Decision making in the surgical treatment of cervical spine metastases

Qualitative systematic review of the literature. To determine whether surgical indications and techniques are influenced by the region of the cervical spine (occipitocervical, midcervical, and cervicothoracic junctions). There are distinct differences in the anatomic as well as biomechanical characteristics at the occipitocervical junction (C0-C2), subaxial spine (C3-C6), and the cervicothoracic junction (C7-T2), and there is no information on whether these differences influence the decision to intervene surgically or influence the choice of surgical approach. A systematic review was designed to answer 2 primary research questions that were determined through consensus among a panel of experts drawn from the Spine Oncology Study Group: 1. Is the decision to operate influenced by the anatomic region of the cervical spine? 2. Is the operative approach influenced by the anatomic region of the cervical spine? For C0-C2 disease, posterior approaches are favored in the majority of cases. In the subaxial cervical spine (C3-C6), anterior approaches were preferred in the majority of cases. A combined anterior/posterior approach was favored for multilevel disease, circumferential tumor involvement, and poor bone quality. At the cervicothoracic junction (C7-T1), anterior or posterior approach was used for decompression. Three column reconstruction from a single posterior approach was an increasingly commonly performed procedure. Although there are no level-1 studies to guide decision-making in this area, a literature review does provide some general guidelines for clinical management. Metastatic involvement of junctional regions of the cervical spine (Occ-C2 and C7-T1) and/or kyphosis and collapse involving any region of the cervical spine are key determinants influencing the decision to stabilize the spine.Posterior techniques are favored at the occipitocervical junction, anterior techniques are generally recommended to in the subaxial cervical spine, and either anterior or posterior approaches can be used at the cervicothoracic junction.