title: Four- and five- level en bloc spondylectomy for malignant spinal tumors.
abstract: METHODS
  Retrospective study.
  
  
  OBJECTIVE
  To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors.
  
  
  BACKGROUND
  EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity.
  
  
  METHODS
  We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease.
  
  
  RESULTS
  Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up.
  
  
  CONCLUSIONS
  Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it.
  
  
  METHODS
  4.
authors.affiliation: *Department of Orthopaedics, Section for Oncological Orthopaedics and Reconstruction of the Spine, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy †Department of Otorhinolarynology, ORL Unit, Istituto Nazionale Tumori, Milan, Italy; and ‡Department of Thoracic Surgery, Istituto Clinico Humanitas, Milan, Italy.
authors.forename: Alessandro D
authors.initials: AD
authors.lastname: Luzzati
authors.forename: Sambhav P
authors.initials: SP
authors.lastname: Shah
authors.forename: Fabio S
authors.initials: FS
authors.lastname: Gagliano
authors.forename: Giuseppe G
authors.initials: GG
authors.lastname: Perrucchini
authors.forename: Walter
authors.initials: W
authors.lastname: Fontanella
authors.forename: Marco
authors.initials: M
authors.lastname: Alloisio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012189:Retrospective Studies; D013125:Spinal Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D055815:Young Adult