Postoperative Outcomes of Subaxial Cervical Spine Metastasis: Comparison Among The Anterior, Posterior, and Combined Approaches

Abstract Background: Incidence of subaxial spinal metastases is increasing due to longer life expectancy resulting from successful modern treatments of cancer. The three most utilized approaches for surgical treatment include the anterior, posterior, and combined approach. However, despite increasing surgical volume, data on the postoperative complication profiles of different operative approaches for this patient population is scarce.Methods: The institutional databases of two large referral centers in Thailand were retrospectively reviewed. Patients with subaxial cervical spine metastasis who underwent cervical surgery during 2005 to 2015 were identified and enrolled. Clinical presentations, baseline characteristics, operative approach, perioperative complications, and postoperative outcomes, including pain, neurological recovery, and survival, were compared among the three surgical approaches.Results: This study included 70 patients (44 anterior approach, 14 posterior approach, 12 combined approach). There were no statistically significant differences in preoperative characteristics, including Charlson Comorbidity Index(CCI), Tomita score, and revised Tokuhashi score, among the three groups. There were also no significant differences among groups for medical complications, surgical complications, neurological recovery, verbal pain score improvement, survival time, or ambulatory status improvement. However, the combined approach did show a significantly higher rate of overall perioperative complications (p=0.01), intraoperative blood loss, (p<0.001), and operative time (p<0.001) compared to the other two approaches. Conclusions: The results of this study do not reveal any clear superiority among the three main surgical approaches used to treat subaxial cervical spine metastasis. Patients in the combined approach group had the highest rates of perioperative complications. However, although the differences were not statistically significant, patients in the combined group tended to have better clinical outcomes after follow-up, and the longest survival time.

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A Novel and Reproducible Classification of the Vertebral Artery in the Subaxial Cervical Spine

Operative Neurosurgery ◽

10.1093/ons/opz310 ◽

2019 ◽

Vol 18 (6) ◽

pp. 676-683

Author(s):

Fabian Winter ◽

Ichiro Okano ◽

Stephan N Salzmann ◽

Colleen Rentenberger ◽

Jennifer Shue ◽

...

Keyword(s):

At Risk ◽

Cervical Spine ◽

High Risk ◽

Vertebral Artery ◽

Intrarater Reliability ◽

Cross Sectional ◽

Cervical Spine Surgery ◽

Subaxial Cervical Spine ◽

Anterior Posterior

Abstract BACKGROUND An injury of the vertebral artery (VA) is one of the most catastrophic complications in the setting of cervical spine surgery. Anatomic variations of the VA can increase the risk of iatrogenic lacerations. OBJECTIVE To propose a novel and reproducible classification system that describes the position of the VA based on a 2-dimensional map on computed tomography angiographs (CTA). METHODS This cross-sectional retrospective study reviewed 248 consecutive CTAs of the cervical spine at a single academic institution between 2007 and 2018. The classification consists of a number that characterizes the location of the VA from the medio-lateral (ML) aspect of the vertebral body. In addition, a letter describes the VA location from the anterior-posterior (AP) aspect. The reliability and reproducibility were assessed by 2 independent raters on 200 VAs. RESULTS The inter- and intrarater reliability values showed the classification's reproducibility. The inter-rater reliability weighted κ-value for the ML aspect was 0.93 (95% CI: 0.93-0.93). The unweighted κ-value was 0.93 (95% CI: 0.86-1.00) for “at-risk” positions (ML grade ≥1), and 0.87 (95% CI: 0.75-1.00) for “high-risk” positions (ML grade ≥2). The weighted κ-value for the intrarater reliability was 0.94 (95% CI: 0.95-0.95). The unweighted κ-values for the intrarater reliability were 0.95 (95% CI: 0.91-0.99) for “at-risk” positions, and 0.87 (95% CI: 0.78-0.96) for “high-risk” positions. CONCLUSION The proposed classification is reliable, reproducible, and independent of individual anatomic size variations. The use of this novel grading system could improve the understanding and interdisciplinary communication about VA anomalies.

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Postlaminectomy cervical deformity

Neurosurgical FOCUS ◽

10.3171/foc.2003.15.3.5 ◽

2003 ◽

Vol 15 (3) ◽

pp. 1-5 ◽

Cited By ~ 59

Author(s):

Harel Deutsch ◽

Regis W. Haid ◽

Gerald E. Rodts ◽

Praveen V. Mummaneni

Keyword(s):

Clinical Results ◽

Surgical Correction ◽

Surgical Approaches ◽

Combined Approach ◽

Cervical Kyphosis ◽

Cervical Deformity ◽

Anterior Posterior

Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identifying factors predisposing to postoperative deformity is essential. The goal is to prevent postlaminectomy cervical kyphosis while exposing the patient to minimal additional morbidity. When postlaminectomy kyphosis does occur, surgical correction is often required and performed via an anterior, posterior, or combined approach. The authors discuss the indications for surgical approaches as well as clinical results.

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Burst Fracture of C5 with Traumatic Anterior Spondyloptosis of C6 and Posterior Spondylolisthesis of C4 Vertebra: A Case Report

Journal of Nepal Medical Association ◽

10.31729/jnma.5289 ◽

2021 ◽

Vol 59 (236) ◽

Author(s):

Poojan Kumar Rokaya ◽

Nilam Kumar Khadka ◽

Praveen Kumar Giri ◽

Robin Khapung ◽

Nirajan Mahaseth

Keyword(s):

Cervical Spine ◽

Cervical Spine Injury ◽

Burst Fracture ◽

Preoperative Assessment ◽

High Energy ◽

Spine Injury ◽

Subaxial Cervical Spine ◽

Injury Treatment ◽

Posterior Instrumented Fusion ◽

Anterior Posterior

Burst fracture of C5 with traumatic anterior spondyloptosis of C6 and posterior spondylolisthesis of C4 vertebra is an exceedingly rare high energy injury. Treatment includes decompression, reduction, stabilization, and fusion via anterior or posterior or combined anterior-posterior approach with or without prior traction. We report this rare subaxial cervical spine injury associated with quadriplegia managed with combined anterior and posterior instrumented fusion. A multidisciplinary approach with preoperative assessment and planning is crucial in managing cervical spine injury. Immediate postoperative critical care support, rehabilitation, and dedicated nursing care are required for a favorable outcome in traumatic quadriplegia.

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Perioperative complications with multilevel anterior and posterior cervical decompression and fusion

Journal of Neurosurgery Spine ◽

10.3171/2019.6.spine198 ◽

2020 ◽

Vol 32 (1) ◽

pp. 9-14 ◽

Cited By ~ 2

Author(s):

Joshua T. Wewel ◽

Bledi C. Brahimaj ◽

Manish K. Kasliwal ◽

Vincent C. Traynelis

Keyword(s):

Cervical Spine ◽

Neck Pain ◽

Cervical Spondylotic Myelopathy ◽

Perioperative Complications ◽

Single Session ◽

Perioperative Morbidity ◽

Complication Risk ◽

Surgeon Experience ◽

Perioperative Complication ◽

Anterior Posterior

OBJECTIVECervical spondylotic myelopathy (CSM) is a progressive degenerative pathology that frequently affects older individuals and causes spinal cord compression with symptoms of neck pain, radiculopathy, and weakness. Anterior decompression and fusion is the primary intervention to prevent neurological deterioration; however, in severe cases, circumferential decompression and fusion is necessary. Published data regarding perioperative morbidity associated with these complex operations are scarce. In this study, the authors sought to add to this important body of literature by documenting a large single-surgeon experience of single-session circumferential cervical decompression and fusion.METHODSA retrospective analysis was performed to identify intended single-stage anterior-posterior or posterior-anterior-posterior cervical spine decompression and fusion surgeries performed by the primary surgeon (V.C.T.) at Rush University Medical Center between 2009 and 2016. Cases in which true anterior-posterior cervical decompression and fusion was not performed (i.e., those involving anterior-only, posterior-only, or delayed circumferential fusion) were excluded from analysis. Data including standard patient demographic information, comorbidities, previous surgeries, and intraoperative course, along with postoperative outcomes and complications, were collected and analyzed. Perioperative morbidity was recorded during the 90 days following surgery.RESULTSSeventy-two patients (29 male and 43 female, mean age 57.6 years) were included in the study. Fourteen patients (19.4%) were active smokers, and 56.9% had hypertension, the most common comorbidity. The most common clinical presentation was neck pain in 57 patients (79.2%). Twenty-three patients (31.9%) had myelopathy, and 32 patients (44.4%) had undergone prior cervical spine surgery. Average blood loss was 613 ml. Injury to the vertebral artery was encountered in 1 patient (1.4%). Recurrent laryngeal nerve palsy was observed in 2 patients (2.8%). Two patients (2.8%) had transient unilateral hand grip weakness. There were no permanent neurological deficits. Dysphagia was encountered in 45 patients (62.5%) postoperatively, with 23 (32%) requiring nasogastric parenteral nutrition and 9 (12.5%) patients ultimately undergoing percutaneous endoscopic gastrostomy (PEG) placement. Nine of the 72 patients required a tracheostomy. The incidence of pneumonia was 6.9% (5 patients) overall, and 2 of these patients were in the tracheostomy group. Superficial wound infections occurred in 4 patients (5.6%). Perioperative death occurred in 1 patient. Reoperation was necessary in 10 patients (13.9%). Major perioperative complications (permanent neurological deficit, vascular injury, tracheostomy, PEG tube, stroke, or death) occurred in 30.6% of patients. The risk of minor perioperative complications (temporary deficit, dysphagia, deep vein thrombosis, pulmonary embolism, urinary tract infection, pneumonia, or wound infection) was 80.6%.CONCLUSIONSSingle-session anterior-posterior cervical decompression and fusion is an inherently morbid operation required in select patients with cervical spondylotic myelopathy. In this large single-surgeon series, there was a major perioperative complication risk of 30.6% and minor perioperative complication risk of 80.6%. This overall elevated risk for postoperative complications must be carefully considered and discussed with the patient preoperatively. In some situations, shared decision making may lead to the conclusion that a procedure of lesser magnitude may be more appropriate.

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Single-Session Combined Anterior-Posterior Approach for Treatment of Ankylosing Spondylitis with Obvious Displaced Lower Cervical Spine Fractures and Dislocations

BioMed Research International ◽

10.1155/2017/9205834 ◽

2017 ◽

Vol 2017 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Baohui Yang ◽

Teng Lu ◽

Haopeng Li

Keyword(s):

Cervical Spine ◽

Posterior Approach ◽

Perioperative Complications ◽

Spine Fractures ◽

Lower Cervical Spine ◽

Single Session ◽

Surgical Methods ◽

Single Posterior Approach ◽

Cervical Spine Fractures ◽

Anterior Posterior

For patients with AS and lower cervical spine fractures, surgical methods have mainly included the single anterior approach, single posterior approach, and combined anterior-posterior approach. However, various surgical procedures were utilized because the fractures have not been clearly classified according to presence of displacement in these previous studies. Consequently, controversies have been raised regarding the selection of the surgical procedure. This study retrospective analysis was conducted in 12 patients with AS and lower cervical spine fractures and dislocations and explored single-session combined anterior-posterior approach for the treatment of AS with obvious displaced lower cervical spine fractures and dislocations which has demonstrated advantages such as good stabilization, satisfied fracture healing, and easy postoperative cares. However, to some extent, the difficulty and risk of this approach should be considered. Attention should be paid to the prevention of perioperative complications.

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Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.5.1.33 ◽

2006 ◽

Vol 5 (1) ◽

pp. 33-45 ◽

Cited By ~ 85

Author(s):

Thomas Einsiedel ◽

Andreas Schmelz ◽

Markus Arand ◽

Hans-Joachim Wilke ◽

Florian Gebhard ◽

...

Keyword(s):

Cervical Spine ◽

Ankylosing Spondylitis ◽

Mortality Rate ◽

Perioperative Complications ◽

Neurological Deficits ◽

Minor Trauma ◽

Trauma Centers ◽

Single Session ◽

Computed Tomography Scanning ◽

Anterior Posterior

Object The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine’s poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment. Methods Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior–posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences. Conclusions The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior–posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10—a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

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Surgical approaches for the management of idiopathic thoracic scoliosis and the indications for combined anterior-posterior technique

Neurosurgical FOCUS ◽

10.3171/foc.1999.6.5.9 ◽

1999 ◽

Vol 6 (5) ◽

pp. E8 ◽

Cited By ~ 9

Author(s):

Michael J. Rauzzino ◽

Christopher I. Shaffrey ◽

James Wagner ◽

Russ Nockels ◽

Mark Abel

Keyword(s):

Thoracic Kyphosis ◽

Surgical Intervention ◽

Sagittal Plane ◽

Posterior Fusion ◽

Surgical Approaches ◽

Combined Approach ◽

Combined Surgery ◽

Flat Back ◽

Instrumentation Failure ◽

Anterior Posterior

The indications for surgical intervention in patients with idiopathic scoliosis have been well defined. The goals of surgery are to achieve fusion and arrest progressive curvature while restoring normal coronal and sagittal balance. As first introduced by Harrington, posterior fusion, the gold standard of treatment, has a proven record of success. More recently, anterior techniques for performing fusion procedures via either a thoracotomy or a retroperitoneal approach have been popularized in attempts to achieve better correction of curvature, preserve motion segments, and avoid some of the complications of posterior fusion such as the development of the flat-back syndrome. Anterior instrumentation alone, although effective, can be kyphogenic and has been shown to be associated with complications such as pseudarthrosis and instrumentation failure. Performing a combined approach in patients with scoliosis and other deformities has become an increasingly popular procedure to achieve superior correction of deformity and to minimize later complications. Indications for a combined approach (usually consisting of anterior release, arthrodesis with or without use of instrumentation, and posterior segmental fusion) include: prevention of crankshaft phenomenon in juvenile or skeletally immature adolescents; correction of large curves (75°) or excessively rigid curves in skeletally mature or immature patients; correction of curves with large sagittal-plane deformities such as thoracic kyphosis (> 90°) or thoracic lordosis (> 20°); and correction of thoracolumbar curves that need to be fused to the sacrum. Surgery may be performed either in a staged proceedure or, more commonly, in a single sitting. The authors discuss techniques for combined surgery and complication avoidance.

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A Safe Surgical Procedure for Old Distractive Flexion Injuries of the Subaxial Cervical Spine

Asian Spine Journal ◽

10.4184/asj.2017.11.6.935 ◽

2017 ◽

Vol 11 (6) ◽

pp. 935-942

Author(s):

Osamu Kawano ◽

Takeshi Maeda ◽

Eiji Mori ◽

Itaru Yugue ◽

Takayoshi Ueta ◽

...

Keyword(s):

Cervical Spine ◽

Surgical Treatment ◽

Surgical Procedure ◽

Neurological Complications ◽

Subaxial Cervical Spine ◽

Anterior Discectomy ◽

Stage 1 ◽

Posterior Anterior ◽

Anterior Posterior ◽

Selection Of

<sec><title>Study Design</title>Retrospective review.</sec><sec><title>Purpose</title>To describe a safe and effective surgical procedure for old distractive flexion (DF) injuries of the subaxial cervical spine.</sec><sec><title>Overview of Literature</title>Surgical treatment is required in old cases when a progression of the kyphotic deformity and/or persistent neck pain and/or the appearance of new neurological symptoms are observed. Since surgical treatment is more complicated and dangerous in old cases than in acute distractive-flexion cases, the indications for surgery and the selection of the surgical procedure must be carefully conducted.</sec><sec><title>Methods</title>To identify a safe and effective surgical procedure, the procedure selected, reason(s) for its selection, and associated neurological complications were investigated in 13 patients with old cervical DF injuries.</sec><sec><title>Results</title>No neurological complications were observed in nine patients (DF stage 2 or 3) who underwent the anterior-posterior-anterior (A-P-A) method and two patients (DF stage 1) who underwent the posterior method. It was initially planned that two patients (DF stage 2) who underwent the P-A method would be treated using the Posterior method alone; however, anterior discectomy was added to the procedure after the development of a severe spinal cord disorder.</sec><sec><title>Conclusions</title>The A-P-A method (anterior discectomy, posterior release and/or partial facetectomy, reduction and instrumentation, anterior bone grafting) is considered to be a suitable surgical procedure for old cervical DF injuries.</sec>

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