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Modern Approaches to Spinal Modern Approaches to Spinal Tumor SurgeryTumor Surgery

Christopher Ames MDChristopher Ames MDDirector Director

Spinal Tumor and Deformity ServiceSpinal Tumor and Deformity ServiceCoCo--Director Director NeurospinalNeurospinal DisordersDisordersUCSF Department of NeurosurgeryUCSF Department of Neurosurgery

OrganizationOrganization--TalkTalk

TranspedicularTranspedicular approach for ventral approach for ventral intraduralintradural tumorstumorsTranspedicularTranspedicular CorpectomyCorpectomyEn Bloc ResectionEn Bloc ResectionEn Bloc En Bloc SpondylectomySpondylectomyEn Bloc Complete En Bloc Complete SacrectomySacrectomyCombined Combined SacrectomySacrectomy/Pelvic Resection/Pelvic Resection

Skull Base Surgery for Skull Base Surgery for the Spinethe Spine

DefinitionDefinition

Minimize or eliminate neural element Minimize or eliminate neural element retraction retraction Accomplish this by maximizing Accomplish this by maximizing exposure through resection of boneexposure through resection of boneIntimate knowledge of local anatomy Intimate knowledge of local anatomy and tumor anatomy allows selection of and tumor anatomy allows selection of optimum approach corridor optimum approach corridor

Application to SpineApplication to Spine

Previous approach to ventral and Previous approach to ventral and ventral lateral ventral lateral intraduralintradural tumorstumors–– LaminectomyLaminectomy and and FacetectomyFacetectomy–– Cut nerve roots Cut nerve roots ––C1C1--C4, T2 and belowC4, T2 and below–– Dentate ligament section and cord Dentate ligament section and cord

rotation/retractionrotation/retraction–– NeuromonitoringNeuromonitoring SSEP/MEP/EMG to alert SSEP/MEP/EMG to alert

to potential problems to potential problems while problem is still while problem is still reversiblereversible

Direct Anterior ApproachDirect Anterior ApproachAccess corridor is deep and narrow for Access corridor is deep and narrow for cervical approachcervical approach——i.e. i.e. corpectomycorpectomyProblematic for multilevel casesProblematic for multilevel cases——sacrificing sacrificing significant anterior column bone to access significant anterior column bone to access lesionlesionCome right down on the tumorCome right down on the tumor——dondon’’t t visualize normal anatomy firstvisualize normal anatomy firstDifficult Difficult duraldural reconstructionreconstructionProbably best used only for single level, Probably best used only for single level, purely ventral lesions purely ventral lesions ––lateral component lateral component may be challenging to reachmay be challenging to reach

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Limitations of Traditional Posterior Limitations of Traditional Posterior ApproachApproach

Poor visualization of tumorPoor visualization of tumorConstant cord retraction in order to Constant cord retraction in order to workworkBlood loss from internal tumor Blood loss from internal tumor debulkingdebulkingNo working roomNo working roomMEP changes may be sudden and MEP changes may be sudden and irreversibleirreversible

NeuromonitoringNeuromonitoring ChangesChanges

Cord already compromised and now Cord already compromised and now must be retracted and rotatedmust be retracted and rotatedBlood loss and hypotension during Blood loss and hypotension during resectionresectionNerve root EMG activity of unclear Nerve root EMG activity of unclear significancesignificance

New TechniqueNew Technique

Lateral Lateral ParamedianParamedian TranspedicularTranspedicularApproach for Approach for IntraduralIntradural TumorsTumors

Spine March 15 2007

Cervical Spine Presents Unique Cervical Spine Presents Unique ChallengesChallenges

Where is the lesion??

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Necessity of Necessity of PediculectomyPediculectomy

Increased working roomImproved nerve root mobilization

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Vertebral Artery Mobilization/Dorsal Vertebral Artery Mobilization/Dorsal CorpectomyCorpectomy (working room)(working room)

Remove with Lempert or upbiting pituitary

Partial Partial CorpectomyCorpectomy TechniqueTechnique DuralDural H FlapH Flap

Downward Downward duraldural traction traction ““deliversdelivers””tumor en bloc away from cordtumor en bloc away from cord Table Rotation Improves ViewTable Rotation Improves View

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Case 1Case 1

18 18 y.oy.o. female about to begin college . female about to begin college with mild LE weakness, right hand with mild LE weakness, right hand weaknessweakness

Case 2 –after bone and pedicle resection prior to table rotation

After table rotation and tumor After table rotation and tumor resectionresection Case 1 ReconstructionCase 1 Reconstruction

Case 2Case 2

38 38 y.oy.o. mother of 2 with progressive LE . mother of 2 with progressive LE weaknessweaknessPMH: NF1PMH: NF1

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Visualization Visualization and Working and Working SpaceSpace

Case 3 Large but LateralizedCase 3 Large but Lateralized

Reconstruction TechniqueReconstruction Technique

Significant vertebral column resection Significant vertebral column resection results in instabilityresults in instabilityLoss of posterior fusion surface Loss of posterior fusion surface Loss of fixation points in lateral mass and Loss of fixation points in lateral mass and pediclespediclesNeed to engage anterior column for Need to engage anterior column for lordosislordosis restorationrestoration

Translational WorkTranslational Work--TechniquesTechniques ReconstructionReconstruction

Artificial pedicle screws Artificial pedicle screws –– Requires only vertebral bodyRequires only vertebral body–– Cortical Cortical –– Control of anterior column for reductionControl of anterior column for reduction–– Placed under direct vision, no danger toPlaced under direct vision, no danger to

vertebral arteryvertebral arteryMay also be used for fractured lateral May also be used for fractured lateral mass bailout for routine pathologymass bailout for routine pathology

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Artificial Pedicle ScrewsArtificial Pedicle Screws VA APS

Construct ShorteningConstruct Shortening

LordosisLordosis Restoration with APSRestoration with APS Fusion SurfaceFusion Surface

BMP-2 Local autograft

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TranspedicularTranspedicular CorpectomyCorpectomyfor for MetastaticMetastatic DiseaseDisease

TokuhashiTokuhashi Scoring systemScoring system(who we operate on)(who we operate on)

1. Who to operate on2. How much surgery to do

TokuhashiTokuhashi Scoring System for Scoring System for MetastaticMetastaticSpine Tumor Prognosis Spine 2005Spine Tumor Prognosis Spine 2005

TokuhashiTokuhashi score and survival score and survival validationvalidation •62F metastatic breast CA

•s/p T2-T3 laminectomy and tumor debulking 1 month ago at outside institution•1 week history of increasing pain and LE weakness•Disease otherwise controlled

T2, T3, T4

TranspedicularTranspedicular corpectomycorpectomy

Eliminates need to open sternum or Eliminates need to open sternum or thoracic cavitythoracic cavityAllows complete Allows complete vertebrectomyvertebrectomy over 1, 2, over 1, 2, 3 or more levels3 or more levelsSimultaneous anterior and posterior Simultaneous anterior and posterior column reconstructioncolumn reconstructionCan be used in cervical, thoracic and Can be used in cervical, thoracic and lumbar spinelumbar spineExpandable cages very beneficial hereExpandable cages very beneficial here

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Posterior ApproachesPosterior Approaches

TranspedicularTranspedicular CorpectomyCorpectomy–– C7C7--L5 L5 –– C2C2--C6 with unilateral vertebral sacrificeC6 with unilateral vertebral sacrifice–– One approach reconstructs anterior and One approach reconstructs anterior and

posterior columnsposterior columns–– The most extensileThe most extensile–– No difficulty with instrumentation placement No difficulty with instrumentation placement

around great vesselsaround great vessels

TechniqueTechnique

TechniqueTechnique TechniqueTechnique

TechniqueTechnique TechniqueTechnique

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TechniqueTechnique TechniqueTechnique

TechniqueTechnique TechniqueTechnique

T2, T3, T4 T2

SternotomySternotomy

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T2

HemiHemi--clamshell/Trapdoorclamshell/Trapdoor

T2

T6

Trapdoor/Trapdoor/HemiclamshellHemiclamshell LimitsLimits

T1 corpectomy-low anteriorCervical/manubrectomy

T2-3 Sternal Split

T4 High Lateral Thoracotomy

TranspedicularCorpectomy

HemiClamshell/Trapdoor

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OutcomeOutcome

Strength dramatically improvedStrength dramatically improvedNow ambulatingNow ambulatingDCDC’’dd to rehab POD #5to rehab POD #5

TPC Case Example 2TPC Case Example 2

63 63 yoyo male, LE male, LE weakness, renal CAweakness, renal CATPC @ L3? L2? L1?TPC @ L3? L2? L1?T1?T1?

S1

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En Bloc ResectionEn Bloc Resection

Mayo 2005 Mayo 2005 ChordomaChordoma

Translational WorkTranslational Work--TechniqueTechnique

JCNS 2007

BorianiBoriani ClassificationClassification

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H and PH and P

44 44 yoyo female with r le weakness female with r le weakness Q/TA/EHL 4/5Q/TA/EHL 4/5Referring DXReferring DX--benign nerve sheath tumor, benign nerve sheath tumor, neurofibromaneurofibroma

PlanPlan

Needle Needle bxbx––LeiomyosarcomaLeiomyosarcoma ––medium medium gradegrade

TXTX

En bloc posterior resection with L5 En bloc posterior resection with L5 hemicorpectomyhemicorpectomy via via sagittalsagittal osteotomyosteotomySacrifice of R L4, L5 rootsSacrifice of R L4, L5 rootsAnteriorAnterior--Ex Lap, Ex Lap, bxbx nodes, completion nodes, completion corpectomycorpectomy for reconstruction, IORTfor reconstruction, IORT

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En Bloc En Bloc SpondylectomySpondylectomy

En Bloc En Bloc SpondylectomySpondylectomy

Complete removal of vertebral segment in Complete removal of vertebral segment in 2 pieces2 piecesMinimize violation of tumor to prevent Minimize violation of tumor to prevent seedingseedingApplication of surgical Application of surgical oncologicaloncologicalprincipals to spinal oncologyprincipals to spinal oncologyChordomaChordoma, , OsteosarcomaOsteosarcoma, , ChondrosarcomaChondrosarcoma, ? Isolated , ? Isolated metastaticmetastaticdiseasedisease

En Bloc En Bloc SpondylectomySpondylectomy

Boriani Spine 1997

Enneking Staging

En Bloc En Bloc SpondylectomySpondylectomy

WBB Surgical Staging

H and PH and P

45 45 y.oy.o male presents with a 6 month male presents with a 6 month history of T/L junction painhistory of T/L junction painNeuroNeuro exam is normalexam is normal

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Needle BX Chondrosarcoma

SpondylectomySpondylectomy TechniqueTechnique

1. Single stage, posterior1. Single stage, posterior–– High to mid thoracicHigh to mid thoracic

2. 2 stage, posterior/anterior2. 2 stage, posterior/anterior–– Lower thoracic, lumbarLower thoracic, lumbar

Single stage, posteriorSingle stage, posteriorHigh to mid thoracicHigh to mid thoracic First StepFirst Step--pass wire sawpass wire saw

Divide SegmentalsFirst!!

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Single stage, posteriorSingle stage, posteriorHigh to mid thoracicHigh to mid thoracic

Back to our caseBack to our case2 stages since T122 stages since T12Larger bodyLarger bodyAny ? Of anterior Any ? Of anterior vessel attachmentsvessel attachments

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Posterior instrumentation already in Posterior instrumentation already in placeplace--no ability to distract and no ability to distract and

compresscompress

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En Bloc Resection for Isolated En Bloc Resection for Isolated MetastaticMetastatic DiseaseDisease

Tomita JSD 2004 12 ptsTomita JSD 2004 12 pts17% Local recurrence rate overall17% Local recurrence rate overall50% recurrence rate if 50% recurrence rate if paraspinalparaspinalextensionextensionInvolvement of pedicle did not effect Involvement of pedicle did not effect recurrence raterecurrence rate

Translational WorkTranslational Work

JCNS 2007 in press

Cervical Spine En Bloc Tumor ResectionCervical Spine En Bloc Tumor Resection

ApproachesApproaches

TransmandibularTransmandibular TransglossalTransglossalTransmandibularTransmandibular Retropharyngeal Retropharyngeal CircumglossalCircumglossal

ApproachApproach

TransoralTransoralTransoralTransoral c c trachtrachTransoralTransoralTransmandibularTransmandibularTransoralTransoralTransglossalTransglossalTransoralTransoralTransmaxillaryTransmaxillaryTransmandibularTransmandibularCircumglossalCircumglossal

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H and PH and P

50 50 yoyo malemaleSevere neck painSevere neck painU/LE weakness 3U/LE weakness 3--4/54/5PMH (PMH (--))Underwent a C1Underwent a C1--C4 PSF/PSI for a C4 PSF/PSI for a ““C2 C2 lesionlesion”” at other facilityat other facilityBX at UCSFBX at UCSF--ChordomaChordoma

En Bloc Resection En Bloc Resection TransoralTransoral

Posterior vertebral mobilization bilateral Posterior vertebral mobilization bilateral C1C1--C3C3OCCOCC--Thoracic fusionThoracic fusionTransmandibularTransmandibular transglossaltransglossalAnterior vertebral mobilizationAnterior vertebral mobilizationEn Bloc marginal resection C2 bodyEn Bloc marginal resection C2 bodyASI C1ASI C1--C3C3

RV LV

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6 months later6 months later 6 months6 months

Cervical Case Example 2Cervical Case Example 2

Needle Bx Chordoma

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TransmandibularTransmandibular CircumglossalCircumglossal Posterior L Vertebral Artery Posterior L Vertebral Artery Occlusion/R Vertebral MobilizationOcclusion/R Vertebral Mobilization

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En Bloc En Bloc SacrectomySacrectomy--Technique Technique EvolutionEvolution

Anterior StageAnterior Stage--no no osteotomyosteotomy--just just DiscectomyDiscectomy L5L5--S1, nerve mobilization, S1, nerve mobilization, sacrifice and protection, sacrifice and protection, silasticsilastic sheetsheet

PosteriorPosterior--no no transiliactransiliac bar, anchoring of bar, anchoring of femur into pelvis with AO screws, BMPfemur into pelvis with AO screws, BMP--22

H and PH and P

63 63 yoyo male with sacral pain and left leg male with sacral pain and left leg painpainNeuroNeuro examexam–– Bilateral S1 4/5Bilateral S1 4/5–– Decreased Decreased perinealperineal sensationsensation

Sacral Sacral ChordomaChordoma

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Original Resection TechniqueOriginal Resection Technique

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ReconstructionReconstruction

GokaslanGokaslan TechniqueTechnique

ISSLS Prize 2005ISSLS Prize 2005

Radiated 14 days after surgery –BMP-2

Advances in challenging Advances in challenging reconstructionsreconstructions

6 level corpectomy

BMP-2

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Early Fusion after proton beamEarly Fusion after proton beam Clinical Use of BMPClinical Use of BMP--2 with Post op 2 with Post op XRT/Proton BeamXRT/Proton Beam

Rh-BMP-2 in Femur

En Bloc Resection of Lateralized En Bloc Resection of Lateralized Sacral LesionsSacral Lesions

Low Grade Low Grade ChondrosarcomaChondrosarcoma Anterior Marking for Tumor Anterior Marking for Tumor BoundaryBoundary

SIJ

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Posterior Guided Posterior Guided OsteotomyOsteotomy

UCSF UCSF NeurospineNeurospine

Thanks for your attentionThanks for your attention