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Giant Cell Tumor
Posted: Feb 5 2020 #(C101374)
A

Painful Lytic Lumbar Lesion in 16F

HPI

A 16-year-old female with long-standing low back pain presents with significantly increased pain in the past 3-5 months. She also recently developed left leg radicular pain mainly in the S1 dermatomal pattern. Imaging obtained and CT guided biopsy performed. Core biopsy was consistent with Giant Cell Tumor.

PMH

None

PE

On physical exam she is a healthy appearing female, appropriately developed. She has tenderness to palpation at the lumbosacral junction. No nerve tension signs. 5/5 motor in bilateral lower extremities. Sensation intact in all dermatomes, Reflexes equal and symmetric. No skin lesions.

Poll
1 of 10
1. Would you obtain a CT guided biopsy at your institution or would you refer to an orthopaedic oncologist to diagnose the tumor?
Yes - I would order the CT guided biopsy myself
25%
203/785
No - I would refer the patient to an orthopaedic oncologist at my medical center
33%
262/785
No - I would refer the patient to an orthopaedic oncologist at an outside tertiary center
31%
244/785
I would not perform a CT guided biopsy - it would not change my treatment
2%
19/785
Outside my area of expertise - best if I don't vote
7%
57/785
2. How would you treat this patient?
Medical Management Only (Denosumab +/- Bisphosphonates)
5%
46/776
Operative Resection & Reconstruction
24%
187/776
Combined Operative Resection & Reconstruction and Medical (Denosumab +/- Bisphosphonates)
55%
431/776
Outside my area of expertise - best if I don't vote
14%
112/776
3. If choosing operative Resection & Reconstruction, what approach would you do?
Posterior Only Procedure
29%
217/740
Anterior Only Procedure
9%
71/740
Combined Anterior and Posterior Procedure
46%
346/740
Outside my area of expertise - best if I don't vote
14%
106/740
4. If performing Operative Resection, what would you do?
Complete Spondylectomy
34%
240/691
Extensive Currettage (leave cortical shell of bone)
50%
349/691
I would not perform Operative Resection
0%
6/691
Outside my area of expertise - best if I don't vote
13%
96/691
5. If performing operative Resection & Reconstruction, what adjuvent treatment would you use for a GCT in this location?
Ethanol
6%
44/669
Phenol
16%
113/669
Hydrogen Peroxide
10%
70/669
Argon Laser
8%
59/669
Multiple of above
18%
122/669
None - I would not perform adjuvent treatment
14%
99/669
Outside my area of expertise - best if I don't vote
24%
162/669
6. As part of your resection, how would you manage the nerve roots in the L6-S1 foramen?
Leave both right and left nerve roots
40%
250/618
Resect right and left nerve roots
1%
11/618
Resect right, leave left
1%
11/618
Inspect and only resect if tumor invades Epineural sheath
39%
247/618
I would not operate on this patient
0%
4/618
Outside my area of expertise - best if I don't vote
15%
95/618
7. Following operative Resection, what would you do for Reconstruction (assuming lesion in extra L6 verterbral body)?
Bone cement in vertebral body only
2%
14/569
Posterior Spinal Fusion from L5 to S1 Only (no cage or cement)
2%
17/569
Bone cement in vertebral body and Posterior Spinal Fusion from L5 to S1 Only
24%
140/569
Corpectomy, Expandable Cage, Posterior Spinal Fusion from L5 to S1
56%
323/569
I would not perform operative Reconstruction
0%
2/569
Outside my area of expertise - best if I don't vote
12%
73/569
8. If choosing and Anterior Procedure, what approach would you do, and who would do it?
Myself - Standard Oblique Retroperitoneal
9%
50/510
Myself - Direct Lateral Approach (XLIF)
3%
20/510
Myself - Oblique Lateral (OLIF)
1%
7/510
Myself - Transperitoneal
2%
12/510
Access Surgeon - Standard Oblique Retroperitoneal
29%
148/510
Access Surgeon - Direct Lateral Approach (XLIF)
4%
23/510
Access Surgeon - Oblique Lateral (OLIF)
4%
21/510
Access Surgeon - Transperitoneal
10%
53/510
I would not do an Anterior Approach
8%
42/510
Outside my area of expertise - best if I don't vote
26%
134/510
9. If you choose an Anterior Approach in this patient, would you also do an anterior approach if the patient was male?
Yes - I would still do a Anterior Approach if the patient was male
53%
254/475
No - in a male I would not due to the risk of retrograde ejaculation
13%
63/475
I would not perform an Anterior Approach in either sex
12%
58/475
Outside my area of expertise - best if I don't vote
21%
100/475
10. If you perform a fusion from L5 to S1, would you put Iliac screws in (assuming lesion in extra L6 verterbral body)?
No, I would place S1 screws only.
28%
134/466
Yes, I would place Iliac fixation
52%
246/466
I would not fusion to the sacrum.
3%
14/466
Outside my area of expertise - best if I don't vote
15%
72/466
PROCEDURE #1 DOP: 2/3/2020

L6 Corpectomy, resection of mass with adjuvent treatment with Argon beam laser and hydrogen peroxide. Corpectomy cage at L6 and anterior instrumentation. Posterior spinal fusion with instrumentation L5-S1 and bilateral iliac fixation with S2-alar-iliac bolt placement. Intra-operative stereotactic image-guided hardware placement. Iliac crest autograft.

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OUTCOMES
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