Surgical treatment of malignomas in the cervical spine involving the vertebral bodies. A modified approach

Introduction: Cervical spine manifestations of primary malignant tumors occur in 50-80% of patients with malignant disease. Metastases in the cervical spine are most frequently located in the vertebral body. Surgical treatment therefore calls for vertebrectomy, vertebral replacement and stabilization. Since Scovilleʹs first description of vertebral body replacement, using methyl-methacrylate (MMA), this procedure quickly became popular. MMA serves as a spacer, without the bony ingrowth necessary for a long-term stable fusion. The key argument against the use of autologous bone graft is that bone graft will not be incorporated into an irradiated bed. Methods: Between 1/1980 and 6/1996, 20 patients with cervical spine malignomas were treated by anterior approach with vertebrectomy, vertebral replacement by MMA (4 patients) or autologous bone graft (16 patients): 10 were metastatic carcinoma, 6 lymphomas, 2 melanomas and 2 unclassifiable tumors. 16 patients underwent pre- and/or postoperative irradiation with an average of 30 Gy. Results: Mean survival time was 20 months, the shortest in carcinomas (9 months) and the longest in lymphomas (41 months). Reduction of severe head/neck pain was seen in 7 patients, 1 patient remained unchanged, however, in 11 patients the pain resolved completely. A stable fusion after bone grafting augmented by plate stabilization plus irradiation was observed in all long-term survivors. This contradicts the widespread opinion that bony ingrowth into the graft cannot occur in an irradiated bed. Discussion and Conclusions: We suggest autologous bone graft as a vertebral body substitute in conjunction with plate stabilization and irradiation for patients with lymphoma or single metastases, having a life-expectancy of more than six months. Solid bony fusion avoids complications inherent in MMA-constructs, seen in long-term survivors. Patients with only short-term survival are candidates for MMA-implant plus plate stabilization, as bone donor site pain is avoided.