Brain and Spine Surgery in the Elderly by Moncef Berhouma & Pierre Krolak-Salmon

Brain and Spine Surgery in the Elderly by Moncef Berhouma & Pierre Krolak-Salmon

Author:Moncef Berhouma & Pierre Krolak-Salmon
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham


IV

Posterior ΒΌ vertebral body and region anterior to dura

Combined anterior and posterior approach

Generally require complete en bloc resection

Most inaccessible lesions, requires extensive reconstruction

Extent

A

Intraosseous

B

Extraosseous

C

Distal spread

Intralesional excision is the processes by which a lesion is cut into and removed often in piecemeal from the inside. It is often accompanied by curettage, or the methodical scraping and debridement of the tumor walls. Intralesional excision is most appropriate for indolent and definitively benign tumors that have little chance of recurrence if trace residual tumorous matter is left behind (e.g., EG, ABC, osteoblastoma/osteoid osteoma). Intralesional techniques can also be used to debulk metastatic disease, especially when the residual tumorous matter is amenable to radiation or elimination by other means [168].

Marginal excision is the process by which a lesion is removed in a single piece with a minimal margin of healthy tissue surrounding it. Because marginal excision does not guarantee that small residual pockets of tumorous cells are not left behind, it is most appropriate for low-grade malignancies like prostate metastases or aggressive benign lesions such as giant cell tumors. Tumors that respond especially well to adjunctive therapies such as radiation may also be amenable to marginal excision, including breast cancer and plasmacytomas [168].

Wide excision is the process by which a lesion is removed in a single piece with a thick margin of surrounding healthy tissue. This technique has the lowest chance that trace amounts of tumor are left behind; however, it is also the most destructive and often requires sacrifice of healthy and often essential structures such as load-bearing bone, nerves, and vessels. Wide excision is reserved for highly malignant and/or aggressive lesions such as osteosarcoma, chordoma, and high-grade chondrosarcoma. All primary malignancies without known metastases should generally be considered candidates for wide excision, as this offers the best chance of disease-free survival. Solitary metastases may also be amenable to wide excision when the chance of survival is high [168].

Surgical decompression is a technique of removing compressive structures from around nerves of the spinal cord. Decompression can be either direct, by removing or debulking tumorous material from around neural structures or by removing retropulsed pathologic fracture fragments from the spinal canal, or indirect, as in removing the lamina and posterior elements to make room for the compressed spinal cord. Spinal cord compression is reported in up to 20 % of patients with widespread cancer [168]. Radiation therapy is often effective for reducing cord compression, especially for metastatic disease; however, many tumors are radioresistant or the presence of bony retropulsion precludes effective irradiation [173]. In such cases, operative decompression is often necessary [173].

Reconstruction is the processes by which excised tissues are replaced by a variety of grafts and/or implants. Although reconstruction is a complex and often a case-specific topic, some basic concepts are universal. First, the anterior, weight-bearing column of the spinal must be restored. An unsupported anterior column will inevitably collapse into kyphosis. Bony autograft or allograft and mechanical cages or spacers are often deployed to transfer loads across the void left by the evacuated pathologic tissue [174].



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