Chapter Clinical Summary
Academic synthesis, diagnostic methodology, and surgical recommendationsThoracic and lumbar vertebrectomy in spinal oncology is an extremely complex and technically demanding surgical procedure aimed at treating primary malignant tumors, aggressive benign tumors, and solitary spinal metastases. Neoplastic involvement of the spine causes biomechanical instability, severe mechanical pain, pathological fractures, and compression of neurological structures, drastically affecting patient function. The main surgical challenges involve executing resections with adequate margins while preserving adjacent neural and vascular structures, as well as managing significant morbidity and high intraoperative bleeding risk. In this scenario, the procedure seeks to provide local tumor control, sustained pain relief, and preservation or recovery of neurological status. Proper candidate selection, supported by a multidisciplinary approach and rigorous assessment of life expectancy and functional status, is decisive in balancing surgical magnitude with expected clinical benefits, yielding satisfactory overall survival rates and quality of life gains.
This chapter aims to train the reader to understand indications and contraindications for thoracic and lumbar vertebrectomy in neoplasms, mastering preoperative planning, surgical staging, and surgical approach selection. Additionally, it details the principles of resection and reconstruction techniques—including innovations such as the Gasbarrini technique—, enabling the specialist to recognize, prevent, and manage severe perioperative complications.
Vertebrectomy is indicated for primary malignant tumors (such as chordomas and sarcomas) seeking marginal or wide resection; aggressive benign tumors that are recurrent or refractory (e.g., giant cell tumors and osteoblastomas); and solitary metastases in patients with controlled systemic disease and long life expectancy, especially radioresistant lesions. Planning utilizes the Weinstein-Boriani-Biagini (WBB) staging system, which maps transverse extension into 12 radiating zones and 5 concentric layers (A to E), in addition to longitudinal levels. Contraindications include noble structure invasion with prohibitive morbidity, patient frailty, low life expectancy, and prior local radiotherapy.
Management requires a multidisciplinary team (with vascular and thoracic surgeons and intensive care staff) and blood product availability. Preoperative embolization (performed at least 48 hours prior) is recommended at the affected level and adjacent levels (three-level protocol) for hypervascular lesions, reducing blood loss. The feeder to the anterior spinal artery must be identified and preserved to avoid spinal cord ischemia. Approach selection varies: posterior or posterolateral approaches are preferred for the upper thoracic spine (T2-T5); for T5-L5, pure posterior, anterior, or combined anteroposterior approaches are used. At the thoracolumbar junction (T11-L2), anatomical relations with the diaphragm, ribs, and pleura must be assessed.
Surgery requires prior stabilization via instrumentation extending at least two levels proximally and two levels distally. During osteotomy and corpectomy, contralateral provisional rod support maintains stability. Posterior elements and adjacent discs are released, extending dissection into the epidural space with dural protection. Anterior column reconstruction employs titanium expandable or static cages, carbon-fiber-reinforced PEEK (CFRP), or 3D-printed custom prostheses combined with bone graft. In the Gasbarrini technique, a semicircular frozen femoral shaft allograft is added to the posterior column, seated between residual spinous processes and fixed with sublaminar bands, aiming to protect the dura mater, prevent adherent scar tissue, and optimize 360-degree fusion.
Five-year survival for primary tumors ranges between 51% and 72%, with local recurrence rates below 10% when clear margins are obtained. However, surgical complication rates and revision needs can exceed 50%, notably surgical site infections, pulmonary complications, and hardware failures. Preventing massive bleeding involves judicious embolization and induced hypotension (SBP 80-100 mmHg). Neurological preservation requires cautious blunt dissection and limiting segmental artery ligation to fewer than four levels. Advances such as video-assisted thoracoscopic surgery (VATS), biportal endoscopy, and robotic systems emerge as alternatives to minimize morbidity.
The presented concepts guide decision-making from initial oncologic screening to postoperative rehabilitation. In the evaluation phase, combining MRI and CT angiography enables anatomical staging by the WBB system, guiding approach corridor selection and en bloc resection feasibility. Clinically, indication must balance tumor control with biomechanical risks; screening for systemic and tumor bone fragility is crucial to plan reinforcement strategies, such as fenestrated cemented pedicle screws or sublaminar bands. During execution, rigorous adherence to hemodynamic support protocols, protecting great vessels by blunt anterior dissection, and intraoperative neuromonitoring are indispensable safety measures. Decisions on anterior and posterior reconstruction, aligned with fixation span (minimum two levels above and two below), are vital to prevent late implant failure, progressive kyphosis, and collapse, especially in patients undergoing adjuvant radiation. In high-risk scenarios, such as prior radiotherapy or non-embolized hypervascular tumors, extreme care is mandatory due to elevated risks of wound dehiscence, infection, massive hemorrhage, and ischemic spinal cord injury.