Strategy in the surgical treatment of primary spinal tumors

Abstract

Primary spine tumors are rare, accounting for only 4% of all tumors of the spine. A minority of the more common primary benign lesions will require surgical treatment, and most amenable malignant lesions will proceed to attempted resection. The rarity of malignant primary lesions has resulted in a paucity of historical data regarding optimal surgical and adjuvant treatment and, although we now derive benefit from standardized guidelines of overall care, management of each neoplasm often proceeds on a case-by-case basis, taking into account the individual characteristics of patient operability, tumor resectability, and biological potential. This article aims to provide an overview of diagnostic techniques, staging algorithms and the authors' experience of surgical treatment alternatives that have been employed in the care of selected benign and malignant lesions. Although broadly a review of contemporary management, it is hoped that the case illustrations given will serve as additional "arrows in the quiver" of the treating surgeon.

Keywords: primary tumors; spinal tumors.

Figure 1

This radiological appearance was considered likely to be a neural sheath tumor. Biopsy revealed chordoma.

Figure 2

The “owl eye sign” (arrow) in a patient with a left L3 Ewing's sarcoma.

Figure 3

Advanced osteoporosis postchemotherapy causing “fish spine” in a 16-year-old male.

Figure 4

Tomita's surgical classification of spinal tumors.

Figure 5

Tomita's view of transpedicular tumor division in the technique of total en bloc spondylectomy (TES).

Figure 6

Osteoid osteoma left L3 pedicle with hypertrophic transverse process (arrow).

Figure 7

T11 hemangioma with pathological fracture.

Figure 8

Postoperative images (case 1).

Figure 9

Intraoperative view T10 hemangioma showing typical cavernous appearance of the involved bone (arrow).

Figure 10

C2 pathological fracture through fibrous dysplasia. Note the congenital fusion of C2 and C3. Congenital fusion is a common association of cervical fibrous dysplasia.

Figure 11

Postoperative reconstruction after excision of C2 fibrous dysplasia.

Figure 12

Large posterior cervical solitary fibrous tumor in a 37-year-old man.

Figure 13

Schematic representation of technique of pedicular division to facilitate wide excision of tumor extending to the dorsal surface of the cervical laminae.

Figure 14

Postoperative image after resection of cervical benign fibrous tumor.

Figure 15

Large chordoma emanating from the left side of C3–4 intervertebral foramen.

Figure 16

Marked reduction in Ewing's tumor volume following neoadjuvant chemotherapy.

Figure 17

Reconstruction following en bloc excision of L3 Ewing's sarcoma.

Figure 18

Large left thoracic mass lesion.

Figure 19

Large chondrosarcoma involving the left fifth rib and posterior chest wall.

Figure 20

Resected specimen involving T6–8 vertebral bodies and ribs 5–9.

Figure 21

Extensive right paravertebral osteogenic sarcoma L2 vertebra.

Figure 22

Resected specimen: osteogenic sarcoma L2 vertebra. Note extensive resection of right paravertebral muscle column.

Figure 23

Loss of sagittal and coronal balance 12 months after massive resection of L1 vertebral osteogenic sarcoma. Note that the deformity occurred inferior to the resected/reconstructed segment.

Figure 24

Rebalancing procedure in case 7.