Abstract
Introduction
The technical challenges facing the spinal surgeon performing a wide vertebral resection are the relationship of proximity, contiguity, and sometime invasion of great vessels, the parenchymal organs, chest wall, and the central, and peripheral nervous system.
Materials and Methods
Over the past 14 years (1998–2008), we performed 41 hemi or total multilevel vertebrectomy (two to five vertebrae in a single block), 2 cervical, 25 thoracic, and 14 lumbar, with spine resection varying from a minimum of 3.6 to a maximum of 15 cm. The tumors treated consisted of 28 primary malignant bone lesions (five chondrosarcomas, eight chordoma, four osteosarcomas, four malignant schwannomas, three synovial sarcoma, one fibrosarcoma, one Ewing sarcoma, and two hemangioendothelioma), 7 single metastases from adenocarcinoma (four kidney clear cell, two breast carcinoma, and one thyroid adenocarcinoma), and 6 cases of lung adenocarcinoma. These operations have been often performed in multispecialized team, with a thoracic/vascular/plastic surgeon.
Results
Thoracic locations have often obliged to partial lung resection associated with extended resections of the chest, two or more ribs, for obtaining surgical margins in healthy tissue. These resections required reconstructions with Marlex nets associated with acrylic cement. In one case, a free microvascularized large latissimus dorsi muscle flap was used. In one case of lower lumbar synovial sarcoma (L3–L4), an associated resection in a single stage of the aortic bifurcation involved by the tumor with the two vertebrae was required. Major vascular axis was so replaced with an aortoiliac bypass. We have systematically performed a 360-degree circumferential reconstruction, linking the short anterior reconstruction to the long posterior hardware, than giving to the entire instrumentation the final compression. The final stability over time has been systematically performed with an anterior interbody fusion between the vertebrae adjacent to the resection, obtained with the iliac autograft with which we have filled different anterior devices (carbon cages, titanium cages, and massive homograft bank) used over the years. The serious complications that we had were as follows: mechanical remote (two cases of kyphosis with severe instability), infectious (six cases, five of which healed with revision surgery), iatrogenic (four cases of injuries to the thoracic duct, all resolved without surgical revision), neurological (five cases of paraparesis, including three with partial recovery at a distance), three local recurrences, one major vascular complication (rupture of an aorta previously irradiated at 25 days postsurgery), and two deaths in the first 30 days
Discussion
The high-complication rate in our series is explained by the complexity of this type of surgery, which however allows oncological results close to those that we gain in complex reconstructions of the upper and lower limbs.