Primary Malignant Tumors of the Cervical Spine

■ Review Article

SPOTLIGHT ON cme ARTICLE spine Earn Category 1 credits Primary Malignant Tumors of the Cervical Spine

PANAYIOTIS J. PAPAGELOPOULOS, MD, DSC*; ANDREAS F. M AVROGENIS, MD*; BRADFORD L. CURRIER, MD†; PAVLOS KATONIS, MD‡; EVANTHIA C. GALANIS, MD§; GEORGE S. SAPKAS, MD*; DEMETRIOS S. KORRES, MD*

educational objectives

As a result of reading this article, physicians should be able to: only 0.8% of all lymphoma cases affected the cervical spine.1 Non-plasma cell 1. Describe the clinical features of primary malignant tumors of the cervical lymphomas are associated with epidural, spine. rather than bony manifestations.16 2. Define the imaging characteristics of these tumors. Chordomas of the spine are the most common solid spine tumors, accounting 3. Discuss work-up, biopsy, and staging in these patients. for 33% of the primary malignant tumors 4. Determine the appropriate treatment of patients with primary malignant of the spine.16 Eighty-five percent of all tumors of the cervical spine including new operative techniques for chordomas occur in the sacrum or the tumor resection. clivus.18,19 In the Mayo Clinic Registry, only 6% of all chordoma cases affected the cervical spine.1 These tumors are rimary malignant tumors of the cer- for Ͻ30% of all spine tumors, whereas in thought to arise from notochordal rem- vical spine are rare1 but challenging adults, approximately 75% of spine nants in the vertebral disks. They are con- Pbecause of the spine’s unique struc- tumors are malignant.15 The male to sidered low-grade, slow-growing, locally ture and proximity to vital structures. A female ratio is 2:1, with an even distribu- invasive, indolent malignancies, that thorough clinical and imaging investiga- tion among all spine levels.1 Multilevel behave aggressively in the region of their tion is necessary for the oncological and involvement may be noted, and at diag- origin and metastasize late in their surgical staging of these lesions. New nosis, the tumor may extend to the par- course. operative techniques for aggressive en avertebral soft tissues.13 Chondrosarcomas are the second most bloc resection of these tumors through Myeloma and solitary plasmatocytoma common solid tumors, accounting for combined anterior and posterior approach- are the most common primary malignant approximately 10% of primary malignant es and reconstruction of the spinal column tumors of the adult spine, accounting for have improved the oncological outcome approximately 30% of all primary malig- From the *First Department of Orthopedics, with low local recurrence rates and nant spine tumors. In the Mayo Clinic Athens University Medical School, Athens, increased patient survival.2-11 Registry, only 3% of all myeloma cases Greece; the †Department of Orthopedics, Mayo affected the cervical spine.1 Solitary plas- Clinic, Rochester Minn; the ‡Department of Orthopedics and Traumatology, University of PIDEMIOLOGY E matocytomas are diagnosed in approxi- Crete, Medical School Heraklion, Crete, Greece; Malignant bone tumors are rare, mately 3% of myelomas, with 50% occur- and the §Division of Medical Oncology, Mayo accounting for 0.4%-1% of all tumors.1 ring in middle-aged men (mean age 50 Clinic, Rochester Minn. Only 10% of these affect the spine, with years).16,17 The authors have no industry relationships to declare. 4.2%-6.3% affecting the mobile spine Non-plasma cell lymphomas account Reprint requests: Panayiotis J. 1,12-14 above the sacrum. In children and for approximately 10% of primary malig- Papagelopoulos, MD, DSc, 4 Christovassili St, adolescents, malignant tumors account nant lesions. In the Mayo Clinic Registry, 154 51 N Psychikon, Athens, Greece.

1066 ORTHOPEDICS | www.orthobluejournal.com CERVICAL SPINE TUMORS | PAPAGELOPOULOS ET AL cme ARTICLE Earn Category 1 credits spine tumors. In the Mayo Clinic Registry, In lower cervical spine tumors, an transverse and longitudinal extent of the only 1.5% of all chondrosarcomas affected insidious onset of cervical pain, usually is tumors, the presence of a reactive tissue the cervical spine.1 Most chondrosarcomas the initial symptom.12,13 Radicular pain is margin, or the invasion of the epidural are relatively indolent and tend to recur most common in cases with soft-tissue or space (Figures 1D and 1E).2,12,26,28,29 locally before distant spreading occurs. bony encroachment on the foramina and Magnetic resonance imaging is most Various low to highly malignant histologic may be associated with hypesthesia and useful in the evaluation and differential subtypes of chondrosarcomas have been muscle weakness. diagnosis of intra- and extradural spinal reported.20-21 lesions. Spine tumors usually are evident Osteosarcomas and Ewing’s sarcomas IMAGING on MRI before canal compromise or are highly malignant bone lesions, Plain radiographs remain the first imag- instability develops. However, MRI may accounting for 10% of malignant primary ing tool in the diagnosis and evaluation of not be feasible in some cases (eg, in tumors of the spine. Osteosarcomas occur malignant tumors of the cervical spine.1,2 patients with pacemakers or other metal- in the spine in Ͻ3% of any other skeletal Standard imaging features include a radio- lic implants and claustrophobia or obesi- location.11,22,23 In the Mayo Clinic lucent and destructive lesion or severe ty).12,29,30 Registry, only 0.5% of all osteosarcomas osteopenia of one or more vertebrae, often Angiography and selective arterial and only 0.4% of all Ewing’s sarcomas associated with pathologic fracture (Figure embolization can be performed for vascu- affected the cervical spine.1 Ewing’s 1A). Other findings include the loss of a lar tumors.18,31-33 tumors occur primarily in children.24 pedicle on an anteroposterior (AP) view, an Osteosarcomas may rise primarily in the osteoblastic lesion, the destruction of one BIOPSY spine (usually seen in adults), or they may or more vertebrae with preservation of the Biopsy is the final step in the preoper- occur secondarily in areas previously irra- disks, or a paraspinal soft-tissue mass, with ative work-up for the determination of the diated or in patients with Paget’s disease or without calcification. Collapse of the histological type and staging of the tumor. (usually seen after age 60 years). vertebral body with radiographic appear- In vascular lesions, embolization is indi- ance of vertebra plana has been reported.27 cated prior to biopsy.33 CLINICAL PRESENTATION Secondary spine deformities, such as Three types of biopsy techniques are Primary malignant tumors of the kyphotic or scoliotic angulation, may also used: percutaneous needle (fine-needle cervical spine usually manifest pain as the be observed.2 aspiration or CT-guided core biopsy), primary symptom. However, they may be Bone scintigraphy shows increased open incision, and excisional biopsy.34-38 diagnosed incidentally on plain radio- radioisotope uptake in the majority of Fine-needle aspiration provides a graphs or physical examination. Severe malignant spinal tumors (Figure 1B). The small amount of tissue and is associated night pain preventing sleep or waking the disadvantage is the low specificity due to with a high rate of false-negative results. patient is a common symptom.3,13 Spasm, the high rates of false-positive findings in In the cervical spine, its use is limited, scoliosis, or torticollis; neck stiffness and coexisting degenerative spondylosis in and generally is performed to confirm tenderness, and dysphagia due to compres- older patients and pyogenic infections of metastatic disease, local recurrence of a sion of the esophagus may be associated the spine. In most cases, hematopoietic known lesion, or lesions with a limited symptoms.9 General symptoms such as and lymphoproliferative tumors, such as differential diagnosis.37,38 weight loss and anorexia can also occur.12 leukemia and plasma-cell dyskrasias plas- Percutaneous CT-guided core biopsy Neurological deficits are common; ma-cell malignancies produce little, if although more difficult, has been per- however, the incidence of neurological any, osteoblastic reaction and therefore formed successfully in the cervical spine.36 deficits at diagnosis is reported to be are not evident on isotope bone scan.17 It is considered the best way to diagnose Ͻ10%.25 Aggressive tumors produce cord Computed tomography (CT) is more primary or secondary spine malignancies, or root compression more rapidly than sensitive than plain films and more accu- with a low incidence of tumor spreading in indolent neoplasms.13,18 rate than magnetic resonance imaging the surrounding tissues. In upper cervical spine tumors, pain (MRI) in imaging bone lesions (Figure Open incision biopsy should be per- usually is the initial symptom.26 1C). Computed tomography is most use- formed in cases where sufficient tissue is Neurologic deficits in these patients are ful in oncological staging for the CT-guid- required for immunohistochemical, mole- less frequent and occur late in the disease ed needle biopsy and the surgical staging cular, and microbiological analyses. Open process because of the wide spinal canal at and instrumentation planning of patients biopsy of cervical spine lesions is best this level. More likely, neurologic symp- with diagnosed malignant tumors of the obtained through an anterior approach toms result from spine instability rather spine.28 Computed tomography and MRI rather than by laminectomy. This prevents than direct compression from the tumor. provide the most detailed views of the contamination of the epidural space by

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1A 1B 1C

Figure 1: Chordoma of C2 vertebra in a 68-year- old woman. Lateral radiograph shows a destructive osteolytic lesion of the C2 vertebra (A). Bone scintigram shows increased radioisotope uptake(B), CT shows osteolysis of the C2 vertebral body (C), and T-1 (D) and T-2 (E) weighted MRI show anterior and posterior tumor soft-tissue extension.

1D 1E violation of the pseudocapsule of the strongly consistent with a certain diagno- tial examination, tumors are staged tumor.34 Meticulous hemostasis should be sis such as recurrent primary tumor, according to histologic type, compart- maintained. Although often impossible in metastatic disease, and in cases in which a mental location, and the presence or the cervical spine, biopsy with an ade- certain diagnosis, such as multiple myelo- absence of metastases. quate margin of healthy tissue should be ma, can be provided. The Enneking staging system2,34,43 included, and all contaminated tissue and divides benign bone tumors into three hematomas should be excised at the defin- STAGING stages: stage 1, also called latent or inac- itive surgical procedure.1,2,12,39 Excisional The purpose of staging is to identify tive; stage 2, active; and stage 3, aggres- biopsy should be reserved for tumors of the location and local or systemic extent sive (Figures 2A-2C). Stage 3 tumors the posterior elements of the cervical of the lesion and to confirm whether it is generally do not have a true capsule, or spine.39 a primary or metastatic, benign or malig- the capsule is thin and discontinuous, and It is recommended that the surgeon nant tumor.12 the tumor extends outside of the vertebral performing the definitive procedure also compartment of origin. Because of the be involved in the biopsy and preoperative Oncologic Staging high rate of local recurrences and proba- staging of the disease.12,34,39-41 The principles of the Enneking staging ble malignant degeneration, treatment In few cases, biopsy can be avoided system of musculoskeletal neoplasms are should focus on an aggressive surgical especially when imaging features are also applied to the spine.2,34,42,43 At the ini- approach, with a safe, wide margin surgi-

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Figure 2: Stage 1 benign tumors (A). The tumor is inactive and contained within its capsule (1). Stage 2 benign tumors (B). The tumor is growing, and the capsule (1) is thin and bordered by a pseudocapsule of reactive tissue (2). Stage 3 benign tumors (C). The aggressiveness of these tumors is evident by the wide reaction of healthy tissue (2), and the capsule (1) is thin and discontinued. Stage IA malignant tumors (D). The capsule, if any, is thin (1) and the pseudocapsule (2) is wide and contains an island of tumor (3). Stage IB malignant tumors (E). The capsule, if any, is thin (1), and the pseudocapsule (2) is wide and contains an island of tumor (3). The tumoral mass is growing outside the compartment of occurrence. Stage IIA malignant tumors (F). The pseudocapsule (2) is infiltrated by tumor (3), and the island of tumor can be found far from the main tumoral mass (skip metastasis, 4). Stage IIB malignant tumors (G). The pseudocapsule (2) is infiltrated by tumor (3), which is growing outside the vertebra. An island of tumor can be found far from the main tumoral mass (skip metastasis, 4). (Reprinted with permission from Boriani S et al. Primary bone tumors of the spine. Terminology and surgical staging. Spine. 1997; 22:1036-1044. Copyright © 1997. Lippincott Williams and Wilkins.)

2 cal excision of the lesion, in addition to true capsule but a thick pseudocapsule of High-grade, stage II malignant bone adjuvant therapy as indicated.43-46 reactive tissue is associated with these tumors are also subdivided into stage IIA According to the same system, malig- lesions. The major difference between (intracompartmental tumors within the nant tumors are staged as low grade (stage stage 3 primary benign and stage I malig- vertebra) and stage IIB (tumors extending I), high grade (stage II), or any grade nant tumors is the potential for satellite outside the vertebra into the surrounding tumor with distant metastases (stage III) lesions or foci of active tumor within the paravertebral region). Stage III includes (Figures 2D-2G). Low-grade, stage I pseudocapsule, which often are neglected the same lesions as stages I and II, but malignant tumors are further subdivided when inadequate resection is performed. with distant metastases, in addition to into stage IA (tumors remaining inside the The treatment of choice for these tumors intra- (stage IIIA) and extra-compartmen- vertebra) and stage IB (tumors extending is wide en bloc excision with adjuvant tal (stage IIIB) extension. Because of the into the paravertebral compartments). No megavoltage irradiation.2 rapid tumor growth, no reactive tissue

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TREATMENT Management of primary malignant tumors of the cervical spine is challenging. Complete excision of the tumor is the goal of treatment. Until recently, because of the unique anatomic structure of the cervical vertebra, the proximity to major vessels and the spinal cord, and the difficulty attaining wide excision of the spinal tumor, most surgical procedures included curettage and piecemeal intralesional tumor resection. As a result, incomplete tumor excision, tumor cell contamination of the surrounding tissues, and high rates of local recurrences and distal metastases 3 were reported.11,47,48 Figure 3: Weinstein, Boriani, and Biagini (WBB) Surgical Staging System. The transverse extension of the Lymphoproliferative and plasma cell vertebral tumor is described with reference to 12 radiating zones (numbered 1 to 12 in a clockwise order) neoplasms usually are radiosensitive even and to 5 concentric layers (A to E, from the paravertebral extraosseous compartments to the dural involvement). The longitudinal extent of the tumor is recorded according to the levels involved. (Reprinted in response to low doses of conventional with permission from Boriani S et al. Primary bone tumors of the spine. Terminology and surgical staging. radiation. Systemic chemotherapy is also Spine. 1997; 22:1036-1044. Copyright © 1997. Lippincott Williams & Wilkins.) frequently indicated. Surgery is rarely necessary. Indications include progressive layer is formed and continuous seeding of A modification of the Enneking onco- neurologic deficits, due to spinal instabil- tumor nodules (satellite nodules) and nod- logic staging system was proposed by ity, spinal cord pressure or nerve entrap- ules at some distance from the main Tomita et al,11 who incorporated a ment by tumor mass, or pathologic frac- lesion (skip metastases) are observed. description of the affected anatomic site ture, or recurrent lesions after maximum Extension can also occur into the epidural and extent of the tumor. This system has dose irradiation.13,17 The prognosis for space. been reported in relation to the thora- solitary plasmacytoma is better than mul- columbar spine; however, it is relevant to tiple myeloma, with a higher mean sur- Surgical Staging the cervical spine as well. According to vival rate.16 Surgical staging is the final step in the this classification system, the vertebral The goal of treatment for chordomas preoperative work-up of the patient. The body is divided into five anatomic sites: of the cervical spine is en bloc surgical unique anatomy of the vertebra and the the body (1), the pedicle (2), the lamina resection (Figure 6).18,49 However, in most difficulty of spine tumor resection led to and spinous process (3), the epidural cases, only marginal or intralesional the first surgical classification system pro- canal (4), and the paravertebral area (5), resection is feasible.42,49 Intralesional posed by Weinstein, Boriani, and Biagini with the numbers reflecting the common excision is associated with high recur- (WWB staging system), which has been sequence of tumor progression (Figure 4). rence rates.13,49 Chordoma is not sensitive further modified and tested.2,34,42,44 In the Intra-compartmental lesions are in sites to chemotherapy and only high-dose radi- WBB staging system, the vertebra in the (1), (2), and (3), and extracompartmental ation therapy seems to slow the evolution transaxial plane is divided into 12 radiat- lesions in sites (4), (5), and (6). A type (7) of the disease.13 ing zones (numbered 1 to 12 clockwise) lesion is one with multiple lesions or Chondrosarcomas are usually low- and 5 layers (named A to E from paraver- “skip” metastases (Figure 5). The purpose grade tumors and are resistant to irradia- tebral extraosseous region to dural of this surgical system is to further define tion and chemotherapy.16 The treatment of involvement) (Figure 3). The extent of the the lesions that can be excised en bloc. choice is wide surgical resection with tumor is identified by the number of sec- This can be attempted in lesions (2) to (5) wide surgical margins, which in some tors occupied and the letters of the layers and with a relative indication in lesions instances requires total en bloc involved.2,42 The transverse and longitudi- (1) and (6). According to the author, wide spondylectomy.21 These tumors tend to nal extent of these tumors is confirmed en bloc surgical resection is not recom- recur locally with prolonged disease-free with CT and MRI, and sometimes with mended in lesions type (7). periods before distant metastases occur. angiography.40-42 The natural course of osteosarcomas

1070 ORTHOPEDICS | www.orthobluejournal.com CERVICAL SPINE TUMORS | PAPAGELOPOULOS ET AL cme ARTICLE Earn Category 1 credits usually is rapid and a poor prognosis is anticipated.13,22 To improve survival, wide tumor resection is recommended with safe margins.13 Although adjuvant radio- therapy has been reported when wide resection is not feasible, osteosarcomas are not radiosensitive. Total en bloc spondylectomy is the treatment of choice for osteosarcomas of the spine, in addition to neoadjuvant and postoperative chemotherapy.9,10,13,22,50 Multi-agent chemotherapy followed by wide tumor resection is the mainstay of treatment for Ewing’s sarcoma.13 In 4 cases of neurologic deterioration, spinal Figure 4: Classifications of different anatomic sites of the vertebra. 1=vertebral body; 2=pedicle; decompression may precede chemothera- 3=lamina, transverse, and spinous processes; 4=spinal canal (epidural space); and 5=paravertebral area. py. High-dose radiation therapy and (Reprinted with permission from Tomita K et al. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine. 1997; 22:324-333. Copyright © 1997. Lippincott Williams chemotherapy may be used as adjuvant to & Wilkins.) surgical treatment or alone when operative treatment is not feasible.24,38 of the anterior aspect of the vertebral the neural foramen at that level. body, blood perfusion disturbance of the Cohen et al52 described a technique for SURGICAL CONSIDERATIONS spinal cord at the level of surgery, and total spondylectomy for osteosarcoma Several studies describing the surgical excessive bleeding from the internal ver- involving the cervical spine. The method excision of primary malignant or aggres- tebral vein and epidural venous plexus.11 involved separately staged posterior and sive benign spine tumors using combined The use of the threadwire saw is anterior approaches (Figure 7). However, anterior and posterior surgical approaches believed to minimize tumor cell contami- the resection described in this case was by have been reported.4,8,11,21,22,50-52 However, nation of the surrounding tissues or the definition intralesional. the combined anteroposterior procedures surgical incision.9 No major complica- Ligation of a vertebral artery may may be more extensive and traumatic than tions such as mechanical damage, dural sometimes be inevitable to avoid massive the single posterior or anterior approach tears or leakage of cerebrospinal fluid, hemorrhage during tumor resection and may increase the chance of contami- damage to the nerve roots, neurological surgery. Although several reports18,57-59 on nation by tumor cells and subsequent complications, or signs of aseptic necro- this approach exist, because of its vital local tumor recurrence.11 sis, such as bone absorption or collapse blood supply and the possibility of other Total en bloc spondylectomy has been and sclerotic changes, have been reported coexisting occlusive disease that might described for complete tumor resection with the use of threadwire saw.9,50,53-56 affect the contralateral vertebral artery and oncologic management of primary In the cervical spine, wide surgical later in the future, the vertebral artery malignant vertebral tumors of the thora- resections have been attempted using should be preserved whenever possible. columbar spine.11,12 The procedure is per- techniques similar to total “en bloc” In a recent study,57 the vertebral artery formed in two steps, consisting of en bloc spondylectomy. In a recent case report by was unilaterally ligated with no postoper- laminectomy after bilateral pediculotomy Fujita et al,18 a chordoma was located on ative signs of spinal cord, brain stem, or using a stainless-steel threadwire saw one side of the C5 vertebral body (Figure cerebellum ischemic dysfunction. (step I), and en bloc corpectomy followed 6). A special modification was made to Ligation of a vertebral artery should be by anterior fusion with instrumentation allow the threadwire saw to be hooked performed for safe margin tumor resec- and spacer grafting and posterior spinal inside the pedicle. This modification tion, only when the tumor is located on instrumentation (step II).10,47,48,51 involved ligating the left vertebral artery the side of the minor or equal diameter of The major risks in total en bloc followed by making troughs in the verte- vertebral artery, which should always be spondylectomy are mechanical damage to bral body and endplates of C6 and C4. confirmed with preoperative angiography. adjacent neural structures during the exci- However, the use of the threadwire saw For the treatment of chordomas origi- sion of the pedicles, possibility of tumor resulted in an intralesional margin on the nating at the cranio-cervical junction, the cell contamination during pediculotomy, dura mater near the insertion of the left lateral transfacetal retrovascular approach injury of major vessels during dissection C6 root because the tumor had invaded has been reported avoiding neuraxis

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5 Figure 5: Schematic diagram of the surgical classification of vertebral tumors. (Reprinted with permission from Tomita K et al. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine. 1997; 22:324-333. Copyright © 1997. Lippincott Williams & Wilkins.)

6 Figure 6: CT showing a lytic lesion in the left C5 vertebral body, sclerotic borders, and widening of the left C5-C6 foramen (A). CT showing an osteolytic lesion with lobular pattern accompanied by soft tissue extension (white arrow) in the vertebral body of C5 (B). T1-weighted MRI showing a slight increase in intensity in the lateral side of C5 with soft tissue extension (C). Schematic illustrating the technique used for cutting the left pedicle of C5 using the threadwire saw (D). Postoperative lateral radiograph showing anterior interbody fusion of C5 to C7 with the plate (E). (Reprinted with permission from Fujita T et al. Chordoma in the cervical spine managed with en bloc excision. Spine. 1999; 24:1848-1851. Copyright © 1999. Lippincott Williams & Wilkins.)

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7 Figure 7: Total cervical spondylectomy for osteosarcoma of the C6 vertebra. Illustrations showing the posterior approach for resection of the posterior elements of C5 to C7, exposure of the nerve roots and vertebral arteries bilaterally, transpendicular C6 partial vertebrectomy, placement of a temporary spacer in the vertebrectomy defect, segmental instrumentation and fusion using lateral mass screws (C3 to C5), pedicle screws (T1 to T3) and cross-links. (A) Illustrations showing the anterior approach for bilateral exposure of the vertebral arteries and nerve roots, and en bloc resection from C5 to C7 vertebral bodies including the C5-C6 and C6-C7 intervertebral disks, and reconstruction with a titanium cage filled with allograft and cervical plate from C4 to T1 (B). (Reprinted with permission from Cohen ZR et al. Total cervical spondylectomy for primary osteogenic sarcoma. Case report and description of operative technique. J Neurosurg Spine. 2002; 97:386-392. Copyright © 2002. American Association of Neurological Surgeons.)

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posterior vertebrectomy and replacement com- retraction.60 This procedure is considered lavage with a cis-platinum solution has bined with posterior instrumentation for spinal an indication for anterior located vertebral been reported after resection of osteosar- metastasis. J Neurosurg. 1996; 85:211-220. body tumors with lateral extension and comas, although the merit of this practice 6. Boriani S, Biagini R, De Iure F, et al. En bloc resections of bone tumors of the thoracolum- 9,66 vertebral artery invasion, with or without is unproven. bar spine. A preliminary report on 29 patients. an intradural mass. It allows for spinal Spine. 1996; 21:1927-1931. cord decompression, C2 corpectomy CONCLUSION 7. Fidler MW. Radical resection of vertebral without C1 or C2 hemilaminectomy, and Primary malignant tumors of the cervi- body tumors. A surgical technique used in ten cases. J Bone Joint Surg Br. 1994; 76:765-772. anterolateral reconstruction and posterior cal spine are rare. Neck or radicular pain is 8. Magerl F, Coscia MF. Total posterior verte- instrumentation. It is considered restric- the most common initial symptom. brectomy of the thoracic or lumbar spine. Clin tive when a spacious cephalad exposure is Appropriate clinical and radiographic eval- Orthop. 1988; 232:62-69. necessary, as in clivus chordomas.60 uation of the patient, biopsy, oncologic and 9. Kawahara N, Tomita K, Fujita T, Maruo S, In the cervicothoracic junction, tumor surgical staging, and adequate operative Otsuka S, Kinoshita G. Osteosarcoma of the thoracolumbar spine: total en bloc spondy- resection often is troublesome because of techniques and adjuvant therapies can lectomy. A case report. J Bone Joint Surg Am. the thoracic cage and adjacent neurovas- improve clinical, oncologic, and functional 1997; 79:453-458. cular structures. A combined cervicotho- outcome. Preoperative angiography and 10. Tomita K, Kawahara N, Baba H, Tsuchiya H, Nagata S, Toribatake Y. Total en bloc racic surgical approach of anterior cervi- selective arterial embolization, adjuvant spondylectomy for solitary spinal metastases. cal access, median sternotomy, and anteri- radiation therapy, or chemotherapy can be Int Orthop. 1994; 18:291-298. or thoracotomy has been reported,61 performed as indicated. 11. Tomita K, Kawahara N, Baba H, Tsuchiya H, resulting in gross tumor resection, with Surgery is the main treatment for most Fujita T, Toribatake Y. Total en block spondylectomy. A new surgical technique for maintenance of the sternoclavicular joint cervical spine malignant tumors. En bloc primary malignant vertebral tumors. Spine. and sparing of the uninvolved neurovas- resection with a wide surgical margin 1997; 22:324-333. cular structures. results in a better prognosis. Total en bloc 12. Abdu WA, Provencher M. Primary bone and Wide excision or total en bloc cervical spondylectomy is a new, promising surgi- metastatic tumors of the cervical spine. Spine. 1998; 23:2767-2777. spondylectomy usually results in spinal cal technique to allow complete tumor 13. Boriani S, Sundaresan N, Weinstein JN. instability, thus spine reconstruction is resection and improve clinical outcome; Primary malignant tumors of the cervical necessary at the level of the resection. however it is difficult to perform in the cer- spine. In: The Cervical Spine. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998:643- Autografts (eg, iliac crest, fibula, or ribs), vical spine. Ligation of a verterbal artery 657. allografts, and artificial spacers have all may be inevitable to achieve safe surgical 14. Weinstein JN. Surgical approach to spine been used to achieve anterior spine fusion margins during excision of a cervical spine tumors. Orthopedics. 1989; 12:897-905. in reconstructive surgery.52,53,62,63 tumor. Posterior alone or combined anteri- 15. DiLorenzo N, Delfini R, Ciapetta P, et al. Recently, structural titanium mesh cages or and posterior surgical approaches can Primary tumors of the cervical spine: surgical experience with 38 cases. Surg Neurol. 1992; have been designed with varying available facilitate complete tumor resection with 38:12-18. diameters and heights, and great resis- low rates of local tumor recurrence. 16. Sundaresan N, Krol G, Hughes JE. Primary tance and maintenance of spinal align- Adjuvant irradiation or chemotherapy is malignant tumors of the spine. In: Youmans ment for anterior vertebral body structur- indicated for certain tumor histologies. JR, ed. Neurological Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co; 53,64,65 al support. Inside these cages, auto- 1990:3548-3573. graft or allograft can be inserted for bone REFERENCES 17. McLain RF, Weinstein JN. Solitary plasmacy- fusion. 1. Unni KK. Dahlin’s Bone Tumors. General tomas of the spine: a review of 84 cases. 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