Neurosurgery notes/Procedures/TL spine procedures/Total En Bloc Spondylectomy

Total En Bloc Spondylectomy

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TL spine procedures
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Single Posterior Approach for TES
Modified Single Posterior Approach (Paraspinal Approach)
Anteroposterior Double Approach
Posterior-Anterior-Posterior Approach

General

  • Removing the entire vertebral body and posterior elements en bloc to achieve oncological complete tumor resection and prevent local recurrence.
  • The choice of surgical approach depends primarily on the affected spinal level(s) and the extent of tumor involvement, particularly whether major vessels or key nerve structures are involved.
  • Different techniques described below

Single Posterior Approaches (Posterior-Only)

General

  • These methods allow for tumor excision and circumferential spinal reconstruction in a single setting. They are generally preferred for certain thoracic and upper lumbar lesions where nerve root sacrifice is permissible or vessels are easily managed from the back.

Single Posterior Approach (Standard TES):

  • This method involves en bloc resection of the posterior element and then en bloc resection of the anterior column, aiming to complete the procedure during one surgical session posteriorly.
  • Indication
    • For tumors above L3 or L4 when major vessels are not involved (most Type 1, 2, 3, and 4 tumors, and some Type 5 and 6 tumors, according to Tomita's classification).
    • Lesions between T3 and L1.
  • Modified Oncological Techniques
    • TES with Sub-marginal Resection: In complex cases where the tumor involves a vertebral lamina or both pedicles, surgeons may aim for a "sub-marginal resection," which is considered an intermediate option between intralesional and marginal resection.
    • TES for Chronic Osteomyelitis: The principles of oncological surgery (performing an en bloc resection with clear margins) can be applied to chronic vertebral osteomyelitis with extensive tissue destruction, using techniques such as the Tomita technique for two-level spondylectomy.

Modified Single Posterior Approach (Paraspinal Approach):

  • This technique uses a posterior-only paraspinal approach in the lumbar spine (L1–L4).
  • This modification aims to provide a wider view of the ventral operative field compared to the traditional posterior midline approach, potentially reducing the risk of injury to the Inferior Vena Cava (IVC) and segmental vessels in the lumbar region.

Combined Approaches (Staged or Simultaneous)

General

  • Combined approaches are typically necessary for tumors in the lower lumbar spine (L3–L5) and for complex lesions (Type 5 or 6) that involve major vessels, adjacent vertebrae, or large paravertebral extensions.

Antero-posterior Approach:

  • This two-stage method begins with anterior dissection of major vessels, often via thoracotomy or extraperitoneal approach, followed by the main posterior TES procedure.
  • This is indicated for Type 5 or 6 tumors involving major vessels or segmental arteries.
  • This approach is considered safer for vessels around the vertebral body than a single posterior approach.

Posterior-Anterior-Posterior Approach:

  • This staged approach starts with posterior laminectomy and stabilization, followed by an anterior en bloc corpectomy and placement of a vertebral prosthesis.
  • This is indicated for spinal tumors at the lower lumbar level (L3 to L5), where the iliac wing and lumbosacral plexus nerves present technical challenges to a purely posterior approach.
  • The anterior stage may use an anterolateral extraperitoneal or an anterior midline transperitoneal approach, particularly at L5.
  • A third posterior stage may be necessary to finalize instrumentation, especially when using a titanium cage for anterior reconstruction.

Staged Posterior-Anterior Approach (Modified TES using Threadwire Saws):

  • A modified two-stage technique exists where the posterior stage involves passing threadwire saws anterior to the vertebral body and securing them to the posterior instrumentation.
  • The second, anterior stage (performed 1 to 7 days later) is used to perform the osteotomies in an anterolateral direction (away from the spinal cord) under direct visualization, reducing the risk of damage to major vessels.
  • This modification is complex but effective for thoracic and lumbar tumors.

Single-stage Combined Anterior-Posterior Approach:

  • Some surgeons utilize this approach, where both anterior and posterior steps are completed in one continuous operation, though the combined approach is most often performed in two stages in the lumbar spine.

References

  • 1. Total en bloc spondylectomy for spinal tumors – PMC Article
  • 2. Total en bloc spondylectomy. A new surgical technique for spinal tumors (Tomita, 1997) – PubMed
  • 3. En-bloc spondylectomy in the lumbar spine – PMC Article
  • 4. Total en bloc spondylectomy – Review and technique – PMC Article
  • 5. Total en bloc spondylectomy for primary tumors of the thoracic and lumbar spine – ScienceDirect
  • 6. Total en bloc spondylectomy in the treatment of postoperative infection – PMC Article
  • 7. Modified Standard Total en bloc Spondylectomy for Solitary Vertebral Metastatic Lesions (2025) – PubMed
  • 8. An improved total en bloc spondylectomy for L5 vertebral giant cell tumor – PubMed
  • 9. Total en Bloc Spondylectomy for Spinal Tumors: Surgical Technique and Clinical Results – PubMed
  • 10. Total en bloc spondylectomy of the lower lumbar spine – PubMed
  • 11. Total en bloc spondylectomy for primary tumors of the spine – PMC Article
  • 12. Total en bloc spondylectomy for locally aggressive and malignant primary bone tumors of the thoracic and lumbar spine – PubMed | DOI
  • 13. Blood loss in total en bloc spondylectomy for primary spinal tumors – PMC Article
  • 14. Total en bloc spondylectomy (2001, Boriani, Lizardi) – PubMed
  • 15. Total En Bloc Spondylectomy for Solitary Metastatic Tumors of the Spine – PubMed
  • 16. Modified total en bloc spondylectomy for thoracolumbar tumors – PMC Article
  • 17. A Novel Technique for Total En bloc Spondylectomy of the Lumbar Spine – PubMed
  • 18. Total En Bloc Spondylectomy for Lumbar Spinal Tumors by a Posterior-Only Approach – PubMed
  • 19. Modified En Bloc Spondylectomy for Tumors of the Thoracic and Lumbar Spine – PubMed
  • 20. Posterior-only approach for total en bloc spondylectomy – PubMed