Anterior expandable cylindrical cage reconstruction after cervical spinal metastasis resection

Cervical vertebral body replacement using a modern in situ expandable and angulable corpectomy cage system: early clinical and radiological outcome

PURPOSE

Vertebral body replacement (VBR) cages are commonly implanted to reconstruct the cervical vertebrae in cases of tumour, trauma, spondylodiscitis, and degeneration. Expandable cages have been widely used for this purpose; however, the lacking congruence at the implant-bone interface and consequent implant displacement were considered as a serious drawback of such systems. Aim of this study is to evaluate the early clinical and radiological outcome of a modern in situ not only expandable but also angulable cervical corpectomy cage system.

METHODS

A total of 42 patients who underwent a single or multilevel cervical VBR procedure were included and retrospectively evaluated in this single-centre case series. The neurological status was assessed using American Spinal Injury Association (ASIA) score. Complications were categorized into surgical (including implant-associated) and general medical. Radiographic parameters included regional angulation, segmental height, and coronal alignment.

RESULTS

Mean age was 59.5 ± 20.6 years. The recorded ASIA score improved postoperatively by 10 points (p  0.0001). Surgical including implant-associated complication rates were 19.05%. Radiographic evaluation showed a height gain of 11.2 mm (p < 0.0001), lordotic correction of 7° (p < 0.0001), and coronal alignment of 3° (p < 0.0001). At the last follow-up, loss of angulation correction of 1.9° (p  0.0002), subsidence of 1.92 mm (p  0.0006), and fusion rates of 68.42% were observed.

CONCLUSIONS

The use of an in situ angulable and expandable cage system in cervical VBR seems to offer better results compared to conventional static or expandable cages regarding segmental height gain, lordotic correction, and clinical improvement as well as low complication and revision rates. Significant height gain in multilevel surgeries is associated with higher rates of implant-associated complications.

Evaluation of Radiological and Neurological Outcomes after Anterior Cervical Corpectomy with Fusion using Expandable Cage Alone and Expandable Cage with Anterior Cervical Plating

Objective After anterior cervical corpectomy expandable cage were used with or without using anterior cervical plate for structural support are being preferred over autologous bone graft and other types of cages. Nowadays, the preferable type of cages and application of anterior cervical plate remain a debatable topic with studies giving divergent results. The purpose of this study is to evaluate the outcomes of expandable cages used alone or expandable cage used with anterior cervical plate following anterior cervical corpectomy.

Materials and Methods This study was conducted on 100 patients from January 2019 to December 2021 and all patients were undergone anterior cervical corpectomy and fusion and divided in two groups with expandable cage only (Group A) and expandable cage with anterior cervical plate (Group B). Various long-term benefits and radiological outcomes were studied in both groups.

Statistical Analysis and Results In this study, 100 patients were included and all patients underwent corpectomy followed by insertion of expandable cage alone or with anterior cervical plate. There was an improvement in C2–C7 Cobb's angle in group B was significantly higher than group A (p < 0.05) and decrease in Nurick's scale score in group B was significantly higher than group A (p < 0.05). The outcomes were measured with fusion rate (94%), subsidence rate (15%) and change in C2–C7 Cobb's angle was 4 degrees in this study.

Conclusion Expandable cage with or without anterior cervical plate was used after anterior cervical corpectomy for various cervical pathological conditions. In this study, we conclude the long-term benefits and radiological outcomes of two groups as expandable cage was used alone or with additional application of anterior cervical plate. In this study, the results were more in favor of additional application of anterior cervical plate as compared with expandable cage alone and more studies were required in future for more established long-term benefits and drawbacks.

Anterior Corpectomy and Plating with Carbon-PEEK Instrumentation for Cervical Spinal Metastases: Clinical and Radiological Outcomes

Background: Anterior cervical corpectomy and plating has been recognized as a valuable approach for the surgical treatment of cervical spinal metastases. This study aimed to report the surgical, clinical and radiological outcomes of anterior carbon-PEEK instrumentations for cervical spinal metastases. Methods: Demographical, clinical, surgical and radiological data were collected from 2017 to 2020. The Neck Disability Index (NDI) questionnaire for neck pain, EORTC QLQ-C30 questionnaire for quality of life, Nurick scale for myelopathy and radiological parameters (segmental Cobb angle and cervical lordosis) were collected before surgery, at 6 weeks postoperatively and follow-up. Results: Seventeen patients met inclusion criteria. Mean age was 60.9 ± 7.6 years and mean follow-up was 12.9 ± 4.0 months. The NDI (55.4 ± 11.7 to 25.1 ± 5.4, p < 0.001) scores and the EORTC QLQ-C30 global health/QoL significantly improved postoperatively and at the last follow-up. The segmental Cobb angle (10.7° ± 5.6 to 3.1° ± 2.2, p < 0.001) and cervical lordosis (0.9° ± 6.7 to −6.2 ± 7.8, p = 0.002) significantly improved postoperatively. Only one minor complication (5.9%) was recorded. Conclusions: Carbon/PEEK implants represent a safe alternative to commonly used titanium ones and should be considered in cervical spinal metastases management due to their lower artifacts in postoperative imaging and radiation planning. Further larger comparative and cost-effectiveness studies are needed to confirm these results.

Vertebral Body Replacement With an Anchored Expandable Titanium Cage in the Cervical Spine: A Clinical and Radiological Evaluation

BACKGROUND

Expandable cervical cages have been used successfully to reconstruct the anterior spinal column.

OBJECTIVE

To perform clinical and radiological evaluation of vertebral body replacement with an anchored expandable titanium cage in the cervical spine after single-level and 2-level corpectomies.

METHODS

Between 2011 and 2017, 40 patients underwent a single-level (N = 32) or 2-level (N = 8) anterior corpectomy and fusion using an anchored expandable vertebral body replacement cage. Clinical and radiological data at admission, postoperatively, and at 3- and 12-mo follow-up were retrospectively analyzed. Clinical assessment was performed via standardized neurological evaluation, Odom score, and McCormick classification. Radiological assessment was performed via evaluation of sagittal profile, postoperative position, fusion, and subsidence rates.

RESULTS

Mean last follow-up was 14.8 ± 7 mo. Overall clinical and myelopathy-related improvements were shown directly after operation and at last follow-up. A stable centralized positioning of cages was achieved in 37 patients (93%). A mild ventral (>1.5 mm) malplacement was noted in 3 patients (7%) without clinical consequences. Sagittal alignment and preoperative cervical kyphosis improved significantly (7.8° gain of lordosis) and remained stable. Mean preoperative height of operated segments increased by 10 mm postoperatively and remained stable. Fusion rate in non-neoplastic patients and subsidence rate at last follow-up comprised 87.5% and 17.8%. With exception of 1 patient suffering from severe osteoporosis and cage subsidence, no patient needed additional secondary stabilization.

CONCLUSION

Anterior corpectomy and fusion by an expandable anchored titanium cage with anchor screws without additional instrumentation resulted in overall clinical improvement and radiological anterior column support, achieving significant and reliable restoration of the physiological sagittal cervical profile.

Application of an Expandable Cage for Reconstruction of the Cervical Spine in a Consecutive Series of Eighty-Six Patients

Background and objectives: Expandable cages are frequently used to reconstruct the anterior spinal column after a corpectomy. In this retrospective study, we evaluated the perioperative advantages and disadvantages of corpectomy reconstruction with an expandable cage. Materials and Methods: Eighty-six patients (45 male and 41 female patients, medium age of 61.3 years) were treated with an expandable titanium cage for a variety of indications from January 2012 to December 2019 and analyzed retrospectively. The mean follow-up was 30.7 months. Outcome was measured by clinical examination and visual analogue scale (VAS); myelopathy was classified according to the EMS (European Myelopathy Scale) and gait disturbances with the Nurick score. Radiographic analysis comprised measurement of fusion, subsidence and the C2–C7 angle. Results: Indications included spinal canal stenosis with myelopathy (46 or 53.5%), metastasis (24 or 27.9%), spondylodiscitis (12 or 14%), and fracture (4 or 4.6%). In 39 patients (45.3%), additional dorsal stabilization (360° fusion) was performed. In 13 patients, hardware failure occurred, and in 8 patients, adjacent segment disease occurred. Improvement of pain symptoms, myelopathy, and gait following surgery were statistically significant (p < 0.05), with a medium preoperative VAS of 8, a postoperative score of 3.2, and medium EMS scores of 11.3 preoperatively vs. 14.3 postoperatively. Radiographic analysis showed successful fusion in 74 patients (86%). As shown in previous studies, correction of the C2–C7 angle did not correlate with improvement of neurological symptoms. Conclusion: Our results show that expandable titanium cages are a safe and useful tool in anterior cervical corpectomies for providing adequate anterior column support and stability.

Management of C2 Body Giant Cell Tumor by Innovatively Fashioned Iliac Crest Graft and Modified Cervical Mesh Cage Used as Plate

BACKGROUND

Locally aggressive vertebral body tumors of the axis must be treated with wide local excision for best outcome. Reconstruction of the load-bearing vertebra needs to be done after tumor resection in such a manner so as to give stable, long-term fusion in this young population.

METHODS

We describe the management strategy of a 25-year-old acutely quadriplegic patient, with respiratory distress, with a C2 giant cell tumor. The use of a novel iliac crest graft modification used for C2 reconstruction along with a modified mesh cage used as an anterior plate has been reported.

RESULTS

The patient had a good outcome at 18 months' follow-up, with neurologic improvement and a solid fusion.

CONCLUSIONS

Iliac crest autograft is inexpensive and easy to harvest and can be considered as a C2 prosthesis, especially in a resource-constrained setting. Modified iliac crest graft can be used for load transmission from C1 lateral mass to C3 body, and the mesh cage can be modified according to need as a plate with good results in an emergency.

Bone graft options for spinal fusion following resection of spinal column tumors: systematic review and meta-analysis

OBJECTIVE With the advent of new adjunctive therapy, the overall survival of patients harboring spinal column tumors has improved. However, there is limited knowledge regarding the optimal bone graft options following resection of spinal column tumors, due to their relative rarity and because fusion outcomes in this cohort are affected by various factors, such as radiation therapy (RT) and chemotherapy. Furthermore, bone graft options are often limited following tumor resection because the use of local bone grafts and bone morphogenetic proteins (BMPs) are usually avoided in light of microscopic infiltration of tumors into local bone and potential carcinogenicity of BMP. The objective of this study was to review and meta-analyze the relevant clinical literature to provide further clinical insight regarding bone graft options. METHODS A web-based MEDLINE search was conducted in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, which yielded 27 articles with 383 patients. Information on baseline characteristics, tumor histology, adjunctive treatments, reconstruction methods, bone graft options, fusion rates, and time to fusion were collected. Pooled fusion rates (PFRs) and I² values were calculated in meta-analysis. Meta-regression analyses were also performed if each variable appeared to affect fusion outcomes. Furthermore, data on 272 individual patients were available, which were additionally reviewed and statistically analyzed. RESULTS Overall, fusion rates varied widely from 36.0% to 100.0% due to both inter- and intrastudy heterogeneity, with a PFR of 85.7% (I² = 36.4). The studies in which cages were filled with morselized iliac crest autogenic bone graft (ICABG) and/or other bone graft options were used for anterior fusion showed a significantly higher PFR of 92.8, compared with the other studies (83.3%, p = 0.04). In per-patient analysis, anterior plus posterior fusion resulted in a higher fusion rate than anterior fusion only (98.8% vs 86.4%, p < 0.001). Although unmodifiable, RT (90.3% vs 98.6%, p = 0.03) and lumbosacral tumors (74.6% vs 97.9%, p < 0.001) were associated with lower fusion rates in univariate analysis. The mean time to fusion was 5.4 ± 1.4 months (range 3-9 months), whereas 16 of 272 patients died before the confirmation of solid fusion with a mean survival of 3.1 ± 2.1 months (range 0.5-6 months). The average time to fusion of patients who received RT and chemotherapy were significantly longer than those who did not receive these adjunctive treatments (RT: 6.1 months vs 4.3 months, p < 0.001; chemotherapy: 6.0 months vs 4.3 months, p = 0.02). CONCLUSIONS Due to inter- and intrastudy heterogeneity in patient, disease, fusion criteria, and treatment characteristics, the optimal surgical techniques and factors predictive of fusion remain unclear. Clearly, future prospective, randomized studies will be necessary to better understand the issues surrounding bone graft selection following resection of spinal column tumors.

Complications analysis of posterior vertebral column resection in 40 patients with spinal tumors

The aim of the present study was to summarize and analyze the complications of posterior vertebral column resection in patients with spinal tumors. The complications of 40 patients following surgery were recorded, and surgery-related parameters including segments, bleeding volume and surgical duration were recorded and analyzed. SPSS 12.0 software was used to analyze the correlation between the complications and these parameters retrospectively. A total of 36 complications were reported. The median follow-up duration of the patients was 14 months (range, 4–78 months). Transient late tracheal extubation was associated with higher intraoperative bleeding volume, lower preoperative forced vital capacity and forced expiratory volume in 1 sec. Replaced spinal segment subsidence was associated with increased duration of surgery, higher intraoperative bleeding volume and higher total blood transfusion volume. Thrombocytopenia was associated with increased duration of surgery and higher total blood transfusion volume. The majority of the complications were minor and did not affect the recovery of the patients. Active prevention is necessary to reduce the incidence of complications, in particular, major ones.

Current paradigms for metastatic spinal disease: an evidence-based review

INTRODUCTION

Management of metastatic spine disease is quite complex. Advances in research have allowed surgeons and physicians to better provide chemotherapeutic agents that have proven more efficacious. Additionally, the advancement of surgical techniques and radiosurgical implementation has altered drastically the treatment paradigm for metastatic spinal disease. Nevertheless, the physician-patient relationship, including extensive discussion with the neurosurgeon, medicine team, oncologists, radiation oncologists, and psychologists, are all critical in the evaluation process and in delivering the best possible care to our patients. The future remains bright for continued improvement in the surgical and nonsurgical management of our patients with metastatic spine disease.

METHODS

We include an evidence-based review of decision making strategies when attempting to determine most efficacious treatment options. Surgical treatments discussed include conventional debulking versus en bloc resection, conventional RT, and radiosurgical techniques, and minimally invasive approaches toward treating metastatic spinal disease.

CONCLUSIONS

Surgical oncology is a diverse field in medicine and has undergone a significant paradigm shift over the past few decades. This shift in both medical and surgical management of patients with primarily metastatic tumors has largely been due to the more complete understanding of tumor biology as well as due to advances in surgical approaches and instrumentation. Furthermore, radiation oncology has seen significant advances with stereotactic radiosurgery and intensity-modulated radiation therapy contributing to a decline in surgical treatment of metastatic spinal disease. We analyze the entire spectrum of treating patients with metastatic spinal disease, from methods of diagnosis to the variety of treatment options available in the published literature.

Axial spondylectomy and circumferential reconstruction via a posterior approach

BACKGROUND

Spinal metastases of the second cervical vertebra are a subset of tumors that are particularly difficult to address surgically. Previously described techniques require highly morbid circumferential dissection posterior to the pharynx for resection and reconstruction.

OBJECTIVE

To perform a biomechanical analysis of instrumented reconstruction configurations used after axial spondylectomy and to demonstrate safe use of a novel construct in a patient case report.

METHODS

Several different published and novel reconstruction configurations were inserted into 7 occipitocervical spines that underwent axial spondylectomy. A biomechanical analysis of the stiffness of the constructs in flexion and extension, lateral bending, and rotation was performed. A patient then underwent a posterior-only approach for axial spondylectomy and circumferential reconstruction.

RESULTS

Biomechanical analysis of different constructs demonstrated that anterior column reconstruction with bilateral cages spanning the C1 lateral mass to the C3 facet in combination with occipitocervical instrumentation was superior in flexion-extension and equivalent in lateral bending and rotation to currently used constructs. The patient in whom this construct was placed via a posterior-only approach for axial spondylectomy and instrumentation remained at neurological baseline and demonstrated no recurrence of local disease or failure of instrumentation to date.

CONCLUSION

When C1 lateral mass to C3 facet bilateral cage plus occipitocervical instrumentation is compared with existing anterior and posterior constructs, this novel reconstruction is biomechanically equivalent if not superior in performance. In a patient, the posterior-only approach for C2 spondylectomy with the novel reconstruction was safe and durable and avoided the morbidity of the anterior approach.

Design and preliminary biomechanical analysis of artificial cervical joint complex

OBJECTIVE

To design an artificial cervical joint complex (ACJC) prosthesis for non-fusion reconstruction after cervical subtotal corpectomy, and to evaluate the biomechanical stability, preservation of segment movements and influence on adjacent inter-vertebral movements of this prosthesis.

METHODS

The prosthesis was composed of three parts: the upper/lower joint head and the middle artificial vertebrae made of Cobalt-Chromium-Molybdenum (Co-Cr-Mo) alloy and polyethylene with a ball-and-socket joint design resembling the multi-axial movement in normal inter-vertebral spaces. Biomechanical tests of intact spine (control), Orion locking plate system and ACJC prosthesis were performed on formalin-fixed cervical spine specimens from 21 healthy cadavers to compare stability, range of motion (ROM) of the surgical segment and ROM of adjacent inter-vertebral spaces.

RESULTS

As for stability of the whole lower cervical spine, there was no significant difference of flexion, extension, lateral bending and torsion between intact spine group and ACJC prosthesis group. As for segment movements, difference in flexion, lateral bending or torsion between ACJC prosthesis group and control group was not statistically significant, while ACJC prosthesis group showed an increase in extension (P < 0.05) compared to that of the control group. In addition, ACJC prosthesis group demonstrated better flexion, extension and lateral bending compared to those of Orion plating system group (P < 0.05). Difference in adjacent inter-vertebral ROM of the ACJC prosthesis group was not statistically significant compared to that of the control group.

CONCLUSION

After cervical subtotal corpectomy, reconstruction with ACJC prosthesis not only obtained instant stability, but also reserved segment motions effectively, without abnormal gain of mobility at adjacent inter-vertebral spaces.