Posterior occiput-cervical fixation for metastasis to upper cervical spine

Translaminar Screw Fixation for Giant C1 Lateral Mass Metastasis From Hepatocellular Carcinoma

Metastatic spinal tumors at the craniovertebral junction (CVJ) are exceedingly rare, with limited reports of C1 lateral mass metastases from hepatocellular carcinoma (HCC). This report presents a case in which posterior fixation alone successfully achieved pain relief and improved stability in a patient with HCC metastasis involving extensive osteolysis of a C1 lateral mass and encasement of the vertebral artery. A 71-year-old male presented with a worsening right cervical pain. The patient had been prescribed nonsteroidal anti-inflammatory drugs and opioid analgesics, yet the pain remained unresolved. Computed tomography (CT) revealed a 5.5 cm osteolytic tumor at the C1 lateral mass with circumferential involvement of the vertebral artery. The patient was diagnosed with spinal metastasis from HCC, characterized by spinal instability (Spinal Instability Neoplastic Score (SINS), 11) and intractable pain (visual analog scale (VAS), 7.7). The patient was bedridden because of an inability to support head loads (performance status (PS), 4), and it was considered difficult to initiate ongoing chemotherapy. The patient was referred for surgical intervention to relieve the pain and improve stability. To address the pain and instability, occipitocervical (C2-C5) posterior fixation was performed without tumor resection. Due to extensive tumor invasion, pedicle screw placement at C2 was not feasible, and C2 translaminar screw fixation was selected instead. Postoperatively, the patient experienced significant pain relief and regained ambulatory ability. At one month postoperatively, fixation remained stable, with VAS improving to 0.8 and PS to 1. The patient was able to maintain pain relief and exhibited improved stability, allowing him to walk, and durvalumab/tremelimumab chemotherapy was initiated two months after surgery. The primary goals of managing metastatic tumors at the CVJ are pain relief, neurological function preservation, and spinal stability. In this case, posterior fixation alone achieved substantial pain alleviation and stability improvement without tumor resection. Notably, the use of C2 translaminar screws minimized the risks of spinal cord and vertebral artery injuries while ensuring effective stabilization. This is the first report to demonstrate the efficacy of posterior fixation alone for HCC metastases with complete destruction of the articular facet at C1. Posterior fixation alone can provide effective pain relief and restore stability in metastatic tumors with severe osteolysis of the C1 lateral mass. Careful selection of fixation techniques can minimize intraoperative complications while improving the patient's quality of life. This report contributes to surgical strategies for similar cases.

Using additive manufacturing for craniocervical reconstruction in traditionally challenging cases

Retrospective case series. The aim of this study was to evaluate the clinical outcomes and effectiveness of using 3D printed implants in upper cervical spine and occipitocervical junction surgery. C2 primary tumor patients who required axial en bloc resection and other patients who required partial bone decompression using customized 3D printed implants or fixation devices for surgery were included. Evaluate the stability and surgical outcomes of 3D printed implants through perioperative and follow-up period. Five tumor patients underwent reconstruction using customized 3D printed artificial vertebral bodies, while another five patients with atlantoaxial joint dislocation underwent reduction and decompression using customized 3D printed internal fixation devices. The postoperative imaging results showed that the 3D printed structures had good immediate stability and had no signs of displacement or subsidence. Follow up showed that all five cases of vertebral body reconstruction had achieved fusion. Only one patient died one month after surgery due to infection and respiratory difficulties. Other patients showed excellent improvement in neurological function in follow up. The use of 3D printed implants in surgery involving the occipitocervical area is a feasible and reliable alternative choice. It is a valuable attempt for complex atlantoaxial dislocation that cannot be treated with conventional instruments. 3D printed implants can improve the safety and accuracy of surgery, provide good immediate stability, have a low incidence of subsidence, fewer related complications during the follow-up period.

Quality of life in patients with malignant spinal cord compression: a systematic review

INTRODUCTION

Malignant spinal cord compression (MSCC) is an oncological emergency that may result in a devastating combination of malignancy and disability. Existing quality of life (QoL) questionnaires commonly used in MSCC literature (EORTC QLQ-C30, BM-22, Brief Pain Inventory, and Spine Oncology Study Group Outcomes) may not capture all the commonly reported symptoms and lack specificity to MSCC. The primary objective of this systematic review is to determine unmet patient needs and underreported QoL issues and compile a comprehensive list of QoL issues. The secondary objective of this review is to compile all existing QoL tools and questionnaires and determine whether any QoL issues are not addressed in the existing tools currently used in the literature.

METHODS

A literature search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases between 1946 and February 6, 2023, to compile all QoL issues and existing questionnaires used to assess QoL in patients with MSCC. All study designs were included given that they discussed QoL issues specific to patients with MSCC.

RESULTS

The results of this systematic review identified the most frequently discussed QoL issues in the literature studying MSCC. This included direct symptoms of MSCC such as back pain, paralysis, limb weakness/numbness, and urinary/bowel incontinence. Indirect symptoms coming from radiotherapy treatment such as dysphagia, painful swallowing, mouth pain, dry mouth, diarrhea, fatigue, and nausea/vomiting were also noted. Other symptoms resulting from corticosteroid treatment included difficulty sleeping, blurring of vision, weight gain, and mood disturbance. Patients also experienced psychosocial issues such as anxiety, depression, emotional distress, low self-esteem, concerns about dependence on others, concerns about getting home, and fear about their prognosis and future.

CONCLUSION

This review highlights the QoL issues specific to patients with MSCC and QoL tools capturing these issues. Relevance of QoL issues identified in this systematic review must be prospectively validated by patients and healthcare professionals with experience in treating MSCC.

Ten Years After SINS: Role of Surgery and Radiotherapy in the Management of Patients With Vertebral Metastases

The objective of the different types of treatments for a spinal metastasis is to provide the best oncological and functional result with the least aggressive side effects. Initially created in 2010 to help clinicians in the management of vertebral metastases, the Spine Instability Neoplastic Score (SINS) has quickly found its place in the decision making and the treatment of patients with metastatic spinal disease. Here we conduct a review of the literature describing the different changes that occurred with the SINS score in the last ten years. After a brief presentation of the spinal metastases’ distribution, with or without spinal cord compression, we present the utility of SINS in the radiological diagnosis and extension of the disease, in addition to its limits, especially for scores ranging between 7 and 12. We take this opportunity to expose the latest advances in surgery and radiotherapy concerning spinal metastases, as well as in palliative care and pain control. We also discuss the reliability of SINS amongst radiologists, radiation oncologists, spine surgeons and spine surgery trainees. Finally, we will present the new SINS-derived predictive scores, biomarkers and artificial intelligence algorithms that allow a multidisciplinary approach for the management of spinal metastases.

Management of Atlantoaxial Instability Due to a Pathological Fracture of the Axis

Metastases to the upper cervical spine are uncommon, and subsequent instability is rare. We report the details of a patient with metastatic breast cancer to the axis manifesting as a pathologic fracture and C1/C2 instability. This was treated by preoperative reduction to appropriate alignment with use of crown halo traction, followed by posterior occipitocervical fusion and postoperative radiation therapy.