Beruflich Dokumente
Kultur Dokumente
PII: S1878-8750(19)32124-2
DOI: https://doi.org/10.1016/j.wneu.2019.07.208
Reference: WNEU 13008
Please cite this article as: Zaldivar-Jolissaint JF, Bobinski L, Duff JM, Multilevel Pedicular Osteotomies
for en-bloc Resection of a Primary Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw
Reconstruction, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.07.208.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.
1
1 Abstract
2 Background
9 Methods
11 large Ewing Sarcoma of the subaxial cervical spine, infiltrating and traversing
12 the posterior bone elements, and extending into the paraspinal muscles.
16 Results
19 Conclusions
20 The described technique enables one stage total tumor resection and
23 spine.
2
1 Introduction
3 only 10% of histologically confirmed Ewing sarcomas and occurs with a peak
5 spine (53%), followed by the lumbar (25%), thoracic (11%) and only rarely the
6 cervical spine (3%), with the remaining involving more than one spinal region
8 primary spine tumors is local pain which arises classically during rest and at
12 For primary bone tumors, the surgical challenge is the feasibility of en bloc
13 tumor resection, as tumor free margins are directly correlated with local
15 highest in patients who undergo tumor-free margin excision 8,9. Another series
19 avoiding tumor margin violation. Radical en bloc surgical tumor excision with
21 tumors in the spine. However, this strategy may induce spinal instability, as in
22 our case. Indeed, iatrogenic spinal deformity following surgical excision is one
23 of the most common complications after excisional surgery for Ewing sarcoma
3
1 The authors present a case of a cervical extradural, intraspinal and paraspinal
4 vertebral bodies and allow en bloc resection with subsequent cervical pedicle
5 screw stabilization. To our knowledge, this is the first English language report
9 Case Description
17 traversing the bony posterior elements into the paraspinal muscles, and
19 and abdomen were normal. Routine blood laboratory values were normal.
23 The patient was positioned in the prone position on the Jackson table with the
24 head fixed in the Mayfield holder and the cervical spine in a neutral position. A
4
1 standard midline posterior skin incision from the occiput to T3 was performed.
3 -Skin and subcutaneous flaps were raised on both sides prior to fascial
7 (Figure 2).
8 -Following exposure of the lateral aspects of the C3/4 and C7/T1 facet joints
10 guidance (O-Arm®).
12 osteotomies10 at the terminal segments below the C4, and above the T1
13 pedicles bilaterally.
14 -At the intermediate segments, the posterolateral portions of the facets were
16 bilaterally across the proximal part of the C5, C6 and C7 pedicles with a high-
18 -Final bone disconnection was achieved by dividing the medial cortical walls
20 -Ligamentous attachments laterally and at the superior and inferior ends were
22 elevation and eventual en bloc removal of the tumor specimen (Figure 2 C).
23 The tumor capsule was in direct contact with the posterior dura but could be
5
1 adjacent dura which looked normal. The ventral tumor surface was not
8 substrate.
13 examination postoperatively. He left the hospital 8 days after the surgery and
15 the patient was fully ambulant, with a normal neurological clinical examination
16 and only mild residual neck pain with no signs of myelopathy (mJOA 18).
17 There were no signs of instability but posterior paraspinal muscle atrophy was
19 and standard x-rays with flexion/extension showed good spinal alignment and
21
22 Discussion:
24 such cases, the prognosis is related to how radical the surgical resection is,
6
1 Infiltration of surrounding structures (dura, spinal cord, nerve roots, vessels)
5 and spinal joints) can cause iatrogenic post-operative pain, instability and
6 spinal deformity13–16.
7 Posterior pedicle screw fixation after tumor resection has been shown to be a
15 pedicles at these levels had been partially resected as part of the specimen.
18 the cervical spine may be a useful option in cases where en bloc resection of
20
7
1 Bibliography:
27 9. Marco RAW, Gentry JB, Rhines LD, et al. Ewing’s sarcoma of the mobile
28 spine. Spine. 2005;30(7):769-773.
29 10. Ames CP, Smith JS, Scheer JK, et al. A standardized nomenclature for
30 cervical spine soft-tissue release and osteotomy for deformity correction.
31 J Neurosurg Spine. 2013;19(3):269-278.
32 doi:10.3171/2013.5.SPINE121067
33 11. Sciubba DM, Okuno SH, Dekutoski MB, Gokaslan ZL. Ewing and
34 osteogenic sarcoma: evidence for multidisciplinary management. Spine.
35 2009;34(22 Suppl):S58-68. doi:10.1097/BRS.0b013e3181ba6436
8
1 13. de Jonge T, Slullitel H, Dubousset J, Miladi L, Wicart P, Illés T. Late-
2 onset spinal deformities in children treated by laminectomy and radiation
3 therapy for malignant tumours. Eur Spine J Off Publ Eur Spine Soc Eur
4 Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2005;14(8):765-771.
5 doi:10.1007/s00586-004-0778-1
10 15. Yao KC, McGirt MJ, Chaichana KL, Constantini S, Jallo GI. Risk factors
11 for progressive spinal deformity following resection of intramedullary
12 spinal cord tumors in children: an analysis of 161 consecutive cases. J
13 Neurosurg. 2007;107(6 Suppl):463-468. doi:10.3171/PED-07/12/463
14 16. Sim FH, Svien HJ, Bickel WH, Janes JM. Swan-neck deformity following
15 extensive cervical laminectomy. A review of twenty-one cases. J Bone
16 Joint Surg Am. 1974;56(3):564-580.
21 18. Placantonakis DG, Laufer I, Wang JC, Beria JS, Boland P, Bilsky M.
22 Posterior stabilization strategies following resection of cervicothoracic
23 junction tumors: review of 90 consecutive cases. J Neurosurg Spine.
24 2008;9(2):111-119. doi:10.3171/SPI/2008/9/8/111
28 20. Jones EL, Heller JG, Silcox DH, Hutton WC. Cervical pedicle screws
29 versus lateral mass screws. Anatomic feasibility and biomechanical
30 comparison. Spine. 1997;22(9):977-982.
35 22. Dunlap BJ, Karaikovic EE, Park H-S, Sokolowski MJ, Zhang L-Q. Load
36 sharing properties of cervical pedicle screw-rod constructs versus lateral
37 mass screw-rod constructs. Eur Spine J Off Publ Eur Spine Soc Eur
38 Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2010;19(5):803-808.
39 doi:10.1007/s00586-010-1278-0
9
1 transpedicular screw fixation in the cervical spine. Spine.
2 1994;19(22):2529-2539.
10
1 Figure Legends
2
3 Figure 1
4 A. T1-weighted gadolinum-enhanced sagittal view showing a posteriorly lying
5 extradural mass with contrast enhancement extending from C5 to C7, and
6 thecal sac and spinal cord compression.
7 B. T1-weighted gadolinum-enhanced axial view at the C6 level showing tumor
8 infiltrating the posterior elements and into the para-vertebral musculature.
9 C. T2-weighted sagittal view showing the tumor mass from C5 to C7.
10 D. T2-weighted axial view at the C6 level.
11
12 Figure 2
13 A. Schematic diagram of the soft tissue resection and pedicle osteotomies. B.
14 Traction of the tumor specimen (arrowhead) allows microsurgical dissection
15 with dural visualization (*)
16 C. Excised tumor
17 D. Post-excisional decompression. The dura appears macroscopically normal
18 (*)
19
20 Figure 3
21 Immediate post-operative CT.
22 A. Sagittal Midline CT showing level of axial CT cuts.
23 B. Sagittal trans-articular CT showing the extent of the posterior element bony
24 removal, with bilateral pedicular osteotomies.
25 C. D and E. Axial CT showing the complete pedicular osteotomies at the C5,
26 C6 and C7 vertebrae respectively (*). Bone graft material is also visible.
27
28 Figure 4
29 A. 2-year Follow-up axial (C6) and coronal CT showing extensive fusion
30 (arrowheads)
31 B. 2-year Follow-up Antero-posterior and lateral standing X-rays showing
32 good spinal alignment, hardware position and bone fusion.
11
A
B C
*
A B
C D
A
A C B
D
E
C D E
* * * *
* *
A
B
1 World Neurosurgery
2
3 Abbreviations
4
5 Multilevel Pedicular Osteotomies for en-bloc Resection of a Primary
6 Ewing Sarcoma of the Subaxial Cervical Spine with Pedicle Screw
7 Reconstruction.
8
9 Abbreviation Signification
10 CPS Cervical Pedicle Screw
11 CT Computed-Tomography
12 mJOA modified Japanese Orthopedic Association score
13 MRI Magnetic Resonance Imaging
14 PVES Primary Vertebral Ewing Sarcoma