Aims

Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

The April 2023 Hip & Pelvis Roundup³⁶⁰ looks at: Do technical errors determine outcomes of operatively managed femoral neck fractures in younger adults?; Single-stage or two-stage revision for hip prosthetic joint infection (INFORM); Fixation better than revision in type B periprosthetic fractures of taper slip stems; Can you maximize femoral head size at the expense of liner thickness?; Plasma D-dimer for periprosthetic joint infection?; How important is in vivo oxidation?; Total hip arthroplasty for HIV patients with osteonecrosis.

Aims. The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. Methods. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. Results. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. Conclusion. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction. Cite this article: Bone Joint J 2023;105-B(2):172–179

Introduction. Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone. Planning Methodology. First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies. Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken. Results. Patient rehabilitated well and was discharged after 42 days. Patient underwent SABR two months post-operatively. Despite left foot drop, she was walking independently 9 months post-operatively. Conclusion. These challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR for maximum local control

Aims. To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection. Methods. In total, 307 patients who underwent TES in a single centre were reviewed retrospectively. There were 164 male and 143 female patients with a mean age at the time of surgery of 52.9 years (SD 13.3). A total of 225 patients were operated on for spinal metastases, 34 for a malignant primary tumour, 41 for an aggressive benign tumour, and seven with a primary of unknown origin. The main lesion was located in the thoracic spine in 213, and in the lumbar spine in 94 patients. There were 97 patients who underwent TES for more than two consecutive vertebrae. Results. Major and minor perioperative complications were observed in 122 (39.7%) and 84 (27.4%) patients respectively. The breakdown of complications was as follows: bleeding more than 2,000 ml in 60 (19.5%) patients, hardware failure in 82 (26.7%), neurological in 46 (15.0%), surgical site infection in 23 (7.5%), wound dehiscence in 16 (5.2%), cerebrospinal fluid leakage in 45 (14.7%), respiratory in 52 (16.9%), cardiovascular in 11 (3.6%), digestive in 19 (6.2%)/ The mortality within two months of surgery was four (1.3%). The total number of complications per operation were 1.01 (SD 1.0) in the single vertebral resection group and 1.56 (SD 1.2) in the group with more than two vertebral resections. Cardiovascular and respiratory complications, along with hardware failure were statistically higher in the group who had more than two vertebrae resected. Also, in this group the amount of bleeding in patients with a lumbar lesion or respiratory complication in patients with a thoracic lesion, were statistically higher. Multivariate analysis showed that using a combined anterior and posterior approach, when more than two vertebral resections were significant independent factors. Conclusion. The characteristics of perioperative complications after TES were different depending on the extent and level of the tumour resection. In addition to preoperative clinical and pathological factors, it is therefore important to consider these factors in patients who undergo en bloc resection for spinal tumours. Cite this article: Bone Joint J 2021;103-B(5):976–983

Abstract. Objectives. To determine the effects of self-management interventions (SMIs) including an exercise component (EC) on low back pain (LBP) and disability and to determine whether SMIs with tailored exercises (TEs) have superior outcomes compared to SMIs with general exercises (GEs). Methods. An electronic systematic search of randomized controlled trials (RCTs) was performed in 5 electronic databases. RCTs compared SMIs with an EC to control interventions. Data were extracted at 3 follow-up points (short-term, intermediate and long-term) and meta-analyses were performed. Reviewed RCTs were divided into subgroups based on whether the EC was tailored or generic. A subgroup meta-analysis was performed at the short-term follow-up to assess whether the SMIs with TEs have superior outcomes compared to SMIs with GEs. Results. 12 original RCTs were included in the review (six including SMIs with TEs) and were of moderate quality. The pooled results revealed the effect sizes (ESs) of −0.26,-0.32 and −0.21 for short, intermediate and long-term pain intensity, respectively and −0.26,-0.22 and −0.21 for short, intermediate, and long-term disability, respectively (negative value indicates a mean difference in favour of SMIs) indicating a moderate but significant reduction in pain and disability compared to controls. Subgroup meta-analysis at the short-term follow-up revealed that SMIs with TEs had ES of –0.19(p=0.004) for pain and –0.20(p=0.002) for disability compared to SMIs with GEs demonstrating positive but not significant improvement in pain (ES −0.48, p=0.09) and disability (ES −0.45, p=0.10). Conclusions. There is moderate quality evidence for SMIs with an EC to have moderate but significant positive effect on pain and disability in people with LBP. The subgroup analysis revealed that SMIs with exercises tailored to person's needs are superior in reducing pain and disability. These results indicate the importance of developing TE solutions supporting self-management to improve its effect on pain and disability in LBP patients. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. The aim of this study was to describe the use of 3D-printed sacral endoprostheses to reconstruct the pelvic ring and re-establish spinopelvic stability after total en bloc sacrectomy (TES) and to review its outcome. Patients and Methods. We retrospectively reviewed 32 patients who underwent TES in our hospital between January 2015 and December 2017. We divided the patients into three groups on the basis of the method of reconstruction: an endoprosthesis group (n = 10); a combined reconstruction group (n = 14), who underwent non-endoprosthetic combined reconstruction, including anterior spinal column fixation; and a spinopelvic fixation (SPF) group (n = 8), who underwent only SPF. Spinopelvic stability, implant survival (IS), intraoperative haemorrhage rate, and perioperative complication rate in the endoprosthesis group were documented and compared with those of other two groups. Results. The mean overall follow-up was 22.1 months (9 to 44). In the endoprosthesis group, the mean intraoperative hemorrhage was 3530 ml (1600 to 8100). Perioperative complications occurred in two patients; both had problems with wound healing. After a mean follow-up of 17.7 months (12 to 38), 9/10 patients could walk without aids and 8/10 patients were not using analgesics. Imaging evidence of implant failure was found in three patients, all of whom had breakage of screws and/or rods. Only one of these, who had a local recurrence, underwent re-operation, at which solid bone-endoprosthetic osseointegration was found. The mean IS using re-operation as the endpoint was 32.5 months (95% confidence interval 23.2 to 41.8). Compared with the other two groups, the endoprosthesis group had significantly better spinopelvic stability and IS with no greater intraoperative haemorrhage or perioperative complications. Conclusion. The use of 3D-printed endoprostheses for reconstruction after TES provides reliable spinopelvic stability and IS by facilitating osseointegration at the bone-implant interfaces, with acceptable levels of haemorrhage and complications. Cite this article: Bone Joint J 2019;101-B:880–888

Aims

The aims of this study were to evaluate the long-term outcome of surgery for bone or soft-tissue metastases from renal cell carcinoma (RCC) and to determine factors that affect prognosis.

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour. Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs. . The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery. Cite this article: Bone Joint J 2014;96-B:1693–8

The main form of treatment of a chordoma of the mobile spine is total en bloc spondylectomy (TES), but the clinical results are not satisfactory. Stand-alone carbon ion radiotherapy (CIRT) for bone and soft-tissue sarcomas has recently been reported to have a high rate of local control with a low rate of local recurrence. . We report two patients who underwent TES after CIRT for treating a chordoma in the lumbar spine with good medium-term outcomes. At operation, there remained histological evidence of viable tumour cells in both cases. After the combination use of TES following CIRT, neither patient showed signs of recurrence at the follow-up examination. These two cases suggest that CIRT should be combined with total spondylectomy in the treatment of chordoma of the mobile spine. Cite this article: Bone Joint J 2013;95-B:1392–5

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss.

We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger’s test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I² = 90%; p < 0.001).

Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.

Cite this article: Bone Joint J 2013;95-B:683–8.

The February 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: the human genome; new RNA; cells, matrix and gene enhancement; the histology of x-rays; THR and VTE in the Danish population; potential therapeutic targets for GCT; optimising vancomycin elution from cement; and how much sleep is enough.

The distal humerus represents 1% of all primary bone tumours. Endoprosthetic replacement can potentially improve function and provide good pain relief. We present out experience with the custom made Stanmore elbow endoprosthesis used after resection of malignant tumours of the distal humerus. Between 1970–2009 we carried out 19 endoprosthetic replacments for malignant tumours of the distal humerus. 10 were a result of metastasis and 9 were primary bone tumours. 7 patients had a pathological fracture as their first presentation and 3 had pathological fractures after the diagnosis was made. 11 patients died between 3 months to 16 year following surgery. The mean survival of the patient group was 7.1 years (range 3 months to 37 years). 4 patients underwent a revision EPR and one patient underwent two revision EPR's due to loosening. Two patients underwent maintenance procedures (rebushing) due to wear of the poly bushing. We have had no revisions since the design of hte implant was changed to a floppy hinge design. One patient underwent an above elbow amputation four years after surgery due to local recurrence. There were no early post operative infections. One patient developed a sinus requiring multiple wound explorations, one year after insertion of the endoprosthesis for a sarcoma. This patient was infection free till the time of death 3 years later. There were no nerve palsies, periprosthetic fractures or wound problems. The mean TES score was 72% (59–78%) in the surviving patients at review. As the majority of the patients were implanted for metastatic disease the initial reliablity and low complication rate of the procedure, in our series, confirms that this is a suitable reconstruction for patients in significant metastatic pain from a destructive lesion of the distal humerus, rapidly restoring function and relieving pain in a predictable manner

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro). 48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery. Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated. 25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES). Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Introduction: Total en bloc spondylectomy (TES) as the only radical treatment option for sarcoma and solitary metastases of the spine was shown to markedly minimize local recurrences, improve patient quality of life and substantially increase overall survival rates. This study analyzes the onco-surgical results after multilevel thoracolumbar TES and reconstruction with a carbon composite vertebral body replacement system (CC-VBR) in a collective of patients. Methods: 26 patients (14f/12m; age 52±14y) treated with thoracolumbar multilevel TES (10x2, 12x3, 3x4, 1x5 segments) for spinal sarcomas (n=16), solitary metastases (n=5) and aggressive primary tumors (n=5) were retrospectively investigated. According to the classification system of Tomita et al. all patients were surgically staged as type 6 (multisegmental/extracom-partimental). Defect reconstruction (14 thoracic, 6 thoraco-lumbar and 6 lumbar) were performed with posterior stabilization and a CC-VBR. Patient charts and the current clinical follow-up results were analyzed for histopathological tumor type, pre- and postoperative data (symptoms, duration of surgery, blood loss, complications, intensive care, adjuvant therapies etc.) and course of disease. Latest radiographs and CT-scans were analyzed at follow up. Oncological status was evaluated using cumulative disease specific and metastases-free survival analysis. Results: With a mean follow up (100%) of 18 (4–44) months 24 patients (92%) were postoperatively ambulatory without any support. Postoperative neurological deficits were seen in two patient (8%). Wide resection margins were attained in 9, marginal in 17 patients. Depending on tumor biology/grading and/or resections margins an adjuvant therapy (radiation/chemotherapy) was performed in 18 (69%) patients. Local recurrence was found in two patient (8%). 19 (73%) patients showed no evidence of disease, 3 were alive with disease while 2 died of disease at 10 and 27 months postoperatively. Conclusion: In selected patients with multisegmental spinal tumor involvement oncological sufficient resections can be reached by multilevel TES. Although the surgical procedure is challenging and the patient’s stress is considerable our encouraging midterm results together with the low complication rate clearly favour and legitimate this technique. However, treatment success strongly depends on adjuvant therapies. Reconstruction with a CC-VBR showed low complication rates, promising biomechanical characteristics, increased volume for bone grafting and lower artefact rates in follow-up MR- and CT-imaging

Introduction: Total en bloc spondylectomy (TES) as the only radical treatment option for sarcoma and solitary metastases of the spine was shown to markedly minimize local recurrences, improve patient quality of life and substantially increase overall survival rates. Due to surgical difficulty of TES and complex biomechanical demands in defect reconstruction multisegmental tumor involvement of the spine has long been considered as a palliative situation, exceeding the limits of surgical feasibility. Thus, multilevel resections reports are very rare. For the first time, this study analyzes the onco-surgical results after multilevel thoracolumbar TES and reconstruction with a carbon composite vertebral body replacement system (CC-VBR) in a collective of patients. Methods: 18 patients (9f/9m; age 52±14y) treated with thoracolumbar multilevel TES (6x2, 9x3, 3x4 segments) for spinal sarcomas (n=9), solitary metastases (n=5) and aggressive primary tumors (n=3) were retrospectively investigated. According to the classification system of Tomita et al. all patients were surgically staged as type 6 (multisegmental/extracompartimental). Defect reconstruction (11 thoracic, 3 thoracolumbar and 4 lumbar) were performed with posterior stabilization and a CC-VBR. Patient charts and the current clinical follow-up results were analyzed for histopathological tumor type, pre- and postoperative data (symptoms, duration of surgery, blood loss, complications, intensive care, adjuvant therapies etc.) and course of disease. Latest radiographs and CT-scans were analyzed at follow up. Oncological status was evaluated using cumulative disease specific and metastases-free survival analysis. Results: With a mean follow up (100%) of 18 (4–44) months 17 patients (94%) were postoperatively ambulatory without any support. Postoperative neurological deficits were seen in one patient (6%). Wide resection margins were attained in 7, marginal in 11 patients. Depending on tumor biology/grading and/or resections margins an adjuvant therapy (radiation/chemotherapy) was performed in 12 (67%) patients. Local recurrence was found in one patient (6%). 13 (72%) patients showed no evidence of disease, 3 were alive with disease while 2 died of disease at 10 and 27 months postoperatively. Conclusion: In selected patients with multisegmental spinal tumor involvement oncological sufficient resections can be reached by multilevel TES. Although the surgical procedure is challenging and the patient’s stress is considerable our encouraging midterm results together with the low complication rate clearly favour and legitimate this technique. However, treatment success strongly depends on adjuvant therapies. Reconstruction with a CC-VBR showed low complication rates, promising biomechanical characteristics, increased volume for bone grafting and lower artefact rates in follow-up MR- and CT-imaging

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications. Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence. Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma

We review the treatment of pelvic Ewing’s sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods.

We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100).

We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing’s sarcoma.

Study Design: Descriptive case series. Objective: To report on the outcome of 4 patients treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to hypernephroma. Summary of background data: Patients with solitary spinal metastases from renal cell carcinoma (RCC) have better prognosis and show longer survival rates as compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radioresistant tumour, which can often present with both back pain and neurological deficit. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. 3 of the 4 had pre-operative embolization and all had radical resection of the primary tumour. Results: All patients reported significant pain relief and demonstrated neurological improvement. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. 3 were alive and well at 18, 26 and 39 months post-op with no radiological evidence of tumour recurrence. There were no major surgical complications. Conclusions: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence