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.

Introduction: Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and stabilisation. Subtotal spondylectomy and circumferential stabilisation can be safely performed via a single posterior transpedicular approach. Polymethyl-methacrylate bone cement (PMMA) has been widely used in spinal column reconstruction with mixed results. PMMA is a potential means for local drug delivery in the prevention of locally recurrent disease. The biomechanical characteristics of anterior reconstruction using PMMA have not been adequately evaluated. Purpose: To evaluate the stability of an anterior cement construct following total spondylectomy and to compare this reconstruction against alternative stabilisation techniques. Methods: Ten fresh-frozen human cadaveric spines (T9-L3) were used. After intact analysis, a total spondylectomy was performed at T12. Three potential reconstruction techniques were tested for their ability to restore stiffness to the specimen: (1) multi-level posterior pedicle screw instrumentation from T10-L2 {MP1} [Depuy Acromed], (2) anterior instrumentation [ATL Z-plate II™, Medtronic, Sofamor Danek Instruments] and rib graft at T11-L1 with multi-level posterior instrumentation from T10-L2 {AMPI}, and (3) anterior cement [Simplex P] and pins construct (T12) with multi-level posterior instrumentation from T10-L2 {CMPI}. Each of the three potential reconstruction techniques was tested on each specimen in random order. Non-destructive testing was performed under load control. The specimen was positioned vertically for axial compression and torsion testing, and horizontal for flexion/extension and lateral bending tests. A customised jig was manufactured for this latter purpose. Results: Only circumferential stabilisation techniques (AMPI, CMPI) restored stiffness to a level equivalent or higher to that of the intact spine in all loading modes (p< 0.05). CMPI provided more stability to the specimen than AMPI in compression and flexion testing (p< 0.05). Posterior instrumentation alone (MPI) did not restore stiffness to the intact level in compression and flexion testing (p< 0.005). Conclusions: Circumferential reconstruction using an anterior cement construct provides equal or more stability than the intact spine in all testing modes. Posterior stabilisation alone is an inadequate method of reconstruction following total spondylectomy. PMMA has the advantage over traditional anterior reconstruction techniques in that it can be inserted using a single posterior approach and offers the potential value of local drug delivery

1. A forty-nine-year-old man had a chondrosarcoma arising from the body of the seventh thoracic vertebra. The tumour protruded into the mediastinum and also into the spinal canal where it displaced the spinal cord.

2. At operation all the seventh thoracic vertebra and parts of the sixth and eighth were removed together with the tumour. The thoracic spine was reconstructed by inserting two iliac bone-blocks between the cut bodies of the sixth and eighth vertebrae and by wiring two strong "A. O." plates to the transverse processes of the third to the sixth and the eighth to the tenth vertebrae.

3. The patient was nursed in a plaster-of-Paris bed for three and a half months.

4. One year and three months after operation, the patient was walking and well, with no signs of recurrence or metastasis. Radiographs showed that a block-vertebra had been created from the iliac grafts and the two cut vertebrae.

To evaluate and compare the stability of an anterior cement construct following total spondylectomy for meta-static disease against alternative stabilization techniques. After intact analysis of ten cadaveric spines (T9–L3), a T12 spondylectomy was performed. Three reconstruction techniques were tested for their ability to restore stiffness to the specimen using non-destructive tests:. 1) multilevel posterior pedicle screw instrumentation (PPSI) from T10–L2 {MPI}, 2) anterior instrumentation from T11–L1 with PPSI {AMPI}, and 3) anterior cement and pins construct (T12) with PPSI {CMPI}. Circumferential stabilization {AMPI, CMPI} restored stiffness to a level of the intact spine. CMPI provided more stability to the specimen than AMPI. MPI alone did not restore stiffness to the intact level. Circumferential reconstruction using an anterior cement construct following total spondylectomy is biomechanically superior to posterior stabilisation alone

Aims

With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values.

The June 2013 Oncology Roundup³⁶⁰ looks at: whether allograft composite is superior to megaprosthesis in massive reconstruction; pain from glomus tumours; thromboembolism and orthopaedic malignancy; bone marrow aspirate and cavity lesions; metastasectomy in osteosarcoma; spinal giant cell tumour; post-atomic strike sarcoma; and superficial sarcomas and post-operative infection rates.

Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases.

In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.

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.