Surgical Treatment of Spine Surgery Experience Primary Spinal Neoplasms ( ) Ziya L. Gokaslan, MD, FACS Approximately 3500 spine tumor

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1 Surgical Treatment of Primary Spinal Neoplasms Ziya L. Gokaslan, MD, FACS Donlin M. Long Professor Professor of Neurosurgery, Oncology & Orthopaedic Surgery Vice Chairman Director of Spine Program Department of Neurosurgery Johns Hopkins University Baltimore, Maryland Ian Suk, BSc., BMC Assistant Professor Medical Illustrator Depts.-Neurosurgery/AAM Spine Surgery Experience ( ) Approximately 3500 spine tumor operations Metastatic - 91% Primary - 9% Surgical Approaches Anterior - 36% Posterior - 64% Combined - 5% PRIMARY TUMORS Osteoma/osteoid Osteoma/osteoblastoma Giant cell tumor* Aneurysmal bone cyst* Hemangioma*/Hemangiopericytoma* CHORDOMA CHONDROSARCOMA Osteogenic Sarcoma Ewing s Sarcoma 1

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5 MANAGEMENT OF COMPLEX SPINE TUMORS GENERAL CONSIDERATIONS METASTATIC TUMORS Tumor Type Goal of Treatment Adjuvant Therapy Options Potential Morbidity Type of Surgery Primary vs. Metastatic Cure vs. Palliation Yes/No Minimal/Significant Intralesional vs. En bloc Goal Palliation Adjuvant Therapy - Available Surgical Technique - Intralesional 5

6 PRIMARY TUMORS Goal Cure/Long Term Survival Adjuvant Therapy Limited Surgical Technique En bloc Primary Bone Tumors Lessons from Long Bones High propensity for local recurrence Usually due to incomplete surgical resection via intralesional techniques En bloc technique is superior for primary malignant bone tumors outside the spine Oncological and clinical outcomes following attempted en bloc sacrectomy with judicious sacral nerve root preservation for primary malignant sacral tumors. Spine 2009 Sep 15;34 (20):

7 Oncological and clinical outcomes following attempted en bloc sacrectomy with judicious sacral nerve root preservation for primary malignant sacral tumors. Spine [In Press] Method of Resection Correlates Strongly with Disease-Free Survival Boriani et al, SPINE 21: ,

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9 Fourney DR, York JE, Cohen ZR, Suki D, Rhines LD, Gokaslan ZL. Management of atlantoaxial metastases with posterior occipitocervical stabilization. J Neurosurg Spine : Summary of diagnostic, pre-, and postoperative data in 19 patients with atlantoaxial region metastases* Pre op 18 mos Post op (Pt refused XRT or Chemo) Age Preop Status Operation Postop Status (1 mo) (yrs), Postop Follow Up Sex Tumor Type Location VAS Med Frkl Resection Fusion Complication VAS Med Frkl Instability (in mos) 43, F breast met C E no Oc C4 none 3 4 E no 4 (died) 74, M prostate met C E no Oc C5 none 5 4 E no 2 (died) 48, M osteosarcoma C E C-2 Oc C5 none 3 2 E no 4 (died) met lami, DTR 74, M renal met C E no Oc C5 bacteremia 5 4 E no 1 (died) 53, F breast met C E C-1 lami Oc C4 none 5 4 E no 32 (died) 82, M renal met C E no Oc C6 none 3 3 E no 4 (died) 64, F breast met C D C-2 lami Oc C6 none 1 3 D no 4 (died) 43, F breast met C E no Oc C5 none 4 4 E no 18 69, F lung met C E C-2 lami, Oc C5 none 3 4 E no 1 (died) DTR 71, F lung met C E no Oc C4 none 2 4 E no 2 (died) 68, M lymphoma C E no Oc C4 meningitis 1 3 E no 25 66, M lung met C E no Oc C4 none 3 4 E no 6 (died) 85, M prostate met C E no Oc C5 none 4 3 E no 2 (died) 45, M renal met C E no Oc C5 none 3 3 E no 13 (died) 44, F cholangiocarcinoma C E no Oc C4 none 5 4 E no 8 (died) 61, F breast met C E no Oc C4 none 1 3 E no 6 (died) 57, F multiple myeloma C E no Oc C6 none 3 3 E no 7 43, M renal met Oc C1 9 4 E no Oc C4 none 1 4 E no 3 65, M renal met C E no Oc C7 none 1 1 E yes 13 * DTR = dorsal tumor resection; Frkl = Frankel grade (E, normal function; D, useful motor function); lami = laminectomy; met = metastasis; Med = medication (categories described in Table 1). No change in Frankel grades from preoperative levels during follow-up evaluations at 1, 3, and 6 months, at 1 year, and every 6 months thereafter. Pathological fracture of dens with C2 5 epidural disease. At 11 months after surgery, progression of disease at C-2 resulted in painful instability; revision of the construct and extension of the fusion to T-2 was performed (see text for details). 9

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11 Silastic sheath T9 Occiput 11

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13 Tumor Top of the tumor 13

14 L Vertebral artery 14

15 Pathology 15

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27 Conclusions Understanding the biology of spinal tumors is critical in defining the goal of treatment in a given patient and determining the most appropriate therapy. Conclusions Surgeons dealing with these spinal neoplasms must be familiar with the various surgical approaches and reconstruction techniques in order to provide optimal care for their patients. 27