Surgical treatment of sarcomas of the spine

Primary sarcomas of the spine are rare diseases and include osteosarcoma, chondrosarcoma, chordoma, and Ewing's sarcoma. Surgery for these lesions remains an important part of their treatment. Strong evidence exists for the en bloc resection of chondrosarcoma and chordoma since these lesions respond poorly to both chemotherapy and radiation. Weaker but important evidence suggests that osteosarcoma and Ewing's sarcoma may also benefit from wide excisions, but after the application of neoadjuvant therapy, which may significantly aid the surgical process as well as independently prolong the survival. The unacceptable morbidity associated with damage to the neural elements makes resection with wide margins difficult in the spine. Nevertheless, this can be achieved in many circumstances and can, on occasion, lead to long term disease-free survival and even cure. There are numerous techniques described for en bloc resections in the mobile spine and pelvis and these vary widely for the region of the spine involved and the preferences of the surgeon. There are constant principles that do apply to all cases. We think of these surgeries as consisting of 2 stages which can be done in 1 or multiple operations. In the first phase, a corridor free of tumor is removed from the bone and the neural elements to be protected are dissected free from surrounding tissues. In the second phase, the tumor and a margin of normal tissue is circumferentially dissected and delivered while sparing the neural structures. Patient selection, in terms of age, overall disease burden, personal preferences, and comorbidities need to be carefully taken into account to optimize the risk benefit ratio. Sarcomas of the spine are a challenging group of lesions to treat but they can also be the most rewarding. Our newly acquired insight into the pathogenesis of these lesions, as well as improved surgical techniques combined with better neoadjuvant and adjuvant therapies are leading to longer survival times as well as long term disease free survivors.