The Effectiveness Of The Whole Isolation Technique In The Total En-bloc Spondylectomy For Solitary Thoracic Tumor

Spinal tumor is relatively rare in clinical oncology. And the occurrence of primary tumor in the spine is rarer. They account for 11% of primary tumor in all the musculoskeletal system, and 4.2% in all spinal tumors. This is only about 0.4% of malignant tumors. Because of the anatomic location and the special structure of the thoracolumbar and deep location, and adjacent important blood vessels and nerve tissue, the operative design and tumor resection has been the difficulty of surgical treatment. Curettage and piecemeal resection of the tumor are the traditional way to achieve the purpose of tumor resection. But the traditional way is easy to cause tumor cells contamination and the boundary between tumor and normal tissue is difficult to determine.If en bloc resection is suitable for spine tumor is controversial, because of anatomic constraints as well as some important anatomical structures are difficult to resect. In order to reduce tumor recurrence and improve the survival rate of patients, in 1981 Stener and Roy-Camille first reported thoracic vertebral column resection by the posterior approach. In the mid-90s of the 20th century, Tomita et al reported further improvement of the posterior total en bloc spondylectomy(total en bloc spondylectomy, TES), technique achieve the total spondylectomy by separation of the posterior arch and vertebral body into blocs. In recent years, with the development of surgical techniques and the application of preoperative embolization, TES technique becomes a mature and an ideal technique for the treatment of thoracolumbar tumor.From 2003, TES technique has been used to spine tumor in department of orthopedics of General Hospital of PLA. After 10 years of continuous learning and accumulation of experience, TES technique has become a mature technique in PLA General Hospital. Since January 2011, authors did some adjustments and improvements in some technical details of thetraditional Tomita technique for one stage posterior TES for thoracic tumor, mainly including:(1) exposure and ligation of 3 pair of segmentalvessels (Tomita et al reported they ligate 1 pair of segmental vessels); (2) To cut off nerve roots of 2～3 pairs (the cut of thoracic nerve roots has tiny effect to patients) to avoid excessive traction to spinal cord; (3) Afterexposure and ligation of blood vessels and nerve roots, the exposure of the whole vertebral body and then followed by the resection of the posterior arch and anterior columnto shorten the interval to reduce the intraoperative blood loss (Tomita reported that after exposure and resection of vertebral arch, management of vascular and nerve root then blunt separation of the side, front of the vertebra and following the anterior column resection). Authors named these adjustments and improvements as the whole isolationtechnique. The whole isolation technique aims at isolation of the whole vertebra including tumors of the vertebral body to blocking the blood supply of vertebral and tumor to reduce blood loss in osteotomy and decompression process. The whole isolation technique was first used in the treatment of aggressive thoracic hemangioma, and gradually extended to other types of thoracic tumors.This research evaluated the efficacy, safty and clinical results of the whole isolation technique in TES of solitary thoracic tumor.Part I Effectiveness of the whole isolation technique in TES of aggressive thoracic vertebral hemangiomas with neurological deficitObjective:To evaluate the feasibility, safety and clinical result of the whole isolation technique in TES of aggressive thoracic vertebral hemangioma with neurological deficit.Methods:17 cases of aggressive thoracic hemangioma that were performed one stage posterior TES from January 2005 to January 2013 in PLA general hospital were retrospectively evaluated. According to different surgical techniques,17 cases were divided into two groups,10 cases were in traditional TES group (before January 2011), and 7 cases were in the whole isolation technique. The following data were evaluated: (1) general situation:age, gender, lesion’s site, symptoms and symptoms duration, spinal cord compression type, neurological ASIA score, tumor Tomita classification, local pack pain VAS score, SINS score; (2) the indicators related to the operation: operation time, intraoperative blood loss, blood transfusion amount, postoperative drainage amount and drainage duration, and complications.Results:Tomita type of 17 patients was evaluated:7 cases with Tomita type IV,7 cases with Tomita type V, and 1 casewith Tomita type VI. All 17 patients showed involvement of vertebral body and posterior arch that cause ventral and dorsal spinal cord compression.7 cases represented pathological fracture. The stability of the spine was evaluated by SINS score. SINS scorein traditional TES group was 9.2±1.2 (8-12), and TES combined with the whole isolation technique group was 10.3±1.5 (8-12). There was no significant difference between the two groups (P> 0.05). The average operation time of traditional TES group was 397.5+98.3min (320-490 min TES), the average operation timeof the whole isolation technique group was 415.7±67.0 min (300-630 min). Operation time between the two groups was not statistically significant (P=0.68). Intraoperative blood loss in traditional TES group and the whole isolation technique group were 2610.0±1009.3ml (980-3270 ml) and 1640±451.5 ml (800 4000 ml).Differencein intraoperative blood loss between two groups was statistically significant (P= 0.03). Blood transfusion amount in traditional TES group and the whole isolated technique group were 17.3±4.6U (11.2-25.0U) and 14.0±4.8 U (7.8-20.3U). The differencein blood transfusion amount between two groups was not statistical significant (P= 0.18). In traditional TES group,2 cases suffered postoperative cerebrospinal fluid leakage and 1 case suffered pleural effusion.1 case suffered rods brokenthatcaused by trauma and underwent revision surgery. In the whole isolation technique group,2 cases suffered postoperative cerebrospinal fluid leakage. Within 28-96 months follow up, no tumor recurrence occurred in 2 groups.Conclusion:For aggressive thoracic hemangioma with severe bone destruction and neurological deficit caused by dorsal and ventral spinal cord compression. TES technique helps to maximize the local recurrence and promote recovery of neurological function. And application of the whole isolation technique may effectively reduce the intraoperative blood loss and reduce the blood transfusion amount. Meanwhile, thewhole isolation technique did not significantly increase the operation time and operation difficulty.Part lithe effectiveness of the whole isolation technique in the TotalEn-bloc Spondylectomy for solitary thoracic tumorObjective:To demonstrate the feasibility and safety of the isolation technique in total En bloc Spondylectomy (TES) for thoracic tumors and retrospectively evaluate the clinical results.Methods:29 patients with a solitary thoracic tumor who were performed TES in PLA General Hospital from January 2008 to January 2014 were included in the study. Among the 29 patients,16 patients were male. And the average age was 48.7 years (range,17-63).12 patients suffered primary thoracic tumor and the other 17 patients suffered metastasis thoracic tumor. According to different surgical techniques,29 cases were divided into two groups,20 patients in conventional TES group; 9 patients in the whole isolation technique group. The clinical data retrospectively examined and compared includingneurological status, back-pain evaluation, estimated blood loss, operation duration, blood transfusion amount, drainage amount, drainage duration and complications.Results:29 patients were all successfully performed TES. There were no statistically significant differences in gender, age, symptom duration, Tomita type, operation duration, drainage amount, and drainage duration between the two groups (p>0.05). However, the differences in the estimated blood loss and blood transfusion amount were statistically significant (p<0.05).1 patient with metastasis tumor died from tumor recurrence 30 months after surgery.Conclusions:The whole isolation technique is a feasible and safe modification to conventional TES for thoracic tumors to reduce the intraoperative blood loss, blood transfusion amount and contamination of the tumor cells. Compared with conventional TES, the use of the isolation technique did not increase the operation duration or complexityor the disturbance to the local tissues and organs.