SECTION
Tumor and Osteomyelitis
CHAPTER
137
Introduction and State of the Art
Spinal neoplastic, infectious, and vascular lesions, perhaps
more than most other spinal disorders, exist at the intersection
between many fields of treatment. Medical treatment, surgery,
radiation therapy, stereotactic radiosurgery, neurointerven-
tional treatment, and pain management may all play a role in
the treatment or management of patient with these disorders.
The spinal surgeon is often the mediator and arbiter in direct-
ing the patients treatment and therefore must understand the
disease and the treatment options.
Surgical techniques for the resection of benign and malig-
nant tumors and options for the reconstruction of the spine
continue to be developed and improved. Spinal surgeons are
approaching more tumors more aggressively, even attempting
en bloc resections (vertebral bisection and excision) from
either sequential posterior/anterior approaches or from a sin-
gle posterolateral approach. A wide array of options for poste-
rior fixation and anterior reconstruction provide immediate
stability after resection. With careful investigation, the effect of
these strategies and techniques on clinical outcome and tumor
control will become evident. The first two chapters in this sec-
tion comprehensively discuss the evaluation and management
of benign and malignant tumors of the spine.
Laufer et al discuss the clinical decision-making consider-
ations and management options for spinal metastatic disease.
Advances in surgical approaches to the spine and in spinal
instrumentation have broadened the armamentarium of sur-
geons treating these common lesions. Another area of active
development and investigation is the use of stereotactic radio-
surgery (SRS) to treat spinal tumors. Adequate radiation doses
can now be given safely within a very small distance of the spi-
nal cord. The wide availability of a variety of SRS systems
increases the options for the treatment of tumors that were pre-
viously difficult or impossible to treat. Again, a thorough evalu-
ation of results over time will help physicians and surgeons to
determine the most effective management of tumors.
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XIII
Peter D. Angevine
The principles of microsurgical treatment of intramedullary
spinal cord tumors have not changed appreciably in recent
decades. Appropriate diagnostic studies, a rational surgical
strategy, and meticulous operative technique remain essential
to achieving optimal clinical and oncological outcomes. Dr.
Hida provides a clear, rational approach to the care of patients
with intramedullary tumors.
Drs. Ogden and McCormick review intradural extramedul-
lary tumors of the spine. In addition to discussing the differen-
tial diagnosis and clinical and radiographical evaluation of
these lesions, a classification system based on the radiographi-
cal appearance and likely site of origin is presented. This has
implications for the surgical treatment of these tumors, as the
fascicle, rootlet, or nerve root of origin is generally nonfunc-
tional and may be sacrificed as part of the resection. With an
understanding of the principles outlined in the chapter, the
surgeon may approach the surgery prepared to perform a safe
excision minimizing the likelihood of neurological morbidity.
Spinal vascular malformations constitute a heterogeneous
group of lesions. Understanding their varied radiographical
appearance, clinical presentation, natural history, and treat-
ment options is essential to their appropriate treatment. Clarke
et al. clearly and concisely distill a large amount of information
into a single chapter covering a broad topic. Both microsurgi-
cal treatment and endovascular intervention, sometimes in
combination, may be appropriate in the management of some
of these lesions. Similar to other spinal cord lesions, the prompt,
correct diagnosis and timely institution of treatment is essential
to maximizing the patients neurological function.
Spinal infections, including osteomyelitis, are primarily a
medical disease, but surgical treatment may be necessary in
cases with neurological impairment, progression despite
appropriate antibiotic therapy, or pain or disability due to
structural compromise of the spinal column. In these cases,
the expanding options for fixation and interbody support offer
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 1486 Section XIII Tumor and Osteomyelitis
the surgeon many possibilities for the effective stabilization of
the spine. New alloys may combine the infection--resistance of
titanium with the metallurgical properties of stainless steel. Dr.
Emery reviews the principles of rational management of
patients with spinal infections. Finally, tumors of the sacrum
are discussed in a separate chapter. Although there is some
pathological overlap with material in other chapters, some of
these tumors are almost exclusive to the sacrum, and the
unique biomechanical considerations of the sacropelvic region
justify separate coverage. While there have been some advances
in the treatment of these tumors, particular in adjuncts to sur-
gery, the main area of surgical progress is in instrumentation
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and sacropelvic reconstruction. Surgeons today have more
options for restoring sacropelvic stability following resection of
a sacral tumor than ever before. Time will tell if this allows for
better tumor control and patient outcomes.
This section covers a wide range of material involving some
of the most delicate of microsurgical procedures (intramedul-
lary spinal cord tumor surgery) to some of the most difficult
biomechanical problems (sacropelvic reconstruction). A unify-
ing principle, if there is one, is that careful preoperative evalua-
tion and planning combined with technical expertise help to
ensure that patients with these disorders receive the best possi-
ble care and achieve the most advantageous outcomes possible.
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