EANS Advanced Course in Spinal Surgery
November 4 — November 6
EANS Advanced Course in Spinal Surgery
November 4 — November 6
AOSpine Advanced Seminar—Tumor, Infection, Metabolic and Inflammatory Disorders of the Thoracolumbar Spine
November 2 — November 3
AOSpine Advanced Seminar—Intraoperative neuro-monitoring in spinal surgery; Signal interpretation and actions
October 19 — October 20
AOSpine Advanced Seminar—Spinal trauma and spinal cord injury
October 19 — October 20
This seminar addresses the evaluation, classification, treatment selection and complications associated with spinal trauma and spinal cord injuries. It explores advances in spinal cord injury treatment and looks at methods of preventing and treating this devastating complication of spinal trauma. The seminar will comprise of didactic lectures and debates by the expert faculty, focusing on providing the best available evidence for each topic. Illustrative cases will also be presented, followed by open and interactive discussion amongst the faculty members and participants.
Maintain normotension in the patient
Recognize spinal instability
Describe the injury based on an image-based morpho-logical classification
Select the treatment based on the available evidence
Recognize regional/junctional differences
Recognize complications as early as possible
Primary spinal peripheral primitive neuroectodermal tumors (pPNETs) are extremely rare entities that predominantly occur in children and young adults.
Microsurgical GTR of the tumor is the preferred method of treatment. Radiotherapy plays an important role in improving the prognosis of patients with pPNETs. GTR combined with radiotherapy and chemotherapy may be the best treatment modality 1).
Spinal PNETs, like their cranial counterparts, are aggressive tumors and patients with these tumors typically have short survival times despite maximal surgery, chemotherapy, and radiation. Because no standard management guidelines exist for treating these tumors, a multitude of therapeutic strategies have been employed with varying success 2).
The clinical data of 24 patients, who had been surgically treated from April 2003 to February 2018 in Department of Neurosurgery, Tongji Hospital, Wuhan, in whom immunohistochemical staining results had confirmed the diagnosis of primary spinal pPNETs, were retrospectively analyzed. To analyze the factors related to prognosis, the Kaplan-Meier method was used for univariate analysis, the log-rank method was used to test the significance of difference, and multivariate analysis was performed using Cox regression.
The overall 1-year, 2-year, and 5-year survival rates were 73.2%, 48.1%, and 12.0%, respectively. The median survival time (MST) of all patients was 21 months. Univariate analysis showed that the extent of tumor resection, adjuvant radiotherapy, and chemotherapy were the factors influencing patient prognosis after surgery (all P < 0.05); sex, age, tumor location, and preoperative Karnofsky performance scale (KPS) scores were not the influential factors for prognosis of patients after surgery (all P > 0.05). Multivariate analysis showed that gross total resection (GTR) of tumors and adjuvant radiotherapy were independent factors influencing the prognosis of patients with pPNETs (all P < 0.05).
Primary spinal pPNETs are extremely rare, and they have a poor prognosis. Microsurgical GTR of the tumor is the preferred method of treatment. Radiotherapy plays an important role in improving the prognosis of patients with pPNETs. GTR combined with radiotherapy and chemotherapy may be the best treatment modality 3).
13 patients (nine females and four males) with primary intraspinal pPNETs who were surgically treated from April 2008 to February 2014. Histopathologic findings revealed the expression of CD99 in all cases. Limb weakness was the most common initial symptom (11/13, 85 %). The tumors were located mainly at the cervical level (6/13, 46 %) and in the epidural space (10/13, 77 %). The radiological diagnosis was neurinoma or meningioma in most cases (10/13, 77 %). Gross total resection was achieved in 77 % (10/13) of patients. During a mean follow-up of 25.5 months, local relapse occurred in 8 (61.5 %) patients and distant metastases occurred in 8 (61.5 %) patients. The overall 1-year survival rate was 77 % (10/13), and the overall 2-year survival rate was 54 % (7/13). The 2-year survival rate was 57.1 % in patients with adjuvant chemotherapy and 50 % in those without chemotherapy. Gross total resection and adjuvant radiotherapy with or without chemotherapy demonstrated a longer survival period (1-year survival rate: 100 %; 2-year survival rate: 86 %). The data showed that primary spinal pPNETs are extremely rare and aggressive tumors with a poor prognosis. Radical resection is advocated. Gross total resection combined with adjuvant radiation may help to significantly improve patient survival period. Chemotherapy may also help to slightly prolong patient life 4).
Three patients of 8, 9 and 18 years of age, who presented with variable grades of neurological deficit were diagnosed as having a dorsal intramedullary lesion, a holocord lesion and cervical extradural tumor with extraspinal extension, respectively, and were operated at our institute. The histopathology of all 3 children revealed PNET. The clinical course, image characteristics and outcome of the 3 children are described, and the relevant literature is reviewed. The following conclusions were drawn from the present study and review of the literature. PNET may manifest itself as a primary lesion of the spine unlike the more common drop metastases from an intracranial lesion. PSPNET may be intramedullary, intradural and extradural with variable extraspinal extension. PSPNET may present as holocord intramedullary lesion, an entity which has not been described earlier. These lesions have a short history, significant neurological deficits and rapid course of illness. PSPNET, though an established entity, did not find a place in the WHO 2000 classification of CNS tumors. Hence its status has to be define 5).
A 26-year-old male presented with progressive low back and lower limb pain for 1 month. Based on MRI and histopathological findings, he was diagnosed with primary intramedullary PNET. The patient was treated two times with microsurgical resections. Follow-up visit at 14 months after the first surgery showed that the patient is neurologically intact and free of disease. PNETs should be considered in the differential diagnosis of an intramedullary spinal cord tumor manifesting as progressive neurological deterioration 6)
A 5-year-old Moroccan boy, who presented with torticollis for 1 month. Computed tomography scan and Magnetic resonance imaging of the cervical spine revealed an extradural, dumbbell-shaped mass with extra-spinal extension at the left C1-C6 level. Multiple biopsy specimens were obtained. Histological examination revealed a highly cellular neoplasm composed of diffuse sheets of tumor cells having monomorphic, round to oval, finely vesicular nuclei. Immunohistochemical findings confirmed the diagnosis of intraspinal peripheral primitive neuroectodermal tumor 7).
A two years old female child presented with weakness both lower limbs. Preoperative MRI of the spine and paravertebral region Iso – hyper intense posterior placed extradural lesion, non contrast enhancing from D11-L2 levels with cord compression D9 to L3 laminectomy done. Granulation tissue found from D11 to L2. with cord compression. The granulation tissue removed in toto. The pathological findings were consistent with PNET. Post operative neurological improvement was minimal. Cranial screening ruled out any intracranial tumour. Hence a diagnosis of primary spinal PNET was made 8).
A 18-year-old female with conus intramedullary tumor diagnosed to be primary spinal primitive neuroectodermal tumor following histopathological examination after surgery. The diagnosis of such a tumor is very crucial as the management strategies for these are relatively unclear and are associated with a poorer outcome compared to the other common intramedullary spinal tumors 9).
2 cases Ellis JA, Rothrock RJ, Moise G, McCormick PC 2nd, Tanji K, Canoll P, Kaiser MG, McCormick PC. Primitive neuroectodermal tumors of the spine: a comprehensive review with illustrative clinical cases. Neurosurg Focus. 2011 Jan;30(1):E1. doi: 10.3171/2010.10.FOCUS10217. Review. PubMed PMID: 21194274 10).
More than half of people over the age of 60 have osteophytes, or bone spurs, somewhere in their bodies. Osteophytes in the spine are a normal sign of aging and are not a cause for concern unless they result in pain or neurological symptoms.
Ezra et al. from the Department of Anatomy and Anthropology, Sackler Faculty of Medicine, School of Nursing Sciences, Yaffo Academic College, The Steinhardt Museum of Natural History and National Research Center, Tel Aviv University and Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Israel, aimed to determine the prevalence and severity of cervical osteophytosis in a large study population. To do so, they developed a grading system for osteophytosis, enabling the assessment of their presence and severity in the cervical spine; and applied it to the analysis of dried cervical vertebral bodies (C3-C7) from 273 individuals. Statistical analyses were carried out per motion segment, while testing for the effect of age, sex and ethnicity. The highest prevalence of osteophytes was found in motion segment C5/C6 (48.2%), followed by C4/C5 (44.1%), and lastly C6/C7 and C3/C4 (40.5%). Severe osteophytes are most commonly seen in motion segment C5/C6. In all motion segments, the inferior discal surface of the upper vertebra manifests more osteophytes than the superior discal surface of the lower one. Osteophytes prevalence is sex-dependent only in the upper cervical vertebrae (C3-C4), and age- and ethnicity-dependent for all vertebrae 1).
Anterior cervical osteophytes can be isolated or diffuse; they are most often idiopathic and part of a form called Forestier disease (diffuse idiopathic skeletal hyperostosis). It may also be a traumatic or iatrogenic form (particularly following spinal surgery).
Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary aspiration. Paradoxical vocal cord motion is an uncommon disease characterized by vocal cord adductions during inspiration and/or expiration. This condition can create shortness of breath, wheezing, respiratory stridor or breathy dysphonia 2).
Anterior cervical osteophytosis as a cause of dyspnoea and stridor 3).
Regression of anterior-disc osteophyte complex occurs following cervical laminectomy and fusion, and likely provides another mechanism of spinal cord decompression 5).
Five patients who underwent surgical resection of the cervical anterior osteophyte due to dysphagia. Videofluoroscopic swallowing studies (VFSSs) were performed before and after surgery on each patient, and kinematic analysis of the video clips from the VFSS of a 5-mL liquid barium swallow was carried out. Functional oral intake improved after surgery in 3/4 patients who had required a modified diet before surgery. Kinematic analysis showed increases in the maximal hyoid vertical movement length (13.16±5.87 to 19.09±4.77 mm, p=0.080), hyoid movement velocities (170.24±84.71 to 285.53±104.55 mm/s, p=0.043), and upper esophageal sphincter opening width (3.97±0.42 to 6.39±1.32 mm, p=0.043) after surgery. In conclusion, improved upper esophageal sphincter opening via enhancement of hyoid movement after cervical anterior osteophyte resection may be the kinetic mechanism of improved swallowing function 6).
Chen et al. llustrate a case of severe dysphagia caused by a large post-traumatic osteophyte with oropharyngeal swallow study showing a significant mass effect on the pharynx and resolution following osteophytectomy 7).
Two patients with Diffuse idiopathic skeletal hyperostosis (DISH) and anterior cervical osteophytes. They underwent anterior cervical osteophytectomies due to severe dysphagia. At more than a year follow-up, both patients noted improvement in swallowing as well as their associated pain. The surgical removal of cervical osteophytes can be highly successful in treating dysphagia if refractory to prolonged conservative therapy 8).
Seo et al. report a rare case demonstrating combined symptoms of dyspnea, dysphonia as well as dysphagia at the same time in a patient with asymptomatic anterior cervical osteophytes. Moreover, this is the first report demonstrating that anterior osteophytes can be a possible etiological factor for paradoxical vocal cord motion that induces serious respiratory symptoms 9).
A typical description of Forestier disease is related based on the cases of two 80- and 79-year-old men referred with gradually worsening swallowing problems leading to dysphagia. Both underwent surgical resection of cervical osteophytes via a lateral cervical approach after failure of the medical treatments.
Based on the clinical presentations and the analysis of the literature, the authors describe the clinical features of the cervical anterior form of DISH presenting with ENT symptoms. The diagnosis and conservative therapeutic, and surgical management of anterior cervical hyperostosis based on ongoing gradual solutions are described 10).
An 85-yr-old man complaining of swallowing difficulties was referred for a videofluoroscopic swallowing test for the evaluation of dysphagia. He had experienced swallowing difficulties for 7 yrs, but he had no complaint of dyspnea or dysphonia. Specifically, he complained of intermittent aspiration symptoms when drinking water or eating semisolid food, and he felt considerable discomfort when swallowing solid food. On physical examination, his gross motor and sensory functions were normal, and no pathologic reflex was detected. In addition, a cranial nerve examination that included gag reflex, mastication, and tongue movement evaluations produced normal findings. However, a videofluoroscopic swallowing test revealed epiglottic closure failure attributable to anterior bony spurring at the C3–6 levels, which presumably explained his complaint of aspiration. In addition, a diffuse osteophyte was found anteriorly encroaching the posterior aspect of the oropharynx and esophagus. However, his swallowing reflex was prompt, and other swallowing movements were normal 11).
A 62-year-old male presented with a history of difficulty in swallowing with a duration of 6 months, which was more for solid food and was associated with a foreign body sensation during swallowing. Previously, he was able to chew food without difficulty, and he did not have regurgitation of food. His general physical examination was essentially normal and neurological examination did not reveal any focal neurological deficit; he showed normal pharyngeal sensation tongue movement, and palatal reflexes. Examination of the oral cavity did not show any abnormalities; however, endoscopic examination revealed a mucosal bulge at the posterior pharyngeal wall. X-ray cervical spine and computed tomography (CT) scan of cervical spine revealed spondylotic changes with a large C2-C3 breaking osteophyte compressing the pharynx. C2-C3 anterior osteophyte was excised by right anterior cervical approach. The postoperative period was uneventful. Patient had a significant improvement in symptoms and was able to swallow solid food 12).
An 81-year-old man had had mild dysphagia for several years. During the six months before admission, the dysphagia worsened, and he had occasional hemoptysis. For several days before admission he had increasing shortness of breath and throat tightness, both of which worsened in the supine position. Laryngoscopic examination revealed marked narrowing of the airway due to a visible retropharyngeal bulge. The patient was admitted to the intensive care unit, where stridor was noted on physical examination. Radiographs of the cervical spine and magnetic resonance images (MRI) of the neck were obtained immediately. The lateral radiograph of the cervical spine revealed a huge mantle of osteophytic bone anterior to the spine from C2 to C7, with fusion of the osteophytes from C4 to C7 (Panel A, arrow). Osteophytes at C2 and C3 compressed the hypopharyngeal airway at the level of the epiglottis (Panel A, arrowhead). A sagittal MRI scan showed anterior displacement of the prevertebral soft tissues by these osteophytes (Panel B, arrow), and an axial scan showed compression of the airway to a slit-like opening (Panel C, arrow). After a difficult intubation, a neurosurgeon and an otolaryngologist performed an anterior resection of the ventral spinal osteophytes with partial diskectomies at C2–C3 and C3–C4. The patient did well postoperatively and was completely asymptomatic at follow-up one month after discharge13).
Papadopoulos et al. report three patients with progressive dysphagia due to large anterior cervical osteophytes. All three patients were treated with anterior cervical approach with removal of the osteophytes without fusion. A review of the literature in addition to the specific case histories, video fluoroscopic and radiographic findings are presented 14).
Spine in XXI Century
October 4 — October 8
AO Foundation Course—Fundamentals of Soft-Tissue Management
September 28 — September 29
Preoperative planning remains crucial for successful Spinal Schwannoma treatment and relies to a great extent on proper tumor classification. The literature includes multiple classification systems for spinal schwannomas, each of which is associated with both positive and negative ramifications for preoperative planning 1) 2) 3). 4).
Consequently, there is a lack of consensus concerning the optimal system of classification for schwannomas 5).
The literature includes numerous schwannoma classification systems. Jinnai and Koyama 6) classified schwannomas into five groups based on the relationship between the tumor and the dura mater and/or intervertebral foramen. This classification system is useful, as it takes into consideration tumor localization relative to the dura, but it does not take into account volume, which is important for preoperative surgical planning.
Park et al. 8) reported the use of a new classification system, and Type VI and Type VII were added. But the classification system as defined by Park et al. were inadequate because both the figures and the tumors were not clearly described in their manuscript.
A case could not be classified based on Sridhar’s spinal schwannoma classification system. Thus, as shown in a case, of Kotil type VIII must be added to the modified Sridhar classification (Kotil classification) system of benign spinal schwannomas 9).
Sun and Pamir however, think classification of seven distinct types of schwannomas using Sridhar et al.’s system is not practical because the characteristics of seven tumors types are difficult to remember. Another drawback of their system is that tumor volume is only considered for dumbbell-shaped tumors, and craniocaudal dimension is not a consideration, which limit the diagnostic value and consistency of the classification system 10).
Asazuma et al. 11) devised a schwannoma classification system for cervical dumbbell- shaped tumors that consisted of nine categories. An important drawback of their classification system is that it cannot be used for thoracic or lumbar schwannomas, which are as common as cervical schwannomas.
Asazuma et al. classification system for dumbbell spinal schwannoma:
Type 1 intradural extradural restricted to the spinal canal. The constriction occurs at the dura.
Type II are all extradural, and are subclassified as:
IIa do not expand beyond the neural foramen.
IIb inside spinal canal + paravertebral.
IIc foraminal + paravertebral.
Type IIIa are intradural and extradural foraminal, IIIb are intradural and extradural paravertebral.
Type IV are extradural and intravertebral.
Type V are extradural and extralaminar with laminar invasion.
Type VI show multidirectional bone erosion.
Craniocaudal spread: IF & TF designate the number of intervertebral foramina and transverse foramina involved, respectively (e.g. IF stage 2 = 2 foramens).
Schwannomas involving C1 & C2: May involve vertebral arteries and require additional caution.
It is based on consideration of tumor volume and localization relative to the dura and spinal canal. For approximate calculation of tumor volume, spinal schwannomas were considered ellipsoid bodies, and tumor volume was calculated using the following formula:
Tumor volume = 4 / 3 π × (craniocaudal length / 2) × (transverse diameter / 2)2 .
Tumors were then assigned to 1–3 volume groups (group A, B, and C) and designated as 1 of 4 types (type I, II, III, and IV) accord- ing to localization (i.e., group B type II tumor). Tumor volume <2 cm3 was considered group A, 2–4 cm3 group B, and >4 cm3 group C. Tumor typing was as follows: localized exclusively intra- durally: type I; intradural localization with extradural extension to the nerve root foramina, but restricted to the spinal canal: type II; intradural dumbbell-shaped tumor in the spinal canal extending to the extraforaminal region: type III; and localized completely outside the root foramina: type IV
Sridhar et al.’s 12) classification system is arguably the most similar of the previously reported systems to the novel classification system described by Sun and Pamir however, they think classification of seven distinct types of schwannomas using Sridhar et al.’s system is not practical because the characteristics of seven tumors types are difficult to remember. Another drawback of their system is that tumor volume is only considered for dumbbell-shaped tumors, and craniocaudal dimension is not a consideration, which limit the diagnostic value and consistency of the classification system 13).
Based on the findings, Sun and Pamir think that all schwannomas should be classified according to localization and volume, so as to achieve the desired benefit of classification—ease and reliability of preoperative decision making and preparation. In addition, this classification system makes tumor localization easier to understand, as compared to other systems, and is suitable for all schwannoma types.
It is a simple and effective tool that shows extremely helpful for avoiding unnecessary surgical approaches and complications. Due to the system’s simplicity of having only three tumor groups and its reliability—indicated by the associated low postoperative side effect rate, use of this novel classification system should be considered by any surgical department that seeks a standardized schwannoma surgery protocol. 14).
Pre-day Course I
Anterior Approaches to the Thoracic and Lumbar Spine
Chairs: Pedro Berjano, Milan, Italy and Hossein Mehdian, London, UK
The anterior approach to the spine has been around for the last 50 years. Originally, the surgery involved a large abdominal incision in which the surgeon would cut through the abdominal muscles and the peritoneal cavity to gain access to the spine. Today, however, anterior approaches to the spine can be done with a minimally invasive approach. As with all surgical procedures, the anterior approach to spine carries with it a few risks and potential complications that are unique to this surgical approach.
Pre-day Course II
Emerging Technologies in Spine Surgery
Chairs: Doniel Drazin and J. Patrick Johnson, USA
This course will explore the new advances in the field of emerging technologies in spine surgery and will provide the current state of the art in the use of technology for treating spinal pathology. Topics include and are not limited to intraoperative imaging, navigation, robotics, next generation microscopes and surgical instruments, combinatorial technologies, augmented reality and surgical simulators.
Sections include: Navigation, emerging technologies, and hands-on
Pre-day Course III
Spine Tango Users Meeting (STUM)
Chairs: Anne Mannion and Emin Aghayev, Zurich, Switzerland
Pre-day Course I, Anterior Approaches to the Thoracic and Lumbar Spine: 4 ECMEC
Pre-day Course II, Emerging Technologies in Spine Surgery: 3 ECMEC
Pre-day Course III, Spine Tango User Meeting (STUM): 3 ECMEC