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Purpose: To explore the diagnostic value of monoexponential diffusion-weighted imaging (DWI), diffusion kurtosis imaging (DKI), and dynamic contrast-enhanced (DCE)-MRI for differentiating between spinal malignant and non-malignant tumors lacking typical imaging signs and correlation between the parameters of the three models.Methods: DWI, DKI, and DCE-MRI examinations were performed in 39 and 27 cases of spinal malignant and non-malignant tumors, respectively. Two radiologists independently evaluated apparent diffusion coefficient (ADC), mean diffusivity (MD), and mean kurtosis (MK) of the DWI and DKI models, and volume transfer constant (Ktrans), rate constant (kep), and extracellular extravascular volume ratio (ve) of the DCE-MRI model for post-processing analyses. Statistical differences of parameters were compared using an independent sample t test. The sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve were determined. Pearson correlation analysis was used to evaluate the correlation between these parameters.Results: ADC, MD, and ve were significantly lower, while MK and kep were significantly higher for spinal malignant tumors than for non-malignant tumors. The MK had the highest area under the ROC curve of 0.940 and sensitivity (96.3%). Ve was weakly positively correlated with ADC (r = 0.468) and MD (r = 0.363) and weakly negatively correlated with MK (r = -0.469). kep was weakly positively correlated with MK (r = 0.375). Ktrans was weakly positively correlated with ADC (r = 0.325).Conclusions: Monoexponential DWI, DKI, and DCE-MRI have potential value in the differentiation of spinal malignant from non-malignant tumors lacking typical imaging signs, and there is a certain correlation between the parameters of the three models. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes between seven different approaches for thoracolumbar corpectomy/spondylectomy in the setting of spinal metastasis.Methods: A systematic review of literature was performed including articles on corpectomy for thoracolumbar spinal metastasis. Data were extracted and sorted by surgical approach: en bloc spondylectomy (group 1), transpedicular (group 2), costotransversectomy (group 3), mini-open retropleural/retroperitoneal (group 4a), lateral extracavitary approach (group 4b), open transthoracic/transretroperitoneal (group 5), and thoracoscopic (group 6). Comparison of demographics, blood loss, directly procedure related complications, operating time, and postoperative improvement of pain.Results: A total of 63 articles were included comprising data of 774 patients with various primary tumor entities. Mean age was 51.8 years, 54% of patients were female, on average 1.46 levels were treated per patient, and mean follow-up was 1.59 years. The following statistically significant findings were observed: Blood loss was lowest for the mini-open retropleural/retroperitoneal (917 ml), thoracoscopic (1107 ml) and transthoracic approach (1172 ml) versus the posterior approach groups (1633-2261 ml); directly procedure related complications were lowest for mini-open retropleural/retroperitoneal and thoracoscopic approach (0% each) versus 7-15% in the other groups; operating time was lowest in mini-open retropleural/retroperitoneal approach (184 min) versus 300-588 min in the other groups.Conclusion: Less invasive approaches (mini-open retropleural/retroperitoneal and thoracoscopic) not only had superior outcome in terms of blood loss and operating time, but also were shown to be safe techniques in cancer patients with low rates of procedure-related complications. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Primary osteosarcoma of the spine is a rare osseous tumour. En bloc resection, in contrast to intralesional resection, is the only procedure able to provide Enneking appropriate (EA) margins, which has improved local control and survival of patients with primary osteosarcoma of the spine. The objective of this study is to compare the risk of local recurrence, metastases development and survival in patients with primary osteosarcoma of the spine submitted to Enneking appropriate (EA) and Enneking inappropriate (EI) procedures.Methods: A systematic search was performed on EBSCO, PubMed and Web of Science, between 1966 and 2018, to identify studies evaluating patients submitted to resection of primary osteosarcoma of the spine. Two reviewers independently assessed all reports. The outcomes were local recurrence, metastases development and survival at 12, 24 and 60 months.Results: Five studies (108 patients) were included for systematic review. These studies support the conclusion that EA procedure has a lower local recurrence rate (RR 0.33, 95% CI 0.17-0.66), a lower metastases development rate (RR 0.39, 95% CI 0.17-0.89) and a higher survival rate at 24 months (RR 1.78, 95% CI 1.24-2.55) and 60 months (RR 1.97, 95% CI 1.14-3.42) of follow-up; however, at 12 months, there is a non-significant difference.Conclusions: EA procedure increases the ratio of remission and survival after 24 months of follow-up. Multidisciplinary oncologic groups should weigh the morbidity of an en bloc resection, knowing that in the first year the probability of survival is the same for EA and EI procedures. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Spinal teratomas are rare tumours noted in adults and are commonly located in the thoracolumbar region. Currently, there appears to be a lack of clear consensus regarding the management and prognosis of these lesions. A comprehensive review along with an illustrative case managed at the author's institute has been presented.Materials and Methods: Online database search was performed for literature review.Results: A 26-year-old male presented with acute onset neurological deficits and imaging revealed features of conus teratoma. Subtotal resection was performed and patient achieved fair recovery. Including the present one, a total of 146 cases have been reported and were analysed. Mean age was 39.6 years (range 18-85 years) and males predominated. Limb weakness and backache were the commonest symptoms. Majority of the lesions were intramedullary and located in the thoracolumbar region. Complete resection (CR) was achieved in 45% of cases. All, except one, were mature teratomas. Recurrences were noted in nine (6.1%) cases. Outcome was good/excellent in 86 (60%) and fair/poor in 26 (18%) cases. The presence of pain, absence of limb weakness and CR were significantly associated with good outcomes. Furthermore, subtotal resection (STR) had significantly higher recurrence rates than CR. Four deaths (2.7%) were noted.Conclusions: Total surgical resection is the standard treatment and appears to be beneficial both in terms of outcomes and recurrences. Overall, recurrences are rare and may be managed by re-surgery. In addition, the present report is the eighth case of adult spinal teratoma with an acute onset presentation. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Introduction: Revision surgery in spine tumor surgery can offer peculiar challenges given the severity of the majority of these lesions and the complexity of surgical procedures that are required.Materials and Methods and Results: Based on literature review and on personal experience, surgical site infection, cerebrospinal fluid leakage, tumor recurrence and hardware failures are some of the possible causes of surgical revision in this set of patients.Conclusions: The aim of this study is to evaluate the most frequent complications that can lead to revision in spine tumor patients, to provide suggestions on how to prevent these events and to offer reasonable strategies to properly plan and perform a revision surgery. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To clarify the clinical features, surgical strategies, and outcomes of intraosseous schwannoma (IOS) of the mobile spine.Methods: We retrospectively reviewed patients with primary benign spinal schwannoma who underwent surgery in our orthopedic department.Results: A total of 101 patients with primary benign schwannoma located in the mobile spine underwent surgery in our orthopedic department from 2005 to 2015. Twenty-five patients presented with aggressive features. Twenty patients were regularly followed up, twelve with lesions in the cervical spine, six with lesions in the thoracic region, and two with lesions in the lumbar spine. Preoperative CT-guided biopsy was performed in fourteen cases; the accuracy of diagnosis was 100%, and IOS is not histologically different from conventional schwannoma. The computed tomography (CT) scan revealed expansile and osteolytic bone destruction in all these cases, with six patients having pathological fracture. On T2-weighted magnetic resonance imaging, the lobulated schwannomas showed heterogeneous signal intensity and significant heterogeneous enhancement on post-contrast images. Gross total resection was performed in seventeen patients and subtotal resection in three. Tumor-involved nerve roots resection were documented to decrease local recurrence in fourteen cases. The visual analog scale score decreased from 5.66 ± 1.79 preoperatively to 1.16 ± 1.77 at the final follow-up. No local recurrence was noticed at the final follow-up.Conclusion: CT-guided biopsy is effective for the preoperative diagnosis of spinal IOS. Total resection is the optimal treatment for IOS, whereas subtotal resection could be an alternative choice for high-risk cases. These slides can be retrieved under electronic supplementary material. [ABSTRACT FROM AUTHOR]

Purpose: We reported the surgical outcomes of total en bloc spondylectomy (TES) with intralesional T-saw transpedicular osteotomy in patients with Enneking stage III spinal giant cell tumors (GCTs).Methods: The medical records and imaging and pathological studies of 25 consecutive patients with Enneking stage III spinal GCTs undergoing surgery at our institution who were followed for at least 2 years were retrospectively reviewed.Results: Eight men and 17 women (mean age: 34.2 years, range 16-51 years, at the time of surgery) were included. Six patients underwent previous tumor excision at another hospital, and one patient had a history of denosumab treatment. The GCTs were at the cervical, thoracic, and lumbar levels in three, nine, and 13 patients, respectively. TES was performed in 13 patients; 12 required intralesional pediculotomy. The remaining patients underwent total piecemeal spondylectomy with further intralesional tumor resection. During a mean follow-up of 99.2 months (range 24-216), two patients who underwent total piecemeal spondylectomy had local tumor recurrence, but no patients who underwent TES with intralesional pediculotomy had recurrence. The 2- and 10-year recurrence-free survival rates of patients treated with total piecemeal spondylectomy were 91.7% and 78.6%, respectively, while those of patients treated with TES were both 100%.Conclusions: TES with intralesional pediculotomy had a good surgical outcome even in patients with Enneking stage III spinal GCT, suggesting that minimal intralesional procedures could radically cure spinal GCTs. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Chordoma is a low-grade malignant tumor with recurrence and metastasis tendency that originates from embryonic notochordal remnants. The sacrococcygeal region is the most commonly involved site. The aim of this paper is to report the results of the use of cryosurgery in the excision of a giant recurrent sacral chordoma and review of pertinent literature.Methods: A 64 years old female patient with a locally recurrent sacral chordoma came to our attention after ten interventions performed at another institute. A surgical treatment was performed using argon cryosurgery.Results: In this case, it was not possible to perform a marginal or wide excision, but it was intralesional with the removal of three major blocks. The fragments sent for the histological analysis measured total 35 × 30 × 8 cm with a weight of 4.260 g.Conclusions: Given the gelatinous structure of the tumor and the possibility of contamination of operatory field, cryosurgery may be indicated when previous surgeries and the dimensions of tumor mass do not allow a resection with negative margins improving radiotherapy efficacy in the local control of tumor. [ABSTRACT FROM AUTHOR]

Background and Aims: The aim of this systematic review is to describe the epidemiology of chordoma and to provide a clear overview of clinical prognostic factors predicting progression-free and overall survival.Methods: Four databases of medical literature were searched. Separate searches were performed for each of the two objectives. Reference and citation tracking was performed. Papers were processed by two independent reviewers according to a protocol that included risk of bias analysis. Disagreement was resolved by discussion. Pooled analyses were planned if homogeneity of data would allow.Results: Incidence-incidence rates ranged between 0.18 and 0.84 per million persons per year and varied between countries and presumably between races. On average patients were diagnosed in their late fifties and gender data indicate clear male predominance. Two of the largest studies (n = 400 and n = 544) reported different anatomical distributions: one reporting the skull base and sacrococcygeal area affected in 32% and 29% of cases, whereas the other reporting that they were affected in 26% and 45% of cases, respectively.Prognostic Factors: Statistically significant adverse prognostic factors predicting progression-free and overall survival include female sex, older age, bigger tumour size, increasing extent of tumour invasion, non-total resection, presence of metastasis, local recurrence, and dedifferentiated histological subtype.Conclusions: Incidence rate and anatomical distribution vary between countries and presumably between races. Most chordomas arise in the skull base and sacrococcygeal spine, and the tumour shows clear male predominance. Multiple adverse prognostic factors predicting progression-free and overall survival were identified in subgroups of patients. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Various 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.Methods: Prospective 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.Results: Thirteen 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.Conclusion: Preliminary results from this series suggest that 3D printing can be effectively used to produce custom-made prosthesis for anterior column reconstruction. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Pedicle screw loosening is a common and significant complication after posterior spinal instrumentation, particularly in osteoporosis. Radiolucent carbon fiber-reinforced polyetheretherketone (CF/PEEK) pedicle screws have been developed recently to overcome drawbacks of conventional metallic screws, such as metal-induced imaging artifacts and interference with postoperative radiotherapy. Beyond radiolucency, CF/PEEK may also be advantageous over standard titanium in terms of pedicle screw loosening due to its unique material properties. However, screw anchorage and loosening of CF/PEEK pedicle screws have not been evaluated yet. The aim of this biomechanical study therefore was to evaluate whether the use of this alternative nonmetallic pedicle screw material affects screw loosening. The hypotheses tested were that (1) nonmetallic CF/PEEK pedicle screws resist an equal or higher number of load cycles until loosening than standard titanium screws and that (2) PMMA cement augmentation further increases the number of load cycles until loosening of CF/PEEK screws.Methods: In the first part of the study, left and right pedicles of ten cadaveric lumbar vertebrae (BMD 70.8 mg/cm3 ± 14.5) were randomly instrumented with either CF/PEEK or standard titanium pedicle screws. In the second part, left and right pedicles of ten vertebrae (BMD 56.3 mg/cm3 ± 15.8) were randomly instrumented with either PMMA-augmented or nonaugmented CF/PEEK pedicle screws. Each pedicle screw was subjected to cyclic cranio-caudal loading (initial load ranging from - 50 N to + 50 N) with stepwise increasing compressive loads (5 N every 100 cycles) until loosening or a maximum of 10,000 cycles. Angular screw motion ("screw toggling") within the vertebra was measured with a 3D motion analysis system every 100 cycles and by stress fluoroscopy every 500 cycles.Results: The nonmetallic CF/PEEK pedicle screws resisted a similar number of load cycles until loosening as the contralateral standard titanium screws (3701 ± 1228 vs. 3751 ± 1614 load cycles, p = 0.89). PMMA cement augmentation of CF/PEEK pedicle screws furthermore significantly increased the mean number of load cycles until loosening by 1.63-fold (5100 ± 1933 in augmented vs. 3130 ± 2132 in nonaugmented CF/PEEK screws, p = 0.015). In addition, angular screw motion assessed by stress fluoroscopy was significantly smaller in augmented than in nonaugmented CF/PEEK screws before as well as after failure.Conclusions: Using nonmetallic CF/PEEK instead of standard titanium as pedicle screw material did not affect screw loosening in the chosen test setup, whereas cement augmentation enhanced screw anchorage of CF/PEEK screws. While comparable to titanium screws in terms of screw loosening, radiolucent CF/PEEK pedicle screws offer the significant advantage of not interfering with postoperative imaging and radiotherapy. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Introduction: The anterior elements of the spine, particularly the odontoid processes, are a rare location for osteoblastomas. Pseudomalignant osteoblastomas are themselves rare histologic types and are also extremely rare in this location. Most osteoblastomas are Enneking stage 2 lesions; less frequently, they can be more aggressive with extra-capsular extension (Enneking stage 3). En bloc resection is recommended for aggressive lesions, but the literature is less clear regarding the approach to stage 2 tumors, particularly those with pseudomalignant histologic features.Case Report: A 6-year-old male child presented with a type III pathologic fracture of the odontoid. The fracture healed but upon 6-month follow-up CT scanning, an expansile lesion was detected. Surgical biopsy revealed an osteoblastoma which was treated with intralesional excision. Meanwhile, the excised specimen showed histological features of a pseudomalignant osteoblastoma. Despite this diagnosis, no further treatment was undertaken. At a 10-year follow-up, the patient was free from pain and had full range of motion of the cervical spine; no recurrence was detected.Conclusion: This unique case of odontoid osteoblastoma illustrates that malignant behavior may not be predicted only by the presence of pseudomalignant features on histology. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this report was to describe a case using combined USG and fluoroscopy for cervical VP via a percutaneous route under sedoanalgesia.Methods: A 70-year-old male patient had severe neck pain for 6 weeks because of metastatic mass lesions in C6. After the decision to VP, the patient was placed on the operating table and 2 mg midazolam and 75 µg fentanyl were administered for conscious sedation. Localisation of the carotid artery, internal jugular vein, and trachea had been determined with USG. 3 mL of 2% lidocaine was infiltrated after proceeding a needle from the axis of the trochar to the C6 vertebra corpus. The trochar entered into the vertebra corpus between the carotid artery and trachea right-antero-laterally under C-arm and USG guidance. 6 mL of PMMA was injected into this field. Then C6 VP procedure had been completed without complications.Results: This case has three differences from studies in the literature. First, cervical VP was conducted under sedoanalgesia. The second important feature of this case is that cervical VP was performed via a percutaneous route. A third important feature of this case is that it was performed under USG guidance for the first time in the literature.Conclusion: We consider that the combined use of C-arm fluoroscopy and USG should improve success rates and prevent vascular and neural injuries and dura perforation. [ABSTRACT FROM AUTHOR]

Purpose: Primary osseous hemangiopericytoma (HPC) of the spine is exceedingly rare. HPC has malignant potential and has the capacity for metastasis and local recurrence. We herein present the first case of recurrent primary osseous HPC in the thoracic spine that was successfully treated by total spondylectomy at three vertebral levels and spinal reconstruction.Methods: We performed a two-stage operation for recurrent HPC using anterior and posterior approaches at the T5-T7 vertebrae. The preoperative embolization of the tumor was performed to prevent massive intraoperative bleeding. Then, total spondylectomy was performed (T5-T7) to resect the tumor. Anterior spinal reconstruction and posterior instrumentation were performed, with abundant bone autograft and allograft used to achieve sufficient boney fusion following the removal of the tumor.Results: At 2 years after surgery, the patient had made a sufficient recovery from his symptoms. The bone union was complete without tumor recurrence or implant failure.Conclusions: Total spondylectomy and spinal reconstruction with instrumentation might be useful for performing the safe and adequate excision of recurrent HPC of the spine. However, patients should be closely monitored to detect local recurrence and the malignant degeneration of the tumor after surgery. [ABSTRACT FROM AUTHOR]

Introduction: Bilateral hypoglossal palsy is a rare complication during airway management in surgery.Case Presentation: Isolated bilateral hypoglossal palsy was noted post-operatively in a patient who underwent multiple spinal surgeries associated with prone anaesthesia.Discussion: Risk factors include difficult, multiple intubations, prolonged surgical time, throat pack, and hyperextension of the neck during intubation.Conclusion: We aim to create awareness about this complication which has a significant morbidity and negative effect on patient outcomes. [ABSTRACT FROM AUTHOR]

Purpose: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions.Methods: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement.Results: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively.Conclusions: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components. [ABSTRACT FROM AUTHOR]

Background: Pars defect and spondylolisthesis are frequent conditions, while bone tumors-particularly the primaries-are rare. The contemporary occurrence can delay the diagnosis of the tumor, if symptoms are considered related to spondylolisthesis, or can make reconstruction more demanding. To our knowledge, only two case reports of this contemporary occurrence have been published in the literature. Being such rare, guidelines on surgical treatment have not been proposed yet.Materials and Methods: A retrospective review of patients treated for spine bone tumors by the senior author from 1990 to 2017 was performed to find cases of contemporary occurrence of spondylolisthesis and/or pars defect and spine bone tumors. General health data, radiological imaging, histological tumor diagnosis, treatment, and follow-up were analyzed and discussed.Results: Among the 1870 patients treated for spinal tumors between 1990 and 2017 by the senior author, 14 cases of association between tumors and spondylolysis/spondylolisthesis were observed. The cohort includes five males (35.7%) and nine females (64.3%), aged 14-72. Mean age of patients at surgery time was 47.Conclusions: Interactions between spondylolisthesis and bone tumors of the spine are episodic. These two conditions rarely occur in the same patient. No treatment strategy has been described until now. The target of this paper is to propose an algorithm to surgically treat patients with concomitant bone tumor and spondylolisthesis. This classification identifies a treatment-oriented algorithm based on two major categories: type A, bone tumor arising on the same vertebra or to an adjacent level; type B, bone tumor arising at least one unit far from the spondylolisthesis. This algorithm can help the surgeon facing this rare combination of diseases in the appropriate preoperative planning. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Management of metastatic spinal disease in the upper cervical spine can be particularly challenging. Depending on the level of the lesion and the patient's anatomy, multiple anterior approaches have been described for resection of the cancer, followed by posterior fixation and instrumentation. Although a single-stage posterolateral approach is now well established for thoracic pathology, less is known about the applicability of these principles when applied as an approach to the cervical spine. The authors present here a case using a posterolateral transpedicular approach for corpectomy and graft placement for circumferential reconstruction as a treatment of metastatic disease in the cervical spine to illustrate the feasibility of this technique, especially in the setting where the patient's anatomy or pathology may impede an anterior or combined circumferential approach. [ABSTRACT FROM AUTHOR]

Purpose: The development of spinal implants marks a watershed in the evolution of metastatic spine tumour surgery (MSTS), which has evolved from standalone decompressive laminectomy to instrumented stabilization and decompression with reconstruction when necessary. Fusion may not be feasible after MSTS due to poor quality of graft host bed along with adjunct chemotherapy and/or radiotherapy postoperatively. With an increase in the survival of patients with spinal tumours, there is a probability of an increase in the rate of implant failure. This review aims to help establish a clear understanding of implants/constructs used in MSTS and to highlight the fundamental biomechanics of implant/construct failures.Methods: Published literature on implant failure after spine surgery and MSTS has been reviewed. The evolution of spinal implants and their role in MSTS has been briefly described. The review defines implant/construct failures using radiological parameters that are practical, feasible, and derived from historical descriptions. We have discussed common modes of implant/construct failure after MSTS to allow further understanding, interception, and prevention of catastrophic failure.Results: Implant failure rates in MSTS are in the range of 2-8%. Variability in patterns of failure has been observed based on anatomical region and the type of constructs used. Patients with construct/implant failures may or may not be symptomatic and present either as early (< 3months) or late failures (> 3months). It has been noted that not all the implant failures after MSTS result in revisions.Conclusion: Based on the observed radiological criteria and clinical presentations, we have proposed a clinico-radiological classification for implant/construct failure after MSTS. [ABSTRACT FROM AUTHOR]

Purpose: Spinal solitary fibrous tumor/hemangiopericytoma (SFT/HPC), a rare mesenchymal tumor that arises from pericytes of Zimmerman, comprises only 0.08% of all primary bone tumors and 0.1% of primary malignant bone tumor and rarely occurs in the spine. We attempt to correlate the clinical factors and different treatment options with the recurrence rate and overall survival of SFT/HPC over time.Methods: A retrospective study of 20 patients with spinal osseous SFT/HPCs who were surgically treated in our center between 2003 and 2015 was performed. Kaplan-Meier curves and log-rank tests were used to compare the survival probability or recurrence-free probability between groups, and P values < 0.05 were considered statistically significant.Results: Three surgical management strategies, including subtotal resection, piecemeal total resection, and total en bloc spondylectomy (TES) were applied. Postoperative radiotherapy was carried out in 14 cases. The mean follow-up period was 38.3 (median 35, range 7-93) months, and 6 patients passed away with the mean follow-up time of 47.7 (median 41, range 24-77) months. Relapse was detected in 9 patients (45%) with the mean time from surgery to recurrence being 36.6 (median 28, range 12-73) months. Our results indicate that grade III is an adverse prognostic factor for both recurrence and over survival (OS) for spinal osseous SFT/HPC, while total resection, especially TES, is a positive prognostic factor.Conclusions: Spinal osseous SFT/HPC is a challenging clinical entity given its high local recurrence rate. Surgical management plays a crucial role in the whole treatment of spinal SFT/HPCs and total excision, especially TES, should be strived for whenever possible. Postoperative radiotherapy is recommended to lower the recurrent rate. This study also confirms that pathology grade III is an adverse prognostic factor for spinal osseous SFT/HPCs. [ABSTRACT FROM AUTHOR]

Purpose: For the selection of treatment in patients with spinal bone metastases (SBM), survival estimation plays a crucial role to avoid over- and under-treatment. To aid clinicians in this difficult task, several prediction models have been developed, consisting of many different risk factors. The aim of this systematic review was to identify prognostic factors that are associated with survival in patients with SBM to support development of predictive models.Methods: A systematic review was performed with focus on prognostic factors associated with survival in patients with SBM. Two reviewers independently selected studies for inclusion and assessed the risk of bias. A level of evidence synthesis was performed for each prognostic factor. Inter-observer agreement for the risk of bias assessment was determined by the kappa-statistic.Results: After screening, 142 full-text articles were obtained, of which 22 met the eligibility criteria. A total of 43 different prognostic factors were investigated in the included studies, of which 17 were relevant to pre-treatment survival estimation. The prognostic factors most frequently associated with survival were the primary tumor and the performance status. The prognostic factors most frequently not associated with survival were age, gender, number and location of the SBM and the presence of a pathologic fracture.Conclusions: Prognostication for patients with SBM should be based on an accurate primary tumor classification, combined with a performance score. The benefit of adding other prognostic factors is doubtful. [ABSTRACT FROM AUTHOR]

Purpose: To assess the safety of surgical intervention for extraspinal tumors in the cervical spine.Methods: 110 consecutive patients were enrolled and followed-up at least 12 months or until death. The complication rates and risk factors were documented and analyzed.Results: The quality of life in the surviving patients was significantly improved. The overall local recurrence rate was 17.3%. Twenty percent of patients developed distant metastasis. The perioperative mortality rate (30 days after surgery) was 0.9%. The complication related mortality was 1.8%. The rates of overall complication and major complication were 41.8% and 20.9%, respectively. The independent predictors for overall complications were Karnofsky score <60, multisegmental resection, and operation time >3 h. The independent predictors of major complications were comorbidity, tumor location at C1-C2, and combined approach.Conclusions: Surgery for cervical spine tumor could improve the quality of life, though it might be accompanied with high morbidity and mortality. It is a highly demanding procedure; however, it can be performed to an acceptable degree of safety. [ABSTRACT FROM AUTHOR]

Background: Protocols including combination of surgery and radiotherapy are more and more frequent in the treatment of bone tumors of the spine. In metastatic disease, combination of surgery and radiotherapy is since long time accepted, as based on clinical evidence. In primary tumors, combination of surgery and radiotherapy can be considered in all the cases in which a satisfactory oncological margin cannot be achieved: high-grade malignancies, recurrent tumors, huge tumors expanding in an extracompartimental area, and when tumor-free margin requires unacceptable functional sacrifices. However, metal implants are an obstacle in the collaboration between surgeons and radiation oncologists. Carbon-fiber-reinforced polyethil-ether-ether-ketone (CFR-PEEK) composite implants could make easier and more effective the treatment as radiolucent and not interfering with ionizing radiation and accelerated particles. The purpose of this article is to report the preliminary results from a cohort of patients treated with CFR-PEEK and to evaluate the safety and the non-inferiority of the device respect the commonly used titanium implants.Materials and Methods: This study concerns an ambispective cohort series of 34 tumor patients (14 metastases and 20 primaries, most of them recurrent) submitted to thoracic and lumbar spine fixation with a CFR-PEEK composite implants. Oncologic surgery was palliative decompression and fixation in 9 cases, tumor excision in 21, and enbloc resection in 4. Data collected for this preliminary report were all intraoperative remarks, incidence of complications, changes in neurological status, local control, and survival. All the cases were followed 6-36 months (mean 13 months).Results: Only one intraoperative screw breakage occurred out of 232 implanted screws. Pain control and neurological improvement were the early clinical results. Two sacral screws loosening were found at 9 and 12 months in multilevel constructs performed on multirecurrent tumors. Six local recurrences were early found thanks to the implant radiolucency. Radiation oncologists' opinion was favourable as concerning better treatment planning on CT and lacking of scattering effect during the treatment.Conclusions: No artifacts on imaging studies mean early local recurrence detection. For radiation oncologists, no artifacts on imaging studies mean easier planning and no scattering effect means more effective and safe radiotherapy, particularly when particles are used. Moreover, it seems that the clinical use of CFR-PEEK composite implants may be safe and at least comparable with the commonly used titanium implants in terms of intraoperative complications, stability at weight bearing and at functional recovery. Larger patient series and longer follow-up are required to confirm these data. [ABSTRACT FROM AUTHOR]

Background: Spinal metastatic paraganglioma (MPG) is rare and only reported in individual case reports. The low incidence makes it difficult to define appropriate therapy and prognosis. Our study illustrated the largest series to discuss the possible treatment and outcomes of patients with spinal MPG.Methods: A retrospective study of 15 patients with spinal MPG who were surgically treated between 2005 and 2014 was performed. Three surgical modalities were applied, and radiotherapy and chemotherapy were utilized as adjuvant therapy.Results: The mean patients age was 40.9 (range 23-58) years. The period between primary surgery and spinal metastasis averaged 8.2 (0.5-15) years. Lesions were mainly located in cervical spine (2), thoracic spine (8), lumbar spine (3), and sacrum (2). The mean follow-up period was 35.0 months. Lesion progression was detected in nine patients, whereas five patients (33.3%) passed away. For solitary spine, multiple bone and both bone and nonosseous metastasis cases, the mean progression-free survival was 41 (range 9-56), 22.5 (range 12-38) and 8.3 (range 3-18) months, respectively.Conclusions: The cases presented in the current study highlight the crucial role of surgery. Total en bloc for solitary spinal MPG could result in a satisfying prognosis and piecemeal total resection with postoperative radiotherapy could be an alternative therapy. Radiotherapy and chemotherapy were advocated, especially for the multiple metastasis. [ABSTRACT FROM AUTHOR]

Purpose: To determine the significance of each parameter of the revised Tokuhashi score and identify which is associated with survival.Background: Spinal metastases are common and can be a challenging medical issue. Treatment options depend on patients' prognosis. Many scoring systems in the literature help estimate prognosis, such as the Tokuhashi, revised Tokuhashi, and Tomita scoring systems.Methods: A retrospective review of all patients from 2003 to 2012 treated for spinal metastases in one center was conducted. Imaging, pathology, and charts were reviewed to determine the modified Tokuhashi scores. Scores were then compared to the actual documented survival. Univariate and multiple regression analyses were used to assess the importance of each individual parameter and survival time. Linear regression was used to determine the relationship between the Tokuhashi score and weighted Tokuhashi score with survival time.Results: A total of 126 patients were reviewed. All parameters in the revised Tokuhashi score were significantly associated with survival time except for primary site using univariate analysis. Only the number of spinal metastases and metastasis to major organs showed statistical significance when multiple variable analysis was used.Conclusion: A number of spinal metastases and metastasis to major organs were the most important predictors of actual survival. Modification to the score based on population characteristics would help better identify patients with spinal metastases that can benefit from surgery. [ABSTRACT FROM AUTHOR]

Background: Surgeries for primary malignancies involving upper sacrum require total en bloc sacrectomy followed by complex mechanical reconstruction, which might be simplified by application of the three-dimensional (3D) printing technique.Purposes: To describe the design of a 3D-printed custom-made prosthesis for reconstruction after total en bloc sacrectomy, the surgical technique, and the clinical and functional outcome of a patient.Methods: A 62-year-old patient with recurrent sacral chordoma was admitted in our center. One-stage total en bloc sacrectomy through posterior approach was planned, and a 3D-printed sacral prosthesis was prepared for reconstruction according to the anticipated osteotomic planes.Results: The patient received one-stage total en bloc sacrectomy through posterior approach followed by reconstruction with the 3D-printed sacral prosthesis. The whole procedure took 5 h, and intra-operative blood loss was 3400 ml. The patient recovered uneventfully and started ambulation at 3 weeks after surgery. An asymptomatic instrument failure was found radiographically at 8-month follow-up. At 1 year after surgery, the patient was disease free and could walk over short distance with crutches without pain or any mechanical instability.Conclusions: The advantages of our reconstruction method included: (1) the prosthesis provided an optimal reconstruction of lumbosacral and pelvic ring by integrating spinal pelvic fixation, posterior pelvic ring fixation, and anterior spinal column fixation in one step and (2) its porous surface could induce bone ingrowth and might enhance stability. Although there was an instrumental failure, we considered that it could be one reconstructive option. More research is warranted focusing on the modification of locations, diameters, and quantity of screws and biomechanical characteristics. The long-term functional and bone in-growth outcome will be followed to validate the use of the prosthesis. [ABSTRACT FROM AUTHOR]

Purpose: This is a retrospective analysis of the strategy and clinical results of surgery combined with intraoperative radiotherapy (IORT) to treat spinal metastases.Methods: We delivered tumour-conformal IORT in 40 patients with 52 metastatic vertebrae based on our surgical classification system. The strategies were evaluated with respect to neurologic function and spinal stability. The EORTC QLQ-BM22, visual analogue scale (VAS) and the Frankel Scale were used to assess quality of life, pain and neurologic function. Local control was evaluated every 3 months using X-rays and MRI.Results: Micro-invasive IORT was performed in 42 vertebrae (80.8%), and open surgery with IORT was performed in 10 vertebrae (19.2%). Single-level, 2-level and 3-level IORT was performed in 30, 8 and 2 cases, respectively. The delivered dose was 9.2 ± 3.6 Gy (8-15 Gy) with a depth of 10.1 ± 2.1 mm. The actual IORT treatment time was 5 min and 16 s. The follow-up period was 6-23 months (mean: 12.5 months). The local control rate was 92.3%. The EORTC QLQ-BM22 scores showed that patients had significant improvements in pain location, degree and function after treatment (P < 0.01). Thirty-five patients (89.7%) achieved pain relief throughout the follow-up period. VAS scores were significantly reduced by 3.4 points 3 months after treatment. Neurological function was improved in 7 patients (87.5%). No radiation-related complications were observed.Conclusions: Surgery combined with tumour-conformal IORT can effectively relieve pain, achieve good local control and improve QOL. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate postoperative recurrence, survival and metastasis results and related factors of sacral chordoma.Methods: Between 1978 and 2013, a total of 171 patients with sacral chordoma were diagnosed at our institution and 162 cases underwent operation. The clinical characteristics, treatment and outcomes of all these patients were reviewed.Results: The 3-year recurrence free survival rate was 83.1%. The median recurrence free survival time was 73 ± 7.8 months. Tumor level in sacrum and surgical margin were significant factors influencing recurrence. Recurrence was significant factor influencing metastasis. One hundred and fifty-seven cases were followed up for an average of 55.6 months. 135 cases (86%) survived, 37 cases (23.6%) developed recurrence, and 17 cases (10.8%) developed metastasis. The overall 5- and 10-year survival rate was 88.3% and 59.6%, respectively. Age (p = 0.037) and metastasis (p = 0.001) were significant factors influencing survival. The 3-year recurrence free survival rate was 80.1%. The median recurrence free survival time was 69 ± 12.7 months. Tumor level in sacrum (p = 0.035) and surgical margin (p = 0.009) were significant factors influencing recurrence. Seventeen cases (10.8%) had metastasis. Recurrence (p = 0.016) was significant factors influencing metastasis.Conclusions: Sacral chordoma tended to occur in elderly male patients and locate below sacral 3 level. The recurrence rate was high, especially for tumor above sacral 3 level. Wide surgical margin is very important for good local control. The patients with metastasis had poor prognosis. [ABSTRACT FROM AUTHOR]

Purposes: We sought to verify the efficacy and safety of RFA in spinal OO and osteoblastomas (OB) (Enneking Stage 2, S2).Methods: We retrospectively reviewed patients treated in our hospital. Surgical resection was indicated for Enneking Stage 3 OB. RFA indications for spinal OO and OB (S2) were no neurological deficits, complete bone cortex around the lesion on computed tomography (CT), and cerebrospinal fluid between a lesion and the spinal cord/nerve root on magnetic resonance imaging. Abundant cerebrospinal fluid (more than 1.0 mm) between the lesion and nerve root/spinal cord was preferred to prevent neurological damage by heat. Otherwise, surgery was recommended. The minimum follow-up was 24 months.Results: Ten patients were treated with CT-guided percutaneous RFA, including three with OB and seven with OO. No patients had neurological deficits or scoliosis. In OO patients, the average visual analog scale (VAS) scores were 7.6/10 (range 6-10) before RFA. In OB cases, the VAS scores were 8, 7, and 9 before RFA. Nine patients had a one-stage biopsy and then RFA, and one patient had a two-stage procedure (biopsy before RFA). The average RFA time for OO was 10 min (range 4-12). In the three OB cases, the RFA time was 12, 12, and 24 min. The time of the whole produce was 98 min (range 65-130 min). All 10 patients were followed-up. The average follow-up time of OO was 46.6 months (range 24-66). Six patients were free of pain, except one who suffered occasional pain with VAS 2/10. The three OB cases were free of pain at 24, 26, and 26 months.Conclusion: CT-guided percutaneous RFA is a safe and effective treatment for spinal OO and S2 OB, especially in lesions with no neurological deficits and intact cortical bone. Cerebrospinal fluid around the lesion is an appropriate indication for percutaneous RFA. [ABSTRACT FROM AUTHOR]

Objective: To present a rare case of serous degeneration of bone marrow which resembles primary spinal tumor or bony metastasis to spine. Serous degeneration of bone marrow or gelatinous marrow transformation is a rare disease characterized by focal marrow hypoplasia, fat atrophy, and accumulation of extracellular mucopolysaccharides abundant in hyaluronic acid. Few literature was reviewed and few clinical case was presented.Methods: Two cases of serous marrow transformation were reported.Results: In the first case, a 29-year-old man suffered from severe left buttock pain. Bone metastasis was impressed in radiology examinations. Percutaneous endoscopic lumbar discectomy was performed along with bone biopsy. In the second case, a 49-year-old man presented lower back pain with radiation to bilateral lower legs. Magnetic resonance imaging revealed a water-like signal lesion in sacrum. Serous marrow transformation was confirmed pathologically in both cases.Conclusion: To the best of our knowledge, a case of serous degeneration of bone marrow resembling malignancy has not been reported in the literature. In this report, two cases demonstrate serous transformation of bone marrow mimics spinal tumor. [ABSTRACT FROM AUTHOR]

Study Design: Case report.Purpose: We present a rare case of a giant chordoma in the thoracolumbar spine and review the current literature. We describe its complicated clinical progression, hoping to shed light on the clinical management of this complex tumor.Methods: We present a previously healthy 41-year-old man who experienced progressive low back pain at T10-L2 for the past 2 years. A giant tumor was detected on magnetic resonance imaging, and aspiration biopsy was used to obtain a definite pathological diagnosis. The postoperative pathology confirmed that it was a chordoma. He underwent complete resection of the tumor and internal fixation of the vertebral bodies, which is a good way to control recurrence and preserve stability.Results: Histopathology confirmed the tumor was a chordoma via immunohistochemical study of both the biopsy sample and the surgically resected tissues. There has been no recurrence or metastasis at the 30-month postsurgery radiographic examination. The internal fixation has remained stable.Conclusion: Primary chordoma in the thoracolumbar spine is extremely rare. The treatment is difficult because the current literature is sparse and patients are rare. Complete resection and internal fixation are effective for reducing recurrences and metastasis. [ABSTRACT FROM AUTHOR]

Purpose: To describe the surgical experience of spondylectomy and spinal reconstruction for aggressive vertebral hemangioma (VH) induced at the C4 vertebra. No reports have described surgical strategy in cases covering an entire cervical vertebra presenting with progressive myelopathy.Methods: A 28-year-old man presented with rapidly progressing skilled motor dysfunction and gait disorder. The Japanese Orthopedic Association (JOA) score was 6. Radiography showed a honeycomb appearance for the entire circumference of the C4 vertebra. Spinal computed tomography and magnetic resonance imaging showed vertebral tumor with extraosseous extension causing spinal cord compression. Results of diagnostic imaging were strongly suggestive of VH. Transarterial embolization of the spinal body branch was performed first to decrease intraoperative bleeding, followed by cervical posterior fixation to stabilize the unstable segment and excision biopsy to obtain a definitive diagnosis. After definitive diagnosis of cavernous hemangioma, two-stage surgery (anterior and posterior) was performed to complete total spondylectomy and 360° spinal reconstruction.Results: Despite multiple operations, JOA scores were 8.5 after posterior fixation, 10.5 after anterior surgery, 11 after final surgery and 16 on postoperative day 90. The patient acquired excellent clinical results without complications and returned to society.Conclusions: The present three-stage surgery comprising fixation, biopsy, and final spondylectomy with circumferential fusion from anterior and posterior approaches may offer a useful choice for aggressive VH covering the entire cervical spine with rapidly progressive myelopathy. [ABSTRACT FROM AUTHOR]

Objective: We present such a case of aggressive osteoblastoma of cervical spine. We describe its complicated clinical progression, hoping to shed light on the surgical strategy of this complex tumor.Methods: We present such a case of aggressive osteoblastoma involving the C6-7 vertebrae. A 25-year-old man was diagnosed as aggressive osteoblastoma of the cervical spine. The lesion encroached upon the radicular foramina and was located adjacent to the canal of the vertebral artery. Preoperative embolization was performed to reduce intraoperative bleeding and to prevent intraoperative injury of the vertebral artery.Results: A pathologic examination showed osteoblasts suggestive of osteoblastoma. At 2-year follow-up, bony union was achieved, and there was no evidence of recurrence on a CT scan.Conclusion: En bloc total resection for highly vascular osteoblastoma is ideal, but this case shows that piecemeal total resection following preoperative embolization is a surgical option for highly expansive osteoblastoma. [ABSTRACT FROM AUTHOR]

Objective: Sinus histiocytosis with massive lymphadenopathy or Rosai-Dorfman disease (RDD) is a rare benign disease of dubious etiology that arises predominantly in lymph nodes with generalized fever and malaise. Isolated intraspinal involvement has its unique characteristics. The purpose of this study is to present the largest series of cases in the spinal Rosai-Dorfman disease literature to increase familiarity with its clinicopathologic features, diagnosis, and treatment of RDD from spine.Methods: We present the case of a 34-year-old man who presented with paraplegia secondary to an isolated thoracic vertebral lesion. On physical exam, the patient displayed progressive weakness and tendon hyperreflexia of the lower limbs. After a totally section, symptoms of the patient were obviously relieved and the patient remained asymptomatic and no signs of recurrences were observed after follow-up for 5 months. We also retrospectively analyzed 60 cases of patients with spinal RDD published in English since 1969. Clinical date, histopathology, and radiological feature were retrospectively analyzed.Results: Spinal RDD should no longer be considered rare and it may occupy an increasingly prominent place in the list of differential diagnoses for intraspinal lesions. Only elaborate histopathology was diagnostic for RDD. Most of the patients were surgically treated and marked improvements were observed in their clinical conditions.Conclusions: RDD with spinal involvement is uncommon and it is challengeable in making a certain diagnosis. Histopathologic characteristics and immunohistochemical findings are considered as the key points for the diagnosis of this disease. The optimal treatment remains controversial, and more efforts should be focused on the investigation of etiology and adjuvant therapy for relapsing cases or subresected lesions. [ABSTRACT FROM AUTHOR]

Purpose: Metastatic epidural spinal cord compression (MESCC) often requires anterior-posterior decompression and stabilization. To reduce approach-related complications, single-stage posterolateral vertebrectomy and 360° fusion is often performed. However, a sufficient reduction of kyphotic deformity through this approach has not been reported. The purpose of this study is to investigate the efficacy of kyphotic deformity reduction by this approach in MESCC.Methods: A retrospective analysis and chart review was performed for 14 consecutive patients who underwent a vertebrectomy and decompression from a posterolateral approach. Anterior mesh stabilization of the ventral column is used as hypomochlion for the posterior compression manoeuvre, which leads to reduction of the kyphotic deformity.Results: Pre-operative back pain was 7.2 on a visual analogue scale. Back pain was reduced to 4.4 at discharge and 2.0 at the latest follow-up with a mean follow-up of 12 months (p < 0.001). The Frankel score remains constant or improved from D to E. Radiological segmental kyphosis was corrected from a mean of 16° to 4° (p < 0.001) post-operatively with a loss of 3° at the final follow-up, but still with significant corrections compared with the pre-operative measurements (p < 0.003).Conclusion: Single-stage posterolateral vertebrectomy and reconstruction is a safe and less invasive approach that allows a sufficient reduction of hyperkyphosis and preservation of neurological function in patients with MESCC. This approach is an efficient alternative to anterior-posterior fusion with good pain reduction and improved sagittal profile. [ABSTRACT FROM AUTHOR]

Purpose: Liposarcoma, one of the most common soft tissue sarcomas originates from primitive mesenchymal cells. But spinal involvement of either primary or metastatic liposarcoma is rare. Here we present our experience of seven consecutive patients with spinal liposarcoma.Method: We retrospectively reviewed our patients who have spinal liposarcoma from January 2009 to December 2013. All patients were surgically treated at least once at our spine tumor center and be confirmed as liposarcoma after surgery. All patients' information and follow-up data were collected afterwards.Results: A total of six male and one female patients have been included. Five of them had mobile spinal involvement while the others had sacral involvement. Six piecemeal and one en-bloc resections were successfully performed. Patients' Frankel scores were upgraded with one level or at least preserved postoperatively. The average time of follow-up was 24.6 ± 13.9 months. Three patients died 13, 15 and 24 months after surgical treatment, respectively while the other four patients were still alive and one of them alive with disease at the end of follow-up.Conclusion: The outcome and prognosis of spinal liposarcoma is poor, and surgical resections should be considered when diagnosis is confirmed. For those whose tumors were too large to resect and/or with multiple metastases, effective treatment options are currently limited. Therefore, multidisciplinary treatment should be adopted, intraoperative chemotherapy, systemic chemotherapy and radiotherapy for instance. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating tumour cells from blood salvaged during metastatic spine tumour surgery (MSTS). This is with the view to pave the path for use of IOCS-LDF in MSTS and musculoskeletal oncological surgery.Methods: Sixty consecutive patients with known primary epithelial tumour, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at three different stages during surgery: from operative field prior to IOCS processing, after IOCS processing and after IOCS-LDF processing. Three separate samples (5 ml each) were taken at each stage. Samples were examined by cell block technique using immunohistochemical monoclonal antibodies to identify tumour cells of epithelial origin in the samples.Results: Of 60 patients, ten were excluded for not fulfilling the inclusion criteria leaving 50 patients. Malignant tumour cells were detected in the samples from operative field prior to IOCS processing in 24 patients and in the samples from the transfusion bag post-IOCS processing in 4 patients. No viable malignant cells were detectable in any of the blood samples after passage through both IOCS and LDF.Conclusions: The findings support the notion that IOCS-LDF combination works effectively in eliminating tumour cells from salvaged blood so this technique can possibly be applied in MSTS and even musculoskeletal oncological surgery. This concept can then be extended to other oncological surgeries in general with further appropriate clinical studies. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to create and validate a score for survival and functional outcome of lung cancer patients with metastatic spinal cord compression (MSCC) after posterior decompressive surgery.Methods: The entire cohort of 73 consecutive patients was randomly assigned to a test group (N = 37) and a validation group (N = 36). In the test group, we retrospectively analyzed 10 preoperative characteristics. Characteristics significantly associated with survival on multivariate analysis were included in the score. Patients in the validation group were used to confirm whether the score was reproducible. Postoperative functional outcome was analyzed both in the test and validation groups.Results: On multivariate analysis, preoperative ambulatory status (P = 0.0017), visceral metastases (P = 0.0002), and time developing motor deficits (P = 0.0004) had significant impact on survival and were included in the scoring system. According to the prognostic scores, which ranged from 0 to 6 points, two risk groups were designed: 0-2 and 3-6 points and the median survival was 2.6 months (95 % CI, 1.0-3.8 months) and 10.7 months (95 % CI, 7.1-13.7 months), respectively (P < 0.0001). In the validation group, the corresponding median survival was 2.7 months (95 % CI, 1.6-5.5 months) and 10.8 months (5.8-13.6 months), respectively (P < 0.0001). In addition, the functional outcome was worse in patients with 0-2 points than in patients with 3-6 points both in the test (P = 0.0023) and validation groups (P = 0.0298).Conclusion: Patients with scores of 0-2 points, who have short survival time (life expectancy less than 3 months) and poor functional outcome, appear best treated with radiotherapy or best supportive care alone. Surgery may be no longer in consideration in most of the patients in this group. Patients with score of 3-6 points should be surgical candidates, because survival prognosis (life expectancy more than 10 months) and functional outcome are favorable after surgery. [ABSTRACT FROM AUTHOR]

Purpose: Simpson grade II removal (coagulation of the dural attachment after gross total removal) of spinal meningioma is considered an acceptable alternative, but increased recurrence after more than 10 years has been reported. More attention must be paid to the long-term surgical outcomes after Simpson grade II removal.Methods: A retrospective review was performed for 20 patients (M:F = 5:15; age, 59 ± 9 years) with Simpson grade II removal (mean follow-up period, 12.9 years; range 10.0-17.5). Magnetic resonance (MR) imaging was conducted in 17 patients at 88 ± 52 months (range 12-157). During the same period, Simpson grade I removal (removal of the dural origin) was performed in 21 patients (follow-up, 89 ± 87 months; range 9-316). Radiological recurrence was defined as a visible tumor on a follow-up MR image, and clinical tumor recurrence was defined as the recurrence of symptoms.Results: At the final follow-up, neurological symptoms had improved in 16/20 patients and remained stable in 4/20. A recurrent tumor was detected in one patient due to increased back pain at 92 months postoperative, but the symptom was stable without surgery until the last follow-up (124 months). The radiological and clinical recurrence-free survival periods were 150 ± 7 months (95 % CI 136-163) and 204 ± 6 months (95 % CI 193-215), respectively. There was no recurrence after Simpson grade I removal, whereas neurological deterioration occurred in two patients after surgery.Conclusions: Simpson grade II removal may be an alternative option if the risk of complications with Simpson grade I removal is expected to be high. [ABSTRACT FROM AUTHOR]

Background: Giant cell tumor of the spine has high rate of postoperative recurrence. There are not much published studies on repeatedly recurrent GCTS (RRGCTS). Also, there are controversies as to the prognostic factors and treatment options for RRGCTS.Methods and Materials: A retrospective survival analysis between 2000 and September 2014 was performed on the 74 times of in-hospital treatment of the 21 patients. Recurrence-free survival was defined as the time between the date of surgery and the date of recurrence. Factors with P values <0.05 in univariate analysis were subjected to multivariate analysis by means of proportional hazard analysis.Result: A total of 21 patients comprising ten males and 11 females with a mean age of 29.7 years (range 15-49) were included, with a total of 74 times of surgery performed. Eighteen patients had no evidence of disease. Univariate and multivariate analysis suggested that total spondylectomy and bisphosphonate therapy were independent prognostic factors for better RFS in RRGCTS patients.Conclusion: Patients of RRGCTS are suitable for further surgical treatment with relatively good healing process and restoration of nervous function. Early diagnosis of recurrence may be associated with better prognosis. Total spondylectomy in combination with bisphosphonate therapy could reduce postoperative recurrence rate. [ABSTRACT FROM AUTHOR]

Background: The management of spine metastases is an increasing concern for spine surgeons. When considering surgery, it is crucial to ensure that its iatrogenic effects will not exceed its potential benefits, particularly in frail patients with short life expectancy. Among all prognostic factors, the primary site of cancer is the most important, lung cancer being the poorest. Although surgery has shown its effectiveness in the management of spine metastases, there is a lack of studies focusing on lung cancer alone.Purpose: To assess the effectiveness and safety of surgery in the management of symptomatic spine metastases from lung cancer.Methods: We retrospectively reviewed all patients (n = 53) who underwent surgery for spine metastasis from lung cancer at the Lille University Hospital between January 2005 and December 2011. Patients for whom surgery was effective to restore or preserve ambulation, to relieve pain, and to ensure stability without severe complication were considered "surgical success".Results: No patient was lost to follow-up and vital status data were available for all patients. The median survival was 2.1 months and was not influenced by the surgical success (p = 0.1766). We reported seven major complications in seven patients, including three epidural haematoma, two massive pulmonary embolisms and two deaths from cardiopulmonary failure. The surgical success rate was 49 % and on univariate analysis, the factors that have influenced the postoperative outcome were the KPS (p < 0.001), the Frankel grade (p = 0.0217) and the delay between the cancer diagnosis and the occurrence of spine metastases (p = 0.0216).Conclusion: A strict patient selection is required to limit the iatrogenic effect of surgery, which may alter the quality of life of these frail patients with limited life expectancy. [ABSTRACT FROM AUTHOR]

Purpose: The timing of surgical intervention is important for ambulatory patients with metastatic epidural spinal cord compression (MESCC), while limited studies have focused on non-ambulant patients. The aim of this study was to investigate the proper timing of surgical intervention for paraplegic patients with MESCC.Methods: Forty-three non-ambulant patients with MESCC who underwent posterior decompression were retrospectively reviewed. The neurological outcomes for pre-operative Frankel B patients with different interval window were further compared.Results: Neurologic deficit improved by at least 1 Frankel grade in 37 patients who underwent surgery within 72 h (86.0 %). Overall, 18 pre-operative Frankel B patients became ambulatory again with an interval of less than 48 h, 15 pre-operative Frankel B patients remained non-ambulatory post-operatively with an interval longer than 48 h besides one with an interval of 8 h (P < 0.001). All nine pre-operative Frankel A patients remained non-ambulatory even though the interval window was less than 24 h.Conclusion: The timing of surgical intervention was key to predicting the post-operative outcome, and 48 h was suggested as the proper interval window for pre-operative Frankel B patients. These patients preserved sensory function which might be a predictor. And the sooner the surgery was performed, the better the result would be. [ABSTRACT FROM AUTHOR]

Purpose: Dumbbell-shaped thoracic tumors represent a distinct type of tumor and involve in both the spinal canal and the posterior thoracic cavity. Successful treatment for the tumors depends on gross total resection (GTR) via an open laminectomy and facetectomy or transthoracic transpleural approach. In this case series, we report our experiments with minimally invasive method for the removal of extradural dumbbell thoracic tumor and present related literature review.Methods: We retrospectively reviewed two patients with dumbbell-shaped thoracic tumors who underwent minimally invasive resection and unilateral transforaminal thoracic intervertebral fusion (TTIF) through unilateral paraspinal muscle approachwith a spotlight expandable tubular retractor. Clinical data, tumor characteristics, and outcomes were analyzed.Results: Two patients underwent successful minimally invasive treatment of their spinal neoplasms. There were no procedure-related complications. The efficacy in terms of neurological recovery, pain improvement and operative variables (length of incision, operative duration, blood loss, and hospital stay) was better when compared with prior published studies. Postoperative CT image demonstrated complete resection of dumbbell tumor in the patients. The solid fusion was obtained after 3 months follow-up and there was no failure of internal fixation.Conclusion: If the medial border of intracanal component of extradural dumbbell tumor is near the midline of canal and the pedicles of adjacent vertebrae to tumor are intact, minimally invasive resection of tumor through unilateral paraspinal muscle approach combined with unilateral TTIF is good choice. [ABSTRACT FROM AUTHOR]

Purpose: Identify risk factors, enabling reduction of the rate of complications and improve outcome in en bloc resection surgeries.Methods: A retrospective study of prospective collected data of 1681 patients affected by spine tumors treated from 1990 to 2015 by the same team.Results: A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary-165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. Median FU was 45 months (0-371). 153 complications were observed in 100 patients (46.2 %). 64 (30 %) suffered one complication, while the rest had two or more. There were 105 major and 48 minor complications. Seven patients (4.6 %) died as a result of complications. The combined approach, neoadjuvant chemotherapy and neoadjuvant radiotherapy were statistically significant independent risk factors for complications occurrence. 33 patients (15.2 %) suffered from local recurrence. Reoperations were mostly due to tumor recurrences, but also to hardware failures, wound dehiscence, hematomas and aortic dissection.Conclusion: The rate of complication is higher in multisegmental resections and when double combined approach is performed. Reoperations display greater morbidity owing to dissection through scar/fibrosis from previous operations and possibly from RT. Careful treatment planning and, in the event of uncertainty, referral to a specialty center must be stressed. The high risk of complications should not discourage surgeons from performing en bloc resection when needed. Most of the patients who sustain complications benefit from the better local control resulting from en bloc resection. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed at evaluating our hypothesis that tumour cells, which pass through the intraoperative cell salvage (IOCS) machine, lose viability due to possible injury to the cell membrane during centrifugation and filtration, enabling safe reinfusion even without filtration.Methods: Thirteen patients who underwent metastatic spine tumour surgery (MSTS) at our institution were recruited. Blood samples (5 ml each) were collected at five different stages during surgery, namely, stage A and B: from patients' vein during induction and at the time of maximum tumour manipulation; stage C, D and E: from the operative blood prior to IOCS processing, after IOCS processing and after IOCS-LDF (leucocyte depletion filter) processing, respectively. The samples were then analysed for viability of tumour cells using microwell-based culture.Results: The median age of the patients was 65 years (range 37-77 years). The most common primary tumour was lung, followed by breast, hepatocellular and renal cell carcinoma. The median blood loss was 680 ml (range 300-1500 ml). Analysis of cultured blood samples showed that CTC-containing clusters were developed from some samples before IOCS-LDF processing (stage A: three patients, stage B: three patients and stage C: one patient). None of the samples from stages D and E generated clusters after culture, suggesting the absence of viable cancer cells after IOCS processing.Conclusions: The salvaged blood may contain some tumour cells after processing with IOCS machine, but these cells are damaged and hence unable to replicate and unlikely to metastasise. The results of this study support the hypothesis that salvaged blood in MSTS is safe for transfusion. [ABSTRACT FROM AUTHOR]

Purpose: To determine the effect of preoperative embolization on intraoperative blood loss in surgery for metastatic spinal tumours stratified by tumour type, type of surgical approach and extent of surgery.Methods: We retrospectively analysed 218 patients undergoing open surgery for metastatic spine tumours in our institution between 2005 and 2014. The cohort was divided to those who underwent preoperative embolization and those who did not. The patients were further stratified into different subgroups by tumour types, types of surgical procedure, levels of instrumentation and levels of decompression. Estimated blood loss, duration of surgery and length of hospital stay were compared between embolized and non-embolized cases in each subgroup. The impact of embolization extent, the time gap between embolization and index surgery on blood loss were also studied.Results: Preoperative embolization was performed in 45 out of 218 patients. Non-embolized cases had insignificantly lesser blood loss and shorter duration of surgery compared to embolized cases in all subgroups. Embolization, however, conferred reduction in length of hospital stay in some of the subgroups, yet the differences were not significant. The patients who achieved total embolization bled less than those who achieved subtotal or partial embolization. The effectiveness of the embolization procedure in reducing intraoperative blood loss was found to be profound when the gap between embolization and surgery was within 24 h.Conclusions: Our study demonstrated that success of embolization in reducing blood loss depends on the extent of embolization and time interval between embolization and index surgery. [ABSTRACT FROM AUTHOR]

Purpose: To retrospectively evaluate the diagnostic role of the contrast-enhanced MRI (CE-MRI) for differentiation between benign VCFs and malignant VCFs focusing on the internal transparent trabecular bone on CE-MRI (the "see-through sign").Materials and Methods: The institutional review board approved this study and informed consent was waived due to the retrospective nature of the study. From January 2012 to December 2013, all 149 consecutive benign or malignant VCF patients were enrolled for consideration in this study from a CE-MRI database. In the first analysis, four radiologists independently evaluated the presence or absence of the see-through sign. The see-through sign was defined as internal transparent trabecular bone morphology on CE-MRI. The intraclass correlation coefficient (ICC), percentage agreement, and Fleiss's kappa statistics were obtained.Results: Fifty-seven patients (M:F = 27:30; mean age, 63 years; age range, 20-88 years) who diagnosed as acute benign (n = 24) and malignant (n = 33) VCFs were finally included for the analysis. The results of all readers showed that the see-through sign was associated with acute benign VCFs (p < 0.05). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of the see-through sign ranged from 75-96, 70-88, 66-85, 81-97 %, respectively. The inter-observer reliability of the see-through sign was sufficient with ICC = 0.847, percentage agreement = 78.9, and κ = 0.578.Conclusion: The see-through sign on CE-MRI is featured in acute benign VCFs, and it can be a useful finding to differentiate between benign and malignant VCFs. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care.Method: We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags.Results: We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided.Conclusion: A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking. [ABSTRACT FROM AUTHOR]

Purpose: This prospective study analyzes clinical characteristics and outcomes of sacral extradural spinal meningeal cysts (SESMC) without spinal nerve root fibers (SNRF) undergoing neck transfixion.Methods: Using the relationship between the cysts and SNRF, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. If the SESMCs were identified as those without SNRFs, the neck of the cyst was transfixed, ligated and the remaining cyst wall removed distal to the clip. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological functions of the patients.Results: Twenty-seven patients were included in this study. The average age was 42.7 ± 11.93 years. The mean preoperative IJOA score was 17.5 ± 2.47, and postoperative IJOA score was 19.1 ± 1.41. The difference between preoperative and postoperative IJOA scores was statistically significant (t = -3.75, P = 0.001), with a significant improvement in neurological function after surgery. Among the improvements in neurological function, the most significant was bowel/bladder function (z = -2.33, P = 0.02).Conclusion: Most patients experienced significant improvement in their neurological function after surgery. The most significant area of neurological improvement was bowel/bladder dysfunction, however, preoperative stool or urine incontinence did not recover completely. [ABSTRACT FROM AUTHOR]

Purpose: Total en bloc spondylectomy (TES) is a surgical procedure performed to achieve complete resection of an aggressive benign spinal tumor or a malignant spinal tumor. When reconstructing the spine after resection, we have been using liquid nitrogen-frozen resected spine bearing tumor as a bone graft, expecting an immunological response to tumor-specific antigen(s). The purpose of this article is to report a successful treatment case of lung adenocarcinoma metastasis with TES and this cryotherapy.Methods: A 59-year-old male presented with rapid progression of neurological deterioration of the lower limbs due to a spinal metastasis from T8 to T10. The primary lung adenocarcinoma had already been excised under thoracoscopy. The patient underwent TES with reconstruction using frozen tumor-bearing vertebra for the bone graft.Results: One month after surgery, a new nodule appeared at the right middle lobe of the lung. However, we carried out no biopsy of the newly emerged nodule and the patient received no adjuvant chemotherapy or radiotherapy. Six months after surgery, the tumor vanished. No local recurrence or metastasis of the tumor has been observed until now.Conclusions: TES with a liquid nitrogen-frozen tumor specimen could be a promising therapeutic option for cancer patients with spine metastasis. [ABSTRACT FROM AUTHOR]