Major complications following total en bloc spondylectomy for giant-cell tumor
We present the case of a 32-year-old female, referred because of pain localized in the mid-dorsal region, with onset several months earlier and progressive worsening. The pain aggravated with local palpation and trunk movement. Lately, she also manifested weakness in the lower limbs.\nThe radiographic study identified an expansive lesion in the eighth thoracic vertebra (T8), with local kyphosis and imminent instability. She performed a computed tomography (CT) scan and magnetic resonance imaging (MRI), which better defined the bone involvement and already revealed invasion of the medullary canal (Fig. ). A percutaneous CT-guided core-needle biopsy was then undertaken, and the histologic report confirmed the diagnosis of giant-cell tumor.\nDue to the advanced stage of the lesion, with associated instability that could result in major neurologic deficits in a short time period, a total en bloc spondylectomy of T8 by a posterior-only approach was performed (Fig. ). The operation followed the technique proposed by Tomita et al. and was complemented with anterior-column reconstruction with a titanium mesh filled with structural allograft, as well as pedicle screw instrumentation, from T6 to T10 (Fig. ). During the procedure, the eighth dorsal nerve routes were sacrificed.\nThe surgery went uneventful, taking 5 h to complete. The immediate postoperative period was favorable, without reported neurologic deficits (besides the ones attributed to T8 nerve root ligation).\nThe patient started the pulmonary rehabilitation protocol by the second postoperative day, showing encouraging progression. However, by the third day, she initiated complaints of progressive dyspnea with associated impaired gas exchange. A CT scan confirmed bilateral hemothorax requiring bilateral thoracentesis (Fig. ), after which she immediately recovered from the previous symptoms.\nIt was only by the 19th postoperative day, which the patient showed worsening of her general status with fever, dyspnea, decreased gas exchange and an increase in inflammatory markers. A new CT scan was performed, revealing a moderate fluid collection in both lungs, compatible with empyema (Fig. ). The patient evolved to a septic state, which required her to be transferred to the intensive care unit.\nDue to the ongoing postoperative infection, a new operation was undertaken with surgical debridement of the infected tissues, allograft and titanium mesh extraction, which were replaced by iliac crest tricortical autograft for anterior support (Fig. ). The posterior pedicle instrumentation was kept, after copious irrigation of the surgical wound. Drains were placed in the thoracic cavity and paravertebral spaces.\nBlood cultures, as well as those from pus samples collected intraoperatively and from the explanted mesh and allograft identified Enterobacter aerogenes as the pathogenic agent. The same bacterium was isolated in a sample of allograft sent for cultures on the day of the index operation. A pathogen-directed course of i.v. antibiotic therapy was initiated.\nTen days after the revision operation, the patient was diagnosed with a lower respiratory tract infection, with Acinetobacter baumannii being identified in sputum samples.\nConcurrently, a newly resurged septated empyema had developed in the paravertebral space, which demanded for a combined anterior and posterior approach, for complete drainage (Fig. ). Twelve days later, an additional posterior open drainage was necessary to address a subcutaneous abscess. Samples collected intraoperatively from this last operation isolated methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa as pathogens.\nThe several complications sustained, as well as the prolonged hospitalization, took a significant toll on the patient, leading to considerable physical and psychological burden.\nIn response to the therapeutic measures adopted, there was a progressive improvement in clinical and analytic parameters, which allowed the discharge from the hospital, 79 days after initial admission. A custom-molded thoracolumbar brace was prescribed, as well as maintenance of physical therapy to regain muscle strength.\nCurrently, after 9 months from the initial surgery, the patient remains stable and asymptomatic with no evidence of infection or tumor relapse (Fig. ). The follow-up imaging studies show encouraging evolution without bone graft resorption or failure of the instrumentation (Fig. ).