Riccardo Ghermandi

En bloc resection of primary tumors of the thoracic spine: indications, planning, morbidity

Abstract Objectives: We aimed to describe surgical planning, technique, and complications of en bloc resection in the thoracic spine in patients who opted for surgery with en bloc resection and a tumor-free margin. Methods: Oncologic and functional results were recorded for 134 patients (53% male, age 44 ± 18 years) who had undergone en bloc resection for primary tumors (90 cases) and bone metastases (44 cases). Patients were followed until death or the latest follow-up examination (0–211 months, median 47 months). Surgeries were performed from 1990 to 2007 by the same team. An ongoing critical analysis of local control rates, surgical complications, and expected versus actual loss of function enabled the authors to refine the surgical technique and propose seven different types of resection. Results and Discussion: En bloc resection is a demanding procedure and requires careful planning after a careful decision-making process. The patient has to correctly understand the purpose of the surgery, based on oncological staging, in order to accept or decide against the procedure after weighing the possible morbidity and functional loss against the expected final result. Techniques of En Bloc Resection: Seven different strategies to perform en bloc resection in the thoracic spine, based on four combinations of surgical approaches (anterior, posterior, anterior followed by posterior, and posterior followed by simultaneous anterior and posterior) are identified and proposed. This planning is based on Weinstein–Boriani–Biagini (WBB) surgical staging. The surgical plan was designed to achieve the required oncologic margin with the minimum achievable morbidity.

Efficacy and Safety of Selective Arterial Embolization in the Treatment of Aneurysmal Bone Cyst of the Mobile Spine. A Retrospective Observational Study.

Study Design. A retrospective observational study. Objective. Our aim is to define the efficacy and safety of serial selective arterial embolization (SAE) in the treatment of aneurysmal bone cysts (ABCs), to explore potential treatment alternatives, and to define a therapeutic algorithm. Summary of Background Data. ABC is a benign lesion with an unpredictable behavior. Its treatment is challenging especially in poorly accessible surgical areas, such as spine and pelvis. Currently, the first-line treatment of ABC is repeated SAE until healing. Other options have been used with variable success rates. Methods. From January 2004 to September 2015, 23 patients affected by ABC of the mobile spine have been treated with SAE and prospectively followed up by computed tomographic scan and magnetic resonance imaging. Signs of neurological deficit, complications, healing of the lesion, and clinical outcomes were registered. Signs of healing are defined as peripheral sclerotic bone rim formation, decrease of the ABC mass, disappearance of the double content image, and bone formation inside the ABC mass, associated with remission of pain. Results. Twenty-three patients underwent SAE according to the protocol. Seventeen patients have healed. The number of procedures necessary to obtain healing (clinical and radiographic) varied from 1 to 10. No complication occurred during the procedure. Follow-up time ranged from 5 to 120 months after the last angiographic procedure. All 17 patients had complete relief of pain symptoms. Six patients did not respond to SAE, presenting a progressive clinical and radiographic worsening, and underwent other medical or minimally invasive treatments. Conclusion. Our study confirms the safety of SAE. The efficacy of the treatment was however lower than expected. SAE is indicated when pathological fracture or signs of cord damage are not detected. Infiltration with autologous bone marrow concentrate or administration of Denosumab is under investigation as alternative choices of treatment. Level of Evidence: 4

Composite PEEK/Carbon fiber implants can increase the effectiveness of radiotherapy in the management of spine tumors

BACKGROUND Combination of surgery and radiotherapy in the treatment of primary spine tumour can be indicated in some cases where a satisfactory oncological margin cannot be achieved. The presence of metal hardware has always limited post-operative radiotherapy due to the scattering effects of ionizing radiation or particles. The use of a fixation system (including rods and screw) fully made in PEEK embedded Carbon fiber (CFR-PEEK) could make easier and more effective the post-operative radiotherapy as it is radiolucent and does not interfere with ionizing radiation and accelerated particles. METHODS An ambispective study was performed on the first 22 consecutive primary tumor patients, who underwent spinal surgery including a composite CFR-PEEK fixation system. Oncologic surgery was palliative decompression and fixation in 3 cases; tumor excision in 15; en bloc resection in 4. The incidence of complications (intra- and postoperative), local control (LC) and local recurrence (LR), and changes in neurological status were considered. RESULTS Only one intraoperative screw breakage occurred and one case of loosening of sacral screws were found at 12 months in one patient. No rod breakage, neither any screw/rod disconnection was found. Post-operative RT has been performed in 19 patients. The overall number of progression of the tumour or LR was 7. The actuarial rate of LR or progression of the tumour, calculated according to the Kaplan-Meier method, was 17.6% at 12 months. CONCLUSIONS The CFR-PEEK fixation system is comparable to standard titanium system in term of intraoperative complications, stability at weight bearing and at functional recovery. Thanks to radiolucency CFR-PEEK stabilization devices are more suitable in patients eligible for RT: the absence of image artifacts together with significantly less dose perturbation improve the treatment accuracy. Moreover the radiolucency is useful in the follow-up of patients thus allowing early detection of LR.

Elastoplasty as a promising novel technique: Vertebral augmentation with an elastic silicone-based polymer

Objective Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) restores the stiffness and the strength of fractured vertebral bodies, but changes the pattern of the stress transfer. This effect may cause a secondary fracture of the adjacent vertebrae. Elastoplasty has emerged as a new technique to overcome this complication. The aim of this study is to retrospectively evaluate the clinical results of the elastoplasty procedure. Materials and methods Thirthy nine patients (9 males, 30 females, 87 spinal levels) were clinically evaluated pre and postoperatively in terms of pain relief, leakage and silicone embolism. The mean age was 67 (range 38–84) years. The mean follow up period was 12,5 months. The patients were evaluated radiologically for the presence of adjacent level fractures postoperatively. Complications were recorded. Results The mean VAS score decreased from 7,5 to 3,5 during the last follow-up. Symptomatic silicone pulmonary embolism was not encountered in any patients. Leakage was observed in 5 (13%) cases. There was an adjacent level fracture in 1 case and another fracture which was not at the adjacent level in another one. A hematoma occurred in the needle entry site in a patient with trombocytopenia (<70,000). Conclusions Elastoplasty is a safe, promising technique in the treatment of vertebral compression fractures (VCFs). Symptomatic silicone pulmonary embolism is not observed. The materials stiffness is close to intact vertebrae. Therefore, elastoplasty may be a good viable option in the treatment of VCFs as it cause less complications and can prevent adjacent level fractures. Level of evidence Level IV, therapeutic study.

Secondary chondrosarcoma of the lumbar spine in hereditary multiple exostoses

We report a case of a 19-year-old woman with hereditary multiple exostoses, confirmed via EXT2 gene mutation, who presented to our clinic with a 4-month history of low back pain. On physical examination, she had a palpable mass on the right lower back and did not have any leg pain or weakness. Her surgical history is notable for osteochondromas removed from her right distal femur and proximal tibia. Radiographs demonstrated calcification in the right lumbar paraspinal soft tissue (Fig. 1, Top), and computed tomography demonstrated an exostoses arising from the L5 spinous process (Fig. 1, Bottom) with a large paraspinal mass containing calcifications. Magnetic resonance imaging (MRI) demonstrated a large lesion with high signal on T2 (Fig. 2, Top) that also enhanced on T1 with gadolinium. The diagnosis of low-grade chondrosarcoma was made based on biopsy. Using our previously published surgical planning algorithm [1], we preformed en bloc resection of the spinous processes of L3, L4, and L5 along with the right paraspinal muscles and portion of the right iliac crest (Fig. 2, Bottom). When managing patients with HME and back pain, one should have a low threshold to obtain imaging including radiograph and MRI to check for the presence of exostoses. A 27% rate of exostoses in the spinal canal have been reported, and some groups make it a routine practice to obtain a screening MRI of the spine in the growing years of children with HME [2]. Although malignant degeneration of exostoses in the spine is rare, one should keep it in their differential.

Aneurysmal bone cyst-like areas as a sign of metastatic disease in the spinal column

Aneurysmal bone cysts (ABCs) are vascular lesions with well-defined radiological signs. A fairly common MRI finding in both ABC and other primary bone tumors with high vascularity is the presence of cysts with fluid-fluid levels. Metastatic lesions with fluid-fluid leveling have not previously been defined in the literature. We report three cases of fluid-fluid leveling of the axial skeleton in metastatic lesions. Two patients had single-level and one multi-level neoplastic disease with distinctive cysts showing fluid-fluid levels on MRI evaluation. Diagnosis of gastric carcinoma in two patients and breast carcinoma in the third was achieved with trocar biopsies. At the time of this report all patients had completed initial oncologic treatments and were disease free.

Management of Metastases to the Spine and Sacrum

The incidence of bone metastatic deposit from carcinoma is second only to pulmonary and hepatic metastases. The most frequently affected segment of the skeleton is the vertebral column. Refinement of the protocols for treating tumour patients has led to a progressive improvement in the prognosis for many tumour histotypes in terms of increase of life expectancy. The choice of the most appropriate treatment is of crucial importance for the patient who may be severely disabled by the presence of untreated spinal metastases. It is commonly accepted that bone metastases are an expression of a systemic disease, and therefore require multi-disciplinary treatment, integrating radiotherapy (RT), chemotherapy (CHT) and surgery. The most appropriate treatment for patients with metastatic disease of the vertebral column is controversial. Appropriate surgical treatment of bone metastases and tumours in general has now become an integral part of the correct approach to the tumour patient. The evolution of anaesthetic techniques now allows more aggressive treatment of some patients with spinal and sacral metastases. These procedures can dramatically improve the patient’s quality of life and may prolong the patient’s life expectancy by preventing complications related to paralysis.

Management of Metastatic Spinal Cord Compression Without Stereotactic Radiotherapy and Targeted Adjuvant Chemotherapy

Metastatic epidural spinal cord compression (MESCC) is defined radiologically as an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the vertebral canal.

Surgeon’s perception of margins in spinal en bloc resection surgeries: how reliable is it?

Purpose and BackgroundEn bloc resections aim at surgically removing a tumor in a single, intact piece, fully encased by a continuous shell of healthy tissue—the “margin”. Intraoperative continuous assessment of the plane of resection regarding the tumor’s margins is paramount. The goal of this study was to evaluate the accuracy of experienced spinal tumor surgeons’ perception of these margins.MethodsA retrospective analysis of a prospectively collected data of 1681 patients affected by spine tumors of whom 217 en bloc resections was performed. Surgeons’ intraoperative assessment was compared to the histopathological assessment.ResultsMost were primary—163 (42 benign and 121 malignant), metastases occurred in 54 cases. ‘Wide’ margins were obtained in 126 cases; ‘marginal’ in 60 cases, and ‘intralesional’ in 31 cases. Surgeons assessed clear margins in 109 cases and contaminated in 108 cases. When considering marginal margins as a contaminated resection, the surgeon’s assessment of clear resection had a sensitivity of 76.89%, specificity of 86.81%, PPV and NPV (positive and negative predictive values) were 88.99 and 73.15%, respectively. Inter-observer agreement was 0.62. When considering marginal margins as a clear resection, the surgeon’s assessment of clear resection had a sensitivity of 64.5%, specificity of 100%, PPV and NPV were 100 and 0%, respectively. Inter-observer agreement was 0.29.ConclusionSurgeons are fairly accurate in their intraoperative assessment of clear margins achieved; however, this accuracy is not perfect and exploring ways to improve this intraoperative assessment is of major importance possibly impacting the outcome of the treatment.

Biomimetic 3D-printed custom-made prosthesis for anterior column reconstruction in the thoracolumbar spine: a tailored option following en bloc resection for spinal tumors

AbstractPurposeVarious techniques for anterior column reconstruction have been described after en bloc resection of spinal tumors. Limited evidence exists regarding one being superior to another. The purpose of this study is to evaluate 3D-printed vertebral bodies for spinal reconstruction after en bloc resection in the thoracolumbar spine. MethodsProspective observational study on custom-made 3D-printed titanium reconstruction of vertebral bodies after en bloc resection for spinal tumor was conducted between November 2015 and June 2017. 3D-printed vertebral bodies were monitored for mechanical complications such as (1) migration, (2) subsidence into the adjacent vertebral bodies, and/or (3) breakage. Complications and related details were recorded.ResultsThirteen patients (7 females and 6 males) were enrolled, and reconstruction of the anterior column was performed using custom-made 3D-printed titanium prosthesis after en bloc resection for spinal tumor (8 primary bone tumors and 5 solitary metastases). Subsidence into the adjacent vertebral bodies occurred in all patients at both proximal and distal bone–implant interfaces; however, it was clinically irrelevant (asymptomatic, and no consequences on posterior instrumentation), in 11 out of 12 patients (92%). In 1 patient (#4), severity of the subsidence led to revision of the construct. At an average 10-month follow-up (range 2–16), 1 implant was removed due to local recurrence of the disease and 1 was revisioned due to progressive distal junctional kyphosis.ConclusionPreliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.