Surgical treatment indications and outcomes in patients with spinal metastases in the cervicothoracic junction (CTJ)

Abstract

Background: The cervicothoracic junction (CTJ) site accounts for approximately 10% of all spinal metastases. The complex anatomical and biomechanical features increase the difficulty in surgical treatment of the CTJ metastases. However, few studies in the literature on surgical treatment for spinal metastases are focusing on this special area. The aim of this study was to evaluate the surgical outcome of patients with CTJ metastases and analyze the prognostic factor for the postoperative survival.

Methods: Total of 34 patients with CTJ metastases who underwent surgery in our department were retrospectively analyzed. We evaluated records for the details of medical history, treatment, surgery, radiographic imaging, and follow-up. Outcomes were assessed by overall survival as well as modified Tokuhashi score, SINS, Frankel grade, visual analog scale (VAS), and Karnofsky Performance Status (KPS).

Results: The entire patients' median survival time was 12.4 months (range, 3.5-36.2 months). Pain improved in 32 patients (94.12%), and the postoperative VAS scores were significantly improved compared with preoperative data. Majority of patients (71%) maintained or improved their Frankel scores 1 year after surgery. KPS scores improved in 13 patients (38%), remained stable in 19 (56%), and worsened in 2 (6%) postoperatively. Notably, patients with neurological deficit that did not improve after surgery had significantly worse median survival than those who had either no deficit or who improved after surgery. There were no instrumentation failures in this study.

Conclusions: Surgical treatment is effective for patients of CTJ metastases, with a tolerable rate of complications. Remained or regained ambulatory status predicted overall survival. Thus, prompt and aggressive decompressive surgery is recommended for CTJ metastases patients with neurological impairment.

Keywords: Cervicothoracic junction; Retrospective study; Spinal metastases; Surgical treatment; Survival.

Fig. 1

A 47-year-old female with lung cancer was admitted because of severe neck pain and upper extremity numbness. Mid-sagittal T1 MR image (a), anteroposterior (b), and lateral (c) radiographs showing C7 body pathological fracture and encroachment of spinal canal. Anteroposterior (d) and lateral (e) radiographs were obtained after C7 anterior cervical corpectomy and fusion (ACCF). The patient’s symptoms were significantly relieved

Fig. 2

A 66-year-old male with prostate cancer was admitted because of severe neck pain and lower extremity weakness. Mid-sagittal T1 (a) and T2 (b) MR image showing multiple level lesions in the cervicothoracic junction area and posterior encroachment of spinal canal. Anteroposterior (c) and lateral (d) radiographs were obtained after posterior tumor resection, decompression, and fixation. The patient’s pain and neurological deficit were significantly improved

Fig. 3

A 63-year-old female with breast cancer was admitted because of nonambulatory and severe pain. Mid-sagittal T1 MR image (a) showing C7 pathological fracture-dislocation and encroachment of spinal canal. Postoperative T1 MR image (b) obtained after combined posterior resection, anterior corpectomy, and reconstructive surgery, showing the spinal canal was significantly decompressed. Postoperative anteroposterior (c) and lateral (d) radiographs showing the good spinal alignment achieved after surgery. The patient regained ambulatory and self-care ability

Fig. 4

Pre- and postoperative median VAS scores during 1 year of follow-up, statistically significant at all time points. (** P < 0.001)

Fig. 5

Kaplan-Meier survival curve for all patients with spinal metastases following surgery. Median survival was 12.4 months (95% CI 11.247–13.553)

Fig. 6

Kaplan-Meier curves for postoperative survival as a function of KPS, ambulatory, SINS, and Modified Tokuhashi score. a No difference in survival between patients with preoperative KPS ≥ 70% and KPS < 70% (P = 0.631). b The survival time was significantly improved for patients with postoperative ambulatory (P = 0.009). c No difference in survival between patients with preoperative SINS = 7–12 and SINS = 13–18 (P = 0.631). d No difference in survival between patients with preoperative Modified Tokuhashi score = 0–8 and 9–12 (P = 0.122). KPS: Karnofsky Performance Status, SINS: Spine Instability Neoplastic Score