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Multisegmentale En-bloc-Spondylektomie

Indikation, Staging und chirurgische Technik

Multisegmental en bloc spondylectomy

Indications, staging and surgical technique

  • Operative Techniken
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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Ziel ist die onkologisch suffiziente Resektion segmentüberschreitender primärer Knochentumoren und solitärer metastatischer Läsionen an der Wirbelsäule durch En-bloc-Exzision multisegmentaler vertebraler Tumormanifestationen zur Minimierung des Lokalrezidivrisikos und zur Verbesserung der systemischen Tumorkontrolle. Suffiziente Defektrekonstruktion zur Wiederherstellung der biomechanischen Wirbelsäulenstabilität, zum Funktionserhalt oder zur Wiederherstellung einer adäquaten neurologischen Funktion.

Indikationen

Primär maligne und benigne, aggressive Wirbelsäulentumore, solitäre Metastasen tumorbiologisch und prognostisch günstiger Primärtumore (entsprechend günstige Werte in den prognostischen Scores) sowie extrakompartimentale multisegmentale vertebrale Tumormanifestationen entsprechend Typ 6 nach Tomita.

Kontraindikationen

Diffuse spinale/vertebrale Tumorausbreitung entsprechend Typ 7 nach Tomita (disseminierte Metastasierung der Wirbelsäule), Nachweis von Fernmetastasen im Staging, biologisch ungünstige Tumorentitäten bzw. primär maligne Systemerkrankungen/diffus disseminierte Malignome (Tomita-Score < 4–5 Punkte, Tokuhashi-Score  < 12 Punkte).

Operationstechnik

Je nach Tumorausdehnung sequentieller ventraler (Thorako- oder Lumbotomie, ggf. Laparotomie zum anterioren Tumorrelease und Gefäßpräparation) sowie dorsaler Zugang. Dorsaler Zugang über dorsomediane Inzision, Exposition der dorsalen Wirbelanteile, Kostotransversektomie, Resektion der Facetten, segmentale Resektion paravertebraler Rippenanteile. Laminektomie im tumorfreien Abschnitt der Laminae; nach Resektion des Ligamentum flavum sowie Erreichen des epi-/extraduralen Raums duralsacknahe Ligatur tumorumwachsener Nervenwurzeln; bilaterale Ligatur der Segmentarterien. Palpatorisch-digitale, möglichst extrapleurale Präparation zu den ventralen Wirbelkörperanteilen und einsetzen S-förmiger, die ventrale Wirbelkörperkontur umfassender Spatel zur Gefäßprotektion. Markierung und Durchtrennung der Bandscheiben und des vorderen/hinteren Längsbands. Instrumentierung der Pedikelschrauben und unilaterale Stabfixation. Mobilisation und verletzungsfreies Herausdrehen der betroffenen Wirbelsegmente um die Längsachse des Myelons. Interposition eines mit autologer Spongiosa gefüllten Cages von dorsal und Komplettierung der dorsalen Stabilisation. Weichteilverschluss, ggf. Goretex-Patch bei notwendiger Thoraxwandrekonstruktion.

Weiterbehandlung

Intensivmedizinische Überwachung mit balancierter Volumensubstitution. Postoperative adjuvante Strahlen- oder Chemotherapie je nach Protokoll und histologischen Resektionsgrenzen.

Ergebnisse

Deskription der Indikationen, Zugänge, chirurgischen Technik und Methoden der Instrumentierung. Defektrekonstruktion (ventrale/dorsale Spondylodese) nach mehrsegmentaler En-bloc-Resektion spinaler Tumore. Beschreibung des onkologischen Outcomes, der Kontraindikationen und intra-/postoperativer Risiken.

Abstract

Objective

Description of the surgical technique including approaches and spinal reconstruction principles for patients scheduled for multilevel en bloc excision of vertebral tumors (multisegmental total en bloc spondylectomy) with the aim to attain tumor-free margins and minimize the risk of local and systemic tumor recurrence. Restoration of biomechanically sufficient spinal stability. Functional preservation and/or regaining of adequate neurological function.

Indications

Primary malignant and benign, aggressive spinal tumors. Solitary metastatic tumors of biologically and prognostically favorable primary tumor (good prognostic scores). Extracompartmental, multisegmental vertebral tumor manifestations according to Tomita type 6.

Contraindications

Diffuse spinal/vertebral tumor spread according to Tomita type 7 (disseminated spinal metastatic disease). Detection of distant metastases in the staging investigation. Biologically unfavorable tumor entities or primary systemic malignant tumors/diffuse disseminated malignoma (Tomita score < 4–5 points, Tokuhashi score < 12 points).

Surgical technique

Depending on tumor growth, sequential performance of the anterior and posterior approach for local tumor release and preparation/replacement of encased large vessels. Posterior approach via dorsomedial incision and exposure of the posterior vertebral elements. Costotransversectomy, resection of the facets, resection of paravertebral rib segments. Laminectomy in the tumor-free lamina segment, resection of the ligamentum flavum and paradural ligation of affected nerve roots, bilateral ligation of the segmental arteries. Digital extrapleural palpation and dissection to the anterior vertebral body parts. Insertion of S-shaped spatulas ventral to the anterior aspect of the spine, and dissection of the disc spaces and the posterior longitudinal ligament. Instrumentation of pedicle screws and unilateral rod fixation, mobilization and careful, manual turning out/rotation of the affected vertebral segments around the longitudinal axis of the spinal cord. Interpositioning of a carbon-composite cage from posterior filled with autologous bone. Completion of the posterior stabilization, soft tissue closure, Goretex patch fixation if required in cases of chest wall resections.

Postoperative management

Intensive care monitoring with balanced volume replacement/transfusion. Postoperative adjuvant radiotherapy or chemotherapy, depending on the protocol and resection margins.

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Authors and Affiliations

  1. Zentrum für Muskuloskeletale Chirurgie, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland

    C. Druschel, A.C. Disch, I. Melcher, N.P. Haas &  K.-D. Schaser

  2. Section for Oncological Orthopaedics and Reconstruction of the Spine, IRCCS Istituto Ortopedico Galeazzi, Milan, Italien

    A. Luzzati

Authors
  1. C. Druschel
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  2. A.C. Disch
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  3. I. Melcher
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  4. A. Luzzati
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  5. N.P. Haas
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  6. K.-D. Schaser
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Correspondence to K.-D. Schaser.

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Druschel, C., Disch, A., Melcher, I. et al. Multisegmentale En-bloc-Spondylektomie. Oper Orthop Traumatol 24, 272–283 (2012). https://doi.org/10.1007/s00064-011-0070-6

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  • DOI: https://doi.org/10.1007/s00064-011-0070-6

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