General Editor: Luiz Vialle

Authors: Ilya Laufer, JJ Verlaan (on behalf of AOSpine Knowledge Forum Tumor)

Metastatic tumors Thoracolumbar, unstable, high ESCC

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Glossary

1 Introduction top

Preoperative planning

Based on CT and MRI imaging, a plan should be prepared to determine:

  • The size and optimal location of implants used
  • Whether spinal cord decompression is necessary and if so, the amount of tissue to remove in order to achieve sufficient spinal cord decompression

Every case will be unique, and we will here illustrate just one example.


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Length of construct and cement augmentation

Bilateral posterior pedicle screw fixation with one or two levels above and below the involved segment should be used.

Fixation of multiple spinal segments does not affect functionality in the thoracic spine due to the presence of rigid rib cage. Adequate screw purchase should be aimed for during initial surgery as revision surgeries are too demanding for these patients.


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Selection of technique

The major posterior approaches to the vertebral body in the thoracic spine are:

  • Transpedicular
  • Costotranversectomy

The costotransversectomy provides a wider working corridor and better exposure of the contralateral vertebral body.

Depending on the desired extent of the vertebral body resection, the surgeon may utilize either approach unilaterally or bilateral transpedicular approach.

We will here demonstrate the use of a bilateral transpedicular approach for the removal of the entire vertebral body.


Use of dexamethasone

Administration of dexamethasone (10 mg bolus, 4 mg every 6 hours) is recommended as soon as ESCC causing neurologic deficit is diagnosed. Dexamethasone should be stopped or tapered as soon as spinal cord decompression is completed.


Embolization

Embolization procedures are recommended to reduce operative blood loss in hyper vascular tumors, especially for larger resections.


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Reconstruction

A corpectomy followed by either PMMA cement (Pins or chest tube) or structural graft/ cage reconstruction can be performed.

2 Patient positioning and surgical approach top

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For this procedure the patient is placed in the  prone position and the posterior midline approach is used.

3 Stabilization top

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Pedicle screw insertion

Pedicle screws are inserted one or two levels above and below the tumor on both sides.

In cases of multilevel tumors or poor bone quality this construct can be extended.

In tumor patients achieving optimal screw purchase is even more important than in trauma patients to minimize risk of pullout.

Optimal pedicle screw purchase will, in order of importance, be achieved by:

  1. Selecting the largest possible screw diameter
  2. Selecting the longest possible screw
  3. Positioning of the screw under the cranial endplate
  4. Cement augmentation of the screw.

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Rod contouring

Rod contouring should mainly follow the curvature of the spine. Reducing preexisting deformities is typically not necessary and may lead to screw pull-out.

For non-fusion surgery, consideration should be given to using larger diameter rods (>6.0 mm) to prevent rod failure.


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Rod insertion and fixation

A unilateral rod is inserted into the screw heads and the screw heads are tightened with the inner nuts.

The contralateral side is used for access to the vertebral body. The second rod is inserted after the completion of vertebrectomy and anterior column reconstruction.

4 Decompression top

Timing of decompression

A patient who is experiencing neurologic deficit from solid tumor ESCC resulting in loss in ability to ambulate, in the absence of medical and oncological contraindications, requires urgent surgical decompression.

Expeditious diagnosis and prompt surgery are recommended to improve the probability of neurological recovery.


Technique

Since most tumors originate in the vertebral body, transpedicular decompression is required in order to provide access to the ventral epidural space to achieve full spinal cord decompression, if this is the goal. In this technique decompression is performed through the pedicle.

This technique can be performed from T1 to L5 levels, without the risk of retracting the thecal sac.


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Based on preoperative planning, the amount of lamina to be removed to achieve enough decompression can be determined beforehand.

A laminectomy is performed to provide full exposure of the tumor, and at least half a level above and below that in order to expose normal tissue planes.

Dissection should start above and below the level of the tumor and then continue into the level affected by the tumor, since the tumor may obscure normal tissue planes.


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The adjacent spinous processes and the intervening ligamentum flavum are excised.

Half of the superior and inferior lamina and the medial portion of the facet joint are removed. 


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For T2-T12 tumors, the nerve roots may be ligated in order to facilitate exposure of the ventral epidural space and the vertebral body.


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The posterior longitudinal ligament (PLL) should be identified and separated from the dura with a dura dissector. The PLL should be cut in order to expose the vertebral body and the epidural tumor.

The spinal cord, dura, and tumor should be manipulated as little as possible.


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In the thoracolumbar/lumbar spine, the disc is often removed by incising the annulus fibrosus and using a series of Kerrison rongeurs and curettes to remove the disc up to the anterior longitudinal ligament.


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Reverse-angle curettes and pituitary rongeurs can be inserted through the opening in the PLL, to remove the vertebral body.


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Anterior reconstruction of the vertebral body following a complete corpectomy can be performed using a prosthesis and/or PMMA.

This reconstruction generally requires unilateral sacrifice of the thoracic nerve root.


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Once the anterior reconstruction is complete, the second rod is inserted and fixed in place.

5 Fusion top

Decision

Life expectancy and performance status should be used to determine whether bone grafting is indicated.

For patients with good prognosis and a long life-expectancy, posterior fusion may optionally be performed using allograft and/or local autograft.


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Fusion

If the surgeon plans for a fusion, the facet capsule is excised, and the joint cartilage surfaces and posterior cortex are denuded/curetted.


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Pieces of bone graft (autograft, allograft) are inserted into the decorticated facet joint for fusion.

6 Intraoperative imaging top

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Prior to wound closure, intraoperative imaging is performed to check the adequacy of reduction, position, and length of screws and the overall coronal and sagittal spinal alignment.

V1.0 2019.01.06