Total En Bloc Spondylectomy of the Lower Lumbar Spine A Surgical Techniques of Combined Posterior-Anterior Approach

Study Design. Ten patients with a spinal tumor of the lower lumbar spine underwent total en bloc spondylectomy (TES) by combined posterior-anterior approach. The oncological and neurologic results are analyzed. Objective. To describe the surgical technique and evaluate the clinical outcome of this surgery. Summary of the Background Data. TES at lower lumbar spine is technically challenging because of its anatomy such as the presence of major vessels and lumbosacral plexus nerves. Methods. Six aggressive benign tumors and 4 solitary spinal metastases involving L4 or L5 were treated. The approache of operative procedure are discussed as follows: Posterior approach: Dissection of the lumbar nerve roots to the conjunction of the adjacent nerves were performed after en bloc laminectomy by T-saw pediculotomy. The psoas muscle was dissected away, from the vertebral body. The posterior halves of the anterior column at the craniocaudal adjacent levels of the lumbar tumor were cut. Anterior approach: Major vessels were dissected from the vertebral body. Anterior halves of the anterior column were cut at the corresponding levels. The tumor vertebral body was removed en bloc, followed by anterior spinal reconstruction. Results. Seven of 10 cases had no evidence of disease at 57 months on average, 1 case was alive with disease at 66 months, 1 case had death of disease at 42 months, and 1 case had death of another disease at 14 months after surgery. All patients improved or preserved neurologic in the last follow up. The resected specimen of vertebral bodies and laminae showed marginal or wide margin in all cases, although pedicles showed intralesional margin in 8 cases. No local recurrence was observed during lifetime with mean 52 months. Conclusion. TES for spinal tumor of L4 or L5 preserving lumbar nerves was achieved by combined posterior-anterior approach.