Objective

To evaluate functional and oncological outcomes following sacral resection

Objective

To evaluate functional and oncological outcomes following resection of sacral tumours and discuss the strategies for instrumentation.

To review indications, complications and outcome for revision surgery in metastatic spinal disease.

Retrospective review of casenotes and radiographs.

13 patients (9 male, 4 female) identified from a cohort of 222 patients who underwent surgery for spinal tumours between 1994- 2001.

Indication for revision, complications, survival. Further recurrence (same or different level). Further surgery, neurological grade and pain score.

Of 13 patients (4 Renal, 6 breast, 2 prostate, 1 myeloma) one is alive 101 months following revision. Two have been lost to follow up, 10 have died (mean survival 25.3 months post op). The mean time between primary and revision surgery was 10 months (range 1- 32 months)

4 disease progression (same level), 4 new level disease, 3 loss of fixation, 1 radiological collapse, 1 progressive kyphus. Approaches used: 4 anterior, 8 posterior, 1 posterior + anterior. The mean number of levels which required instrumentation on revision was 5.

Modal pain score pre op 5, modal post op 3, minimum one point improvement. Preop modal Frankel grade E, postoperatively all preserved or improved one grade. Modal Karnofsky score preop 70 (30- 90), postop 80 (40-90)- all but one at least 10 point increase. Complications: 1Dural tear, 1 bacteraemia, 1 chylothorax, 1 loss of fixation. 3 patients required further surgery (range 4 months- 18 months, mean 11 months)

Patients with metastatic disease may benefit from second procedures for recurrent disease whether locally or distant with excellent survival, low complications and good function.

To evaluate functional and oncological outcomes following resection of primary malignant bone tumours.

Primary malignant tumours of the sacrum are rare, arising from bony or neural elements, or bone marrow in haematological malignancies.

Management of these lesions is dictated by anatomical considerations and the behaviour of tumours. The three key issues which arise are the adequacy of tumour resection, mechanical stabilisation and the need for colostomy.

A retrospective review of the surgical management of primary malignant sacral tumours from 2004 - 2009.

The study included 46 patients (34 males, 12 females) with an average age of 49 (range 7 – 82). Median duration of symptoms before presentation was 26 months.

10 patients had inoperable tumours at presentation. 6 patients had chemotherapy. 2 patients opted for palliative radiotherapy. 1 patient was unfit for surgery.

25 patients (54%) underwent surgical resection. 8 underwent instrumented stabilisations with fibula strut graft vs. 17 uninstrumented.

Colostomy was performed in 10 patients (40%). Mean follow post-operatively was 19.0 months.

Wound healing problems were present in 5/25 (20%). There was no difference in infection rates between definitive surgery with and without colostomy. Mechanical failure of stabilisation was noted in 75%. There was one peri-operative death.

Local recurrence occurred in 12%(3/25) of operated patients although follow-up period was noted to be short.

Mechanical stabilisation for extensive lesions in the sacrum are particularly challenging in tumour surgery. Despite radiological failure in 7/8 instrumented stabilisations, patients were relatively asymptomatic and only 1/8 required revision stabilisation surgery.

Ethics approval: None: Audit Interest Statement: None

We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques.

Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups.

Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group.

We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope.

Study Design: A retrospective review of case notes and histology reports.

Summary of Background Data: Up to 8% of cancer patients develop second malignancies. The vertebral column is frequently involved in metastatic disease and may represent the first manifestation of malignancy in up to 40% of patients. The rate of vertebral metastasis from a second tumour in patients with a known primary is not well known.

Objective: We sought to identify the incidence of a second primary in patients referred to our unit with spinal malignancy and a previously diagnosed primary tumour.

Subjects: 222 patients underwent definitive surgery for spinal metastatic disease of whom 135 had a prior history of malignancy.

Outcome measures: Histological tissue of origin of spinal metastasis in light of previous known malignancy.

Results: In 16 patients (11.9%) the vertebral histology differed from the initial primary. The period between first and second malignancies varied widely (19 months – 22 years). Thirteen patients (9.6%) had identifiable tissue origins for the metastasis that was not in keeping with the previous malignancy. Three further patients showed sufficient histological and imunohistochemical differences such that a further tumour of unknown origin and not de-differentiation of the previous tumour was suspected. Three previously unrecognised tumours were diagnosed on biopsy and eight on tissue obtained at definitive surgery.

Conclusion: The incidence of second primaries, in particular myeloma, presenting with vertebral metastases is significant and should always be borne in mind when assessing patients and planning treatment. Biopsy should be performed when possible. Comparison needs to be made between the histological features of the previous primary and metastasis.

Aims: The validation of two previously published prognostic scoring systems in relation to survival following surgery for metastatic disease of the spine. Methods: 169 patients operated upon for metastatic disease of the spine were retrospectively reviewed and prognostic scores calculated according to the systems of Tokuhashi and Tomita. Surgical approach and strategy, complications and reoperations were also recorded. Patient survival was compared by prognostic group and surgical strategy within and between the two systems. Results: 126 patients were conþrmed dead at a mean of 8.3 months and 43 alive at a mean 31.2 months. Patients with Tokuhashi scores of 9–12 had 50% survivial of 23 months compared to 5 months and 2 months for scores of 5–8 and 1–4 respectively (p< 0.05). Tomita scoring showed a similar trend with 50% survivals of 15 and 5 months for predicted long and medium term groups (p< 0.05). Each prognostic parameter was signiþcantly related to survival for both systems. There was no difference in survival within the better prognostic groups in relation to surgical stratergy. Tomitañs system was less sensitive to early mortality. Conclusions: Both systems are potentially useful in deciding the suitability for surgery in patients with metastatic spinal disease. There use in the emergency, unstaged patient has not been validated here. They may help in comparing patient status in future studies allowing more meaningful analysis of data.