Total Spondylectomy of C2 and Circumferential Reconstruction via Combined Anterior and Posterior Approach to Cervical Spine for Axis Tumor Surgery
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摘要
As a result of the complex anatomy in upper cervical spine, the operative treatment of axis neoplasms is always complicated. Although the procedure for the second cervical vertebra (C2) surgery had been described previously in diverse approaches and reconstruction forms, each has its own limita- tions and restrictions that usually result in less satisfactory conclusions. The purpose of this study was to evaluate the operation efficacy for axis tumors by using a combined anterior (retropharyngeal) cervical and posterior approach in achieving total resection of C2 and circumferential reconstruction. Eight con-secutive C2 tumor patients with mean age of 47.6 years in our institute sequentially underwent vertebra resection and fixation through aforementioned approach from Jan. 2006 to Dec. 2010. No surgical mortality or severe morbidity occurred in our group. In terms of complications, 2 cases developed transient difficulty in swallowing liquids (one of them experienced dysphonia) and 1 developed cerebrospinal fluid leakage (CSFL) that was resolved later. During a mean follow-up period of 31.9 months, the visual analogue scale (VAS) and Japanese orthopedic association (JOA) score revealed that the pain level and neurological function in all patients were improved postoperatively, and there was no evidence of fixation failure and local recurrence. It is concluded that the anterior cervical retropharyngeal approach permits a visible exposure to facilitate the C2 vertebra resection and perform an effective anterior reconstruction at the same time. The custom-made mesh cage applied in our cases can be acted as a firm and convenient implant in circumferential fixation.
As a result of the complex anatomy in upper cervical spine, the operative treatment of axis neoplasms is always complicated. Although the procedure for the second cervical vertebra (C2) surgery had been described previously in diverse approaches and reconstruction forms, each has its own limita- tions and restrictions that usually result in less satisfactory conclusions. The purpose of this study was to evaluate the operation efficacy for axis tumors by using a combined anterior (retropharyngeal) cervical and posterior approach in achieving total resection of C2 and circumferential reconstruction. Eight con-secutive C2 tumor patients with mean age of 47.6 years in our institute sequentially underwent vertebra resection and fixation through aforementioned approach from Jan. 2006 to Dec. 2010. No surgical mortality or severe morbidity occurred in our group. In terms of complications, 2 cases developed transient difficulty in swallowing liquids (one of them experienced dysphonia) and 1 developed cerebrospinal fluid leakage (CSFL) that was resolved later. During a mean follow-up period of 31.9 months, the visual analogue scale (VAS) and Japanese orthopedic association (JOA) score revealed that the pain level and neurological function in all patients were improved postoperatively, and there was no evidence of fixation failure and local recurrence. It is concluded that the anterior cervical retropharyngeal approach permits a visible exposure to facilitate the C2 vertebra resection and perform an effective anterior reconstruction at the same time. The custom-made mesh cage applied in our cases can be acted as a firm and convenient implant in circumferential fixation.
As a result of the complex anatomy in upper cervical spine, the operative treatment of axis neoplasms is always complicated. Although the procedure for the second cervical vertebra (C2) surgery had been described previously in diverse approaches and reconstruction forms, each has its own limita- tions and restrictions that usually result in less satisfactory conclusions. The purpose of this study was to evaluate the operation efficacy for axis tumors by using a combined anterior (retropharyngeal) cervical and posterior approach in achieving total resection of C2 and circumferential reconstruction. Eight con-secutive C2 tumor patients with mean age of 47.6 years in our institute sequentially underwent vertebra resection and fixation through aforementioned approach from Jan. 2006 to Dec. 2010. No surgical mortality or severe morbidity occurred in our group. In terms of complications, 2 cases developed transient difficulty in swallowing liquids (one of them experienced dysphonia) and 1 developed cerebrospinal fluid leakage (CSFL) that was resolved later. During a mean follow-up period of 31.9 months, the visual analogue scale (VAS) and Japanese orthopedic association (JOA) score revealed that the pain level and neurological function in all patients were improved postoperatively, and there was no evidence of fixation failure and local recurrence. It is concluded that the anterior cervical retropharyngeal approach permits a visible exposure to facilitate the C2 vertebra resection and perform an effective anterior reconstruction at the same time. The custom-made mesh cage applied in our cases can be acted as a firm and convenient implant in circumferential fixation.
引文
1 Melcher RP, Harms J. Biomechanics and materials of reconstruction after tumor resection in the spinal column. Orthop Clin North Am, 2009,40(1):65-74
2 Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine, 1997,22(3):324-333
3 Sar C, Eralp L. Transoral resection and reconstruction for primary osteogenic sarcoma of the second cervical vertebra. Spine, 2001,26(17):1936-1941
4 Cohen ZR, Fourney DR, Marco RA, et al. Total cervical spondylectomy for primary osteogenic sarcoma. Case report and description of operative technique. Neurosurg, 2002,97(3 Suppl):386-392
5 Cloyd JM, Chou D, Deviren V. En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature. Spine J, 2009,9(11):928-935
6 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
7 Fang HSY, Ong GB. Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am, 1962,44:1588-1604
8 Jiang L, Liu ZJ, Liu XG, et al. Upper cervical spine chordoma of C2-C3. Eur Spine J, 2009,18(3):293-298
9 Laus M, Pignatti G, Malaguti MC, et al. Anterior extraoral surgery to the upper cervical spine. Spine, 1996,21(14):1687-1693
10 Konya D, Ozgen S, Ger ek A, et al. Transmandibular approach for upper cervical pathologies: report of 2 cases and review of the literature. Turk Neurosurg, 2008,18(3):271-275
11 Eleraky M, Setzer M, Vrionis FD. Posterior transpedicular corpectomy for malignant cervical spine tumors. Eur Spine J, 2010,19(2):257-262
12 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
13 Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumentation at C1–3 via the high anterior cervical approach. J Neurosurg, 2000,92(1 Suppl):24-29
14 Park SH, Sung JK, Lee SH, et al. High anterior cervical approach to the upper cervical spine. Surg Neurol, 2007,68(5):519-524
15 Colak A, Kutlay M, Kibici K, et al. Two-staged operation on C2 neoplastic lesions: anterior excision and posterior stabilization. Neurosurg Rev, 2004,27(3):89-193
16 Yang X, Wu Z, Xiao J, et al. Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior approach:surgical technique and results in 11 patients. Neurosurgery, 2011,69:184-193
17 Boriani S, Weinstein JN, Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine, 1997,22(9):1036-1044
18 McAfee PC, Bohlman HH, Riley LH, et al. The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am, 1987,69(9):1371-1383
19 Hsu W, Kosztowski TA, Zaidi HA, et al. Image-guided, endoscopic, transcervical resection of cervical chordoma. J Neurosurg Spine, 2010,12(4):431-435
20 Wang B, Lü G, Deng Y, et al. Anterior endoscopically assisted transcervical reconstruction of the upper cervical spine. Eur Spine J, 2011,20(9):1526-1532
21 Baird CJ, Conway JE, Sciubba DM, et al. Radiographic and anatomic basis of endoscopic anterior craniocervical decompression: a comparison of endonasal, transoral, and transcervical approaches. Neurosurgery, 2009,65(6 Suppl):158-163
22 Yang X, Huang W, Xiao J, et al. Combined preand retrovascular extraoral approach for tumors at lateral mass of the atlas. Spine, 2011,36(2):129-136
23 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
24 Southwich WO, Robinson RA. Surgical approaches to the vertebral bodies in the cervical and lumbar regions. J Bone Joint Surg Am, 1957,39-A(3):631-644
25 De Andrade JR, Macnab I. Anterior occipito-cervical fusion using an extrapharyngeal exposure. J Bone Joint Surg Am, 1969,51(8):1621-1626
26 Haller JM, Iwanik M, Shen FH. Clinical relevant anatomy of high anterior cervical approach. Spine, 2011,36 (25):2116-2121
27 tulík J, Kozák J, ebesta P, et al. Total Spondylectomy of C2: report of three cases and review of the literature. J Spinal Disord Tech, 2010,23(8):e53-58
28 Scheer JK, Tang J, Eguizabal J, et al. Optimal reconstruction technique after C-2 corpectomy and spondylectomy: a biomechanical analysis. J Neurosurg Spine, 2010,12(5): 517-524
29 Kanayama M, Ng JT, Cunningham BW, et al. Biomechanical analysis of anterior versus circumferential spinal reconstruction for various anatomic stages of tumor lesions. Spine, 1999,24(5):445-450
30 Karam YR, Dahdaleh NS, Magnetta MJ, et al. Biomechanical comparison of anterior, posterior, and circumferential fixation after one-level anterior cervical corpectomy in the human cadaveric spine. Spine, 2011,36(7):E455-460
31 Puttlitz CM, Harms J, Xu Z, et al. A biomechanical analysis of C2 corpectomy constructs. Spine J, 2007,7(2): 210-215
32 Jeszenszky D, Fekete TF, Melcher R, et al. C2 prosthesis: anterior upper cervical fixation device to reconstruct the second cervical vertebra. Eur Spine J, 2007,16(10): 1695-1700
33 Kandziora F, Pflugmacher R, Schaefer J, et al. Biomechanical comparison of cervical spine interbody fusion cages. Spine, 2001,26(17):1850-1857
34 Sucu HK, Bezircio lu H, Rezanko T. Partial spondylectomy for primary leiomyosarcoma of C2 vertebra: case report. Spine, 2011,36(21):E1422-1426
35 Matsumoto M, Watanabe K, Ishii K, et al. Complicated surgical resection of malignant tumors in the upper cervical spine after failed ion-beam radiation therapy. Spine, 2010,35(11):E505-509
2 Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy. A new surgical technique for primary malignant vertebral tumors. Spine, 1997,22(3):324-333
3 Sar C, Eralp L. Transoral resection and reconstruction for primary osteogenic sarcoma of the second cervical vertebra. Spine, 2001,26(17):1936-1941
4 Cohen ZR, Fourney DR, Marco RA, et al. Total cervical spondylectomy for primary osteogenic sarcoma. Case report and description of operative technique. Neurosurg, 2002,97(3 Suppl):386-392
5 Cloyd JM, Chou D, Deviren V. En bloc resection of primary tumors of the cervical spine: report of two cases and systematic review of the literature. Spine J, 2009,9(11):928-935
6 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
7 Fang HSY, Ong GB. Direct anterior approach to the upper cervical spine. J Bone Joint Surg Am, 1962,44:1588-1604
8 Jiang L, Liu ZJ, Liu XG, et al. Upper cervical spine chordoma of C2-C3. Eur Spine J, 2009,18(3):293-298
9 Laus M, Pignatti G, Malaguti MC, et al. Anterior extraoral surgery to the upper cervical spine. Spine, 1996,21(14):1687-1693
10 Konya D, Ozgen S, Ger ek A, et al. Transmandibular approach for upper cervical pathologies: report of 2 cases and review of the literature. Turk Neurosurg, 2008,18(3):271-275
11 Eleraky M, Setzer M, Vrionis FD. Posterior transpedicular corpectomy for malignant cervical spine tumors. Eur Spine J, 2010,19(2):257-262
12 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
13 Vender JR, Harrison SJ, McDonnell DE. Fusion and instrumentation at C1–3 via the high anterior cervical approach. J Neurosurg, 2000,92(1 Suppl):24-29
14 Park SH, Sung JK, Lee SH, et al. High anterior cervical approach to the upper cervical spine. Surg Neurol, 2007,68(5):519-524
15 Colak A, Kutlay M, Kibici K, et al. Two-staged operation on C2 neoplastic lesions: anterior excision and posterior stabilization. Neurosurg Rev, 2004,27(3):89-193
16 Yang X, Wu Z, Xiao J, et al. Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior approach:surgical technique and results in 11 patients. Neurosurgery, 2011,69:184-193
17 Boriani S, Weinstein JN, Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine, 1997,22(9):1036-1044
18 McAfee PC, Bohlman HH, Riley LH, et al. The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am, 1987,69(9):1371-1383
19 Hsu W, Kosztowski TA, Zaidi HA, et al. Image-guided, endoscopic, transcervical resection of cervical chordoma. J Neurosurg Spine, 2010,12(4):431-435
20 Wang B, Lü G, Deng Y, et al. Anterior endoscopically assisted transcervical reconstruction of the upper cervical spine. Eur Spine J, 2011,20(9):1526-1532
21 Baird CJ, Conway JE, Sciubba DM, et al. Radiographic and anatomic basis of endoscopic anterior craniocervical decompression: a comparison of endonasal, transoral, and transcervical approaches. Neurosurgery, 2009,65(6 Suppl):158-163
22 Yang X, Huang W, Xiao J, et al. Combined preand retrovascular extraoral approach for tumors at lateral mass of the atlas. Spine, 2011,36(2):129-136
23 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
24 Southwich WO, Robinson RA. Surgical approaches to the vertebral bodies in the cervical and lumbar regions. J Bone Joint Surg Am, 1957,39-A(3):631-644
25 De Andrade JR, Macnab I. Anterior occipito-cervical fusion using an extrapharyngeal exposure. J Bone Joint Surg Am, 1969,51(8):1621-1626
26 Haller JM, Iwanik M, Shen FH. Clinical relevant anatomy of high anterior cervical approach. Spine, 2011,36 (25):2116-2121
27 tulík J, Kozák J, ebesta P, et al. Total Spondylectomy of C2: report of three cases and review of the literature. J Spinal Disord Tech, 2010,23(8):e53-58
28 Scheer JK, Tang J, Eguizabal J, et al. Optimal reconstruction technique after C-2 corpectomy and spondylectomy: a biomechanical analysis. J Neurosurg Spine, 2010,12(5): 517-524
29 Kanayama M, Ng JT, Cunningham BW, et al. Biomechanical analysis of anterior versus circumferential spinal reconstruction for various anatomic stages of tumor lesions. Spine, 1999,24(5):445-450
30 Karam YR, Dahdaleh NS, Magnetta MJ, et al. Biomechanical comparison of anterior, posterior, and circumferential fixation after one-level anterior cervical corpectomy in the human cadaveric spine. Spine, 2011,36(7):E455-460
31 Puttlitz CM, Harms J, Xu Z, et al. A biomechanical analysis of C2 corpectomy constructs. Spine J, 2007,7(2): 210-215
32 Jeszenszky D, Fekete TF, Melcher R, et al. C2 prosthesis: anterior upper cervical fixation device to reconstruct the second cervical vertebra. Eur Spine J, 2007,16(10): 1695-1700
33 Kandziora F, Pflugmacher R, Schaefer J, et al. Biomechanical comparison of cervical spine interbody fusion cages. Spine, 2001,26(17):1850-1857
34 Sucu HK, Bezircio lu H, Rezanko T. Partial spondylectomy for primary leiomyosarcoma of C2 vertebra: case report. Spine, 2011,36(21):E1422-1426
35 Matsumoto M, Watanabe K, Ishii K, et al. Complicated surgical resection of malignant tumors in the upper cervical spine after failed ion-beam radiation therapy. Spine, 2010,35(11):E505-509