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Prevention and Management of Surgical
Complications of Thoracolumbar Tumors
Memorial Hospital, Sun Yat-sen University, China
Shen Hui-yong, Huang Lin, Chen Keng, Cai Zhao-peng
Spine metastases
SRES
70%
Symptoms
10%
Primari
es:
Breast
Prostate
Kidney
Thyroid
Lung
Myeloma
Lymphoma
GI tract
Most common site
90%
Thoracic
Lumbar
70%
%
20
Operations for thoracolumbar tumors
2009.12 – 2015.12
Nighty-eight Operations from 2009.12 to 2015.12
TES
43 cases
Blood loss
1800-7200 ml
Mean 3600ml
Complications
Complications
#
Neurological impairment 8
Temporary impairment in 7 cases and
recovered spontaneously
Pleural injury
28
Closed drainages ware necessitating in 8 cases
Dura mater laceration
16
Surgical repairmen was required in 1 case
Dislocation of titanium
mesh
7
Surgical revisions were necessitating in 4 cases
Preoperation Strategy
•
•
•
Type 1 - 3： Intra-compartment
Type 4 - 6: Extra-compartment
Type 7: Multiple
Preoperation Strategy
•
•
•
Type 1 - 3： Intra-compartment
Type 4 - 6: Extra-compartment
Type 7: Multiple
Approaches
•
Anterior approach alone:Type1-2
•
Posterior approach alone: superior or at L3 level
•
Anterior-posterior or posterior-anterior combined
approaches: L4 or L5
Anatomic factorsLumbar vs. Thoracic
Shape
Kidney-shape, large
Heart-shape, small
Deep
Shallow
Case 1 T12 Lung cancer metastasis
Anterior approach alone
Case 2 L1 lung cancer metastasis
Posterior approach alone
CASE 3 Spine recurrent GCT
•
First surgery: Curettage of T12 GCT in another
hospital
•
Blood loss during the first surgery: 10000ml
•
Postoperative radiotherapy
•
Recurrence 6 months later with spinal cord
compression
•
and incomplete paralysis
Before the first surgery
Recurrence
Revision:
TES via a single posterior approach
Repair the
defected dura
Artificial dura
substitute
Case 4 L4 breast cancer metastasis
Breast invasive ductal carcinoma: T2N0M0
• Modified radical mastectomy
• Chemotherapy: CTF protocol
• L4 breast cancer metastasis with
pathological fracture 7 years later
1. Posterior approach:
Resection of neural arch
2 Anterior
approach: Trans
medial
abdominal
rectus
retroperitoneal
approach
Vertebra
exposure
Reconstruction of stability
Anesthesia protocol
•
Induction：Venous fast induction
•
Maintenance：
① Sedatives: propofol
② Analgesics: remifentanil
③ Muscle relaxants: cis-atracurium
Common Intraoperative Complications
•
•
•
•
•
Vascular injury, mass blood loss
Spinal cord injury
Dural mater laceration
Pneumothorax, Hemopneumothorax, Pulmonary atelectasis,
Pneumonia
Posture related: acroisa, brachial plexus injury, lateral femoral
cutaneous nerve injury, pressure sore
2.1 Mass blood loss
•
Specific blood supply
•
Causes
•
Prevention
•
Management
Preoperative assessment: tumor with rich blood supply
Benign
Primary malignancy
Metastasis
Hematoma
Chordoma
Renal cell carcinoma
Aneurysm bone cyst
Osteosarcoma
Thyroid carcinoma
GCT
Chondrosarcoma
HCC
Osteoidosteoma
Ewing's sarcoma
Breast cancer
Osteoblastoma
Plasmocytoma/MM
Sarcoma
Paraganglioma
GCT
Melanoma
Osteochondroma
Hemangioperithelioma
PNET
Chondroma
Lymphoma
•
Ozakan E
Control
•
•
•
•
•
•
•
Controlled hypotension：
65-75mmHg
Reduction in blood loss without affecting spinal cord blood supply
Prevent hypothermia-induced coagulopathy；
Care of major vessels, index finger to feel, to separate
En bloc resection better than piece by piece; Control the bleeding during curettage via
tumor resection ASAP.
Management of venous plexus bleeding：bipolar coagulation, gelatin sponge and et al.c
2.2 Spinal cord injury
1.
2.
3.
4.
Management of preoperative neural injury
Intraoperative protection
Management of intraoperative injury
Postoperative recovery
Preoperative corticoid application
Mechanism
•Medication for acute Spinal cord compression
•Reduce spinal cord swelling and compression, improve short term neural function
•Alleviate inflammation, and tumor-induced pain
Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by
metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643-648.
•Our experience:corticoid 500mg before deal with spinal canal
Procedures
Process
Procedure
Prevention
Resection of posterior arch
Wire saw placement
Resection of capitulum costae, exposure of nerve root
canal, wire saw accumbent to the lamina
Intraspinal bleeding
Hemostasis
Using the bipolar coagulation in direct vision,
preventing iatrogenic compression
Dissection of IVD
Dissection of posterior
longitudinal ligament
Prevent traction of spinal cord, Keep scalpel or
osteotome from posterior IVD
Resection of vertebra
Spine instability
Temporary fixation before IVD dissection
Remove the vertebra
Compression or contusion
to spinal cord
Circling the spinal cord, or remove from lateral to the
temporary rod
Reconstruction
Titanium mesh-induced
compression or traction
Prevent excessive procedure
Intraoperative Neuromonitoring
•
•
•
SEP: monitoring ascending pathway (sensory, dorsal funiculus）
MEP: monitoring descending pathway (motor, anterior funiculus）
Free-run EMG: monitoring never root
 Reflecting the integrity of spinal cord and nerve roots
2.3 Dural mater laceration
Causes
• Tumor adhesion
• Wire saw injury
Sequels of CSF leakage
• Wound adhesion
• Infection
• Intracranial hypotension
• Central nerve system metastasis
Management
Direct suture；Dura repair：
•
“Sandwich” repairmen
•
Drainage
Uncontrolled SCF leakage：
 Lumbar cistern drainage
 Reoperation (Pseudo dural cyst)
 Musculocutaneous flap
 CSF shunt
2.4 Pleura laceration
Procedure
Prevention
Reckless dissection of intercostal tissues
Dissection of intercostal tissues to thoracic transverse
fascia
Rib stump injury
Using gauze, bone wax, and gelatin sponge to prevent
injury during and after rib resection
Resection of vertebra
Sufficient exposure, using gauze for separation
Titanium mesh placement
Separate the pleura, buffing the mesh, or use artificial
vertebral body as replacement
2.4 Pleura laceration
•
Protect wound from enlargement
•
lung inflation before closing the wound
•
Complete closure
•
Thoracic close drainage
•
“Sandwich ” repairmen
3.1 Wound complications
Radiotherapy
→surgery
Surgery
→radiotherapy
• 46 reports
• 51 reports
• 5836 pts
• 7090 pts
• Wound complications • 5-21 days interval
were increased in
surgeries within 7d
after radiotherapy
Our
Experiences
• Interval over 7 days
• IORT
Itshayek E, Yamada J, Bilsky M, et al. Timing of surgery and radiotherapy in the management of metastatic spine disease: a systematic review. Int J
Oncol. 2010 Mar;36(3):533-44. Review.
Clinical application of IORT
Mobile accelerator
Traditional accelerator
TrueBeam ® Linear accelerator
（Electron beam）
MOBETRON ®
（Electron beam）
Intra Beam ®
（Photon beam）
IORT via vertebral puncture
IORT
Preliminary results
•
Local control in all 40 cases
•
Follow-up: 12.5 months
•
Local control rate: 92.3%
•
Early ambulation
•
No radiation injury
•
No surgical complication
3.2 Hardware complications
Case5：L5 lung cancer metastasis
TES via anterior and posterior approaches + reconstruction
• Immediate stability is critical for reconstruction of L4 or L5
• Especially L5 due to the sacral slope.
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Guangzhou, China