Novel application of FiberWire for intervertebral disc transection in en bloc spondylectomy: a case report

Introduction

Primary bone tumors of the spine encompass 11% of primary musculoskeletal tumors (1). Only 4% of tumors of the spine are primary tumors, with the vast majority of spinal oncologic processes deriving from metastatic pathology (2). The surgical management of primary spine tumors versus metastatic disease to the spine generally differs. Aggressive benign and malignant primary spine tumors are removed using an en bloc resection, which involves the removal of the tumor and a surrounding margin of healthy tissue as a single unit (3-5). In contrast, metastatic disease to the spine is surgically managed through gradual curettage and/or excision of the lesion, although cases of solitary and well-defined lesions can be managed with an en bloc resection (6). Modern stereotactic radiosurgery techniques have also expanded the role of adjuvant radiation in tumor management (7).

A total en bloc spondylectomy (TES) involves the removal of one or more vertebrae with tumor involvement. The goal of TES is to achieve negative surgical margins and decrease the likelihood of local recurrence of disease and improve survival (8,9). TES has been shown to have superior oncologic outcomes when compared to intralesional excision and/or curettage of primary spinal tumors (10-12). However, the complex nature of the procedure in its length, proximity to the spinal cord, great vessels, and major organs, and technique, portends the risk of complications (13,14). Large volume blood loss, hardware failure, neurologic deficits, cerebral spinal fluid (CSF) leaks, respiratory complications, and surgical-site infections characterize a majority of perioperative complications associated with TES (14-17). Further, a systematic review by Yamazaki et al. demonstrated the mortality rate of TES for primary spinal tumors varies up to 7.7% due to perioperative complications and local recurrence (18).

To mobilize the vertebral body of interest while preventing the violation of the thecal sac, a variety of tools can be utilized, including threadwire saws, scalpels, or gigli saws (10,19). However, it has recently become difficult to obtain threadwire Tomita saws due to the manufacturer’s discontinuation of this product. This represents a major humanitarian issue for surgeons treating patients needing TES. This report introduces a technique for vertebral body mobilization through the transection of the superior and inferior intervertebral discs, utilizing FiberWire, a braided polyblend suture, as a precise and controlled cutting tool to enhance en bloc spondylectomy while minimizing the risk of thecal sac violation (20). We present this article in accordance with the CARE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-172/rc).

Case presentation

Patient history

A 31-year-old female with an unremarkable medical history was referred to Vanderbilt University Medical Center for evaluation of a biopsy-confirmed L3 chordoma. She reported a longstanding history of intermittent lower back pain, which had led her to seek chiropractic care for 2 years. Three months prior to presentation, she developed radicular pain radiating from the lower back to the left leg, prompting lumbar spine magnetic resonance imaging (MRI), which identified a lesion in the L3 vertebra. Subsequent consultations with local providers and a computed tomography (CT)-guided core needle biopsy confirmed the diagnosis, leading to her referral for further management.

Preoperative examination and diagnosis

On physical examination, motor and sensory function were intact. Reflexes were brisk and symmetric in both upper and lower extremities. Hoffmann’s sign and straight leg raise tests were negative bilaterally.

Following the patient’s initial evaluation at Vanderbilt University Medical Center, a total spine MRI with and without contrast was performed. Imaging demonstrated a diffuse T1 hypointense marrow signal throughout the L3 vertebral body, with associated paraspinal muscle edema extending from L3 to L5 (Figure 1). No pathologic fracture or epidural involvement was identified. The lesion was localized to the posterior aspect of the L3 vertebral body without pedicle involvement, and no contrast enhancement was observed.

Figure 1 Preoperative sagittal T1- and T2-weighted magnetic resonance images of the lumbar spine.

A multidisciplinary review of the imaging findings and pathology from the prior CT-guided core needle biopsy confirmed the diagnosis of L3 chordoma. Given the characteristics of the tumor, radical spondylectomy was recommended.

Procedure details

A two-stage TES was planned. The first stage involved a posterior approach for L2–L4 laminectomy and foraminotomy, followed by L1–L5 spinal instrumentation and arthrodesis (Figure 2). The second stage was performed through an anterior approach, consisting of L3 corpectomy and cage insertion, L4–L5 lumbar interbody fusion with intervertebral body cage placement, and L2–L4 spinal instrumentation and arthrodesis (Figure 3).

Figure 2 Intraoperative C-arm fluoroscopic imaging of the first-stage total en bloc spondylectomy demonstrating L2–L4 laminectomy and foraminotomy, as well as L1–L5 posterior spinal instrumentation and arthrodesis.

Figure 3 Intraoperative C-arm fluoroscopic imaging of the second-stage total en bloc spondylectomy demonstrating L3 corpectomy with cage insertion, L4–L5 lumbar interbody fusion with intervertebral body cage placement, and L2–L4 anterior spinal instrumentation and arthrodesis.

In the first stage of the procedure, the spine was exposed subperiosteally from L1 to L5, and pedicle screws were placed at L1, L2, L4, and L5 with fluoroscopic confirmation. A high-speed burr was used to thin the lamina of L2, L3, and L4 in preparation for an L2–L4 laminectomy. Using 3 and 4 mm Kerrison rongeurs, a central L2–L4 laminectomy, medial facetectomy, and bilateral foraminotomy were performed. An L3 transpedicular decompression was then carried out, and bilateral pedicle margins were sent for pathological analysis, which were confirmed to be negative for malignancy.

Following decompression, the superior and inferior intervertebral discs of L3 were circumferentially exposed. The disc was incised, and #5 FiberWire sutures were threaded ventrally to the L3 vertebra, passing through both the L2–L3 and L3–L4 discs and ventral to the dura, demonstrated stepwise in an include video (Video 1). Specialized Statinski vascular clamps were used to pass the suture ventral to the vertebral body. The sutures were coiled and positioned to the left of L3 for use in the second stage of surgery. Finally, a posterolateral arthrodesis from L1 to L5 was performed, utilizing a flat femoral allograft strut over the laminectomy defect. Operative time was 351 minutes with an estimated blood loss (EBL) of 200 mL.

The second stage of the procedure, 2 days after the first stage, began with the vascular surgery service exposing the anterior lumbar spine from L2 to L5. After exposure, the previously passed #5 FiberWire sutures were drawn through the L2–L3 and L3–L4 disc spaces from left to right, as described by Tomita et al. (8,19), to fully disconnect the L3 vertebra from the cephalad and caudal disc spaces, while preserving the integrity of the thecal sac. Again, this process is demonstrated stepwise in an included video (Video 2). The L3 vertebra was then removed en-bloc using a Kocher clamp (Figure 4). Following vertebral resection, the adjacent intervertebral discs were excised, and the endplates were prepared for bony fusion. An expandable corpectomy cage, filled with allograft bone, was placed in the L3 space, and a plate spanning L2 to L4 was secured. The L4–L5 disc was excised and replaced with an allograft-filled interbody cage. After irrigation and hemostasis, the incision was closed, and a dressing was applied, with an operative time of 405 minutes and EBL of 50 mL. The patient was then awakened, extubated, and transferred to the post-anesthesia care unit without complication.

Figure 4 Superior and dorsal surfaces of the resected L3 vertebra.

Pathologic review of the excised L3 vertebral body and associated oncologic process was consistent with an L3 chordoma. The surgical margins were negative for malignancy. A multi-disciplinary institutional tumor board concluded that oncologic surveillance with the orthopedic oncology group would be appropriate, as well as the consideration of radiation therapy in the case of recurrence.

Postoperative course

Postoperatively, the patient was transferred to the neurological intensive care unit. Mild leg numbness/weakness was reported shortly after the second stage, but it quickly resolved. On postoperative day 2, she developed symptomatic anemia (hemoglobin 6.7 g/dL) and received two units of packed red blood cells, leading to appropriate stabilization. Anterior-posterior (AP) and lateral lumbar spine radiographs confirmed well-seated spinal hardware and maintained spinal alignment (Figure 5). On postoperative day 3, she was transferred to the step-down unit. There were no new sustained neurologic deficits throughout hospitalization and a leg temperature discrepancy noted preoperatively improving post-surgery. Further, postoperative pain was primarily abdominal, was well controlled with analgesics, and improved throughout hospitalization. Following the removal of surgical drains and initiation of an oral multimodal pain regimen, she was discharged on postoperative day 5 without further complications.

Figure 5 Postoperative anterior-posterior and lateral lumbar spine radiographs demonstrating well-positioned spinal hardware and preserved spinal alignment.

The patient returned to clinic on post-operative day 13 for a scheduled post-operative follow-up appointment, where no wound or neurologic complications were noted. At the patient’s most recent follow-up, she reported some mild left lower extremity sensory disturbances but was overall pleased with her surgical outcome. Neurological examination revealed no neurologic deficits. AP and lateral radiographs of the lumbar spine redemonstrated well-engaged hardware and no new osseous abnormalities.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The commercial discontinuation of Tomita threadwire saws represents a significant challenge for spinal oncology surgeons performing TES. These tools have long been favored for their precision in disc transection (8). While we would sincerely advocate for the reinstatement of their production, the technique described here—using #5 FiberWire—offers a practical alternative for carefully selected cases. FiberWire, while not specifically designed for this purpose, is comparable and may offer some advantages compared to traditional threadwire saws (Table 1). Similarly, recent work describing modified en bloc resection techniques highlight the ongoing evolution of instrumentation aimed at improving safety and reproducibility (21).

One of the most technically demanding aspects of TES is achieving safe, controlled disc cuts without injuring the thecal sac (22). Traditional tools like scalpels or osteotomes may lack precision and carry higher risks of dural or vascular injury. Recent innovations in TES instrumentation, including modified intervertebral cutting tools, further highlight the need for adaptable techniques (23). FiberWire provides a flexible and durable option that can be passed ventrally to the vertebral body and tensioned in a controlled manner. Although not originally designed for this use, the mechanical properties of FiberWire make it well-suited for disc transection in cases where bone cuts are not needed.

The FiberWire used in this case is a braided suture made of ultrahigh-molecular-weight polyethylene and polyester. It has strong biomechanical performance, including high tensile strength and excellent knot security (24). Its flexibility allows it to contour around anatomical structures, and its smooth surface reduces the risk of damaging neighboring tissues. The ultrahigh-molecular-weight polyethylene core provides the high tensile strength needed for controlled reciprocating motion, while the braided polyester jacket contributes to smooth handling and predictable tensioning. These combined properties enable precise disc transection without fraying or abrupt failure and help explain why FiberWire performs comparably to traditional threadwire saws. While FiberWire was successfully employed in this case, multiple other companies manufacture similar products which would likely be just as effective in this setting (24). These features make FiberWire and other similar tools potentially useful substitutes when traditional Tomita threadwire saws are unavailable.

However, success with this technique depends on proper case selection (3,25). It is best suited for tumors confined to a single vertebral body, without invasion into neighboring structures. Clean disc spaces above and below the vertebra make suture passage easier and safer. On the other hand, calcified discs, sclerotic margins, or prior surgical scarring may limit the effectiveness of this method. Preoperative imaging and intraoperative judgment are essential for deciding when this approach is appropriate.

The use of FiberWire in this case opens the door to the advent of novel surgical instruments specifically designed for this purpose. Future development could include suture-based cutting systems designed specifically for spinal tumor surgery, promoting both precision and safety. Furthermore, these innovations could improve ergonomics and reliability, especially in cases where rigid cutting tools are not ideal.

Importantly, there are several limitations to consider with this technique. Negative margins were achieved in this case, which is critical for reducing local recurrence and progression in malignant spinal tumors (25-27). However, long-term follow-up will be necessary to determine how this technique compares to traditional TES methods in terms of fusion integrity and oncologic outcomes (28). Further, surgeons attempting these cases should have the necessary experience, willing and able senior partners to serve as an assistant, or they should refer patients to a tertiary academic medical center with experience in TES. While we feel the #5 FiberWire suture and other similar products represent a great option for cases like this, it is not suited for cases that require any margin through bone (rather than disc material, as in this case). Finally, this report reflects a single case, with only a few other cases performed, and additional work is needed to better understand the generalizability, comparative safety, and long-term outcomes related to FiberWire assisted disc transection.

Conclusions

In summary, this FiberWire-based adaptation of Professor Tomita’s original technique provides a practical and effective solution in the context of the discontinued threadwire saw. While not a universal substitute, it offers a valuable option in well-selected cases, particularly when disc-only resection is feasible. Further research and innovation are warranted to develop dedicated instruments that combine the safety and precision of suture-based systems with improved handling and reproducibility. Until then, experienced spinal oncology teams may find this approach a reliable interim solution.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-25-172/rc

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-172/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-172/coif). B.F.S. received institutional research funding from Globus and Stryker, and is an editorial board member for the research journal Spine Research. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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