Ligation and partial excision of the cauda equina as part of a wide resection of vertebral osteosarcoma: a case report and description of surgical technique.
METHODS
A case report.


OBJECTIVE
To describe the unique challenges and novel surgical approach to treatment of vertebral osteosarcoma involving the dura as a margin.


BACKGROUND
Osteosarcoma of the vertebral column is a rare, malignant osseous tumor, carrying a poor prognosis. Currently, best available evidence supports that optimal surgical treatment entails wide excision of the tumor. Intentionally compromising neurologic function in order to ensure resection of the tumor with wide surgical margins can pose a difficult dilemma for the surgeon and patient. We describe here the first reported case, to our knowledge, of wide surgical resection of a vertebral osteosarcoma, including ligation and resection of part of the cauda equina and conus medullaris.


METHODS
The clinical and radiographic presentations of a patient with osteosarcoma of L2 are presented. The challenges of surgical treatment of a primary malignant tumor of the spine, involving the dura as a margin, are discussed. The ultimate surgical technique employed to achieve wide surgical margins is described in detail.


RESULTS
Four-year follow-up shows the patient is doing well, ambulating in a wheelchair, with no clinical or radiologic evidence of active disease or back or neuropathic pain and solid bony fusion.


CONCLUSIONS
Currently, there is sufficient evidence to support the premise that the best chance for cure in sarcomas of the spine can be afforded through en bloc resection with negative margins. Neurologic forfeit in resection of spinal tumors, however, is usually at the root level, and this is the only case where such dramatic neurologic sacrifice was carried out. Although it is still early, the surgical and medical goals have been met, but most importantly, the patient's foremost goal of survival has been accomplished.
Keynan
Ory
O
Division of Spine, Department of Orthopaedics, University of British Columbia and the Combined Neurosurgical and Orthopaedic Spine Program at the Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada.
Fisher
Charles G
CG
Boyd
Michael C
MC
O'Connell
John X
JX
Dvorak
Marcel F
MF
D000328:Adult; D002420:Cauda Equina / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007796:Laminectomy / Q000295:instrumentation / Q000379:methods*; D008026:Ligation; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*; D012516:Osteosarcoma / Q000000981:diagnostic imaging / Q000601:surgery*; D011859:Radiography; D013120:Spinal Cord Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*