Cervicothoracic junction instrumentation strategies following separation surgery for spinal metastases

Vikram B. ChakravarthyDepartments of Neurosurgery and
Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio;

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Ibrahim HussainDepartments of Neurosurgery and
Department of Neurosurgery, Weill Cornell Medical College, New York, New York; and

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Ilya LauferDepartment of Neurological Surgery, New York University Grossman School of Medicine, New York, New York

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Jacob L. GoldbergDepartments of Neurosurgery and
Department of Neurosurgery, Weill Cornell Medical College, New York, New York; and

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Anne S. ReinerEpidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York;

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Jemma VillaviejaDepartments of Neurosurgery and

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William Christopher NewmanDepartments of Neurosurgery and

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Ori BarzilaiDepartments of Neurosurgery and

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Mark BilskyDepartments of Neurosurgery and

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OBJECTIVE

The cervicothoracic junction (CTJ) is a challenging region to stabilize after tumor resection for metastatic spine disease. The objective of this study was to describe the outcomes of patients who underwent posterolateral decompression and instrumented fusion (i.e., separation surgery across the CTJ for instability due to metastatic disease).

METHODS

The authors performed a single-institution retrospective study of a prospectively collected cohort of patients who underwent single-approach posterior decompression and instrumented fusion across the CTJ for metastatic spine disease between 2011 and 2018. Adult patients (≥ 18 years old) who presented with mechanical instability, myelopathy, and radiculopathy secondary to metastatic epidural spinal cord compression (MESCC) of the CTJ (C7–T1) from 2011 to 2018 were included.

RESULTS

Seventy-nine patients were included, with a mean age of 62.1 years. The most common primary malignancies were non–small cell lung (n = 17), renal cell (11), and prostate (8) carcinoma. The median number of levels decompressed and construct length were 3 and 7, respectively. The average operative time, blood loss, and length of stay were 179.2 minutes, 600.5 ml, and 7.7 days, respectively. Overall, 58 patients received adjuvant radiation, and median dose, fractions, and time from surgery were 27 Gy, 3 fractions, and 20 days, respectively. All patients underwent lateral mass and pedicle screw instrumentation. Forty-nine patients had tapered rods (4.0/5.5 mm or 3.5/5.5 mm), 29 had fixed-diameter rods (3.5 mm or 4.0 mm), and 1 had both. Ten patients required anterior reconstruction with poly-methyl-methacrylate. The overall complication rate was 18.8% (6 patients with wound-related complications, 7 with hardware-related complications, 1 with both, and 1 with other). For the 8 patients (10%) with hardware failure, 7 had tapered rods, all 8 had cervical screw pullout, and 1 patient also experienced rod/screw fracture. The average time to hardware failure was 146.8 days. The 2-year cumulative incidence rate of hardware failure was 11.1% (95% CI 3.7%–18.5%). There were 55 deceased patients, and the median (95% CI) overall survival period was 7.97 (5.79–12.60) months. For survivors, the median (range) follow-up was 12.94 (1.94–71.80) months.

CONCLUSIONS

Instrumented fusion across the CTJ demonstrated an 18.8% rate of postoperative complications and an 11% overall 2-year rate of hardware failure in patients who underwent metastatic epidural tumor decompression and stabilization.

ABBREVIATIONS

BPI = Brief Pain Inventory; CSF = cerebrospinal fluid; CTJ = cervicothoracic junction; ECOG = Eastern Cooperative Oncology Group; ESCC = epidural spinal cord compression; MDASI = MD Anderson Symptom Inventory; MESCC = metastatic epidural spinal cord compression; PMMA = poly-methyl-methacrylate; QOL = quality of life; SBRT = stereotactic body radiation therapy.
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