Doc-to-Doc: Surgical Management of Primary and Metastatic Spinal Tumors
Stefan A. Mindea, MD is Assistant Professor of Neurosurgery and Director of the Minimally Invasive Spinal Surgery Program at Stanford Medical Center. He specializes in non-fusion spinal surgery, minimally invasive spinal surgery and spinal tumors. To contact Dr. Mindea about speaking engagements, please call 312- 286-7713 or send him an email. For patient referrals, contact the Referring Physician Concierge Service by phone at 866-742-4811, via fax at 650-320-9443, or send and email to referral@stanfordmed.org.
The management of primary and metastatic spinal tumors has undergone a substantial paradigm shift over the last decade. Coupled with burgeoning technological advancements in the field of spinal neurosurgery, Class 1 evidence has clearly demonstrated the utility of surgical decompression in concert with radiation therapy to achieve improved functional outcomes and pain relief.
However, achieving disease-free surgical survival in this subset of patients has proven to be more elusive. To date, it is generally accepted that wide surgical margins in combination with multimodal therapy represents an essential precondition for achieving disease-free survival. Resection of spinal tumors is difficult due to the topographic proximity of vital neurovascular structures ( i.e., spinal cord, nerve roots, aorta, vena cava, etc) to the vertebral column that profoundly complicate obtaining wide resection margins in these tumors.
Conventionally, curettage or piecemeal surgical excision of vertebral tumors has been commonly practiced by neurosurgical spinal oncologists. However, clear disadvantages of these approaches include the high risk of tumor cell contamination of the surrounding structures and residual tumor tissue at the operative site due to the difficulty of distinguishing tumor from healthy tissue. These factors contribute to incomplete resections of the tumor as well as high local recurrence rates in these spinal tumors.
To address these limitations in resecting both primary and metastatic spinal tumors, major spinal oncology centers worldwide have embraced the TES (total en bloc spondylectomy) surgical technique. The tenet of this technique is removal of the entire vertebra, both body and lamina, as one entire compartment to thus reduce the chance of tumor cell contamination and incomplete tumor resection.
Based on markedly improved 5-year survival data for both primary and metastatic spinal tumors, the procedure has been increasingly gaining recognition and is now widely accepted by neurosurgical spinal oncologists as a definitive treatment strategy for these neoplasms. The TES procedure is however regarded as one of the most sophisticated and demanding operations; it requires a high level of technical ability and adequate knowledge and consideration of surgical anatomy, physiology, and biomechanics of both the spinal column and cord. As such, appropriate patient selection in the setting of a detailed and individualized clinical evaluation by the medical and radiation oncologists, radiologist, and neurosurgeon is critical to optimizing long-term results.
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