Primary Osseous and Metastatic Neoplasms of the CVJ

Abstract

Surgery for both primary and metastatic spinal tumors at the craniovertebral junction (CVJ) presents a unique set of technical challenges both in terms of tumor resection and spinal reconstruction. This is primarily due to the multiple anatomic compartments in the head and neck as well as the proximity of vital neurovascular structures. Knowledge of the bony anatomy of the occiput, atlas, and axis and their respective biomechanics is necessary prior to any attempted surgery in this region. Tumor resection strategies at the CVJ often require combined anterior and posterior approaches, for both resection and reconstruction. Primary osseous tumors in this region can be particularly difficult to resect, especially if attempted en bloc. In many cases, en bloc resection is not able to be achieved lest significant morbidity is incurred. Careful preoperative planning can help mitigate the risk of causing morbidity/mortality. Advances in radiotherapy and chemotherapy/immunotherapy have improved the treatment armamentarium available to patients with either primary or metastatic CVJ tumors. Use of these tools in an adjuvant or neoadjuvant setting might improve patient’s risk of recurrence and progression free survival. They can also reduce surgical morbidity in some tumor types by minimizing the degree of surgical resection necessary for the patient. While they can be daunting, both primary and metastatic tumors of the CVJ can be effectively treated through proper surgical planning and technique, while working with other oncologic practitioners in an interdisciplinary manner to maximize patient outcome and reduce morbidity.