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Tumors and Lesions of the Spine and Sacrum

- Primary Spinal Tumors:
    - primary spinal cord neoplasia
    - primary tumors of vertebral body:
           - 75% percent of vertebral body tumors are malignant;
           - multiple myeloma (most common primary tumor of spine)
           - chordoma
           - osteosarcoma
           - hemangioma
           - giant cell tumor of bone: sacrum;
           - eosinophilic granuloma
                  - produces vertebra plana on lateral x-ray;
                  - observe unless it causes a deficit
                  - low dose xrt may be helpful to prevent paraplegia;
           - giant cell tumor of the sacrum.
           - osteosarcoma of the spine
           - osteoid-osteoma and osteoblastoma of the spine
    - primary tumors of the posterior elements:
           - 35% of tumors of the posterior elements are malignant;
           - aneurysmal bone cyst: MRI defines lesions by showing enhancement of septations of abc;
           - osteoblastoma: (neurologic deficits)
           - osteoid osteoma (most common benign tumor in spine):
           - Giant cell tumor of the sacrum.
           - Osteosarcoma of the spine
           - Osteoid-osteoma and osteoblastoma of the spine.

- Metastatic Tumors of the spine:
           - carcinoma of the breast, kidney, or multiple myeloma may have relatively good long term prognosis;
           - metastatic carcinoma of the prostate or lung may have poor 1 year survival;
           - patients w/ combination of spinal metatasis along with either brain or visceral involvement may have an especially poor prognosis (survival less than 1 year);
    - radiographic signs:
           - missinng owl eye sign:
                 - the finding of a missing pedicle on an AP radiograph (missing own eye) is a strong indicatory of metastatic disease or lymphoma of bone;
                 - when metastatic deposits involve vertebrae cortices of pedicles are usually thinned and therefore cannot be seen on plain film;
    - MRI:
           - useful for showing vertebral involvement by metastatic disease
           - normal fatty marrow is replaced by tumor which has a higher water content (and therefore T1 signal changes from high to low and T2 signal changes from low to high);
    - treatment of advanced metastatic dz of spine:
           - anterior decompression:
                 - in cases of neurologic deficit and/or spinal instability, anterior decompression and stabilization (preserving intact posterior structures) has role and may result in recovery of neurologic f(x);
           - posterior decompression:
                 - indicated when there is neurologic deficit due to epidural compression from tumor or pathologic fracture;
                 - decompression is especially indicated when there is persistent pain and in cases in which radiation therapy cannot be used;
                 - relative contraindications may include cases in which there is direct anterior cord compression;
                 - technique involves wide posterior decompression which can include removal of both pedicles and any offending tissue (frx fragments and/or tumor);
                 - bone graft is not necessarily required;
    - references:
           - Current Concepts Review.  Metastatic Disease of the Spine.
           - Current Concepts: Spinal Cord Compression From Epidural Metastases.
           - Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy.
           - The pattern of vertebral involvement in metastatic vertebral breast cancer.
           - A profile of metastatic carcinoma of the spine.
           - A Role for Vertebral Biopsy in Selected Patients with Known Malignancy. A Report of Three Cases.
           - Vertebral body resection for epidural compression by malignant tumors. Results of forty-seven consecutive operative procedures.
           - Anterior decompression of vertebral osteosarcomas to relieve paraparesis. Report of two cases.

- Diff Dx: Lytic Lesion of the Spine:
    - osteosarcoma, chondrosarcoma, fibrosarcoma, ewing's sarcoma, myeloma,  plasmacytoma, lymphoma, and leukemia;
    - giant cell tumor, hemangioma, eosinoophlic granuloma;
    - cystic and dysplastic lesions that can involve one or a few vertebra include abc, fibrosdysplasia, brown tumor, and pagets dz;
    - pagets dz may involve the entire bone;
          - in its early lytic stages commonly involves the cortex as well as the trabecular bone;
          - pagets dz produces as thickening of the trabeculae in their normal alignment;
    - differential diagnosis of " ivory vertebra"
          - pagets disease (bone should be expanded)
          - multiple myeloma
          - lymphoma
          - hemangioma (coarse markings)
          - metastatic disease
    - cervical spine: (diff dx):
          - breast carcinoma:
                - most common malignant lesion of the cervical spine;
                - chordoma:
                - neurofibroma
                - focal enlargement of the intervertebral foramen and look for paraspinal soft tissue swelling;
    - references:
          - Treatment of tumors of the cervical spine.
          - Echinococcal infestation of the spine in North America.
          - Coccygeal glomus tumors: a case of mistaken identity
          - Differentiation between spinal tumors and infections with magnetic resonance imaging.

Total posterior vertebrectomy of the thoracic or lumbar spine.

Treatment of tumors of the thoracic and lumbar spinal column.

Complete removal of vertebrae for extirpation of tumors. A 20-year experience.

Spinal stabilization of vertebral column tumors.

The Biological and Biomechanical Effects of Irradiation on Anterior Spinal Bone Grafts in a Canine Model.

The fate of anterior vertebral bone grafts in patients irradiated for neoplasm.

Cephalad sacral resection with a combined extended ilioinguinal and posterior approach.

Surgical treatment of primary tumors of the sacrum.

Sacral resection. Operative technique and outcome.

Effectiveness and pitfalls of percutaneous transpedicle biopsy of the spine.

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