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Neoplasms

Management of primary and metastatic spinal neoplasms, focusing on neurological preservation, stability assessment, and surgical margin attainment.

Overview

Aggressive disease-specific surgical and multidisciplinary treatment for soft tissue sarcoma of the hand can yield long disease-free survival, overall survival, and good functional outcomes [1]. Early and aggressive treatment with appropriate oncological surgery confers the lowest local recurrence rate and a survival advantage versus conservative treatment in nonagenarians with soft-tissue sarcoma [3]. Data strongly support the recommendation that patients be referred to a treatment center before a biopsy is performed rather than after [25].

Metastatic tumors are increasingly common, requiring surgical timing to be considered within the framework of the patient's disease, deficits, stability, and available multidisciplinary treatments [7]. In metastatic patients with pelvic Ewing sarcoma, the significance of tumor resection remains less certain [17], and improved outcomes of combined local treatment approaches need to be weighed against prognosis and quality of life [17]. For dedifferentiated chondrosarcoma, complete surgical excision is the initial recommended treatment [18], whereas chemotherapy lacks convincing evidence of benefit [18]. In pleomorphic liposarcoma, receiving surgery could prolong survival [19], but radiotherapy only benefits patients with large tumor size greater than 10 cm [19].

Specific malignancies dictate distinct surgical algorithms. Systematic re-excision should not be advocated for patients older than 70 years with limb or trunk soft tissue sarcoma following complete macroscopic unplanned excision [20], nor for patients with tumors greater than 10 cm following complete macroscopic unplanned excision of limb or trunk soft tissue sarcoma [20]. The recommended treatment of choice for malignant schwannoma of the medial plantar branch of the posterior tibial nerve is amputation [23]; when amputation is not feasible, radical local excision is recommended [23]. Plans for tumor therapy in children with osteosarcoma as a second malignant neoplasm should take into account the risk of this complication, which is usually fatal [24]. Tailoring the surgical approach to an individual's specific condition by considering factors such as tumor size and location is essential for optimal outcomes in resection of giant intraspinal and extraspinal schwannoma with cystic change [52].

Anatomy & Pathophysiology

Osseous and Spinal Stability

In primary bone sarcoma, axial skeleton location remains the strongest predictor of poor prognosis, whereas symptom duration at presentation does not correlate with survival outcomes [2]. Spinal instability may arise from the extent of tumor excision, and late diagnosis can induce structural spinal changes [16]. While scoliosis can result from benign osteoblastoma in the thoracic or lumbar spine, curves secondary to osteoid-osteoma of the rib are initially functional and resolve upon removal of the painful focus [16, 100]. In neurofibromatosis, stabilization of unstable vertebrae is critical for spontaneous dislocation; notably, neurological deficits may resolve even without attempted reduction [99]. Post-resection spinal fixation carries a mechanical failure rate of 10% [94], though early fusion effectively prevents further collapse in giant-cell tumors [95]. For ankylosing spondylitis, percutaneous treatment of thoracolumbar fractures improves pain, neurological function, and kyphotic deformity with effects comparable to traditional methods [92].

Metastatic Management and Prognosis

Decisions for metastatic cervical spine tumors must integrate histology, clinical presentation, patient prognosis, and spinal stability [82]. Similarly, management of thoracic and lumbar metastatic disease is guided by neurologic compromise, spinal instability, and individual patient factors [90]. Future strategies for cervical fibrous dysplasia should prioritize spinal cord integrity and utilize only minimal traction [91].

Reconstruction and Biomaterials

Pelvic ring reconstruction following tumor resection is mechanically feasible, maintains integrity over time, and results in only mild functional loss [96]. 3D-printed modular hemipelvic endoprostheses after periacetabular resection demonstrate stable fixation with acceptable early functional and radiographic outcomes [102]. For anterior reconstruction after thoracic spondylectomy, 3D-printed tantalum vertebral body replacements (AVBs) offer superior biomechanical and clinical performance compared to titanium mesh, significantly reducing endplate stress, implant subsidence, and hardware failure rates while promoting earlier fusion [103].

Diagnostic Considerations and Kinematics

Diagnostic pitfalls in pediatric cervical spine roentgenograms include incomplete ossification, epiphyseal variations, unique bone architecture, and relative hypermobility [97]. Preoperative planning for pedicle screw insertion in adolescent idiopathic scoliosis must account for anatomical limitations at the apical vertebra level and the degree of apical vertebral rotation [98]. Posterior and posterior superior labral injuries alter glenohumeral kinematics, leading to joint instability, increased loading, and potential damage [89]. Overall bone metabolism of the operated intervertebral disc space at six weeks provides the highest diagnostic accuracy for predicting fusion status at one year [101].

Physical Examination

Spinal physical examination encompasses inspection, palpation, range of motion testing, and neurologic evaluation to identify pathology [80]. This assessment must also include maneuvers to detect nonspinal conditions and signs of symptom magnification [80].

Classification

Musculoskeletal Oncology Framework: Musculoskeletal oncology encompasses the diagnosis and management of neoplastic conditions affecting the musculoskeletal system, including benign tumors, sarcomas, and metastatic carcinoma [11]. Classification relies on histomorphology to yield insight into behavior and prognosis [11]. Orthopaedic oncology terminology integrates specific classification systems such as Lichtenstein, Enneking, and AJCC, alongside staging criteria for bone and soft-tissue tumors, biopsy techniques, and molecular markers associated with specific sarcomas [60]. Rigid diagnostic criteria are necessary to ensure accurate classification and prognosis evaluation of osteogenic series sarcomas [67].

PUMCH Classification: The PUMCH classification for extremity and pelvic hemophilic pseudotumors is based on anatomic pathology and surgical strategy [51].

Other Considerations: Differentiation of malignant from benign lesions of the musculoskeletal system is best made by a combination of clinical and imaging parameters rather than by any single MR characteristic [26]. A novel joint fusion approach integrating clinical metadata and imaging data outperformed state-of-the-art models in classifying primary bone tumours [75]. The main difference between scores derived from MRI and CT for spinal instability was in defining the type of bony lesion [21]. High-grade tumors have a poor prognosis regardless of delay in diagnosis [5]. Prognosis for local recurrence and disease-specific survival in chondrosarcomas should be based on the highest grade seen, even when seen in only a few cells [47]. Disease-specific survival is equal in different subtypes of chondrosarcoma after adjustment for histological grade [64]. High-grade malignant primary bone tumors typically undergo neoadjuvant therapies and surgery, while low-grade lesions are usually managed with surgery alone [54]. Surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies, including responsible arterial vascular embolization procedures, significantly reduce surgical trauma and local recurrence rate [65].

Clinical Presentation

Musculoskeletal oncology encompasses the diagnosis and management of neoplastic conditions affecting the musculoskeletal system, including benign tumors, sarcomas, and metastatic carcinoma [11]. Classification of these neoplasms is based on histomorphology to yield insight into behavior and prognosis [11]. Malignant disease must be included in the differential diagnosis for patients presenting with constant pain, an unusual history, poor response to conventional treatment, or a diagnostic dilemma [10]. In pediatric patients, most bone and soft-tissue tumors are benign, yet correct and prompt diagnosis remains challenging [31]. Soft-tissue tumors in children represent a heterogeneous group of lesions that may be benign or malignant [37].

A thorough history and physical examination, followed by appropriate imaging studies, are essential to establish a correct diagnosis for soft-tissue tumors in children [37]. Careful history, physical examination, and radiographic staging identify the primary lesion in 85% of patients with metastatic bone disease [6]. Key clinical features of bone and soft tissue tumors such as local bony tenderness and careful observation for swelling, mass, or deformity should be included in the physical examination [12]. A high index of suspicion and thorough evaluation including radiographs and biopsy are essential to avoid misdiagnosis in patients with known metastatic disease [15].

Biopsy is required when the primary site remains unidentified in patients with metastatic bone disease [6]. Diagnosis of malignant tumors of the foot and ankle requires imaging and biopsy before treatment [33]. The diagnosis of Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in pediatric phalanges can be challenging due to presenting symptoms and radiographic findings [14]. Histological examination is the most important method for final diagnosis of Erdheim-Chester disease [36].

Prognostic factors vary by tumor type and location. Longer duration of symptoms at the time of presentation is not associated with worse survival in primary bone sarcoma [2]. Location in the axial skeleton remains the strongest predictor of a worse prognosis in primary bone sarcoma [2]. The prognosis of primary bone sarcoma is most strongly associated with tumor grade, with high-grade tumors having a poor prognosis regardless of delay in diagnosis [5]. The prognosis for mesenchymoma of bone is poor regardless of therapy, with metastasis and death most often occurring within two years [8].

Specific anatomical sites present unique diagnostic and management challenges. Malignant tumors of the foot and ankle are rare and often diagnosed with delay, leading to increased rates of amputation or local recurrence [33]. The prognosis of malignant tumors of the foot and ankle is generally similar to other sites, though complex anatomy makes large resections and conservative treatments difficult [33]. Successful identification and treatment of malignant tumors of the hand may include referral to a sarcoma center for staging, workup, and multidisciplinary treatment [35]. All differential diagnoses for soft-tissue masses should be considered when planning surgical management in pediatric patients [34].

Surgical timing and follow-up depend on disease stability and specific pathology. Surgical timing for metastatic spinal tumors must be considered within the framework of the patient's disease, deficits, stability, and available multidisciplinary treatments [7]. In the event of late diagnosis of benign osteoblastoma with structural changes in the spine, or when the spine becomes unstable due to the extent of excision, correction and stabilization may be required [16]. Patients with giant cell tumor (GCT) should be followed indefinitely and referred promptly if new symptoms, particularly pain, emerge [30]. Careful serial follow-up after surgical resection is required to identify recurrence and progression to systemic disease in Erdheim-Chester disease [36].

Investigations

Plain radiography: A thorough knowledge of epidemiology, presentation, and imaging features of benign bone tumors is essential for successful management [4]. Key clinical features such as local bony tenderness, swelling, mass, or deformity must be included in the physical examination to differentiate pathologies and guide initial imaging choices [12]. Most benign bone tumors exhibit characteristic features suggesting specific diagnoses, allowing surgeons to follow with imaging or refer to an orthopaedic oncologist [71]. However, diagnosis of Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in pediatric phalanges remains challenging due to overlapping presenting symptoms and radiographic findings [14].

MRI: MRI is the imaging modality of choice for the majority of soft-tissue tumors, and thorough evaluation with quality imaging is essential to identify sarcomas before unplanned resection [49]. Clinico-radiological surveillance for growing cartilage lesions utilizes MRI as the preferred modality [48]. Differentiation of malignant from benign musculoskeletal lesions is best achieved by combining clinical and imaging parameters rather than relying on any single MR characteristic [26]. While MRI findings and location may aid in diagnosing tenosynovial giant cell tumors, careful assessment is mandatory, particularly in unusual locations [70]. Specialized pulse sequences and techniques are required for evaluating the spine to define the three tumor compartments and characterize commonly encountered spinal tumors [76]. Radiologists must be familiar with the imaging characteristics of giant cell tumors of the mobile spine invading adjacent vertebrae [43].

CT: CT is utilized in conjunction with MRI to establish the correct diagnosis in most cases of hematopoietic islands mimicking osteoblastic metastases within the axial skeleton [46]. The primary distinction between the Spinal Instability Neoplastic Score derived from MRI versus CT lies in defining the type of bony lesion [21]. Sensitive imaging methods including CT are necessary to rule out osteoid osteoma in young patients with persistent joint-adjacent pain, as these lesions may fail to disclose in early tumor growth stages [68].

Bone scan: Thallium-201 scanning should be employed alongside other imaging modalities for the diagnosis, treatment planning, and follow-up evaluation of osteosarcoma and soft-tissue sarcoma [39].

Other Considerations: A high index of suspicion and thorough evaluation including radiographs and biopsy are essential to avoid misdiagnosis in patients with known metastatic disease [15]. Low-grade myofibroblastic sarcoma demonstrates unique radiological and pathological features dependent on its site of origin [66]. Advanced imaging techniques such as PET/CT and MRI are essential for evaluating shoulder pain in patients with a history of malignancy [77]. Despite the availability of these tools, there is a high prevalence (32.4%) of inappropriate advanced imaging of musculoskeletal tumors prior to referral [79].

Treatment

Non-Operative

Systemic therapies alone provide limited benefit for renal cell carcinoma with bone metastases, highlighting the need for individualized, multidisciplinary treatment strategies [44]. Chemotherapy can significantly improve progression-free survival in multiple Langerhans cell histiocytosis with spinal involvement [9]. Radiotherapy has achieved good results in local control for multiple Langerhans cell histiocytosis with spinal involvement [9]. Upfront surgery is not advantageous compared to more conservative treatments such as observation or medical treatment for patients with desmoid tumors [63].

Operative

Indications: Aggressive disease-specific surgical and multidisciplinary treatment can yield long disease-free survival, overall survival, and good functional outcomes for soft tissue sarcoma of the hand [1]. Early and aggressive treatment with appropriate oncological surgery confers the lowest local recurrence rate and a survival advantage versus conservative treatment in nonagenarians with soft-tissue sarcoma [3]. Complete surgical excision is the initial recommended treatment for dedifferentiated chondrosarcoma [18]. Receiving surgery could prolong survival in pleomorphic liposarcoma [19]. In the setting of nonmetastatic disease, amputation is the treatment of choice for angiosarcoma in the upper extremity related to a nonfunctioning arteriovenous fistula [41]. The recommended treatment of choice for malignant schwannoma of the medial plantar branch of the posterior tibial nerve is amputation [23]. Complete surgical resection is the treatment of choice for large enchondroma of the thoracic spine to provide immediate relief of symptoms and avoidance of recurrence [73]. Excision of symptomatic elastofibroma should be considered in young athletes if conservative measures fail [74].

Surgical Approach / Technique: Systematic re-excision should not be advocated for patients older than 70 years or with tumors greater than 10 cm following complete macroscopic unplanned excision of limb or trunk soft tissue sarcoma [20]. When amputation is not feasible for malignant schwannoma of the medial plantar branch of the posterior tibial nerve, radical local excision is recommended [23]. Excellent rates of survival can be obtained with carefully planned operative treatment alone for patients with subcutaneous soft-tissue sarcomas of the extremities, including those with large or high-grade tumors and those with residual tumor following a previous operation [40]. Overall survival of patients with bone metastasis from differentiated thyroid cancer is improved by complete resection [42]. Multifaceted approaches including surgical and nonsurgical options are vital in the management of metastatic bone disease with respect to prevention of pathological fractures or surgical stabilization of established fractures [53]. Inactivated autograft should be applied with caution for primary malignant musculoskeletal tumors, and patients should be selected with strict surgical indications [59].

Adjuncts: Patients should be referred to a treatment center before a biopsy is performed rather than after [25]. Clinicians should note that elbow tumours present with unexplained and unremitting non-mechanical pain, swelling or fracture, and early specialist referral is recommended [62]. Thorough knowledge of the epidemiology, common presentation, imaging, and treatment of benign bone tumors is essential for their successful management [4].

Other Considerations: The prognosis for mesenchymoma of bone is poor regardless of therapy, with metastasis and death most often occurring within two years [8]. In metastatic pelvic Ewing sarcoma patients, the significance of tumor resection remains less certain, and improved outcomes of combined local treatment approaches need to be weighed against prognosis and quality of life [17]. Chemotherapy lacks convincing evidence of benefit for dedifferentiated chondrosarcoma [18]. Radiotherapy only benefits patients with pleomorphic liposarcoma with large tumor size (> 10 cm) [19]. Aggressive tumors like angiosarcoma in the upper extremity uniformly have a poor survival rate [41]. Plans for tumor therapy in children with osteosarcoma as a second malignant neoplasm should take into account the risk of this complication, which is usually fatal [24]. The overall survival of patients treated for a sarcoma of the limb is not inferior with a less intensive surveillance regimen than a more intensive protocol [38]. Among patients with malignant fibrous neoplasms of long bones, age (> 60 years), tumour size (> 10 cm), distant stage, and non-surgical treatment are factors for poor survival [69]. The prognosis of a patient with synovioma recognized and treated in the non-palpable phase should be optimum [72]. Despite the benign nature of musculoskeletal desmoid tumors, multidisciplinary care is needed to provide combined treatment options [61]. Continued research and clinical trials are essential for improving treatment efficacy and developing novel therapeutic strategies for standard chordoma arising in the mobile spine and sacrum [45].

Complications

Prognosis and Disease-Specific Outcomes: Aggressive disease-specific surgical and multidisciplinary treatment for soft tissue sarcoma of the hand can yield long disease-free survival, overall survival, and good functional outcomes [1]. Early and aggressive treatment with appropriate oncological surgery confers the lowest local recurrence rate and a survival advantage versus conservative treatment in nonagenarians with soft-tissue sarcoma [3]. In patients with pelvic Ewing's sarcoma, resection is associated with a twofold increase in the survival rate at a median follow-up of thirty-six months [28]. Conversely, the prognosis for mesenchymoma of bone is poor regardless of therapy, with metastasis and death most often occurring within two years [8]. Location in the axial skeleton is the strongest predictor of a worse prognosis in primary bone sarcoma [2]. Age and location of the tumor affect the time of onset of pulmonary metastasis in osteogenic sarcoma under the age of twenty-one but not the five-year survival figure [29].

Oncological Complications and Recurrence: Tumor-free margin resection for chondrosarcoma in the mobile spine reduces the risk of local tumor recurrence and prolongs recurrence-free survival and overall survival compared with intralesional spondylectomy, though it carries higher risks and is associated with a greater number of perioperative complications [56]. Due to the propensity for late recurrence or metastasis in low-grade fibromyxoid sarcoma, wide excision is essential and longer-term follow-up is required [58]. Long-term oncological success contributed to a high rate of implant failure in prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur because more patients lived long enough for the prosthesis to fail [22]. Limb salvage compared with amputation for osteosarcoma of the distal end of the femur did not provide a measurable benefit in the quality of life of survivors at long-term follow-up [13].

Other Considerations: Metastatic tumors are increasingly common, requiring surgical timing to be considered within the framework of the patient's disease, deficits, stability, and available multidisciplinary treatments [7]. Chemotherapy can significantly improve progression-free survival in multiple Langerhans cell histiocytosis with spinal involvement [9]. Radiotherapy has achieved good results in local control for multiple Langerhans cell histiocytosis with spinal involvement [9]. Aggressive surgical management is usually not indicated for Langerhans cell histiocytosis of the spine in children in the absence of systemic disease or spinal deformity; only follow-up is necessary to monitor recovery and spinal balance [78]. A short-course of preoperative denosumab (three or fewer doses) was associated with no differences in clinical scores, histological and radiological response, or local recurrence-free survivorship compared with longer-course denosumab for giant cell tumor of bone [27]. Spontaneous regression of reticulum-cell sarcoma of bone can occur, with a patient remaining free of disease six years following initial presentation without receiving curative therapy [81]. A patient with cortical osteosarcoma involving the medullary cavity and soft tissue was disease-free four years after the operation with no evidence of local recurrence or distant metastasis [83]. Monostotic fibrous dysplasia of the spine has a benign natural history where symptoms typically resolve within two years and lesions generally remain static over long-term follow-up without progression to sarcoma or pathologic fracture [84].

Recovery

Light activity (weeks): Specific timelines for light activity are not explicitly defined in the provided evidence; however, early and aggressive treatment with appropriate oncological surgery is associated with the lowest local recurrence rates and a survival advantage in nonagenarians with soft-tissue sarcoma [3]. For patients with metastatic spinal tumors, multidisciplinary therapy including palliative posterior spinal stabilization surgery and postoperative adjuvant therapy can extend survival time beyond preoperative life expectancy [55].

Full activity (months): Evidence does not specify a month range for full activity return; however, limb salvage compared with amputation for osteosarcoma of the distal femur did not provide a measurable benefit in quality of life for survivors at long-term follow-up [13]. In patients with pelvic Ewing's sarcoma, resection was associated with a twofold increase in the survival rate at a median follow-up of thirty-six months [28].

Complete recovery / outcome plateau (months): Long-term oncological success contributed to a high rate of implant failure in prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur because more patients lived long enough for the prosthesis to fail [22]. A short-course of preoperative denosumab (three or fewer doses) was associated with no differences in clinical scores, histological and radiological response, or local recurrence-free survivorship compared with longer-course denosumab for giant cell tumor of bone [27].

Rehabilitation protocol: The provided evidence does not contain specific details regarding physical therapy phasing, immobilisation duration, weight-bearing progression, or brace removal timing.

Functional milestones: Aggressive disease-specific surgical and multidisciplinary treatment for soft tissue sarcoma of the hand can yield long disease-free survival, overall survival, and good functional outcomes [1].

Other Considerations: Prognostic factors significantly influence recovery trajectories and survival expectations. Longer duration of symptoms at presentation is not associated with worse survival in primary bone sarcoma [2], whereas location in the axial skeleton remains the strongest predictor of a worse prognosis in primary bone sarcoma [2]. The prognosis of primary bone sarcoma of the pelvis is most strongly associated with tumor grade, with high-grade tumors having a poor prognosis regardless of delay in diagnosis [5]. A time to treatment initiation of more than 30 days after diagnosis was independently associated with poorer survival in patients with localized high-grade soft-tissue sarcoma in the extremity or trunk [88]. Age and location of the tumor affect the time of onset of pulmonary metastasis in osteogenic sarcoma under the age of twenty-one but not the five-year survival figure [29]. Survival time after pathological fractures is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival [93]. Approximately one-half of all patients survive for one year after surgery for osseous metastases from renal cell carcinoma, and one-tenth survive for longer than five years [57]. The prognosis for malignant hemangioendothelioma of bone is poor, with a five-year survival for only two of the six patients in the series [85]. Median duration of survival after treatment of metastatic bone disease has increased, which was a consistent finding in nearly all cancer types [86]. Chemotherapy can significantly improve progression-free survival in multiple Langerhans cell histiocytosis with spinal involvement, and radiotherapy has achieved good results in local control for the same condition [9]. Careful history, physical examination, and radiographic staging identify the primary lesion in 85% of patients with metastatic bone disease, while biopsy is required when the primary site remains unidentified [6].

Key Evidence

  • [L2] Aggressive disease-specific surgical and multidisciplinary treatment can yield long disease-free survival and overall survival, and good functional outcomes. (10.1016/j.jhsa.2024.05.003)
  • [L3] Location in the axial skeleton remains the strongest predictor of a worse prognosis. (10.1302/0301-620x.100b5.bjj-2017-1235.r1)
  • [L4] Early and aggressive treatment with appropriate oncological surgery confers the lowest local recurrence rate and a survival advantage versus conservative treatment in this cohort of patients. (10.1302/0301-620x.104b1.bjj-2021-0761.r1)
  • [L5] A thorough knowledge of the epidemiology, common presentation, imaging, and treatment of benign bone tumors is essential for successful management of these lesions. (10.5435/00124635-201302000-00002)
  • [L3] The prognosis is most strongly associated with tumor grade, with high-grade tumors having a poor prognosis regardless of delay in diagnosis. (10.2106/00004623-199903000-00003)
  • [L5] Metastatic tumors are increasingly common, requiring surgical timing to be considered within the framework of the patient's disease, deficits, stability, and available multidisciplinary treatments. (10.5435/jaaos-d-21-00710)
  • [Case_report] The prognosis is poor, regardless of the therapy, with metastasis and death most often occurring within two years. (10.2106/00004623-199301000-00014)
  • [L3] Chemotherapy can significantly improve progression-free survival, and radiotherapy has achieved good results in local control. (10.1302/0301-620x.105b6.bjj-2022-1129.r1)
  • [L5] Malignant disease should be in the differential diagnosis in patients presenting with constant pain, an unusual history, poor response to conventional treatment, or a diagnostic dilemma. (10.1016/j.arthro.2006.01.016)
  • [L4] Key clinical features of bone and soft tissue tumours such as local bony tenderness and careful observation for swelling/mass/deformity should be included in the physical examination to help differentiate between the two pathologies and help guide the choice of initial imaging for the primary contact clinician. (10.1177/17585732251324656)
  • [L3] However, it did not provide a measurable benefit in the quality of life of survivors at the time of the long-term follow-up. (10.2106/00004623-199405000-00004)
  • [L4] The diagnosis in pediatric cases can be challenging due to presenting symptoms and radiographic findings. (10.1016/j.jhsa.2020.05.002)
  • [Case_report] A high index of suspicion and thorough evaluation including radiographs and biopsy are essential to avoid misdiagnosis in patients with known metastatic disease. (10.1177/15589447211028922)
  • [L4] In the event of late diagnosis and the presence of structural changes in the spine, or when the spine becomes unstable due to the extent of the excision, correction and stabilization may be required. (10.2106/00004623-198163070-00012)
  • [L3] In metastatic patients, the significance of tumor resection remains less certain, and improved outcomes of combined local treatment approaches need to be weighed against prognosis and quality of life. (10.1186/s13018-020-02028-3)
  • [L4] Complete surgical excision is the initial recommended treatment, while chemotherapy lacks convincing evidence of benefit. (10.1186/1749-799x-7-38)
  • [L3] Receiving surgery could prolong the survival, while radiotherapy only benefits patients with large tumor size (> 10 cm). (10.1186/s13018-021-02327-3)
  • [L2] Systematic re-excision should not be advocated for patients older than 70 years or with tumors greater than 10 cm. (10.3390/cancers16071365)
  • [L4] The main difference between the scores derived from MRI and CT was in defining the type of bony lesion. (10.1302/0301-620x.103b5.bjj-2020-1823.r1)
  • [L3] Long-term oncological success contributed to the high rate of implant failure as more patients lived long enough for the prosthesis to fail. (10.2106/00004623-199805000-00004)
  • [Case_report] The recommended treatment of choice is amputation, and when this is not feasible, radical local excision. (10.2106/00004623-197557050-00025)
  • [L4] Plans for tumor therapy should take into account the risk of this complication, which is usually fatal. (10.2106/00004623-199274070-00015)
  • [L4] The data strongly support the recommendation that patients be referred to a treatment center before a biopsy is performed rather than after. (10.2106/00004623-199605000-00004)
  • [L2] Differentiation of malignant from benign lesions of musculoskeletal system is best made by a combination of clinical and imaging parameters rather than by any single MR characteristic. (10.1186/1471-2474-10-125)
  • [L3] A short-course of preoperative denosumab (three or fewer doses) was associated with no differences in clinical scores, histological and radiological response, or local recurrence-free survivorship compared with longer-course denosumab. (10.1097/corr.0000000000001285)
  • [L4] A twofold increase in the survival rate was seen at a median follow-up of thirty-six months in the patients who had the resection. (10.2106/00004623-198365060-00003)
  • [L4] Patients with GCT should be followed indefinitely, and referred promptly if new symptoms, particularly pain, emerge. (10.1302/0301-620x.104b12.bjj-2022-0401.r1)
  • [L5] Malignant tumours of the foot and ankle are rare and often diagnosed with delay, leading to increased rates of amputation or local recurrence; diagnosis requires imaging and biopsy before treatment, and while prognosis is generally similar to other sites, the complex anatomy makes large resections and conservative treatments difficult. (10.1302/2058-5241.2.160078)
  • [Case_report] We strongly recommend considering all differential diagnoses for soft-tissue masses when planning surgical management. (10.1186/s12891-020-03312-3)
  • [L5] Successful identification and treatment of malignant tumors of the hand may include referral to a sarcoma center for staging, workup, and multidisciplinary treatment. (10.5435/jaaos-d-20-00333)
  • [Case_report] Histological examination is the most important for final diagnosis, and careful serial follow-up after surgical resection is required to identify recurrence and progression to systemic disease. (10.1186/s12891-021-04061-7)
  • [L5] Soft-tissue tumors in children are a heterogeneous group of lesions that may be benign or malignant; a thorough history and physical examination, followed by appropriate imaging studies, can establish a correct diagnosis and help determine appropriate treatment recommendations. (10.5435/00124635-200309000-00006)
  • [L1] The overall survival of patients treated for a sarcoma of the limb is not inferior with a less intensive regimen than a more intensive protocol. (10.1302/0301-620x.100b2.bjj-2017-0789.r1)
  • [L4] It should be used in conjunction with other imaging modalities for diagnosis, treatment planning, and follow-up evaluation. (10.2106/00004623-199304000-00008)
  • [L3] Excellent rates of survival for patients who have a subcutaneous sarcoma, including those who have a large or high-grade tumor and those who have residual tumor following a previous operation, can be obtained with carefully planned operative treatment alone. (10.2106/00004623-199706000-00013)
  • [Case_report] In the setting of nonmetastatic disease, amputation is the treatment of choice; however, this aggressive tumor uniformly has a poor survival rate. (10.1177/1558944717702466)
  • [Case_report] Overall survival of patients with bone metastasis is improved by complete resection. (10.1186/s12891-015-0748-2)
  • [L4] Radiologists should be familiar with this imaging characteristic. (10.1186/s12891-021-04610-0)
  • [L3] Systemic therapies alone provide limited benefit, highlighting the need for individualized, multidisciplinary treatment strategies. (10.1186/s12891-025-09021-z)
  • [L5] Continued research and clinical trials are essential for improving treatment efficacy and developing novel therapeutic strategies for this locally aggressive tumor type. (10.5435/jaaos-d-24-01119)
  • [L4] However, the combination of MRI and CT allows for making the correct diagnosis in most cases. (10.1186/s12891-022-05402-w)
  • [L3] When categorizing the grade of the resection specimen, the prognosis for local recurrence and disease-specific survival should be based on the highest grade seen, even when seen in only a few cells. (10.1302/0301-620x.100b5.bjj-2017-1243.r1)
  • [L3] Clinico-radiological surveillance can identify growing cartilage lesions, with MRI as the modality of choice. (10.1302/0301-620x.98b11.37864)
  • [L1] RFA may be routinely implemented in all cases involving refractory pain or radiotherapy-resistant tumours but controlled trials are required to compare the efficacy of RFA to current frontline treatments. (10.1186/s13018-021-02775-x)
  • [L4] The PUMCH classification is based on the anatomic pathology and surgical strategy for HPTs. (10.2106/jbjs.22.00781)
  • [Case_report] Tailoring the approach to an individual's specific condition by considering factors such as tumor size and location is essential for optimal outcomes. (10.1186/s12891-024-07821-3)
  • [L4] Survival time extended beyond the preoperative life expectancy in many patients. (10.1186/s13018-018-0735-z)
  • [L3] Tumor-free margin resection carries higher risks and is associated with a greater number of perioperative complications, but reduces the risk of local tumor recurrence and prolongs recurrence-free survival and overall survival, providing patients with better prognoses. (10.1186/s13018-025-05712-4)
  • [L2] Approximately one-half of all patients survive for one year after surgery for renal cell metastases, and one-tenth survive for longer than five years. (10.2106/jbjs.f.00603)
  • [L4] Due to the propensity for late recurrence or metastasis, wide excision is essential, and longer-term follow-up is required. (10.1186/1749-799x-6-15)
  • [L4] Thus, we should apply this method with caution and choose the patients with strict surgical indication. (10.1186/s13018-015-0324-3)
  • [L5] Despite the benign nature of these tumors, multidisciplinary care is needed to provide combined treatment options. (10.5435/00124635-200804000-00002)
  • [L4] Clinicians should note that elbow tumours present with unexplained and unremitting non-mechanical pain, swelling or fracture, and early specialist referral is recommended. (10.1177/1758573215586151)
  • [L3] Upfront surgery is not advantageous compared to more conservative treatments such as observation or medical treatment for patients with desmoid tumors. (10.1186/s12891-020-03897-9)
  • [L3] Disease-specific survival is equal in different subtypes after adjustment for histological grade. (10.1302/0301-620x.103b5.bjj-2020-1082.r2)
  • [L3] Responsible arterial vascular embolization procedures together with associated surgical protocols developed on the basis of the clinical classification of metastatic spinal malignancies are worthy of clinical dissemination by significantly reducing surgical trauma and local recurrence rate. (10.1186/s12891-023-07092-4)
  • [Case_report] LGMS demonstrates unique radiological and pathological features depending on its site of origin. (10.1186/s12891-025-08565-4)
  • [L4] It emphasizes the need for rigid diagnostic criteria to ensure accurate classification and prognosis evaluation. (10.2106/00004623-196648010-00001)
  • [L4] Osteoid osteoma should be ruled out via sensitive imaging methods (MRI and CT) in young patients with persistent pain adjacent to the joint, as these methods may fail to disclose lesions in the early stage of tumor growth. (10.1016/j.jse.2007.02.119)
  • [L3] Among patients with MFN of long bones, age (> 60 years), tumour size (> 10 cm), distant stage, and non-surgical treatment are factors for poor survival. (10.1186/s12891-019-2971-8)
  • [L4] Although MRI findings and location might help in the diagnosis of a T-GCT, careful assessment is mandatory, especially in unusual locations. (10.1186/s12891-016-1050-7)
  • [Case_report] The prognosis of a patient with a synovioma recognized and treated in the non-palpable phase should be optimum. (10.2106/00004623-197860060-00022)
  • [Case_report] Complete surgical resection is the treatment of choice for immediate relief of symptoms and avoidance of recurrence. (10.1186/s12891-017-1519-z)
  • [L4] Excision of the mass should be considered in young athletes if conservative measures fail. (10.1016/j.jse.2010.05.017)
  • [L4] The joint fusion approach developed in this study, integrating clinical metadata and imaging data, outperformed state-of-the-art models in classifying primary bone tumours. (10.1186/s12891-024-07934-9)
  • [L5] This report describes specialized pulse sequences and imaging techniques for evaluating the spine, defines the defining characteristics of the three compartments into which spinal tumors can be classified, and provides a basic knowledge of the tumors commonly encountered in the spine. (10.2106/jbjs.h.00825)
  • [Case_report] A high index of suspicion and the use of advanced imaging techniques like PET/CT and MRI are essential for evaluating shoulder pain in patients with a history of malignancy. (10.1016/j.jse.2009.09.003)
  • [L4] The natural history of these lesions in the spine in the absence of systemic disease or spinal deformity is such that aggressive surgical management is usually not indicated; only follow-up is necessary to monitor recovery and spinal balance. (10.2106/00004623-200408000-00019)
  • [L2] Our data indicate a high prevalence (32.4%) of inappropriate advanced imaging of musculoskeletal tumors prior to referral. (10.2106/jbjs.n.00186)
  • [L4] The patient remained free of disease six years following the initial presentation without receiving curative therapy. (10.2106/00004623-195941050-00016)
  • [L5] Management decisions should be based on histology, clinical presentation, patient prognosis, and spinal stability. (10.5435/jaaos-23-01-38)
  • [Case_report] The patient was disease-free four years after the operation with no evidence of local recurrence or distant metastasis. (10.2106/00004623-199409000-00018)
  • [L4] Monostotic fibrous dysplasia of the spine is a rare condition with a benign natural history; symptoms typically resolve within two years, and lesions generally remain static over long-term follow-up without progression to sarcoma or pathologic fracture. (10.2106/jbjs.i.00727)
  • [L4] Prognosis is poor, with a five-year survival for only two of the six patients in this series. (10.2106/00004623-197557010-00015)
  • [L4] Median duration of survival after treatment of metastatic bone disease has increased, which was a consistent finding in nearly all cancer types. (10.5435/jaaos-d-23-00332)
  • [L3] A time to treatment initiation of more than 30 days after diagnosis was independently associated with poorer survival. (10.1302/0301-620x.103b6.bjj-2020-2087.r1)
  • [L5] The PPS injury produces alterations in GH kinematics with implications for GH joint instability, increased GH joint loading, and potential joint damage. (10.1016/j.jse.2024.12.023)
  • [L5] Management is guided by three key issues: neurologic compromise, spinal instability, and individual patient factors. (10.5435/00124635-201101000-00005)
  • [L3] This procedure can improve patients' pain, neurological function and kyphotic deformity and achieve effects similar to traditional methods, making it an ideal surgical treatment for thoracolumbar fractures in AS patients. (10.1186/s13018-022-03378-w)
  • [L3] Survival time is short and correlated with primary tumor type, with lung cancer as the strongest negative predictor of survival. (10.1186/s13018-023-03620-z)
  • [L1] The spinal fixation mechanical failure rate was 10%. (10.1186/s13018-022-03007-6)
  • [L4] The technique is mechanically feasible and the reconstruction will hold up with time and use, causing only mild loss of function. (10.2106/00004623-197860060-00003)
  • [L4] Preoperative planning to accurately select and insert pedicle screws in adolescent idiopathic scoliosis should be based on anatomical limitations in the apical vertebra region, apical vertebra level, and apical vertebral rotation degree. (10.1186/s12891-022-05799-4)
  • [L4] Stabilization of the unstable vertebrae was the important aspect of treatment, and in this patient, all neurological deficits resolved even though reduction of the deformity was not attempted. (10.2106/00004623-199173090-00018)
  • [Case_report] The scoliotic curve is initially functional and will resolve after the painful focus has been removed. (10.2106/00004623-198365050-00022)
  • [L2] Overall bone metabolism of the operated intervertebral disc space at six weeks had the highest diagnostic accuracy for predicting the fusion status at one year. (10.1186/s13018-025-05814-z)
  • [L4] These preliminary results demonstrate stable fixation with acceptable early functional and radiographic outcomes. (10.2106/jbjs.19.01437)
  • [L3] AVBs made of 3D-printed tantalum demonstrate superior biomechanical and clinical performance compared to titanium mesh for anterior reconstruction after TES, significantly reducing endplate stress, implant subsidence, and hardware failure rates while promoting earlier fusion. (10.1186/s13018-025-06351-5)

See Also

References

[1] Clinical Outcomes After Definitive Treatment of Soft Tissue Sarcoma of the Hand: A Retrospective Cohort Study of 109 Patients. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.05.003

[2] Longer duration of symptoms at the time of presentation is not associated with worse survival in primary bone sarcoma. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b5.bjj-2017-1235.r1

[3] Outcomes of soft-tissue sarcoma in nonagenarians. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b1.bjj-2021-0761.r1

[4] Benign Tumors of the Spine. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/00124635-201302000-00002

[5] Delay in the Diagnosis and Treatment of Primary Bone Sarcoma of the Pelvis. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199903000-00003

[6] Chapter 148 Metastatic Bone Disease. 2019.

[7] Spinal Tumors: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-00710

[8] Mesenchymoma of bone. A case report.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199301000-00014

[9] Multiple Langerhans cell histiocytosis with spinal involvement. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b6.bjj-2022-1129.r1

[10] Non‐Hodgkin's Lymphoma of the Knee Diagnosed by Arthroscopy. Arthroscopy. 2006. DOI: 10.1016/j.arthro.2006.01.016

[11] 5. Musculoskeletal Oncology. 2013.

[12] Shoulder girdle neoplasm misdiagnosis and clinical manifestations: A scoping review. Shoulder & Elbow. 2025. DOI: 10.1177/17585732251324656

[13] Limb salvage compared with amputation for osteosarcoma of the distal end of the femur. A long-term oncological, functional, and quality-of-life study.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199405000-00004

[14] Bizarre Parosteal Osteochondromatous Proliferation (Nora Lesion) in Pediatric Phalanges. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.05.002

[15] A Case of Metastatic Prostate Cancer to the Distal Phalanx. HAND. 2021. DOI: 10.1177/15589447211028922

[16] Scoliosis caused by benign osteoblastoma of the thoracic or lumbar spine.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163070-00012

[17] Pelvic Ewing sarcoma: a retrospective outcome analysis of 104 patients who underwent pelvic tumor resection at a single supra-regional center. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-02028-3

[18] Clinical outcome for patients with dedifferentiated chondrosarcoma: a report of 9 cases at a single institute. Journal of Orthopaedic Surgery and Research. 2012. DOI: 10.1186/1749-799x-7-38

[19] Survivorship and prognostic factors for pleomorphic liposarcoma: a population-based study. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02327-3

[20] Improved Metastatic-Free Survival after Systematic Re-Excision Following Complete Macroscopic Unplanned Excision of Limb or Trunk Soft Tissue Sarcoma. Cancers. 2024. DOI: 10.3390/cancers16071365

[21] Can MRI be used as a safe and expedient option for calculating Spinal Instability Neoplastic Score for patients with metastatic spinal cord compression?. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b5.bjj-2020-1823.r1

[22] Prosthetic Knee Replacement after Resection of a Malignant Tumor of the Distal Part of the Femur. Medium to Long-Term Results. The Journal of Bone & Joint Surgery*. 1998. DOI: 10.2106/00004623-199805000-00004

[23] Malignant schwannoma of the medial plantar branch of the posterior tibial nerve (unassociated with von Recklinghausenʼs disease). A case report. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557050-00025

[24] Osteosarcoma as a second malignant neoplasm in children.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274070-00015

[25] The Hazards of the Biopsy, Revisited. For the Members of the Musculoskeletal Tumor Society. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199605000-00004

[26] Relevance of MRI in prediction of malignancy of musculoskeletal system-A prospective evaluation. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-125

[27] Is a Short-course of Preoperative Denosumab as Effective as Prolonged Therapy for Giant Cell Tumor of Bone?. Clinical Orthopaedics & Related Research. 2020. DOI: 10.1097/corr.0000000000001285

[28] Pelvic Ewingʼs sarcoma. Advances in treatment.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365060-00003

[29] Osteogenic Sarcoma under the Age of Twenty-one: A REVIEW OF ONE HUNDRED AND FORTY-FIVE OPERATIVE CASES.. The Journal of Bone and Joint Surgery. American Volume. 1970.

[30] A systematic review of multicentric giant cell tumour with the presentation of three cases at long-term follow-up. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b12.bjj-2022-0401.r1

[31] Chapter 5 Benign and Malignant Musculoskeletal Neoplasms. 2020.

[33] Malignant tumours of the foot and ankle. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160078

[34] Synovial sarcoma presenting as an intra-articular mass in a pediatric patient: a case report. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03312-3

[35] Malignant Tumors of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00333

[36] Isolated thoracic intramedullary Erdheim-Chester disease presenting with paraplegia: a case report and literature review. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04061-7

[37] Pediatric Soft-Tissue Tumors. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200309000-00006

[38] Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb?. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b2.bjj-2017-0789.r1

[39] Thallium-201 scanning for the evaluation of osteosarcoma and soft-tissue sarcoma. A study of the evaluation and predictability of the histological response to chemotherapy.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199304000-00008

[40] Oncological Outcomes of Operative Treatment of Subcutaneous Soft-Tissue Sarcomas of the Extremities. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199706000-00013

[41] Case Report: Angiosarcoma in the Upper Extremity Related to a Nonfunctioning Arteriovenous Fistula. HAND. 2017. DOI: 10.1177/1558944717702466

[42] Metastasis of differentiated thyroid cancer in the subchondral bone of the femoral head: a case report. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0748-2

[43] Giant cell tumors of the mobile spine with invasion of adjacent vertebrae: an unusual imaging finding. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04610-0

[44] The prognostic role of key factors in renal cell carcinoma with bone metastases. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-09021-z

[45] Contemporary Management of Standard Chordoma Arising in the Mobile Spine and Sacrum. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01119

[46] Hematopoietic islands mimicking osteoblastic metastases within the axial skeleton. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05402-w

[47] The role of grade in local recurrence and the disease-specific survival in chondrosarcomas. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b5.bjj-2017-1243.r1

[48] Surveillance of intramedullary cartilage tumours in long bones. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b11.37864

[49] Chapter 68 Soft-­Tissue Tumors: Evaluation and Diagnosis. 2020.

[50] What is the effectiveness of radiofrequency ablation in the management of patients with spinal metastases? A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02775-x

[51] A Novel Surgical Classification for Extremity and Pelvic Hemophilic Pseudotumors. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.00781

[52] Resection of a giant intraspinal and extraspinal schwannoma with cystic change using a two-step surgery: a case report. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07821-3

[53] Chapter 69 Metastatic Bone Disease. 2020.

[54] Chapter 67 Malignant Primary Bone Tumors. 2020.

[55] Clinical results of multidisciplinary therapy including palliative posterior spinal stabilization surgery and postoperative adjuvant therapy for metastatic spinal tumor. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-018-0735-z

[56] Comparation of tumor-free margin or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications and prognosis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05712-4

[57] Patient Survival After Surgery for Osseous Metastases from Renal Cell Carcinoma. The Journal of Bone & Joint Surgery*. 2007. DOI: 10.2106/jbjs.f.00603

[58] The clinical significance of the FUS-CREB3L2 translocation in low-grade fibromyxoid sarcoma. Journal of Orthopaedic Surgery and Research. 2011. DOI: 10.1186/1749-799x-6-15

[59] The long-term outcomes following the use of inactivated autograft in the treatment of primary malignant musculoskeletal tumor. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0324-3

[60] Chapter 141 Overview of Orthopaedic Oncology and Systemic Disease. 2019.

[61] Musculoskeletal Desmoid Tumors. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200804000-00002

[62] Primary osseous tumours of the elbow: 60 years of registry experience. Shoulder & Elbow. 2015. DOI: 10.1177/1758573215586151

[63] Upfront surgery is not advantageous compared to more conservative treatments such as observation or medical treatment for patients with desmoid tumors. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-020-03897-9

[64] Clinical differences between central and peripheral chondrosarcomas. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b5.bjj-2020-1082.r2

[65] The new clinical classification of metastatic spinal malignancies serves as a vital reference for surgical management: a retrospective case-control study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-07092-4

[66] Early diagnosis and treatment of low-grade myofibroblastic sarcoma in the left distal femur: a case report and literature review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08565-4

[67] Sarcomata of the Osteogenic Series (Osteosarcoma, Fibrosarcoma, Chondrosarcoma, Parosteal Osteogenic Sarcoma, and Sarcomata Arising in Abnormal Bone). The Journal of Bone & Joint Surgery. 1966. DOI: 10.2106/00004623-196648010-00001

[68] Osteoid osteoma of the proximal humerus: A misleading case. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.02.119

[69] Malignant fibrous neoplasms of long bones: analysis of the surveillance, epidemiology, and end results database from 1973 to 2015. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-019-2971-8

[70] Tenosynovial giant cell tumors in unusual locations detected by positron emission tomography imaging confused with malignant tumors: report of two cases. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1050-7

[71] Chapter 66 Benign Bone Tumors. 2020.

[72] Minute synovial sarcoma in the occult non-palpable phase. A case report.. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860060-00022

[73] Large enchondroma of the thoracic spine: a rare case report and review of the literature. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1519-z

[74] Symptomatic elastofibroma in young baseball pitchers: Report of three cases. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.017

[75] Impact of metadata in multimodal classification of bone tumours. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07934-9

[76] Magnetic Resonance Imaging of Spine Tumors: Classification, Differential Diagnosis, and Spectrum of Disease. Journal of Bone and Joint Surgery. 2008. DOI: 10.2106/jbjs.h.00825

[77] Subscapularis muscle metastases of duodenal adenocarcinoma: A case report. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.09.003

[78] Langerhans Cell Histiocytosis of the Spine in Children. The Journal of Bone and Joint Surgery-American Volume. 2004. DOI: 10.2106/00004623-200408000-00019

[79] Evaluation of Imaging Utilization Prior to Referral of Musculoskeletal Tumors. Journal of Bone and Joint Surgery. 2015. DOI: 10.2106/jbjs.n.00186

[80] Chapter 12 Physical Examination of the Spine. 2019.

[81] Spontaneous Regression of Reticulum-Cell Sarcoma of Bone. The Journal of Bone & Joint Surgery. 1959. DOI: 10.2106/00004623-195941050-00016

[82] Management of Metastatic Cervical Spine Tumors. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-23-01-38

[83] Cortical osteosarcoma involving the medullary cavity and soft tissue. A case report.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199409000-00018

[84] Monostotic Fibrous Dysplasia of the Spine. The Journal of Bone and Joint Surgery-American Volume. 2010. DOI: 10.2106/jbjs.i.00727

[85] Malignant hemangioendothelioma of bone. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557010-00015

[86] Life Expectancy After Treatment of Metastatic Bone Disease: An International Trend Analysis. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00332

[88] Patients with an increased time to treatment initiation have a poorer overall survival after definitive surgery for localized high-grade soft-tissue sarcoma in the extremity or trunk. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b6.bjj-2020-2087.r1

[89] 2025 Basic Science Neer Award Winner: The impact of posterior and posterior superior labral injuries and the effect of their treatment on glenohumeral kinematics in the deceleration and follow-through phase of throwing: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.023

[90] Metastatic Disease in the Thoracic and Lumbar Spine. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201101000-00005

[91] Fibrous dysplasia of the cervical spine: a fatal complication of treatment. A case report.. The Journal of Bone and Joint Surgery. American Volume. 1990.

[92] Surgical treatment of thoracolumbar fracture in ankylosing spondylitis: A comparison of percutaneous and open techniques. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03378-w

[93] Age, sex, primary tumor type and site are associated with mortality after pathological fractures: an observational study of 1453 patients from the Swedish Fracture Register. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03620-z

[94] Factors associated with spinal fixation mechanical failure after tumor resection: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03007-6

[95] GIANT-CELL TUMOR OF THE SPINE: A Report of Two Cases.. The Journal of Bone and Joint Surgery. American Volume. 1953.

[96] Reconstruction of the pelvic ring following tumor resection.. The Journal of Bone & Joint Surgery. 1978. DOI: 10.2106/00004623-197860060-00003

[97] Pseudosubluxation and Other Normal Variations in the Cervical Spine in Children: A STUDY OF ONE HUNDRED AND SIXTY CHILDREN.. The Journal of Bone and Joint Surgery. American Volume. 1965.

[98] Three-dimensional morphological analysis of the thoracic pedicle and related radiographic factors in adolescent idiopathic scoliosis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05799-4

[99] Spontaneous dislocation of a vertebra in a patient who had neurofibromatosis. Report of a case with dural ectasia.. The Journal of Bone & Joint Surgery. 1991. DOI: 10.2106/00004623-199173090-00018

[100] Scoliosis secondary to an osteoid-osteoma of the rib. A case report.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365050-00022

[101] 18F-fluoride PET/CT as an early predictor of bony fusion after posterior lumbar interbody fusion– a prospective study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05814-z

[102] 3D-Printed Modular Hemipelvic Endoprosthetic Reconstruction Following Periacetabular Tumor Resection. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01437

[103] 3D-printed tantalum artificial vertebral body or titanium mesh in anterior column reconstruction post-spondylectomy for thoracic vertebral tumors: a retrospective comparative cohort study and finite element analysis. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06351-5

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2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.