The upper cervical spine tumor pathology C1-C2 - therapeutic attitude

Abstract

Surgical treatment of upper cervical spine tumors, whether they are vertebral, epidural, subdural or intramedullary, raises technical and decisional difficulties regarding the approach of the region as well as in maintaining its stability. The authors performed a retrospective study on C1, C2 spinal tumor pathology, managed surgically in the Spinal Surgery Department of Bagdasar Arseni Clinical Hospital, between January 2007 and December 2011. We included in the study 44 patients, operated for C1, C2 cervical spine tumors, 23 men and 21 women with ages between 13 and 71 years. The pathology included 24 C1-C2 vertebral tumors, 11 subdural tumors, 2 epidural tumors and 7 intramedullary tumors. Presenting symptoms were cervical pain, occipital neuralgia, medullary compression syndrome, and/or cranio-spinal junction instability. The purpose of surgery was to establish a histopathologic diagnosis and to decompress the neural elements by attempting a total tumor removal as well as to stabilize the cranio - cervical junction in order to improve the patient's quality of life. The approach was chosen based on tumor location, prognosis and the need for fixation. For 6 patients an anterior approach was used, for 31 pacients we used a posterior approach and 7 patients required a combined anterior and posterior approach. Neurological improvement was observed in 17 patients, with a mean increase of 8 points on ASIA scale, 7 patients worsened immediately postoperatively with a mean decrease of 10 points on ASIA scale, (2 patients died), and 20 patients without neurological deficits preoperatively remained unchanged. In all cases where the craniospinal junction instability was the cause of occipito-cervical pain we noted the disappearence of pain after surgery. The development of new surgical techniques and fixation systems paved the way to a successful treatment for these difficult tumors, some of them considered inoperable in the past.

C1-C3 Lateral Mass Screw-Rod Fixation and Fusion for C2 Pathologies and Hangman's Fractures

“…The treatment of these upper cervical spine tumors involving C1 and C2 segments has improved considerably in the last few decades. The upper cervical spine tumor pathology C1-C2 imaging investigations that allow the precise definition of the anatomical structures involved in tumor pathology, together with refined surgical techniques including more and more complex fixation instrumentation allows for the complete removal of craniospinal junction tumors with the preservation or the regaining of stability [ 3 , 22 ]. Tumors located in the region of the upper cervical spine and the craniocervical junction may be benign or malignant, and are quite rare.…”

“…Presenting symptoms of such tumors are cervical pain, occipital neuralgia, medullary compression syndrome, and/or cranio-spinal junction instability. The purpose of surgery is to establish a histopathologic diagnosis, and to decompress the neural elements by attempting a total tumor removal, as well as to stabilize the cranio-cervical junction in order to improve the patient's quality of life [ 3 ]. Preoperative work-up included an MRI with a minimum of T1, T2, and T1 with contrast, useful both as a diagnostic tool and for surgical planning.…”

“…A reasonable enough indication for biopsy is the suspicion of a certain histopathological type of tumor that is essentially treatable by non-surgical therapy (radio/chemotherapy or percutaneous vertebroplasty with polyacrilic cement, etc.) [ 3 ]. The surgical treatment for cranio-spinal junctional tumors challenges the neurosurgeon with many difficulties due to the less frequent tumoral pathology at this level, and the unique biomechanical characteristics of the region.…”

“…Hangman's fractures or traumatic spondylolisthesis of the axis commonly affect young people following trauma [ 1 , 2 ]. Nontraumatic pathologies include lymphoma, myeloma, tuberculosis, metastasis and other rare bone tumors [ 3 , 4 ]. In Hangman's fracture, surgical reduction and stabilization is usually indicated in cases with neuro-deficit with spinal cord compression, cases with instability, or after failure of conservative treatment.…”

“…In other pathologies, stabilization and fusion is usually needed along with removal of the C2 pathology. Different surgical approaches, both anterior and posterior, have been described for treating Hangman's fractures and other pathologies [ 1 , 2 , 3 ]. We report our experience of eight patients treated with C1-C3 lateral mass rod-screw stabilization and fusion in the treatment of Hangman's fracture and other axis pathologies.…”