LAUSR

This is a very interesting case report that also reviews much of the literature relevant to the choice of approach for metastatic disease to the upper cervical spine [1]. The authors have done a great job explaining their rationale for performing cervical corpectomy from a posterior approach. Although there are certainly drawbacks to it, it is definitely worth being aware of this option when faced with situations where an anterior approach would be problematic (e.g., previous radiation exposure, tracheo-espohageal comorbidities). Anterior approaches are particularly challenging at C3 from a standard Smith–Robinson exposure when the patient has a short neck, heavy build or a large mandible. The detailed preoperative planning and thorough description of the operative steps provided by the authors is much appreciated. In recently published articles, we described our “LMNOP” strategy [2, 3] for approach planning in metastatic spine tumors: (L) location of disease with respect to the anterior and/or posterior columns of the spine and number of spinal levels involved (contiguous or non-contiguous); (M) mechanical instability as graded by the Spine Instability Neoplastic Score (SINS), [4, 5] (N) neurology (i.e., symptomatic epidural spinal cord compression); (O) oncology (i.e., histopathologic diagnosis); and (P) patient fitness, patient wishes, prognosis and response to prior therapy. The main indication for surgery in this patient was neurology (N). She had significant spinal cord compression at C3, and although her confused mental state may have made it difficult to determine symptoms, she had upper motor neuron signs including sustained clonus. Problematic from the point of view of her operative candidacy was the very advanced stage of her metastatic breast cancer and her cognitive function. I agree with the authors that if one was to consider surgery for this patient, then a foremost consideration would be to limit yourself to a single-stage procedure with as little potential for morbidity as possible. Anterior corpectomy, which would likely require a submandibular approach at C3, would necessitate a second stage posterior stabilization to achieve sufficient construct longevity, at least in my opinion. As such, I agree that the only option for circumferential single-stage decompression here was the posterior corpectomy advocated by the authors. Looking at her preoperative MRI, the majority of the spinal cord compression was ventral. Without the preoperative CT, I could not tell how much of that pathology was soft tumor versus retropulsed bone fragments. If it were all soft tissue, then I would have simply done a C2–4 laminectomy and C1–5 posterior instrumentation, with the plan to start palliative radiation therapy after allowing at least 3–4 weeks for wound healing. Even advanced breast cancer usually responds to radiation therapy [6]. Admittedly, my approach * Daryl R. Fourney [email protected]