An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Yu ¹ ,  AI Fuzhi ¹ , FU Suochao ¹ , LI Keke ² , XIA Hong ¹ , WU Zenghui ¹ , MA Xiangyang ¹

1. Department of Orthopedics, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China;
2. Department of Spinal Surgery, Huaxin Orthopaedic Hospital, Guangzhou Guangdong, 510100, P.R.China;

Corresponding author：

AI Fuzhi, Email: spine2000@126.com

Keywords：

Craniovertebral junction; transoral approach; submandibular approach; primary malignant osseous tumor

DOI：

10.7507/1002-1892.202001014

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Objective To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness.Methods The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C_{0, 1}, 3 cases of C₂, 1 case of C_{1, 2}, 1 case of C_{2, 3}, and 1 case of C_0-2. Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation.Results The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 (t=7.638, P=0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score (t=1.549, P=0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases.Conclusion Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.

Citation： ZHANG Yu, AI Fuzhi, FU Suochao, LI Keke, XIA Hong, WU Zenghui, MA Xiangyang. An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(9): 1149-1157. doi: 10.7507/1002-1892.202001014 Copy

1.	Abdu WA, Provencher M. Primary bone and metastatic tumors of the cervical spine. Spine (Phila Pa 1976), 1998, 23(24): 2767-2777.
2.	Girolami M, Boriani S, Ghermandi R, et al. Function preservation or oncological appropriateness in spinal bone tumors? A case series of segmental resection of the spinal canal content (spinal amputation). Spine (Phila Pa 1976), 2019. [Epub ahead of print].
3.	Sundaresan N, Boriani S, Rothman A, et al. Tumors of the osseous spine. J Neurooncol, 2004, 69(1-3): 273-290.
4.	Cañete AN, Bloem HL, Kroon HM. Primary bone tumors of the spine. Radiologia, 2016, 58 Suppl 1: 68-80.
5.	Wiesner EL, Hillen TJ, Long J, et al. Percutaneous CT-guided biopsies of the cervical spine: Technique, histopathologic and microbiologic yield, and safety at a single academic institution. AJNR Am J Neuroradiol, 2018, 39(5): 981-985.
6.	Gupta S, Henningsen JA, Wallace MJ, et al. Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations. Radiographics, 2007, 27(2): 371-390.
7.	Molinari R, Bessette M, Raich AL, et al. Vertebral artery anomaly and injury in spinal surgery. Evid Based Spine Care J, 2014, 5(1): 16-27.
8.	Batouli A, Gholamrezanezhad A, Petrov D, et al. Management of primary osseous spinal tumors with PET. PET Clin, 2019, 14(1): 91-101.
9.	Chi JH, Bydon A, Hsieh P, et al. Epidemiology and demographics for primary vertebral tumors. Neurosurg Clin N Am, 2008, 19(1): 1-4.
10.	Nathoo N, Mendel E. The National Cancer Institute’s SEER registry and primary malignant osseous spine tumors. World Neurosurg, 2011, 76(6): 531-532.
11.	Mukherjee D, Chaichana KL, Adogwa O, et al. Association of extent of local tumor invasion and survival in patients with malignant primary osseous spinal neoplasms from the surveillance, epidemiology, and end results (SEER) database. World Neurosurg, 2011, 76(6): 580-585.
12.	Kerr DL, Dial BL, Lazarides AL, et al. Epidemiologic and survival trends in adult primary bone tumors of the spine. Spine J, 2019, 19(12): 1941-1949.
13.	Mesfin A, El Dafrawy MH, Jain A, et al. Total en bloc spondylectomy for primary and metastatic spine tumors. Orthopedics, 2015, 38(11): e995-e1000.
14.	Kato S, Murakami H, Demura S, et al. Patient-reported outcome and quality of life after total en bloc spondylectomy for a primary spinal tumour. Bone Joint J, 2014, 96-B(12): 1693-1698.
15.	Zhong N, Yang X, Yang J, et al. Surgical consideration for adolescents and young adults with cervical chordoma. Spine (Phila Pa 1976), 2017, 42(10): E609-E616.
16.	Zaldivar-Jolissaint JF, Bobinski L, Duff JM. Multilevel pedicular osteotomies for en bloc resection of a primary ewing sarcoma of the subaxial cervical spine with pedicle screw reconstruction. World Neurosurg, 2019, 132: 303-308.
17.	Suchomel P, Buchvald P, Barsa P, et al. Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note. J Neurosurg Spine, 2007, 6(6): 611-618.
18.	Rhines LD, Fourney DR, Siadati A, et al. En bloc resection of multilevel cervical chordoma with C-2 involvement. Case report and description of operative technique. J Neurosurg Spine, 2005, 2(2): 199-205.
19.	Luksanapruksa P, Buchowski JM, Wright NM, et al. Outcomes and effectiveness of posterior occipitocervical fusion for suboccipital spinal metastases. J Neurosurg Spine, 2017, 26(5): 554-559.
20.	Weinstein JN, McLain RF. Primary tumors of the spine. Spine (Phila Pa 1976), 1987, 12(9): 843-851.
21.	Denaro L, Berton A, Ciuffreda M, et al. Surgical management of chordoma: A systematic review. J Spinal Cord Med, 2018. [Epub ahead of print].
22.	Zuckerman SL, Bilsky MH, Laufer I. Chordomas of the skull base, mobile spine, and sacrum: an epidemiologic investigation of presentation, treatment, and survival. World Neurosurg, 2018, 113: e618-e627.
23.	Rahme R, Boubez G, Bouthillier A, et al. Acute swan-neck deformity and spinal cord compression after cervical laminectomy. Can J Neurol Sci, 2009, 36(4): 504-506.
24.	Luzzati A, Scotto G, Perrucchini G, et al. Salvage revision surgery after inappropriate approach for primary spine tumors: long term follow-up in 56 cases. World Neurosurg, 2017, 98: 329-333.
25.	Menezes AH, Ahmed R. Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up. J Neurosurg Pediatr, 2014, 13(3): 260-272.
26.	Hyun SJ, Rhim SC, Riew KD. A combined posterior, lateral, and anterior approach to ventrolaterally situated chordoma of the upper cervical spine. Surg Neurol, 2009, 72(4): 409-413.
27.	张宇, 李柯柯, 艾福志, 等. 颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜肿瘤. 中国修复重建外科杂志, 2019, 33(12): 1480-1485.
28.	Brook I. Microbiology and treatment of brain abscess. J Clin Neurosci, 2017, 38: 8-12.
29.	Jecko V, Rué M, Castetbon V, et al. Vertebral artery (V2) pseudo-aneurysm after surgery for cervical schwannoma. How to prevent it and a review of the literature. Neurochirurgie, 2015, 61(1): 38-42.
30.	Osorio JA, Benet A, Hess CP, et al. Primary vertebral artery reanastomosis during retrosigmoid skull base approach following iatrogenic near-transection with monopolar electrocautery. Neurosurgery, 2014, 10 Suppl 4: 631-639.
31.	Bişkin S, Erdemir RU, Eliçora SŞ, et al. Metastatic chordoma of the tongue: Case report. Ear Nose Throat J, 2017, 96(3): E1-E3.
32.	Thariat J, Tessonnier T, Bonvalot S, et al. Proton therapy in soft tissue and bone sarcomas. Bull Cancer, 2018, 105(9): 830-838.
33.	Miller JA, Balagamwala EH, Angelov L, et al. Stereotactic radiosurgery for the treatment of primary and metastatic spinal sarcomas. Technol Cancer Res Treat, 2017, 16(3): 276-284.
34.	McGirt MJ, Gokaslan ZL, Chaichana KL. Preoperative grading scale to predict survival in patients undergoing resection of malignant primary osseous spinal neoplasms. Spine J, 2011, 11(3): 190-196.
35.	Goetze E, Moergel M, Gielisch M, et al. Safety of resection margins in CAD/CAM-guided primarily reconstructed oral squamous cell carcinoma-a retrospective case series. Oral Maxillofac Surg, 2019, 23(4): 459-464.
36.	Jahangiri FR, Silverstein JW, Trausch C, et al. Motor evoked potential recordings from the urethral sphincter muscles (USMEPs) during spine surgeries. Neurodiagn J, 2019, 59(1): 34-44.
37.	禚汉杰, 周英杰, 柴旭斌, 等. 超声骨刀在椎管内肿瘤切除椎管成形术中的应用. 中国修复重建外科杂志, 2019, 33(1): 61-65.
38.	Boriani S, Tedesco G, Ming L, et al. Carbon-fiber-reinforced PEEK fixation system in the treatment of spine tumors: a preliminary report. Eur Spine J, 2018, 27(4): 874-881.

1. Abdu WA, Provencher M. Primary bone and metastatic tumors of the cervical spine. Spine (Phila Pa 1976), 1998, 23(24): 2767-2777.
2. Girolami M, Boriani S, Ghermandi R, et al. Function preservation or oncological appropriateness in spinal bone tumors? A case series of segmental resection of the spinal canal content (spinal amputation). Spine (Phila Pa 1976), 2019. [Epub ahead of print].
3. Sundaresan N, Boriani S, Rothman A, et al. Tumors of the osseous spine. J Neurooncol, 2004, 69(1-3): 273-290.
4. Cañete AN, Bloem HL, Kroon HM. Primary bone tumors of the spine. Radiologia, 2016, 58 Suppl 1: 68-80.
5. Wiesner EL, Hillen TJ, Long J, et al. Percutaneous CT-guided biopsies of the cervical spine: Technique, histopathologic and microbiologic yield, and safety at a single academic institution. AJNR Am J Neuroradiol, 2018, 39(5): 981-985.
6. Gupta S, Henningsen JA, Wallace MJ, et al. Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations. Radiographics, 2007, 27(2): 371-390.
7. Molinari R, Bessette M, Raich AL, et al. Vertebral artery anomaly and injury in spinal surgery. Evid Based Spine Care J, 2014, 5(1): 16-27.
8. Batouli A, Gholamrezanezhad A, Petrov D, et al. Management of primary osseous spinal tumors with PET. PET Clin, 2019, 14(1): 91-101.
9. Chi JH, Bydon A, Hsieh P, et al. Epidemiology and demographics for primary vertebral tumors. Neurosurg Clin N Am, 2008, 19(1): 1-4.
10. Nathoo N, Mendel E. The National Cancer Institute’s SEER registry and primary malignant osseous spine tumors. World Neurosurg, 2011, 76(6): 531-532.
11. Mukherjee D, Chaichana KL, Adogwa O, et al. Association of extent of local tumor invasion and survival in patients with malignant primary osseous spinal neoplasms from the surveillance, epidemiology, and end results (SEER) database. World Neurosurg, 2011, 76(6): 580-585.
12. Kerr DL, Dial BL, Lazarides AL, et al. Epidemiologic and survival trends in adult primary bone tumors of the spine. Spine J, 2019, 19(12): 1941-1949.
13. Mesfin A, El Dafrawy MH, Jain A, et al. Total en bloc spondylectomy for primary and metastatic spine tumors. Orthopedics, 2015, 38(11): e995-e1000.
14. Kato S, Murakami H, Demura S, et al. Patient-reported outcome and quality of life after total en bloc spondylectomy for a primary spinal tumour. Bone Joint J, 2014, 96-B(12): 1693-1698.
15. Zhong N, Yang X, Yang J, et al. Surgical consideration for adolescents and young adults with cervical chordoma. Spine (Phila Pa 1976), 2017, 42(10): E609-E616.
16. Zaldivar-Jolissaint JF, Bobinski L, Duff JM. Multilevel pedicular osteotomies for en bloc resection of a primary ewing sarcoma of the subaxial cervical spine with pedicle screw reconstruction. World Neurosurg, 2019, 132: 303-308.
17. Suchomel P, Buchvald P, Barsa P, et al. Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note. J Neurosurg Spine, 2007, 6(6): 611-618.
18. Rhines LD, Fourney DR, Siadati A, et al. En bloc resection of multilevel cervical chordoma with C-2 involvement. Case report and description of operative technique. J Neurosurg Spine, 2005, 2(2): 199-205.
19. Luksanapruksa P, Buchowski JM, Wright NM, et al. Outcomes and effectiveness of posterior occipitocervical fusion for suboccipital spinal metastases. J Neurosurg Spine, 2017, 26(5): 554-559.
20. Weinstein JN, McLain RF. Primary tumors of the spine. Spine (Phila Pa 1976), 1987, 12(9): 843-851.
21. Denaro L, Berton A, Ciuffreda M, et al. Surgical management of chordoma: A systematic review. J Spinal Cord Med, 2018. [Epub ahead of print].
22. Zuckerman SL, Bilsky MH, Laufer I. Chordomas of the skull base, mobile spine, and sacrum: an epidemiologic investigation of presentation, treatment, and survival. World Neurosurg, 2018, 113: e618-e627.
23. Rahme R, Boubez G, Bouthillier A, et al. Acute swan-neck deformity and spinal cord compression after cervical laminectomy. Can J Neurol Sci, 2009, 36(4): 504-506.
24. Luzzati A, Scotto G, Perrucchini G, et al. Salvage revision surgery after inappropriate approach for primary spine tumors: long term follow-up in 56 cases. World Neurosurg, 2017, 98: 329-333.
25. Menezes AH, Ahmed R. Primary atlantoaxial bone tumors in children: management strategies and long-term follow-up. J Neurosurg Pediatr, 2014, 13(3): 260-272.
26. Hyun SJ, Rhim SC, Riew KD. A combined posterior, lateral, and anterior approach to ventrolaterally situated chordoma of the upper cervical spine. Surg Neurol, 2009, 72(4): 409-413.
27. 张宇, 李柯柯, 艾福志, 等. 颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜肿瘤. 中国修复重建外科杂志, 2019, 33(12): 1480-1485.
28. Brook I. Microbiology and treatment of brain abscess. J Clin Neurosci, 2017, 38: 8-12.
29. Jecko V, Rué M, Castetbon V, et al. Vertebral artery (V2) pseudo-aneurysm after surgery for cervical schwannoma. How to prevent it and a review of the literature. Neurochirurgie, 2015, 61(1): 38-42.
30. Osorio JA, Benet A, Hess CP, et al. Primary vertebral artery reanastomosis during retrosigmoid skull base approach following iatrogenic near-transection with monopolar electrocautery. Neurosurgery, 2014, 10 Suppl 4: 631-639.
31. Bişkin S, Erdemir RU, Eliçora SŞ, et al. Metastatic chordoma of the tongue: Case report. Ear Nose Throat J, 2017, 96(3): E1-E3.
32. Thariat J, Tessonnier T, Bonvalot S, et al. Proton therapy in soft tissue and bone sarcomas. Bull Cancer, 2018, 105(9): 830-838.
33. Miller JA, Balagamwala EH, Angelov L, et al. Stereotactic radiosurgery for the treatment of primary and metastatic spinal sarcomas. Technol Cancer Res Treat, 2017, 16(3): 276-284.
34. McGirt MJ, Gokaslan ZL, Chaichana KL. Preoperative grading scale to predict survival in patients undergoing resection of malignant primary osseous spinal neoplasms. Spine J, 2011, 11(3): 190-196.
35. Goetze E, Moergel M, Gielisch M, et al. Safety of resection margins in CAD/CAM-guided primarily reconstructed oral squamous cell carcinoma-a retrospective case series. Oral Maxillofac Surg, 2019, 23(4): 459-464.
36. Jahangiri FR, Silverstein JW, Trausch C, et al. Motor evoked potential recordings from the urethral sphincter muscles (USMEPs) during spine surgeries. Neurodiagn J, 2019, 59(1): 34-44.
37. 禚汉杰, 周英杰, 柴旭斌, 等. 超声骨刀在椎管内肿瘤切除椎管成形术中的应用. 中国修复重建外科杂志, 2019, 33(1): 61-65.
38. Boriani S, Tedesco G, Ming L, et al. Carbon-fiber-reinforced PEEK fixation system in the treatment of spine tumors: a preliminary report. Eur Spine J, 2018, 27(4): 874-881.

Chinese Journal of Reparative and Reconstructive Surgery

An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction

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