Disclosures Treatment of Spinal Malignant and Infectious Etiologies - - PDF document

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Disclosures Treatment of Spinal Malignant and Infectious Etiologies - - PDF document

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Vertebral Column Resection In The Disclosures Treatment of Spinal Malignant and Infectious Etiologies Nuvasive Consultant Intl. Spine Symposium of 4 Univ. Tokyo, Japan, March 30, 2019 Aaron J. Clark, MD, PhD Assistant Professor Department

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Vertebral Column Resection In The Treatment of Spinal Malignant and Infectious Etiologies

  • Intl. Spine Symposium of 4 Univ.

Tokyo, Japan, March 30, 2019

Aaron J. Clark, MD, PhD

Assistant Professor Department of Neurological Surgery University of California, San Francisco

Disclosures

  • Nuvasive ‐ Consultant
  • Background

– Pathologies

  • Technique

– Fixation – Decompression – Reconstruction

  • Outcomes

– Intraoperative – Radiographic – Neurologic

Background Background Technique Technique Outcomes Outcomes

  • Background

– Pathologies

  • Technique

– Fixation – Decompression – Reconstruction

  • Outcomes

– Intraoperative – Radiographic – Neurologic

Background Background Technique Technique Outcomes Outcomes

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SLIDE 2
  • Background

– Pathologies

  • Technique

– Fixation – Decompression – Reconstruction

  • Outcomes

– Intraoperative – Radiographic – Neurologic

Background Background Technique Technique Outcomes Outcomes

Background

  • Pathologic fractures can be a source of pain and

disability

– Pain is the most common presenting symptom for spine osteomyelitis and spinal metastatic disease – Neurologic deficit can result from spinal cord compression

  • Pathologic fractures may result in spinal

deformity requiring anterior column reconstruction

Background Background Technique Technique Outcomes Outcomes

Surgical goals

  • Spinal cord

decompression

  • Removal of pathologic

tissue

  • Arthrodesis
  • Maintenance/improve

ment in sagittal alignment

Background Background Technique Technique Outcomes Outcomes

Anterior reconstruction

Background Background Technique Technique Outcomes Outcomes

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SLIDE 3

Background Background Technique Technique Outcomes Outcomes Background Background Technique Technique Outcomes Outcomes

Thoracic corpectomy

  • Risks

– Lung injury – Vascular injury – Pneumothorax

Background Background Technique Technique Outcomes Outcomes

  • Can a large rectangular end plate expandable

cage be safely placed from an all posterior approach?

Background Background Technique Technique Outcomes Outcomes

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SLIDE 4

Background Background Technique Technique Outcomes Outcomes Safaee et al., 2019, Operative Neurosurgery (in press)

Instrumentation levels

  • Resection

– Circumferential bony removal – Levels dictated by spinal cord compression, bony destruction, and/or deformity

  • Fixation

– Increase levels above and below as number of levels resected increases

  • 2‐4 above and below

– Do not terminate at apex of thoracic kyphosis

Background Background Technique Technique Outcomes Outcomes

The use of titanium cages for

  • steomyelitis at UCSF

Background Background Technique Technique Outcomes Outcomes

Aryan et al., 2007

  • 15 patients with osteomyelitis (retrospective)
  • Corpectomy

– One level (1 patient) – Two level (13 patients) – Six level (1 patient)

  • Follow up 11‐33 months

– 0 recurrent infections – 100% fusion rate

Background Background Technique Technique Outcomes Outcomes

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SLIDE 5

The use of titanium cages for

  • steomyelitis at UCSF

Background Background Technique Technique Outcomes Outcomes

Lu et al., 2009

  • 36 patients with osteomyelitis (retrospective)
  • Follow‐up (10‐39 months)
  • 2/36 (5.6%) recurrence

Background Background Technique Technique Outcomes Outcomes

Fixation techniques

  • Pedicle screws
  • Proximal junctional kyphosis prevention

– Transverse process hooks at the cephalad level – Posterior ligamentous complex augmentation

Background Background Technique Technique Outcomes Outcomes

Exposure

  • Wide exposure

– Expose transverse processes at all instrumented levels

  • Expose rib heads at

levels of planned corpectomy

Background Background Technique Technique Outcomes Outcomes

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SLIDE 6

Temporary stablization

  • Stabilize with pedicle

screw based racks

  • Allows controlled

distraction and compression

Background Background Technique Technique Outcomes Outcomes

Decompression

  • Laminectomy

– Involved vertebra – Partial above and below

Background Background Technique Technique Outcomes Outcomes

Decompression

  • Bilateral facetectomy
  • Rib head removal

bilaterally

  • Bilateral pediculectomy

– Usually at least partially destroyed

Background Background Technique Technique Outcomes Outcomes

Rhizotomy

  • Bilateral if possible
  • For T8‐12, temporary

clip for 10 minutes

– Check MEPs every minute

Background Background Technique Technique Outcomes Outcomes

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Rhizotomy

Background Background Technique Technique Outcomes Outcomes

Rhizotomy

Background Background Technique Technique Outcomes Outcomes

  • For 3 level

corpectomies

– Divide 3 nerve roots on

  • ne side

– Divide only one on the

  • ther

Corpectomy

  • Define interval between the PLL and the

thecal sac

  • Annulotomy
  • Remove disc and vertebral body with
  • steotomes

– Be careful to not violate the endplates

  • Once a defect is created, remove the central

region with the impactors

Background Background Technique Technique Outcomes Outcomes

Anterior reconstruction

  • Rectangular footprint

expandable titanium cage

  • Deformity correction

– 3‐5 degrees of kyphotic angulation

  • Spinal shortening

Background Background Technique Technique Outcomes Outcomes

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Final construct

Background Background Technique Technique Outcomes Outcomes

45 patients at UCSF

Background Background Technique Technique Outcomes Outcomes

Variable N=45 Age 58 (16-83) Female gender 23 (51%) Diagnosis Tumor Infection Deformity 23 (51%) 14 (31%) 8 (18%) VCR level Upper thoracic Middle thoracic Lower thoracic Lumbar 10 (22%) 17 (38%) 14 (31%) 4 (9%) Number of VCR One Two Three 24 (53%) 18 (40%) 3 (7%) Number of levels fused 8 (4-15) Procedure duration 264 min (152-437) EBL 1,900 ml (250-4,000) Length of stay 9 (3-37) ICU days 3 (1-36) Follow-up 8 (0-35)

Neurologic changes and complications

Variable N=45 Clinical outcome Improved Stable Worse* 17 (37%) 28 (61%) 1 (2%)* Complications Medical Surgical Return to OR 7 (15%) 7 (15%) 3 (7%)

Complications Description Medical

  • 1. Atrial fibrillation
  • 2. DVT/PE
  • 3. Ileus
  • 4. Delirium
  • 5. C.diff infection
  • 6. Sepsis, prolonged intubation due to

ARDS

  • 7. UTI

Surgical

  • 1. Return to OR for evacuation of

hematoma x2 (occult coagulopathy) with new neurologic deficit

  • 2. Pseudarthrosis with planned revision

surgery

  • 3. Proximal junctional kyphosis (x2)
  • 4. Distal junctional kyphosis
  • 5. Pseudomeningocele requiring

surgical revision

  • 6. Return to OR for wound exploration

and washout of presumed infection

Background Background Technique Technique Outcomes Outcomes

Radiographic improvement

Background Background Technique Technique Outcomes Outcomes

  • 2 cases (4%) of subsidence (endplate violation

during surgery

– 0 progression at 14 and 35 months

Table 2. Radiographic outcomes Radiographic parameter (mean) Preoperative Postoperative Last follow-up Significance (p value) Pelvic incidence 54° 55° 58° 0.448 Pelvic tilt 21° 19° 21° 0.662 Lumbar lordosis 51° 48° 48° 0.799 Thoracic kyphosis 47° 31° 35° 0.007 Global kyphosis 55° 45° 48° 0.100 SVA 3.9 cm 2.5 cm 2.9 cm 0.460 Regional kyphosis 32° 10° 11° <0.001 Thoracic kyphosis = T5-T12 Global kyphosis = T2-T12

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SLIDE 9

Case 1

  • 46 year old male
  • Metastatic

rhabdosarcoma

  • Severe back pain
  • Bilateral leg numbness
  • Hyperreflexia in lower

extremities

Background Background Technique Technique Outcomes Outcomes

Case 1

Background Background Technique Technique Outcomes Outcomes

Case 1

  • T7 pathologic fracture with ventral epidural

tumor and spinal cord compression

  • T7 transpedicular corpectomy, T3‐10 PSF

Background Background Technique Technique Outcomes Outcomes

Case 1

Background Background Technique Technique Outcomes Outcomes

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SLIDE 10

Case 2

  • 53 year old male
  • IV drug use
  • Back pain and leg

numbness

  • MRSA bacteremia and

mitral vegetations

  • 6 weeks IV vanco

Background Background Technique Technique Outcomes Outcomes

Case 2

Background Background Technique Technique Outcomes Outcomes

Case 2

Background Background Technique Technique Outcomes Outcomes

  • T7‐8 pathologic fracture, ventral epidural

abscess, spinal cord compression

  • T7‐8 transpedicular corpectomy, anterior

reconstruction, T3‐11 PSF

Case 2

Background Background Technique Technique Outcomes Outcomes

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SLIDE 11

Case 3

  • 40 year old female

nurse

  • Severe back pain
  • Neurologically intact

Background Background Technique Technique Outcomes Outcomes

Case 3

Background Background Technique Technique Outcomes Outcomes

Case 3

  • T8, 9, 10 pathologic

fractures with epidural tumor and spinal cord compression

  • T8, 9, 10 transpedicular

corpectomies, T5‐12 PSF, kyphoplasties

Background Background Technique Technique Outcomes Outcomes

Case 3

Background Background Technique Technique Outcomes Outcomes

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Conclusion

Background Background Technique Technique Outcomes Outcomes

  • Pathologic fractures may require anterior

reconstruction for deformity correction and spinal cord decompression

  • Large rectangular end plate cages may be

associated with lower rates of subsidence

  • With bilateral rib head resection and

rhizotomy, rectangular end plate cages can be placed from an all posterior approach

Thank you!

  • Course directors

– Chris Ames, MD – Vedat Deviren, MD – Lionel Metz, MD

  • My team

– Tiffany Pong, PA – Diego Esquivel

  • UCSF Neurosurgery

– Mitchel Berger, MD – Michael Safaee, MD

  • UCSF Orthopedic

Surgery

– Murat Pekmezci, MD – Alekos Theologis, MD