Embolization procedures are recommended to reduce operative blood loss in hypervascular tumors, especially during more extensive resections.
Embolization should be considered for hypervascular tumors, such as giant cell tumors, aneurysmal bone cysts, and hemangiomas.
The role of the embolization is:
To reduce the vascularity of the tumor
To facilitate dissection around the tumor
Mapping of spinal cord vascular supply
Embolization on its own may also have a therapeutic effect.
This image shows the embolization of a hypervascular tumor.
Most benign primary tumors will be localized in the posterior element with variable extension into the vertebral body. These tumors are approached and resected through a posterior approach only.
A wide visualization is essential in these cases, and a laminectomy involving half a level above and below the tumor is recommended.
The goal is to achieve:
Good visualization of normal and abnormal anatomy
Safe decompression of the neural elements
In patients requiring posterior lateral decompression but no anterior column reconstruction, at least two levels above and below the involved segment should be instrumented. In cases of multilevel tumors or poor bone quality, this construct can be extended.
Short segment constructs lead to increased stress on the posterior implants, which increases the risk of implant failure (screw pullout/fracture).
The risk of implant failure may be decreased by cement augmentation of fenestrated screws and reconstitution of the anterior column using cement augmentation or a cage.
Vertebral body reconstruction
Depending on the extent of the vertebral body resection, anterior reconstruction may be required. Reconstruction can be achieved posteriorly using PMMA or anteriorly using an expandable cage.
If anterior vertebral body reconstruction is chosen, the posterior instrumentation, resection, and fusion are first performed before the patient is turned, and vertebral body reconstruction is performed anteriorly.
As the procedure is often curative, it is important to verify that the spine is reconstructed in good alignment, and a solid bony union should be attempted.
If a posterior element tumor only involves segments 1 and/or 12, resection can be performed without the need for an instrumented fusion.
In unilateral cases, instrumentation of the unaffected side may be performed, especially if radiation is not being considered.
Every case is unique.
To illustrate the surgical principle of a posterior intralesional resection, including a significant portion of the vertebral body, we will use an L2 tumor located in segments 1–8 of the WBB classification.