Purpose of study: Cervical corpectomy is a well established procedure for spinal pathology. We have applied this technique using a titanium standalone cage or a cage with cervical locking plate filled with bone debris of the corpectomy for vertebral reconstruction. The study was aimed to determine the efficacy and assess the morbidity of this procedure. Methods: Case notes of all patients who underwent cervical corpectomy from March 2004 to September 2008 were reviewed retrospectively. Results: 47 patients were identified 28 male and 19 female. The mean age was 58 (range 40 to 82). Single level corpectomy was performed in 21 patients, 2 levels in 19 and 3 levels in 6 patients. One case was abandoned and one had additional laminectomy and lateral mass fusion. 89% of cases needed corpectomy for degenerative disease, whilst 11% for malignant disease. Complications included dural tear in 5 patients, subsidence in 4, laryngeal nerve palsy in 2, postoperative haematoma in 2 and infection in 1 patient. At mean follow-up of 25 months (range 3 to 52), 84% were better, 10% remained same and 4 % of patients worsened. Conclusion: Cervical corpectomy is a safe and effective method of managing cervical pathology. It not only provides stable vertebral reconstruction but also eliminates donor graft site related morbidity. Ethics approval: None Audit/service standard in trust Ethics committee COREC number:. Interest Statement: None Local grant/National grant Commercial/industry support

Primary malignant tumours should be resected with wide margins. This may be difficult to apply to lesions of the spine. We undertook total vertebrectomy on seven patients, four males and three females with a mean age at operation of 26.5 years (6.3 to 45.8). The mean follow-up was 52.3 months. Histological examination revealed a Ewing’s sarcoma in two patients and osteosarcoma, leiomyosarcoma, spindle-cell sarcoma, chondrosarcoma and malignant schwannoma in one each. In five patients, histological examination showed that a wide resection had been achieved. At follow-up there was no infection and a permanent neurological deficit was only seen in those patients in whom the surgical procedure had required resection of nerve roots. Despite the high demands placed on the surgeon and anaesthetist and the length of postoperative care we consider total vertebrectomy to be an appropriate procedure for the operative treatment of primary malignant lesions of the spine

Purpose of Study. Debate exists in the literature about the surgical management of sub-axial cervical burst fractures regarding the approach and types of fixation of these injuries. Our Acute Spinal Injury (ASCI) unit prefers anterior only cervical corpectomy and plate fixation in the management of these injuries. The objective of this study was to radiologically assess the long term outcomes (minimum 2 yrs) of our series. Patients and Methods. Patients were identified using the Acute Spinal Injury Unit (ASCI) database that had had anterior only corpectomy and plate fixation for trauma as a standardised procedure between 2006 and 2009. Initial post-op radiological review included the sagittal alignment, hardware characteristics and surgical technique. Radiological review after a minimum of 24 months involved the union, sagittal alignment, hardware characteristics, graft incorporation and adjacent level degeneration at the site of injury. Results. A total of 51 patients were identified but only 11 were available for review at the minimum 24 months. There were 10 males and 1 female with an average age of 28.1years (18–62). The follow up duration was on average 50.6months (27–71) median 60 months. The levels fused were C3-5 (2), C4-6 (5), C5-7 (3), and C4-7 (1 double level). There was NO metalwork failure, NO screw osteolysis and a varying degree of degenerative changes but a 100% FUSION RATE. The average loss of cervical lordosis was 2.5 ° over the follow up period. Conclusion. Anterior stand alone cervical corpectomy and plating alone appears to be a safe, cost effective and time saving alternative in the management of cervical burst fractures in the sub axial spine with no significant long term complications. NO DISCLOSURES

Study design: Retrospective study. Objectives: To determine whether apical vertebrectomy for correction of severe spinal deformity in patients with cerebral palsy or mental retardation significantly improves curve correction and to study complications of such a procedure. Summary of Background data: Although a combined anterior-posterior procedure for correction of severe deformity in cerebral palsy patients is well established, apical vertebrectomy to improve correction has not been described. Subjects: 5 patients (2M, 3F) operated on between 2000–2003 (anterior apical vertebrectomy followed by posterior instrumented fusion), mean age 14 years, average follow-up 1.5 years. All had group II (Lonstein & Akbarnia) rigid (mean 96degrees bending to 83degrees) thoracolumbar/lumbar curves with marked pelvic obliquity. Results: Preoperative mean Cobb angle of 96 degrees corrected to 36 degrees, (63% correction, and 57% correction over and above the bending Cobb angle), 42 degrees at final follow-up. Mean apical vertebral translation (AVT) correction was 57 % (86mm to 37mm) and regional AVT correction 53%. Pelvic tilt correction was 72% (29degrees to 9degrees). Thoracic kyphosis remained unchanged but lumbar lordosis of 4.2 degrees (range−66 to +68) was corrected to 63 degrees. Mean blood loss was 1100mls (range 300–3000) for anterior surgery and 3400mls for posterior surgery. Operative time was 3 hours for anterior surgery. There were no intra-operative or post-operative complications (infection, pseudarthrosis, metalwork failure). Subjective outcome was excellent in all patients. Conclusion: In patients with rigid, rotated curves with wide apical translation, apical vertebrectomy and posterior instrumented fusion can achieve significant correction of Cobb angle over and above the bending cobb angle and also the AVT and pelvic tilt leading to high parent / caregiver satisfaction and improvement in functional status of the patient

Introduction. Primary malign tumors and solitary metastatic lesions of the thoracic and thoracolumbar spine are indications for radical en bloc resections. Extracompartimental tumor infiltration makes the achievement of adequate oncological resection more difficult and requires an extension of the resection margins. We present a retrospective clinical study of patients that underwent chest wall resection in combination with vertebrectomy due to sarcomas and solitary metastases for assessing the clinical outcome especially focusing on onco-surgical results. Method. From 01/2002 to 01/2009 20 patients (female/male: 8/12; mean age: 52 (range of age: 27–76yrs)) underwent a combined en bloc resection of chest wall and vertebrectomy for solitary primary spinal sarcoma and metastatic lesions. The median follow-up was 20,5 (3–80) months. Histological analysis revealed 17 primary tumors and 3 solitary metastatic lesions. In the group of primary tumors 10 sarcomas, 1 giant cell tumor, 2 PNET, 1 histiocytoma, 1 aggressiv fibrous dysplasia, 1 pancoast tumor and 1 plasmocytoma were histologically documented. We included 1 rectal carcinoma, 1 breast cancer metastases and 1 renal cell carcinoma. All patients underwent a chestwall resection en bloc with multilevel (1/2/3/4 segments: n=4/6/6/4) hemi (n=7) or total vertebrectomy (n=13) with subsequent defect reconstruction. Reconstruction of the spinal defect following total resections was accomplished by combined dorsal stabilization and carbon cage interposition. The chest wall defects were closed with a goretex ® -patch. One patient also received a musculocutaneus latissimus dorsi flap. Results. The surgical margins were R0 in 19 (wide in 14, marginal in 5) and one R1 resection. Marginal/R1 resections were due to extracompartimental sarcoma invasion (spinal canal) and dural involvement. In these patients postoperative radiotherapy was performed. Surgical complications requiring revision occurred in 1 patient due to injury of the ductus thoracicus and persisting chylothorax. Temporary subileus or mild pneumonia appeared in 3 patients. No superficial/deep infection or neurological deficits (except those related to oncologically required dissection of thoracic nerve roots) were observed. At follow up 2 patients died due to the disease after 7,5 months. Local recurrences were seen in 3 patients at median 24 months (13–43). Pulmonary metastases necessitating polychemotherapy were seen in 7 patients after median 17 months (7–44). Conclusion. Despite the only midterm follow up, the combined en bloc resection of chest wall and multilevel en bloc spondylectomy/hemivertebrectomy is a challenging but safe and effective technique in order to achieve adequate margins and local control in selected with spinal sarcomas extending to the dorsolateral chest wall

Introduction: Restoration of vertebral height for burst fractures can be achieved either anteriorly, posteriorly or combined. Aim: To biomechanically assess and compare stiffness of 1) posterior pedicle screws with Synex, 2) Synex+ Double screw+rod Ventrofix 3) Synex+ Double screw+ Single rod and 4) Synex+ Single screw+ Single rod in reconstructing an unstable burst fracture following anterior corpectomy. Method: Fresh frozen calf lumbar spines (L3–L5) were dissected and L4 corpectomy performed. L3 and L5 were mounted on a plate and fixed. Loads were applied as a dead weight of 2Nm. The range of movement was measured using the Qualisys motion analysis system using external marker clusters attached to L3 and L5. Bony landmarks were identified with marker clusters as baseline. The movement was measured between the 2 marker clusters. Five specimens were implanted for each group 1) with pedicle screw (into L3 and L5) and tested with/without Synex (expandable) cage anteriorly, 2) implanted with a Synex cage and Double screw+rod Ventrofix system, 3) Synex cage and Double screw+ Single rod Ventrofix construct and 4) Synex cage and Single screw+ Single rod Ventrofix system. Results: Reconstruction of the anterior column with the combination of Synex and double rod Ventrofix produces a stiffer construct than the pedicle screw system in all planes of movement (p= 0.001 in rotation). The double screw/ single rod system is less effective than the Ventrofix System but is comparable to the pedicle screw construct. The single screw/ single rod construct leads to unacceptable movement about the axis of the inferior screw particularly in extension with a ROM much greater than the intact spine (p< 0.001). Conclusion: Thus biomechanically we recommend Synex and double rod Ventrofix construct to reconstruct the anterior vertebral column following corpectomy for unstable burst fractures

In case of spine tumors, when en bloc vertebral column resection (VCR) is indicated and feasible, the segmental defect should be reconstructed in order to obtain an immediate stability and stimulate a solid fusion. The aim of this study is to share our experience on patients who underwent spinal tumor en bloc VCR and reconstruction consecutively.

En bloc VCR and reconstruction was performed in 138 patients. Oncological and surgical staging were performed for all patients using Enneking and Weinstein-Boriani-Biagini systems accordingly. Following en bloc VCR of one or more vertebral bodies, a 360° reconstruction was made by applying posterior instrumentation and anterior implant insertion. Modular carbon fiber implants were applied in 111 patients, titanium mesh cage implants in 21 patients and titanium expandable cages in 3 patients; very recently in 3 cases we started to use custom made titanium implants. The latter were prepared according to preoperative planning of en bloc VCR based on CT-scan of the patient, using three dimensional printer.

The use of modular carbon fiber implant has not leaded to any mechanical complications in the short and long term follow-up. In addition, due to radiolucent nature of this implant and less artifact production on CT and MRI, tumor relapse may be diagnosed and addressed earlier in compare with other implants, which has a paramount importance in these group of patients. We did not observe any implant failure using titanium cages. However, tumor relapse identification may be delayed due to metal artifacts on imaging modalities.

Custom- made implants are economically more affordable and may be a good alternative choice for modular carbon fiber implants. The biocompatibility of the titanium make it a good choice for reconstruction of the defect when combined with bone graft allograft or autograft. Custom made cages theoretically can reproduce patients own biomechanics but should be studied with longer follow-up.

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis.

We describe the clinical features, investigations and treatment options.

Abstract. Objectives. The principle of osteoporotic vertebral compression fracture (OVCF) is fixing instability, providing anterior support, and decompression. Contraindication for vertebroplasty is anterior or posterior wall fracture. The study objectives was to evaluate the efficacy and safety of vertebroplasty with short segmented PMMA cement augmented pedicle screws for OVCF with posterior/anterior wall fracture patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ±0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20±5.90 to 5.30±1.40 postoperative with 5% (3.30± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80±11.9% t0 87.6±13.1% postoperative with 4.5±4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because It provides anterior support with cementing that avoids corpectomy. Short segment fixation has less stress risers at the junctional area

Abstract. Objectives. To evaluate the safety and efficacy of vertebroplasty with short segmented cement augmented pedicle screws fixation for severe osteoporotic vertebral compression fractures (OVCF) with posterior/anterior wall fractured patients. Methods. A retrospective study of 24 patients of DGOU type-4 (vertebra plana) OVCF with posterior/anterior wall fracture, were treated by vertebroplasty and short segment PMMA cement augmented pedicle screws fixation. Radiological parameters (kyphosis angle and compression ratio) and clinical parameters Visual analogue scale (VAS) and Oswestry disability index (ODI) were analysed. Results. A significant improvement was noted in VAS (preoperative, 7.90 ± 0.60; final follow-up 2.90 ± 0.54) and ODI (77.10 ± 6.96 to 21.30 ± 6.70), (P < 0.05). Neurological improvement was noted in all patients. Kyphosis corrected significantly from preoperative 23.20 ± 5.90 to 5.30 ± 1.40 postoperative with 5% (3.30 ± 2.95) loss of correction at final follow-up. Anterior vertebral height restored significantly from 55.80 ± 11.9% to 87.6 ± 13.1% postoperative with 4.5 ± 4.0% loss at final follow-up. One case had cement leakage was found, but the patient is asymptomatic. No implant-related complication was seen. No iatrogenic dural or nerve injury. Conclusions. Treatment with vertebroplasty with cement augmented screw fixation and direct decompression is a great option in treating such a complex situation in fragile age with fragile bones because. Vertebroplasty is viable option for restoring vertebral anterior column in patients who are considered as contraindications for vertebroplasty, like DGOU-4. It provides anterior support avoiding corpectomy, minimise blood loss and also duration of surgery. Addition of short segment fixation gives adequate support with less stress risers at the junctional area

Introduction: Introduction of the minimal invasive surgery as a new concept in spinal surgery necessitated the need for implants that can be applied through minimal invasive approaches. One of the great challenges was the development of anterior minimal invasive vertebral replacement implants that are mechanically fit and easily applicable. Many studies were concerned with the early results of such implants but not yet the long-term or late ones. Methods: Between January 2003 and December 2003 we have operated 23 patients (13 males and 10 females) with traumatic thoracic or thoracolumbar fractures that were indicated for corpectomy. In addition to posterior transpedicular instrumentation, anterior thoracoscopically assisted corpectomy and reconstruction using a telescopic vertebral body replacement cage was done in all patients. Patients were operated either in one or two sittings. Preoperative complete clinical, neurological and radiological evaluation was done. Postoperatively, clinical and radiological outcomes were evaluated, including postoperative neurological improvement, ODI (Oswestry Disability Index) and fusion rate. The average follow up period was 4 years. Results: Fusion rate was 100% at the final follow up. The mean age was 52.5 years. 6 patients had preoperative neurological deficits varying from Frankel B to Frankel A that were improved postoperatively in 5 cases and not improved in one case. The average corpectomy time was 148 minutes (range 75–240 min.). The average ODI was 8.6 (range 0 – 31). Postoperative complications included wound healing problems in one patient, psoas abscess in one patient and pulmonary embolism in one patient. The average preoperative kyphosis (Cobb angle) was 22.43 that were improved to 7.28 degrees postoperatively, and it was 11.8 degrees at the final follow up. Considerable cage sinking (more than 5 mm) was detected in two cases. Conclusion: Vertebral body replacement cage that can be thoracoscopically applied is a good solution for ventral implants in cases of thoracolumbar fractures that required corpectomy. It showed good early as well as 4 years follow up results. Study Type: Prospective observational study

Objective: To evaluate the efficacy and safety of an expandable titanium cage for anterior column replacement after partial or total corpectomy in the thoracolumbar spine. Design: A retrospective study evaluating the clinical and radiographic outcome following insertion of a novel implant. Subjects: Twenty-three patients with anterior column insufficiency secondary to tumour, fracture, and infection were treated with a vertebral replacement capable of rapid and controlled in-situ expansion. Follow up consisted of a clinical and radiological review at a mean of 15.2 months (range 6–20 months). Outcome Measures: The clinical outcome was measured by the degree of pain relief post-operatively, the ability to ambulate and the reliance on walking aids. Neurological deficit was measured using the Frankel Grade. Radiological follow-up compared preoperative radiographs with those taken at maximal follow-up. The degree of kyphosis and the degree of subsidence was measured. Results: Twenty-three patients with a mean age of 43.6 years (range 20–72) underwent surgery. Indications included metastatic tumour in eight, acute fractures in five, infection in four, degenerative conditions in three, post-traumatic kyphosis in two and pseudathrosis in one. Nineteen patients underwent a single-level corpectomy and four patients a two-level corpectomy. Fourteen patients had a significant neurological deficit preoperatively. Supplementary instrumentation was used in 20 of 23 cases (anterior in nine, posterior in eleven). Excellent pain relief was observed in 19. Ten of 14 patients showed neurological improvement. Eleven patients improved their ambulatory status. There was no hardware failure. An average correction of 110 of kyphosis was observed. The average subsidence was 1.3 mm (range 0.2–2.3). Conclusions: The use of an expandable vertebral body replacement with supplementary instrumentation following corpectomy appears to be safe and efficacious in correcting kyphosis. This implant appears to have a high resistance to subsidence

Introduction: Recombinant human bone morphogenetic protein-2 (rhBMP-2) (Infuse) has been shown to cause osteolysis rather than accelerated fusion in some series. This paper reports two cases of vertebral osteolysis in patients undergoing anterior cervical corpectomy with stabilization using titanium prosthesis where rhBMP-7 (OP1) has been used in high concentration. Methods: Case series and review of literature. Results: OP1 was used in 23 patients undergoing anterior cervical surgery. Each case had at least two CT scans during the first twelve months of follow-up. The two cases of osteolysis were identified amongst a subgroup of 8 patients undergoing anterior cervical corporectomy and reconstruction using a titanium rod and buttress implant. The first case was a 71 year old man who underwent C4-T1 corpectomy for spondylotic cord compression and the second case was a 62 year old man who underwent C3-T1 corpectomy for spondylotic cord compression. In both cases a bottle of OP1 (3.5mg) was mixed with 5mls of carboxy-methyl-cellulose/tri-calcium phosphate (CMC/TCP) putty, approximately half of which was then applied to the ends of the titanium rod and buttress prosthesis and compressed between the buttress end and the vertebral endplate, and some residual OP1-containing putty was placed at the sides of each buttress. CT scans performed at 3 months postoperative in case 1 and 3.5 months postoperatively in case 2 demonstrated osteolysis in the vertebral bodies adjacent to the implant. In both cases however, CT scans performed 12 months post-operatively showed that the osteolytic cysts were beginning to resolve and fusion at the bone-titanium junction may have begun. No other cases of cystic osteolysis were found amongst other anterior cervical cases or 115 posterior lumbar interbody fusion (PLIF) cases similarly followed-up with serial CT scans. The concentration of rhBMP-7 used in a subgroup of 8 corpectomy cases undergoing anterior cervical corporectomy and reconstruction using a titanium rod and buttress implant was at least twice the concentration used in other anterior cervical cases and approximately one quarter to one fifth the concentration used in lumbar interbody PLIF cages. Discussion: These are the first reported cases of osteolysis associated with the use of BMP-7. Osteolysis has been described in association with the use of rhBMP-2. Following these reports, the manufacturers of rhBMP-2 have advised surgeons strongly not to use more than the (recently) recommended dose, despite there being no published evidence that osteolysis is dose-related. Similar recommendations have not been made regarding the use of BMP-7 (OP1). The concentration of BMP-7 (OP1) which led to osteolysis in these cases was much greater than used elsewhere in the spine, where OP1 (3.5mg) is usually mixed with 10–15 mls of finely-milled autograft. This suggests that the concentration achieved by mixing 3.5 mg of OP1 with 5 mls of CMC/TPC putty may increase the risk of osteolysis when inserted into the anterior cervical spine

Purpose: Tumours arising from the pulmonary apex or the posterior mediastinum may be removed en bloc in combination with total or partial vertebrectomy in the event of spinal invasion. Extra-tumour resection is a perfectly described surgical procedure recognised for its carcinological effectiveness. Raymond Roy-Camille and Bertill Steiner described en bloc spinal resection of a thoracic vertebra via a simple posterior approach. Paulson, described resection of tumours of the pulmonary apex (Pancoast Tobias) via a cervicothoracic approach. We associated these two techniques to allow en bloc resection of posterior mediastinal tumors or pulmonary apex tumours associated with spinal invasion. Material and methods: We recommend different surgical approaches to the cervicothoracic and mid thoracic spine. For the cervicothoracic spine, an anterior approach is used with simple dislocation of the sterno-clavian joint without resection of the clavicle. The subclavian vessels and the brachial plexus are dissected and exposed. The tumour is then dissected followed by the peripheral, particularly œsophageal, attachments. The tumour is not detached from the spine to which it adheres tightly. Conventional thoracotomy is used for the thoracic level with dissection of the tumour from the adjacent soft tissue. In the event of a tumour in the posterior mediastinum, the anterior time is followed by a posterior approach. For primary pulmonary tumours, lobectomy or segmentectomy, or even pneumonectomy, is performed during the anterior time. Total or partial vertebrectomy, depending on the level of spinal involvement, is performed during the posterior approach. Results: Thirty-six patients underwent this type of procedure. Total vertebrectomy was necessary in seven patients, partial vertebrectomy in 29. Mean follow-up has been six days to 7.2 years (mean 23.3). One patient died during the postoperative period due to a cause unrelated to the tumour. Only 35 patients were retained for analysis. Twenty-one patients (60%) died after a mean survival of 16.7 months (8–44 months). The 14 others (40%) are living at a mean 38.2 months survival (8–87 months). Discussion: This technique requires a long learning curve and an extremely careful evaluation of tumour extension. Results obtained to date confirm the feasibility of the technique and point out its contribution in case of wide resection. Certain patients have lived more than five years after resection

Intraspinal re-implantation after traumatic avulsion of the brachial plexus is a relatively new technique. Three different approaches to the spinal cord have been described to date, namely the posterior scapular, anterolateral interscalenic multilevel oblique corpectomy and the pure lateral. We describe an anatomical study of the pure lateral approach, based on our clinical experience and studies on cadavers

Purpose: Malignant primary tumours of the spine require wide resection with preservation of the cord and radicular elements. The purpose of this work was to report our oncological results and complications after spinal surgery for this indication. Material and methods: Twenty-two patients, mean age 30 years (15–65) underwent surgery. The pathology diagnosis was made preoperatively. There were 16 high-grade tumours, Ewing (n=7), osteosarcoma (n=5), other (n=4), and six low-grade tumours, chondrosarcoma (n=5), osteosarcoma (n=1). Four patients experienced local recurrence after an insufficient initial resection and three required emergency laminectomy. Sagittal hemivertebrectomy was performed in 11 patients for pediculotransverse tumours and total vertebrectomy in 10 patients for corporeal tumours. Posterior fixation was not used in one patient (Ewing tumour) in order to preserve the Adamkiewitz artery. Results: Complete oncological resection was achieved in 14 patients. The surgical margins were in a malignant zone in 7. At mean 6-year follow-up, ten patients were surviving disease-free (4 Ewing, 4 osteosarcoma, 2 chondrosarcoma), and one was living with active disease (chondrosarcoma). Eleven patients died: metastasis (n=4), local recurrence (n=6), infarction 3 months after surgery (n=1). Among the seven patients with local recurrence,osteosarcoma (n=5),chondrosarcoma (n=2), three had local recurrence at initial management and only one was living at last follow-up (active chondrosarcoma). There were no neurological complications; there were four mechanical complications (nonunion) after total vertebrectomy which required four re-operations. Discussion: Survival rate in this series was 45% at six years, comparable with rates reported in the literature (40 – 50% at 5 years). Local recurrence was observed in 85% of patients whose surgical margins were in malignant tissue (67–100% in the literature). Among the four patients who had recurrent disease at the time of surgery, complete resection was possible in only one. This patient is living (Ewing sarcoma responding to adjuvant therapy). Incomplete surgery or a poor biopsy procedure aggravates the prognosis. Mechanical failure is observed after total vertebrectomy if anterior osteosynthesis is not associated with the posterior fixation. Conclusion: Wide surgical resection of primary bone sarcomas of the spine provides encouraging results when the initial operation is successful. Better local control of Ewing sarcoma can be explained by its sensitivity to adjuvant therapy. Reconstruction after total vertebrectomy required anterior and posterior fixation

Incoming of a spine metastasis remains a major bad prognosis factor in cancer evolution. Consensus over the years is now well accepted in most of European teams dealing with spinal metastasis. Two major opportunities exist in the treatment of spine metastasis:. Conservative treatment with an association of radio and or chemotherapy and or hormonotherapy. Efficiency of such treatments is well documented and must not be considered as a patient abandon. Surgical treatment is based on two major options. The first one is palliative with the aim of decompression and stabilization. Aim is to cure pain and neurological involvement. The second one is curative with total or partial vertebrectomy in the aim to cure the cancer. In all cases decision must be made considering age- general condition histo – pathology – neurological status. Considering surgical indications through out this symposium we would like to address three controversial points. The first topic to be addressed will be: “Total vertebrectomy: when?” presented successively Doctor MARTIN BENLLOCH and Professor BORIANI. The goal of this presentation is to determine the indications of total vertebrectomy more than the surgical technique. These indications appearing essential within the framework of the metastatic patients, while insisting not only on the natural history, but also on the tumoral extension which determines the feasibility of the vertebrectomy. Professor POINTILLART and Professor BORIANI will then discuss about the strategy to adopt when confronted with multi-metastatic patients “Multi-metastatic patients: what strategy?”. This topic will focus primarily on the problem of multi level spinal metastatic lesions: the strategies to be adopted with respect to the patients presenting other metastatic lesions, as well as on a functional forecast (fragility of the long bone), or on the other hand, on metastasis without immediate functional incidence. We also would like to discuss the treatment of the primitive tumour, i.e. if it is the metastasis which is revealing cancer, is it necessary to first treat the primitive tumour, than proceed to the treatment of the metastatic lesions? The third topic of this session will be “When Not to Operate on Metastatic Patients?”, presented by Professor POINTILLART. The goal of this discussion is to be able to give a progress report on the surgical indications within the framework of a spinal metastatic patient. In a certain number of cases surgery is questionable with the discovery of lesions, because of their extended character, or the extreme malignity of the primitive tumour. In other situations, too many lesions will make surgery disputable. Last case scenario is a recurring tumor, because of its extension, its development, even its neurological complications, will make surgery challenging. All these points in our opinion should be openly discussed. Each session will be followed by a 10 minute discussion

Introduction: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the postero lateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumors are presented. Methods: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumors (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumors N=49 involving the lateral part of the vertebral body such as osteoïd osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumors. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilization procedure is still necessary when more than one disc are resected and when the discs are soft and not collapsed. Results: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the preoperative score was noted in 79% of patients with myelopathy stabilization in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilization procedure was observed only in 3 cases which in fact were preoperatively unstable. Complete tumor resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumors extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realized in 13 out of the 126 cases of tumor. Conclusion: Oblique corpectomy techniques is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumors. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilization technique and avoids the use of instrumentation

INTRODUCTION: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the posterolateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumours are presented. METHODS: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumours (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumours N=49 involving the lateral part of the vertebral body such as osteoid osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumours. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilisation procedure is still necessary when more than one disc is resected and when the discs are soft and not collapsed. RESULTS: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the pre-operative score was noted in 79% of patients with myelopathy stabilisation in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilisation procedure was observed only in three cases which in fact were pre-operatively unstable. Complete tumour resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumours extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realised in 13 out of the 126 cases of tumour. CONCLUSION: Oblique corpectomy technique is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumours. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilisation technique and avoids the use of instrumentation

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding