Is the Posterior-Only Approach Sufficient for Treating Cervical Spine Metastases? The Evidence from a Case Series.

OBJECTIVES: Few studies have evaluated surgical options in the treatment of cervical metastatic disease. The aim of this study is to report the surgical outcomes of patients treated with the posterior-only approach for metastatic cervical disease. METHODS: In this retrospective analysis, all cases treated in our institution from 2009 to 2017 were reviewed. Six (20%) patients had intracompartimental lesions (Tomita 1-3), whereas 24 (80%) patients had extracompartimental lesions (Tomita 4-7), with extensive anterior column involvement. All patients were surgically treated with laminectomy and posterior stabilization. Pain and neurologic function were evaluated before and after surgery. RESULTS: Thirty patients were included (15 female, 15 male), with a mean age of 60.6 ± 11.56 years (range 35-82 years). Lesions were located in 7 patients (23.3%) in the upper cervical spine and in 14 patients (46.6%) and in 9 patients (30,1%) in the mid-cervical and in the cervicothoracic junction, respectively. At a mean follow up of 13.7 ± 14.8 months, 15 (50%) patients died from their disease. Pain decreased in all patients after surgery, (preoperative NRS 5.57 ± 1.81 postoperative Numeric Rating Scale of 2.1 ± 1.0, P < 0.00001). Two patients (6.7%) had significant neurologic worsening after surgery. Two (6.9%) patients had surgical-site infection that required reintervention. No mechanical failures were observed. CONCLUSIONS: In our series, posterior-only fixation provided postoperative pain relief and achieve spinal stability, ultimately improving the quality of life. In conclusion, posterior-approach decompression and stabilization is a safe and feasible procedure in patients with neurologic or mechanical instability for cervical spine metastasis.

Four- and five- level en bloc spondylectomy for malignant spinal tumors.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors. SUMMARY OF BACKGROUND DATA: EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity. METHODS: We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease. RESULTS: Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up. CONCLUSION: Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it. LEVEL OF EVIDENCE: 4.