Postoperative outcomes of subaxial cervical spine metastasis: Comparison among the anterior, posterior, and combined approaches

Abstract

Background: The incidence of subaxial spinal metastases increases due to longer life expectancy resulting from successful modern cancer treatments. The three most utilized approaches for surgical treatment include the anterior, posterior, and combined approaches. However, despite increasing surgical volume, data on the postoperative complication profiles of different operative approaches for this patient population is scarce.

Methods: The institutional databases of two large referral centers in Thailand were retrospectively reviewed. Patients with subaxial cervical spine metastasis who underwent cervical surgery during 2005 to 2015 were identified and enrolled. Clinical presentations, baseline characteristics, operative approach, perioperative complications, and postoperative outcomes, including pain, neurological recovery, and survival, were compared among the three surgical approaches.

Results: The 70 patients (44 with anterior approach, 14 with posterior approach, 12 with combined approach) were enrolled. There were no statistically significant differences in preoperative characteristics, including Charlson Comorbidity Index (CCI), Tomita score, and Revised Tokuhashi score, among the three groups. There were no significant differences among groups for medical complications, surgical complications, neurological recovery, verbal pain score improvement, survival time, or ambulatory status improvement. However, the combined approach did show a significantly higher rate of overall perioperative complications (p = 0.01), intraoperative blood loss (p < 0.001), and operative time (p < 0.001) compared to the other two approaches.

Conclusions: Patients in the combined approach group had the highest rates of perioperative complications. However, although the differences were not statistically significant, patients in the combined group tended to have better clinical outcomes after follow-up and the longest survival time.

Keywords: Anterior approach; Combined approach; Posterior approach; Postoperative outcomes; Subaxial cervical spine metastasis; Thailand.

Fig. 1

Radiographic study of a 41-year-old woman (patient #3). (A) Plain radiograph lateral view of the cervical spine shows pathological C4 fracture with kyphosis. (B) T2-weighted magnetic resonance imaging (MRI) demonstrates spinal metastasis at the C4 vertebral body without significant pressure on the cervical cord. (C, D) Postoperative anteroposterior and lateral radiographs demonstrate anterior corpectomy of the C4 vertebral body with reconstruction using polymethylmethacrylate (PMMA) with K-wire augmentation, and stabilization with cervical plate.

Fig. 2

Radiographic study of a 69-year-old woman (patient #30). (A) Plain radiograph lateral view of the cervical spine demonstrates spinal metastasis at the posterior part of the body, and at posterior elements of the C4 vertebra with anterior listhesis of C3 over C4. (B, C) Postoperative anteroposterior and lateral radiographs show decompressive laminectomy from partial C2 to C5 with cervical stabilization using lateral mass screw and pedicle screw systems.

Fig. 3

Radiographic study of a 41-year-old woman (patient #39). (A) Plain radiograph lateral view of the cervical spine reveals pathological fracture of C4 with kyphosis. (B) T2-weighted magnetic resonance imaging (MRI) shows spinal metastasis at the C4 vertebral body and circumferential spinal cord compression caused by posterior elements. (C, D) Postoperative anteroposterior and lateral radiographs demonstrate anterior corpectomy of C3-C5 vertebral body and reconstruction using a titanium cage with polymethylmethacrylate (PMMA) augmentation, and stabilization with anterior cervical plate, lateral mass crew, and pedicle screw systems.

Fig. 4

American Spinal Injury Association (ASIA) grading in (A) all patients, (B) the anterior group, (C) the posterior group, and (D) the combined group.

Fig. 5

Kaplan-Meier survival curves compared among groups.