Cervical spinal metastasis: anterior reconstruction and stabilization techniques after tumor resection

The Effect of High-Normal Preoperative International Normalized Ratios on Outcomes and Complications After Anterior Cervical Spine Surgery

Hematoma after anterior cervical spine surgery can result in neurologic and airway compromise. Current guidelines recommend an international normalized ratio (INR) <1.5 before elective spine surgery because of increased complications. The risk associated with an INR of 1.25 is not well studied. The purpose of this study was to determine the risk of complications associated with a preoperative INR >1.25 and ≤1.5 in patients undergoing elective anterior cervical spine surgery. The American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective anterior cervical spine surgery from 2012 to 2016 who had an INR recorded within 24 hours of surgery were included. Outcomes of interest included postoperative hematoma requiring surgery, 30-day mortality, and 30-day readmissions and reoperations. A total of 2949 patients were included. The incidence of a postoperative hematoma that required surgical management was 0.2%, 0.6%, and 4.5% in the INR≤1, 11.25 and ≤1.5 before elective anterior cervical spine surgery is associated with significantly higher rates of postoperative hematoma formation as well as 30-day readmission and reoperation; there was a trend toward significance in mortality rate. [Orthopedics. 2024;47(1):e26-e32.].

Comparison of Outcomes in Patients with Cervical Spine Metastasis After Different Surgical Approaches: A Single-Center Experience

OBJECTIVE

In patients undergoing cervical spine surgery for metastatic spine disease, we sought to 1) compare perioperative and oncologic outcomes among 3 different operative approaches, 2) report fusion rates, and 3) compare different types of anterior vertebral body replacement.

METHODS

A single-center retrospective cohort study of patients undergoing extradural cervical/cervicothoracic spine metastasis surgery between February 2010 and January 2021 was conducted. Operative approaches were anterior-alone, posterior-alone, or combined anterior-posterior, and the grafts/cages used in the anterior fusions were cortical allografts, static cages, or expandable cages. All cages were filled with autograft/allograft. Outcomes included perioperative/postoperative variables, along with fusion rates, functional status, local recurrence (LR), and overall survival (OS).

RESULTS

Sixty-one patients underwent cervical spine surgery for metastatic disease, including 11 anterior (18.0%), 28 posterior (45.9%), and 22 combined (36.1%). New postoperative neurologic deficit was the highest in the anterior approach group (P = 0.038), and dysphagia was significantly higher in the combined approach group (P = 0.001). LR (P > 0.999), OS (P = 0.655), and time to both outcomes (log-rank test, OS, P = 0.051, LR, P = 0.187) were not significantly different. Of the 51 patients alive at 3 months, only 19 (37.2%) obtained imaging ≥3 months. Fusion was seen in 11/19 (57.8%) at a median of 8.3 months (interquartile range, 4.6-13.7). Among the anterior corpectomies, the following graft/cage was used: 6 allografts (54.5%), 4 static cages (36.3%), and 1 expandable cage (9.0%), with no difference found in outcomes among the 3 groups.

CONCLUSIONS

The only discernible differences between operative approaches were that patients undergoing an anterior approach had higher rates of new postoperative neurologic deficit, and the combined approach group had higher rates of postoperative dysphagia.

The Use of Carbon Fiber-Reinforced Instrumentation in Patients with Spinal Oncologic Tumors: A Systematic Review of Literature and Future Directions

INTRODUCTION

Metastatic spine tumors affect over 30% of patients who have been diagnosed with cancer. While techniques in surgical intervention have undoubtedly evolved, there are some pitfalls when spinal instrumentation is required for stabilization following tumor resection. However, the use of carbon fiber-reinforced polyetheretherketone (CFR-PEEK) implants has become increasingly popular due to improved radiolucency and positive osteobiologic properties. Here, we present a systematic review describing the use of CFR-PEEK-coated instrumentation in the oncologic population while identifying advantages and potential shortcomings of these devices.

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted in March 2022 to identify articles detailing the use of CFR-PEEK implants for spinal instrumentation in patients with primary and secondary spine tumors. The search was performed using the PubMed, Scopus, and Embase databases.

RESULTS

An initial search returned a total of 85 articles among the three databases used. After the exclusion of duplicates and screening of abstracts, 21 full-text articles were examined for eligibility. Eleven articles were excluded due to not fitting our inclusion and exclusion criteria. Ten articles were subsequently eligible for full-text review.

CONCLUSIONS

CFR-PEEK possesses a similar safety and efficacy profile to titanium implants but has distinct advantages. It limits artifact, increases early detection of local tumor recurrence, increases radiotherapy dose accuracy, and is associated with low complication rates (9.96%)-making it a promising alternative for the demands unique to the treatment/outcome of spinal oncologic patients.

Comparison of intraoperative neuromonitoring accuracies and procedures associated with alarms in anterior versus posterior fusion for cervical spinal disorders: A prospective multi-institutional cohort study

A prospective multicenter cohort study. To clarify the differences in the accuracy of transcranial motor-evoked potentials (TcE-MEPs) and procedures associated with the alarms between cervical anterior spinal fusion (ASF) and posterior spinal fusion (PSF). Neurological complications after TcE-MEP alarms have been prevented by appropriate interventions for cervical degenerative disorders. The differences in the accuracy of TcE-MEPs and the timing of alarms between cervical ASF and PSF noted in the existing literature remain unclear. Patients (n = 415) who underwent cervical ASF (n = 171) or PSF (n = 244) at multiple institutions for cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, spinal injury, and others were analyzed. Neurological complications, TcE-MEP alarms defined as a decreased amplitude of ≤70% compared to the control waveform, interventions after alarms, and TcE-MEP results were compared between the 2 surgeries. The incidence of neurological complications was 1.2% in the ASF group and 2.0% in the PSF group, with no significant intergroup differences (P-value was .493). Sensitivity, specificity, negative predictive value, and rate of rescue were 50.0%, 95.2%, 99.4%, and 1.8%, respectively, in the ASF group, and 80.0%, 90.9%, 99.5%, and 2.9%, respectively, in the PSF group. The accuracy of TcE-MEPs was not significantly different between the 2 groups (P-value was .427 in sensitivity, .109 in specificity, and .674 in negative predictive value). The procedures associated with the alarms were decompression in 3 cases and distraction in 1 patient in the ASF group. The PSF group showed Tc-MEPs decreased during decompression, mounting rods, turning positions, and others. Most alarms went off during decompression in ASF, whereas various stages of the surgical procedures were associated with the alarms in PSF. There were no significant differences in the accuracy of TcE-MEPs between the 2 surgeries.

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.

Cervical Spine Reconstruction with Chest Tube Technique After Metastasis Resection: A Single-Center Experience

BACKGROUND

The silastic tube technique, in which a chest tube is placed into the vertebral body defect and impregnated with polymethyl methacrylate, showed good results in patients with lumbar and thoracic neoplastic diseases. There has been only 1 study about the effectiveness and safety of this technique in patients with cervical metastases. We aimed to report our experience in using this technique to reconstruct the spine after corpectomy for cervical metastasis.

METHODS

All patients with cervical spinal metastasis who underwent surgical treatment using a chest tube impregnated with polymethyl methacrylate in conjunction with anterior cervical plate stabilization were retrospectively recruited. Demographics, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, preoperative and postoperative ambulatory status, perioperative complications, and survival time were collected.

RESULTS

This study included 16 patients. The most common primary tumor site was the lung (6 patients; 37.5%). The mean (SD) survival time was 408 (401) days (range, 1-2797 days), and the median survival time was 72 days (95% confidence interval 28-116 days). Four patients (25%) died within 30 postoperative days. There was no surgical site infection or instrument failure after the surgery. Five patients (31.2%) lived >180 days, and 3 patients (18.8%) lived >360 days. One patient (6.2%) was still alive at the end of the study.

CONCLUSIONS

The silastic tube technique in conjunction with anterior cervical plate stabilization might be safe, effective, and cost-effective for patients with cervical spine metastasis.

Combined transoral and endoscopic approach for cervical spine tumor resection

This study aimed to explore the feasibility and clinical effectiveness of a combined transoral and endoscopic approach for the removal of benign cervical spine tumors.First, we obtained detailed anatomical measurements of the atlantoaxial joint from 20 fresh cadaveric specimens and performed simulated surgeries with the combined transoral and endoscopic approach on 10 cadaveric specimens. Then, we applied the combined approach for the resection of benign cervical spine tumors in 8 patients at our hospital from October 2013 to October 2015. All patients underwent enhanced axial, coronal, and sagittal computed tomography (CT) examination before and after surgery. Preoperative 3-dimensional (3D) reconstruction and printing models were used in 5 cases.On the basis of CT measurements of fresh cadaveric atlantoaxial anatomy and practical experiences from simulated surgeries on the cadaveric specimens with latex perfusion, cervical tumors were completely removed from 8 patients without complications. The average surgery time was 73 minutes, and the average intraoperative bleeding volume was 34 mL. The average hospital stay was 6.5 days. The average NRS score of patients was 2.25 points at 3 days postoperation. At the 12-month postoperative follow-up, the atlantoaxial vertebral bone had been largely repaired, and no recurrence was observed by cervical CT examination.The combined transoral and endoscopic approach could be used safely and effectively to excise cervical spine tumors with substantial advantages, including direct surgical access, relatively simple operation, short operative time, quick postoperative recovery, a reliable curative effect, and few complications.

The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors

BACKGROUND CONTEXT

Spine metastases occur frequently in patients with cancer. A variety of surgical approaches, including anterior transcavitary, lateral extracavitary, posterolateral, and/or combined techniques are used for spinal cord decompression and restoration of spinal stability. The incidence of symptomatic hardware failure is unknown for the majority of these approaches.

PURPOSE

The purpose of this study was to determine the incidence of symptomatic hardware failure and the associated risk factors in patients with metastatic epidural spinal cord compression (MESCC).

STUDY DESIGN/SETTING

This was a retrospective study.

PATIENT SAMPLE

The current series analyzes a cohort of 318 patients who underwent separation surgery, which involves single-stage posterolateral decompression and posterior segmental instrumentation for MESCC.

OUTCOME MEASURES

The event of interest was hardware failure; the competing event was death resulting from any cause. All patients were monitored for survival analysis. A competing risk analysis was conducted to examine univariately a number of potential risk factors associated with hardware failure, including junctional level, gender, construct length, and the presence or absence of prior chest wall resection.

METHODS

A retrospective analysis and chart review were performed for 318 consecutive patients who underwent posterolateral decompression and posterior screw-rod fixation without supplemental anterior fixation from March 2004 to June 2011 at our institution. The median follow-up time for survivors without hardware failure was 399 days (range, 9-2,828), with a mean operative time of 3 hours. A total of 78% of patients died during the 7-year study period.

RESULTS

Of the 318 patients, nine (2.8%) exhibited signs and symptoms of hardware failure and required revision of the instrumentation. Patients with chest wall resection and those with initial construct length greater than six contiguous spinal levels exhibited a statistically significantly higher risk of symptomatic hardware failure than their counterparts. We observed a trend toward an increased risk of failure in women compared with men (p=.09).

CONCLUSIONS

The incidence of hardware failure is low in patients with MESCC who undergo posterolateral decompression and posterior screw-rod instrumentation. Moreover, the short operative time and low morbidity profile associated with this approach make it a reliable and acceptable method for the surgical treatment of MESCC. Patients with constructs spanning six or more levels or those with prior chest wall resection are at higher risk for instrumentation failure.

Spine metastases: current treatments and future directions

Spinal metastases are the most frequently encountered spinal tumour and can affect up to 50% of cancer patients. Both the incidence and prevalence of metastases are thought to be rising due to better detection and treatment options of the systemic malignancy resulting in increased patient survival. Further, the development and access to newer imaging modalities have resulted in easier screening and diagnosis of spine metastases. Current evidence suggests that pain, neurological symptoms and quality of life are all improved if patients with spine metastases are treated early and aggressively. However, selection of the appropriate therapy depends on several factors including primary histology, extent of the systemic disease, existing co-morbidities, prior treatment modalities, patient age and performance status, predicted life expectancy and available resources. This article reviews the currently available therapeutic options for spinal metastases including conventional external beam radiation therapy, open surgical decompression and stabilisation, vertebral augmentation and other minimally invasive surgery (MIS) options, stereotactic spine radiosurgery, bisphosphonates, systemic radioisotopes and chemotherapy. An algorithm for the management of spine metastases is also proposed. It outlines a multidisciplinary and integrated approach to these patients and it is hoped that this along with future advances and research will result in improved patient care and outcomes.

Preliminary experience of titanium mesh cages for pathological fracture of middle and lower cervical vertebrae

The advantages and disadvantages of titanium mesh cages (TMCs) assisted by anterior cervical plates (ACPs) for interbody fusion following cervical corpectomy were investigated. Between January 2002 and September 2006, 17 patients with cervical radiculomyelopathy caused by metastasis-induced pathologic fractures were selected for anterior corpectomy. TMCs were inserted into the post-corpectomy defect and stabilized by placement of ACPs filled with Triosite. Post-operative plain X-ray films indicated maintenance of spinal stability. No ceramic, donor site or surgery-related complications were observed. True trabeculation was observed in axial and reconstructive CT scans in all surviving patients one year after surgery. Neurological recovery, pain control, and good quality of life were achieved. Short hospital stays, minimal blood loss, short operation times and brief periods of bed confinement were also observed. We conclude that a TMC assisted by an ACP is safe and effective for interbody fusion following cervical corpectomy for pathological fractures resulting from cervical vertebral metastases.

Considerations for airway management for cervical spine surgery in adults

Surgery on the cervical spine runs the gamut from minor interventions done in a minimally invasive fashion on a short-stay or ambulatory basis, to major surgical undertakings of a high-risk, high-threat nature done to stabilize a degraded skeletal structure to preserve and protect neural elements. Planning for optimum airway management and anesthesia care is facilitated by an appreciation of the disease processes that affect the cervical spine and their biomechanical implications and an understanding of the imaging and operative techniques used to evaluate and treat these conditions. This article provides background information and evidence to allow the anesthesia practitioner to develop a conceptual framework within which to develop strategies for care when a patient is presented for surgery on the cervical spine.

Titanium Cage-assisted Polymethylmethacrylate Reconstruction for Cervical Spinal Metastasis: Technical Note

OBJECTIVE:

Reconstruction and stabilization of the cervical spine after vertebrectomy is an important goal in the surgical management of spinal metastasis. The authors describe their reconstruction technique using a titanium cage-Silastic tube construct injected with polymethylmethacrylate (PMMA) augmented by an anterior cervical plate. The surgical results using this technique are reviewed.

METHODS:

Six patients ranging from 43 to 70 years of age underwent resection of metastatic tumor in the cervical spine followed by cage-assisted PMMA reconstruction of the anterior spinal column. The following reconstruction technique was performed. A Silastic tube is incised longitudinally and placed circumferentially around a titanium cage with the opening facing anteriorly. The cage-Silastic tube construct is carefully tapped into the corpectomy defect and filled with PMMA. The final construct is then augmented with anterior cervical plate fixation.

RESULTS:

Two patients required additional posterior stabilization with lateral mass screws and rods. All patients achieved immediate stabilization, restoration of vertebral body height and normal lordosis, and preservation of the ability to walk independently. Five patients experienced significant palliation of biomechanical neck pain. There were no complications of neurological worsening, postoperative hematoma, wound infection, subsidence, graft dislodgement, or construct failure during a follow-up period of 1 to 19 months (mean, 6.8 mo).

CONCLUSION:

Titanium cage-assisted PMMA reconstruction augmented with an anterior cervical plate is an effective means of reconstruction after tumor resection in patients with cervical spinal metastasis. The Silastic tube holds the PMMA within the cage and protects the spinal cord from potential thermal injury.