Objectives To estimate the clinical outcome of various resection protocols in patients with chondrosarcoma (CHS) at the challenging region of cervical and cervicothoracic spine (CCT). Summary of Background Data It is challenging to surgically manage CHS of the spine. Although total en-bloc resection has proven to be an ideal treatment, this option is not always feasible in the spine because of the constrains of critical neurovascular structures in the vicinity. Lesions at the CCT region pose even more difficulties, and few large clinical series concerning various protocols and long-term outcomes of these lesions exist at present. Methods Fifteen patients with CHS at the CCT region who underwent surgical management in our institute were retrospectively studied. Twelve piecemeal resections and 3 en-bloc resections were performed. Intraoperative local chemotherapy and postoperative cyberknife radiotherapy were given as adjuvant therapy. Neurologic status, local recurrence, distant metastasis, and treatment-related complications were evaluated. Results The mean follow-up time was 58.7 months (median 37 mo; ranging from 18 to 141 mo). Local recurrence was detected in 5 of 5 cases (100%) treated by intracapsular piecemeal resection, and in 1 of 7 cases (14.3%) treated by extracapsular piecemeal resection, whereas no recurrence was found in 3 cases treated by en-bloc resection. Of the 6 recurrent patients, 5 died of disease 24 to 46 months after present surgery, and the remaining patient was alive with disease in the final follow-up. There were no signs of recurrence in the remaining 9 patients. Conclusions For CHS at the CCT region, intralesional piecemeal resection has a poor prognosis and should be avoided. Oncologically, en-bloc resection remains the best form of disease management and should be the primary treatment of choice. For cases in which an uncontaminated en-bloc resection could not be achieved, the extracapsular piecemeal resection with adjuvant therapy including local chemotherapy and cyberknife radiotherapy is an effective and achievable option.

Combined anterior C2-C3 fusion and C2 pedicle screw fixation for the treatment of unstable hangman's fracture: a contrast to anterior approach only.

Study Design. A retrospective clinical study was used to evaluate the effect of a new surgical treatment of the hangmans fractures. Objective. To determine the treatment efficacy of combined anterior C2-C3 reduction and fusion and posterior compressive C2 pedicle screw fixation for the management of unstable hangmans fractures. Summary of Background Data. The classification of hangmans fractures as proposed by Levine-Edwards was used to classify and guide the treatment of these injuries. Most of these fractures respond to a variety of conservative therapies, but recently, earlier surgery has been increasingly advocated by authors from several countries for the rapid stabilization of these fractures. If surgery is indicated, an anterior approach using a C2-C3 reduction and fusion is preferred usually. Another well-accepted surgical method is the direct transpedicular osteosynthesis by the dorsal approach. However, there was rare report of the combined use of these 2 techniques. Methods. A group of 45 surgical patients were all diagnosed with radiograph, magnetic resonance imaging (MRI), and 3D CT scans. Initial and final radiographs were measured for anterior translation and angulation of the C2-C3 complex. Initial external skull traction with extension was used in all patients after admission to reduce the fracture. Then an anterior C2-C3 discectomy followed by an interbody fusion and locking plate fixation was performed. Intraoperative reduction was confirmed by fluoroscopic control. About 29 patients therefore received anterior surgeries only since satisfactory reduction was achieved during the procedure. For the 16 patients who had persistent large residual gaps after the anterior procedure, additional same stage posterior C2 compressive pedicle screws were placed. Clinical and radiologic comparisons were performed in these 2 groups. Results. The follow-up ranged from 24 to 54 months, with an average 33.6 months. There was radiographic evidence of continuity of the fracture and the bone graft seen at 4.7 months on average. Neck pain and neurologic deficits resolved in nearly all patients after surgery. The anterior translation of anterior-posterior surgery group decreased more significant compared to anterior surgery group, although with no statistical significance. The fractures were closed with a slight gap no more than 2 mm in anterior-posterior surgery group. The residual kyphosis in anterior-posterior surgery group was still a little larger than it in anterior surgery group. No internal fixation failures or infections were observed. Conclusion. We believe that the need for single stage 360° fusion of hangmans fractures can be somewhat predicted by a combination of high resolution imaging. For hangmans fractures with significant deformity and gapping, it is our experience that immediate single-stage anterior-posterior reduction, instrumentation, and arthrodesis achieve superior postoperative reduction and long-term functional outcomes.

Anterior decompression and interbody fusion with BAK/C for cervical disc degenerative disorders.

Study Design A retrospective clinical study of 64 patients who underwent anterior cervical discectomy and fusion (ACDF) with BAK/C for disc degenerative disorders. Objective To evaluate the long-term outcome of BAK/C in the treatment of cervical disc degenerative disorders. Summary of Background Data ACDF has been demonstrated to be effective in the treatment of cervical disc degenerative disorders. BAK/C, a kind of thread cage widely used for interbody fusion in the lumbar spine, was used in the cervical spine to avoid the donor site complications of traditional autologous bone graft. Methods Sixty-four patients with cervical disc degenerative disorders underwent ACDF with BAK/C technique in our institution between September 1997 and December 2000. All the patients were followed up for at least 6 years. The changes of segmental stability, bone fusion, cervical lordosis, and intervertebral height on radiographs were evaluated in detail immediately after operation, at 6 and 12 months postoperatively, and yearly thereafter. The clinical outcome of neurologic improvement and pain relief was also investigated. Results Solid fusion was achieved at 1 year postoperatively in all patients, and the segmental stability was maintained during the whole follow-up. The cervical lordosis and intervertebral height were well restored immediately after operation, and gradually lost during the follow-up. Especially, the anterior height of intervertebral space decreased significantly after 1 year, when compared with the anterior height immediately after operation. BAK/C subsidence was observed in 9 patients, including 5 with 1-level fusion, 1 with 2–separated-level fusion, and 3 with 2–adjacent-level fusion, according to the standard of loss of intervertebral height more than 3 mm. BAK/C fusion was generally effective in the treatment of cervical disc degenerative disorders, according to the evaluation of neurologic improvement and pain relief. However, neck pain tended to reoccur in the patients with cage subsidence, and 2 of them even needed revision surgery because of the recurrence of myelopathy and progressive neck pain. Conclusions Although BAK/C technique was generally effective and safe in the treatment of cervical disc degenerative disorders, the pitfalls of cage design resulted in the disability of maintenance of cervical lordosis and intervertebral height in the long-term follow-up. Cage subsidence, which tended to develop in the patients with 2-level fusion, was possibly responsible for the recurrence of neck pain.

Primary chordomas of the cervical spine: a consecutive series of 14 surgically managed cases

OBJECT Cervical chordomas are rare lesions and usually bring about challenges in treatment planning because of their wide extension and complicated adjacent anatomy. There are few large published series at present focusing on cervical chordomas. The authors studied a consecutive series of 14 patients with primary cervical chordomas who underwent surgical treatment and were observed between 1989 and 2008. By reviewing the clinical patterns and follow-up data, they sought to investigate the clinical characters, tailor the appropriate surgical techniques, and establish prognosis factors for cervical chordomas. METHODS Hospitalization and follow-up data in the 14 patients were collected. All patients underwent piecemeal tumor excision and reconstruction for stability; total spondylectomy was achieved in 5 cases. Postoperative radiotherapy was administered in all patients. Kaplan-Meier plots were used to represent tumor recurrence and patient survival, and log-rank testing was used to determine the risk factors of local recurrence. RESULTS Follow-up ranged from 8 to 120 months (mean 58.6 months). Symptom and neural status in most patients improved after surgery. The 1- and 5-year disease-free survival rates were 78.6% and 50%, respectively, and the 1- and 5-year survival rates were 92.9% and 85.7%, respectively. Log-rank tests revealed that the following variables were significantly associated with a high rate of tumor recurrence: age less than 40 years or greater than 70 years (p = 0.006) and an upper cervical tumor location (p = 0.019). CONCLUSIONS Chordomas in the cervical spine are usually neoplasms that exhibit insidious growth and a wide extension by the time of diagnosis. Radical intralesional debulking surgery and postoperative radiotherapy have been effective treatment. A limited application of en bloc tumor resection and the highly likely intraoperative intralesional tumor seeding may partially explain the high local recurrence rate, whereas the chance of distant metastases, fortunately, is very low. Most recurrence were documented within 3 years. Some specific surgical techniques should be emphasized to minimize tumor seeding. Patients with upper cervical chordomas, younger adults, and elderly adults have worse prognosis. For patients with chordoma extending to both the anterior and posterior spinal columns, total spondylectomy combined with piecemeal excision is recommended for a better prognosis.

Surgery in the cervicothoracic junction with an anterior low suprasternal approach alone or combined with manubriotomy and sternotomy: an approach selection method based on the cervicothoracic angle: Clinical article

OBJECT The authors propose an easy MR imaging method to measure and categorize individual anatomical variations within the cervicothoracic junction (CTJ). Furthermore, they propose guidelines for selection of the appropriate approach based on this new categorization system. METHODS In the midsagittal section of the cervicothoracic MR imaging studies obtained in 95 Chinese patients, a triangle was drawn among 3 points: the suprasternal notch (SSN), the midpoint of the anterior border of the C7/T1 intervertebral disc, and the corresponding anterior border in the CTJ at the level of the SSN. The angle above the SSN was specified as the cervicothoracic angle (CTA). The spatial position between the brachiocephalic vein (BCV), the aortic arch, and the CTA was also measured. Based on these measurements involving the CTA, 3 different patient-specific categorizations are proposed to assist surgeons with selection of the appropriate anterior approach to the CTJ. Three categories of operative approach based on whether the most caudal part of the lesion site was above, within, or below the area of the CTA were classified. The patients were divided into long- or short-necked groups based on whether their own CTA was greater than (long necked) or less than (short necked) the average CTA. Finally, a left BCV was called superiorly located when it coursed above the manubrium. The method was evaluated in 21 patients with spinal bone tumors in the CTJ to illustrate the measurement of both the CTA and the great vessels, and corresponding approach selections. RESULTS In this series of 95 patients, the most common vertebra above the SSN was T-3, especially the upper one-third of T-3. The mean CTA was 47.64 degrees . The left BCV was superior to the manubrium in 21.1% of the 95 cases, and 93.6% of the left BCVs were at the T-2 and T-3 levels. Type A and most Type B lesions could be addressed via a low suprasternal approach, or this approach combined with manubriotomy, if necessary. Type C lesions falling below the CTA will need alternative exposure techniques, including manubriotomy, sternotomy, lateral extracavitary, or thoracotomy. The spinal levels that could be exposed in the long-necked CTJ group were always 1 or 2 vertebral levels lower than those in the short-necked CTJ group during the anterior low suprasternal approach without the manubriotomy. CONCLUSIONS Imaging of the thoracic manubrium should be routinely included on MR imaging studies obtained in the CTJ. It is important for the surgeon to understand the pertinent anatomy of the individual patients and to determine the feasible surgical approaches after evaluating the CTA and vascular factors preoperatively. An anterior low suprasternal approach, or this approach combined with manubriotomy, is applicable in most of the cases in the CTJ. It should be cautioned that preoperatively unrecognized variations of the left BCV above the SSN might result in potential intraoperative trauma during an anterior approach.

Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach: surgical technique and results in 11 patients.

BACKGROUND Surgical treatment of C2 tumors remains challenging. Because of the deep location and unique anatomical complexity, anterior exposure in this region is considered difficult and dangerous, and few reports concerning anterior tumor resection and reconstruction exist. OBJECTIVE To describe a technique of sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior approach. METHODS Eleven patients with C2 tumors underwent sequentially staged tumor resection and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were involved. Tumor resections and anterior reconstructions with conventional constructs were accomplished by an anterior retropharyngeal approach, and occipitocervical fusions through posterior access were performed in the same anesthesia. RESULTS No operative mortality occurred in this series. All patients experienced pain relief and neurological improvement after surgery. Except for 1 incidence of screw pullout, which was corrected by revision surgery, solid fusion was achieved in all patients. A follow-up period of 12 to 37 months was available for this study. Two patients with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases. No evidence of local recurrence was found in the other patients. CONCLUSION The anterior retropharyngeal approach is a favorable route to treat tumor lesions of the C2 vertebral body that allows tumor resection and placement of anterior constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column reconstruction could safely be accomplished simultaneously through the combined anterior retropharyngeal–posterior approach.

Solitary plasmacytoma of cervical spine: treatment and prognosis in patients with neurological lesions and spinal instability.

Study Design. A consecutive series of 19 cases of solitary plasmacytoma (SP) of cervical spine that underwent surgical treatment and one case that underwent pure radiotherapy were observed from 1995 to 2006. Objective. To discuss the clinical characteristics, therapeutic methods and factors affecting prognosis of SP in the cervical spine. Summary of Background Data. SP of bone is a rare plasma cell tumor which represents the proliferation of monoclonal plasma cells without evidence of significant bone marrow plasma cell infiltration. Although radical radiotherapy is the treatment of choice for SP of the bone, recommendations for treatment methods of this disease have been solely based on limited data from retrospective studies. Methods. Data of 20 patients with SP of the cervical spine that were identified and treated between January 1995 and December 2006 were reviewed retrospectively. There were 13 men and 7 women ranging in age from 32 to 76 years with a mean of 56 years. Among them, 1 patient underwent radiotherapy alone, and the other 19 patients received surgery with adjuvant radiotherapy. According to the Weinstein-Boriani-Biagini staging system, the surgical procedures consisted of subtotal resection and gross-total resection. All cases were managed using an anterior approach or a combined anterior and posterior approach in 1 stage. Reconstruction of the cervical spine was achieved through an anterior cervical titanium plate and titanium mesh cage filled with autoiliac graft or bone cement, or anterior and posterior combined instrumented fusion. All surgery patients received radiotherapy as adjunctive therapy postoperatively. Results. Follow-up of the 20 patients ranged from 25 to 132 months with a mean of 61 months. Neck pains improved significantly, and motor or sensory deficits disappeared or improved in varying degrees after surgery. Neurologic function level of the patients improved by 1 to3 grades based on the Frankel grading system 3 months after surgery. All the internal fixations fused well, stability of the cervical vertebrae was secure, and no spinal instability was observed in our series. The bone graft fusion rate reached 100%. During the follow-up period, 4 surgery cases progressed to multiple myeloma (MM), in which 2 elderly patients died of respiratory and circulatory failure at 90 and 43 months, respectively. The other 15 patients achieved disease-free survival after surgery with adjunctive radiotherapy. No significant abnormity was detected on M protein, bone marrow aspiration, and emission computed tomography or positron emission tomography/computed tomography examinations. Conclusion. SP of the cervical spine is relatively rare, and no typical early symptoms are present. Gross total tumor resection or total spondylectomy by piecemeal manner with adjuvant radiotherapy can markedly reduce local recurrences and lower the possibility of progressing to MM. Patients with progression to MM should be treated with individualized chemotherapy, but the prognosis may be poor.