Open Journal of Modern Neurosurgery, 2014, 4, 26-30
Published Online January 2014 (http://www.scirp.org/journal/ojmn)
http://dx.doi.org/10.4236/ojmn.2014.41006
OPEN ACCESS OJMN
Total En Bloc Spondylectomy for Lumbar Renal Cell
Carcinom a and Review of the Literature
Darweesh Al-Khawaja1*, Tamadur Mahasneh2, Jonathan Li3, Sue-Ellen Holmes4
1Neurosurgical Department, Nepean Hospital, Kingswood, NSW, Australia
2Department of Neuropathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
3Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
4Researcher, Private Neurosurgical Practice, Penrith, NSW, Australia
Received November 13, 2013; revised December 13, 2013; accepted December 21, 2013
Copyright © 2014 Darweesh Al-Kha waja et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In accordance of the Creative Commons Attribution License all Copyrights © 2014 are reserved for SCIRP and the owner of the
intellectual property Darweesh Al-Khawaja et al. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.
ABSTRACT
Introduction: Total en bloc spondylectomy (TES) is gaining increasing favour as a treatment of choice for can-
cers of the spine that are resistant to radiological and chemotherapeautic intervention such as renal cell carci-
noma (RCC). Until recently, RCC of the lumbar spine has presented a surgical challenge due to anatomical and
vascular constraints. The development of the combined posterior-anterior en bloc spondylectomy offers improv-
ed access to the lumbar region. This case report and review of the literature presents a combined posteri-
or-anterior lumbar en bloc spondylectomy for RCC involving L3 vertebra, which we believe is the first reported
in Australia. Methods: A 46-year-old male with a seven-year history of renal cell carcinoma resulting in a left
nephrectomy presented with a lytic lesion involving the L3 vertebral body, extending to the epidural space and
compressing the cauda equina and left L3 and L4 nerve roots on MRI. A literature review revealed ten previous
cases of the posterior-anterior TES in the lumbar spine for cancerous lesions but none from Australia. Results: A
posterior-anterior TES and L2-L4 fusion was performed to remove a cancerous renal cell carcinoma of L3 with
wide margins. Blood loss was the major complication. The patient remains recurrence free at nineteen months
post procedure. Conclusion: Despite being an aggressive and invasive procedure, TES is rapidly becoming the
treatment of choice for curative and palliative care in select patients with isolated metastatic tumours of the
lumbar spine.
KEYWORDS
En Bloc Spondylectomy; Renal Cell Carcinoma; Lumbar Spine; En Bloc Spondylectomy
1. Introduction
Increasingly, total en bloc spondylectomy (TES) devel-
oped by Tomita et al., [1-4] where the tumour is removed
in an entire encapsulated piece, has proven effective at
extending the long-term survival and functional outcomes
for patients with metastatic disease of the spine. A recent
comprehensive review demonstrates the beneficial im-
pact on morbidity and mortality of margin-free surgical
resection [5]. This is particularly the case for isolated , so -
litary spinal tumours seeded from cancers such as renal
cell carcinoma (RCC), which are resistant to radiation
and chemotherapeutic regimes [6,7]. At the clinically re-
commended dosage, radiotherapy can also compromise
the integrity of surrounding neural elements [5]. Appro-
ximately 29% of RCC exhibited spinal metastases post-
mortem [8]. Achievement of wide marginal resection
with TES is not only feasible; the technique has attained
an encouraging reduction in recurrence with relatively
low complications [9].
However, TES is not without controversy as a highly
invasive palliative measure, demanding an advanced le-
vel of surgical proficiency [10]. This is particularly so in
the lower lumbar spine due to extensive vascularisation
and unique anatomy, and as such TES in this region is
*Corresponding a uthor.

D. AL-KHAWAJA ET AL.
OPEN ACCESS OJMN
27
less common with fewer examples in the literature [10,
11]. In addition, the posterior only approach favoured for
lumbar spondylectomy carries an increased concern for
injury to the major vessels due to indirect visualisation of
ventral structures [5]. This case report and review of the
literature presents a combined posterior-anterior lumbar
en bloc spondylectomy for RCC involving L3 vertebra,
which we believe is the first reported in Australia.
2. Case Report
2.1. History
Our patient is 46-year-old male with a history of RCC
diagnosed seven years prior resulting in a left nephrect-
omy. He presented with lower back pain, parasthesia and
radiculopathy in the L3 distribution down his left leg
after twisting his back at work.
2.2. Examination
On Examination the patient presented with tenderness of
the midlumbar region and weak left knee extention of po-
wer 4/5 with diminished left knee jerk. He had decreased
sensation around left L3, L4 dermatomes.
2.3. Imaging
An MRI of the lumbar spine revealed a lytic lesion in-
volving the L3 vertebral body, extending to the epidural
space and compressing the cauda equina and left L3 and
L4 nerve roots (Figures 1 and 2). Surprisingly, a bone
SPECT scan returned as negative for any significant hot
spots.
2.4. Treatment
A revised Tokuhashi score of 10 (with 9 being the rec-
ommended cut-off for alternative palliative measures ), in
Figure 1. Pre-Operative T2 weighted sagittal MRI of L3
RCC tumour.
Figure 2. Pre-Operative T2 weighed axial MRI of L3 RCC
tumour.
conjunction with multi-disciplinary team review, achi-
eved consensus on his eligibility for the En bloc Spon-
dylectomy procedure.
Embolisation of lumbar arteries feeding the tumour
occurred one day prior to adm i s s i on for surgery .
2.5. Operation
2.5.1. Posterior Approach
The patient was placed in a prone position on the Jackson
table. After a midline incision, a bilateral periosteal dis-
section was completed to completely expose the lef t L3/4
facet joint and transverse process (TP) on both sides. Ap-
plying the Gigli saw from beneath the left TP, the left L3
pedicle and TP were cut in a superior posterior direc-
tion. The right L3 lamina was removed.
On the left side, the L3 vertebral body was dissected
from the psoas muscle to the anterior border, L2 and L4
pedicle screws inserted and connected with rods and
cross link. Using an osteotome a sagittal split was com-
pleted on the left side 5 mm from the border of the tumor,
then advanced anteriorly to the anterior cortical edge of
the vertebral body. The tumor was dissected from the du-
ra completely and epidural veins were coagulated. Every
effort was made to avoid breaching the tumour and to
keep the capsule intact (Figure 3). L2/3 and L3/4 discec-
tomy to the level of the sagittal split on the right side and
as far as possible both anteriorly and laterally on the left
side occurred, before removal of the annulus on the left
side, and finally closure.
2.5.2. Anterior Approach
The patient was rotated 180˚. A midline abdominal inci-
sion was performed from the retroperitoneal approach,
wher eby t he Ao rta w as mobilized. The L3 vertebral body
with the above and below disc spaces were identified and
an L2/3 and L3/4 discectomy completed from the front.

D. AL-KHAWAJA ET AL.
OPEN ACCESS OJMN
28
Figure 3. Anterior view of the dural sac and left L3 nerve
root after L3 vertebra removed.
L3 vetebrectomy removed the tumour anteriorly (Figure
4) with subsequent interbody fusion using an expandable
cage with bone graft and bone marrow aspirate.
2.5.3. Postoperative Cours e
Transient weakness (3/5 power) of left sided hip flexion
was likely due to dissection of the psoas muscle. The
patient required a blood transfusion and developed deep
vein thrombosis of both lower limbs for which he re-
ceived a prolonged course of anti-coagulants. Mobilisa-
tion was encouraged after three days with a thoracolum-
ber corset worn. Post-operative management involved ad-
juvant radiotherapy. A postoperative CT scan showed
screws a nd cage in good position (Figure 5).
2.5.4. Histopathology
Histopathology r evealed a low-grade clear cell renal car-
cinoma confined within the vertebral body with wide free
margins (Figure 6).
2.5.5. Follow-Up
On eighteen months follow-up the patient remained free
of local recurrence.
3. Discussion
Historically, radiotherapy has been the treatment of
choice for spinal metastases because surgery carried the
risk of substantial morbidity due to tumour cell spillage
at the resection site and recurrence due to residual can-
cerous tissue [11]. Applying Enneking et al.’s [12] con-
cept of tumour compartmentalisation due to anatomic
barriers in the spine, the anterior longitudinal ligament,
cartilaginous endplate and annulus fibrosus contain the
progression of tumour spread to the vertebra and serve to
retard distant proliferation [2-4,11]. Since the introduc-
tion of TES in 1989 [2] this surgical intervention has in-
Figure 4. L3 vertebra and en bloc tumour excision.
Figure 5. Post-operative sagittal CT of L3 corpectomy.
Figure 6. Histopathology of clear cell type renal carcinoma
(Haematoxylin and Eosin, original magnification ×400). Ex-
tensive replacement of bony tissue by nests of malignant
cells with ab undan t clear cytoplas m an d s m all round nuclei.

D. AL-KHAWAJA ET AL.
OPEN ACCESS OJMN
29
creasingly enhanced the quality of life and improved
survival chances for all oncology patients with the ex-
ception of those suffering complete paraplegia [13]. Fur-
thermore, a recent randomised trial comparing radiothe-
rapy with surgery for spinal cord decompression in me-
tastatic cancer, where the endpoint measured was rees-
tablishment of amubulation, was halted early due to the
overwhel ming superiority of surgical treatment [14].
Life expectancy has been shown to be the best predic-
tor of prognostic optimism for patients with spinal me-
tastases [15,16]. The Revised Tokuhashi Scale assesses a
patient’s eligibility for TES on the basis of life expec-
tancy across six oncological domains: general perfor-
mance status, number of extraspinal bone metastases foci,
number of metastases in the vertebral body, metastases to
the major internal organs, primary site of cancer, and the
presence of palsy. The scale provides an evidence-based
rationale to informing the surgeon’s decision to treat
spinal metastases with radical surgery [15]. In this in-
stance, the RCC patient was under 65 years-old, achieved
a good performance status, and had a solitary, intracom-
partmental tumour with no sign of systemic disease, and
thus was considered favourable for therapeutic interven-
tion and post-operative long evity [10,15].
Due to the poor response of RCC to radiation and
chemotherapy, approximately 50% of patients die within
the first year of presentation with only 10% surviving
more than five years [10,13]. In their recent comprehen-
sive review of TES, Cloyd and colleagues (2010) re-
ported an average five year disease-free survival of 77
patients with solitary metastatic tumours of the thoracic
and lumbar spine, including 28 cases of RCC, ranging
from approximately 25% - 56%. A mean time to recur-
rence of 26 months was also found [5]. A more conserva-
tive figure for five year survival rates in patients under-
going TES for spine metastases of greater than 15% by
Yao et al. (2003) [17] still represents an improvement on
adjuvant therapies alone. The patient herein is alive and
recurrence free nineteen months post-operatively, which
is consistent with the surgical goals of oncological con-
trol, spinal stabilisation, mitigation of neurolog ical symp -
toms and histologica l di a gnosis [13].
The posterior surgical approach for primary metastatic
tumours of the lumbar spine is prevalent in the case se-
ries literature with an initial total of 26 patients [5]. A
disadvantage of the posterior only method is the risk to
major vessels due to poor visualisation of ventral struc-
tures [1,15]. As well, in an inves tigation of eight patients
who underwent TES for solitary spinal metastases, Abe
et al. (2001) linked the posterior alone approach to a 25%
local recurrence for tumours anterior to the vertebral
body [18].
Since, a further case-series of ten has been reported
using posterior-anterior TES in the lumbar spine [10].
This approach reduces the likelihood of vascular com-
plications and potential compromise of lumbosacral ple-
xus nerves at the expense of longer operative times [5]
due to the need to turn the patient mid-surgery. The ad-
vantage of TES for the prevention of neoplastic dissemi-
nation is particularly relevant in the highly vascular lum -
bar region.
In addition, wide tumour-free margins correlate most
favourably with lack of local recurrence and extended
patient survival [10,15]. In this instance, the patient had
an expansile bony tumour of approximately 3 centimetres
in the superior/inferior dimension on the left of the L3
vertebra, extending centrally 4.2 centimetres in the ante-
rior-posterior and 3.3 centimeters in the transverse di-
mensions, involving the extra dural space, encroachment
on the left pedicle and posterior pedicular elements. Wide
tumour free margins were confirmed histopathologically.
No relationship between bisection at a tumour afflicted
pedicle and local recurrence has been found [18].
To date, none of the reported TES cases in the litera-
ture were performed in Australia. To our knowledge this
is the first record of TES for lumbar RCC using the post-
erior-anterior approach in this country. Operating times,
blood loss and complications with this procedure are
high and necessitate careful consideration of the benefits
for individual candidates. Despite a fifteen hour operat-
ing time and the need for a blood transfusion, the patient
tolerated the procedure well and recovered full mobility
within days. Such considerations though, should improve
over time with application of the technique, [19] which
offers a worthwhile addition to options for better out-
comes and quality of life in RCC spinal tumour patients.
4. Conclusion
Despite being an aggressive and invasive procedure, TES
is rapidly becoming the treatment of choice for curative
and palliative care in select patients with isolated metas-
tatic tumours of the spine. Ameliorating the functional
impairment and resistance to radiation of RCC in the
spine means it is an ideal condition for this treatment.
REFERENCES
[1] Tomita, K., Kawahara, N., Baba , H., Tsuchiy a, H., Fujita,
T. and Toribatake, Y. (1997) Total en bloc spondylecto-
my. A new surgical technique for primary malignant ver-
tebral tumors. Spine, 22, 324-333.
http://dx.doi.org/10.1097/00007632-199702010-00018
[2] Tomita, K., Kawahara, N., Baba , H., Tsuchiya, H., Naga-
ta, S., Toribatake, Y. (1994) Total en bloc spondylectomy
for solitary spinal me tasta ses. International Orthopaedics,
18, 291-298. http://dx.doi.org/10.1007/BF00180229
[3] Tomita, K., Kawahara, N., Kobayashi, T., Yoshida, A.,
Murakami, H. and Akamaru, T. (2001) Surgical strategy
for spinal metastases. Spine, 26, 298-306.

D. AL-KHAWAJA ET AL.
OPEN ACCESS OJMN
30
http://dx.doi.org/10.1097/00007632-200102010-00016
[4] Tomita, K., Toribatake, Y., Kawahara, N., Ohnari, H. a nd
Kose, H. (1994) Total en bloc spondylec tomy and circu m-
spinal decompression for solitary spinal metastasis. Para-
plegia, 32, 36-46. http://dx.doi.org/10.1038/sc.1994.7
[5] Cloyd, J.M., Acosta, F.L., Polley, M.Y. and Ames, C.P.
(2010) En bloc resection for primary and metastatic tu-
mors of the spine: A systematic review of the literature.
Neurosurgery, 67, 435-445.
[6] Fottner, A., Szalantzy, M., Wirthmann, L., Stähler, M.,
Baur-Melnyk, A., Jansson, V. and Roland Dürr, H. (2010)
Bone metastases from renal cell carcinoma: Patient survi-
val after surgical treatment. BMC Musculoskeletal Disor-
ders, 11, 145-151.
http://dx.doi.org/10.1186/1471-2474-11-145
[7] Jung, S.T., Ghert, M.A., Harrelson, J.M. and Scully, S.P.
(2003) Treatment of osseous metastases in patients with
renal cell carcinoma. Clinical Orthopaedics and Related
Research, 409, 223-231.
http://dx.doi.org/10.1097/01.blo.0000059580.08469.3e
[8] Mut, M., Schiff, D. and Shaffrey, M. (2005) Metastasis to
nervous system: Spinal epidural and intramedullary me-
tastases. Journal of Neuro-Oncology, 75, 43-56.
http://dx.doi.org/10.1007/s11060-004-8097-2
[9] Garcia-Picazo, A., Capilla, R.P., Pulido, R.P., Garcia de
Sola, R. (1990) Utility of surgery in the treatment of epi-
dural vertebral metastases. Acta Neurochirurgica, 103,
131-138. http://dx.doi.org/10.1007/BF01407520
[10] Melcher, I., Disch, A.C., Khodadadyan-Klostermann, S.T.,
Smolny, M., Stockle, U., Haas, N.P., et al. (2007) Prima -
ry malignant bone tumors and solitary metastases of the
thoracolumbar spine: Result by management with total en
bloc spondylectomy. European Spine Journal, 16, 1193-
1202. http://dx.doi.org/10.1007/s00586-006-0295-5
[11] Disch, A., Druschel, C., Melcher, I., Luzzati, A. and Sha-
ser, K. (2011) En-bloc spondylectomy for thoracolumbar
primary tumours and solitary metastases of the spine. Ar-
gospine News & Journal, 23, 163-170.
http://dx.doi.org/10.1007/s12240-011-0030-x
[12] Enneking, W.F., Spanier, S.S. an d Goodmann, M.A. (1980)
A system for the surgical staging of musculoskeletal sar-
coma. Clinical Orthopaedics, 153, 106-120.
[13] Fuchs, B., Trousdale, R.T. and Rock, M.G. (2005) Solita-
ry bony matastasis from renal cell carcinoma: significance
of surgical treatment. Clinical Orthopaedics and Related
Research, 431, 187-192.
http://dx.doi.org/10.1097/01.blo.0000149820.65137.b4
[14] Patchell, R.A., Tibbs, P.A., Regine, W.F., Payne, R., Sa-
ris, S., Kryscio, R.J., Mohiuddin, M. and Young, B. (2005)
Direct decompressive surgical resection in the treatment
of spinal cord compression caused by metastatic cancer:
A randomised trial. The Lancet, 366, 643-648.
http://dx.doi.org/10.1016/S0140-6736(05)66954-1
[15] Tokuhashi, Y., Matsuzaki, H., Oda, H., Oshima, M. and
Junnosuke, R.A. (2005) Revised scoring system for pre-
operative evaluation of metastatic spine tumor prognosis.
Spine, 30, 2186-2191.
http://dx.doi.org/10.1097/01.brs.0000180401.06919.a5
[16] Mollahoseini, R., Farhan, F., Khajoo, A., Jouibari, M.A.M.
and Gholipour, F. (2011) Is Tokuhashi score suitable for
evaluation of life expectancy before surgery in Iranian pa-
tients with spinal metastases? Journal of Research in Me-
dical Sciences, 16, 1183-1188.
[17] Yao, K.C., Boriani, S., Gokasl an, Z.L. a nd Sundaresan, N.
(2003) En bloc spondylectomy for spinal metastases: A
review of the techniques. Neurosurgical Focus, 15, 1-5.
http://dx.doi.org/10.3171/foc.2003.15.5.6
[18] Abe, E., Kobayashi, T., Mura i, H., Suzuki, T., Chiba, M.
and Okuyama, K. (2001) Total spondylectomy for prima-
ry malignant, aggressive benign, and solitary metastatic
bone tumors of the thoracolumbar spine. Journal of Spin-
al Disorders, 14, 237-246.
http://dx.doi.org/10.1097/00002517-200106000-00009
[19] Tomita, K., Kawahara, N., Murakami, H. and Demura, S.
(2006) Total en bloc spondylectomy for spinal tumours:
Improvement of the technique and its associated basic
background. Journal of Orthopaedic Science, 11, 3-12.
http://dx.doi.org/10.1007/s00776-005-0964-y