Criteria for Fusion After Spinal Cord Tumor Surgery Described in Review Article
One of the hotly contested topics after spine tumor surgery is when and if to fuse the spine.—Ali A. Baaj, MD
A recent literature review identified seven criteria for instrumented fusion after spinal cord tumor resection in adults. Overall, 8% of adults with spinal cord tumor surgery required fusion, the study authors reported in Clinical Neurology and Neurosurgery.
“We have summarized guidelines and practices to help spine surgeons decide on when spinal fusion is necessary after tumor resection,” said senior author Ali A. Baaj, MD, Spinal Neurosurgeon and Assistant Professor of Neurological Surgery at Weill Cornell Medical College, Cornell University, in New York, NY.
Impetus for the Review
“One of the hotly contested topics after spine tumor surgery is when and if to fuse the spine,” Dr. Baaj said. “In my practice, I see many patients with spine tumors and I wanted to better understand the existing guidelines and practices for spine fusions after spinal tumor resections. Specifically, I felt that this summary and review will help me and fellow surgeons in the decision-making process of these challenging cases.”
The authors reviewed the literature on this topic from January 1980 to March 2015 to analyze practice patterns for stabilization and fusion after intradural tumor resection in adults. Of 639 relevant articles found during the initial search, 35 studies were selected for the analysis. Most of the studies (32) were retrospective case series and 2 were literature reviews.
The studies included 1,288 cases of intradural spinal cord tumors in adults, 104 of which (8.1%) required fusion. The median time to follow-up in these studies was 24 months.
Common Characteristics of Spine Tumor Cases Requiring Fusion
The following characteristics were common in cases requiring fusion:
- spine deformity was present before surgery (ie, kyphosis in the cervical spine)
- surgery involved ≥3 vertebral levels
- patients were “young adults” (mean, 33 years)
- ≥50% of the facet joints were removed (unilateral or bilateral)
- persistence of neck/back pain or failure of conservative management 1 year after surgery
- surgery encompassed a spinal junction (cervico-thoracic or thoracolumbar)
- laminectomy of the C2 vertebra
Findings Provide a Framework for Assessing the Need for Spinal Fusion
“I hope that this work can provide a framework for spine surgeons in assessing when spinal fusion is necessary after spine tumor resection,” Dr. Baaj concluded. “This is a difficult question and is based on each individual case, but our review has summarized the existing guidelines and practices.”
“In this era of increased healthcare financial scrutiny, it is imperative for surgeons to be aware of the quality, value, and costs of their treatments,” Dr. Baaj said. “Spinal fusions can add significant costs and, though often necessary, can be avoided in certain cases after tumor resection.”
Arnold H. Menezes, MD, FACS, FAAP, FAANS
Professor and Vice Chairman
Department of Neurosurgery
University of Iowa Hospitals and Clinics
Iowa City, IA
The authors have reviewed pertinent manuscripts (639) and selected 35 for detailed analysis. They have presented the usual criteria for consideration of fusion in patients with intradural (extramedullary and intramedullary) spinal cord tumors. We agree with their criteria. As per our last manuscript, the intradural intramedullary spinal cord tumors in children require consideration quite early on with planning.1
In these individuals, the extent of their primary spinal cord procedure dictates the fusion. This should be considered after tiding the patient over the operative procedure and a potential neurological setback. A growing spine and an extensive spinal cord tumor resection will require sincere consideration for spinal fusion. This also should encompass the fact that these patients may require radiation therapy.
In the case of the cervical spine, an associated fusion is usually done if it is at junctional areas such as the craniocervical or cervicothoracic junction. The fusion is mostly carried out at the same time as the spinal cord tumor resection, if the criteria have been fulfilled as the authors have described. However, it is crucial to keep in mind that instrumentation of the spine will affect the follow-up with magnetic resonance imaging. This is a very common occurrence and has to be weighed into the decision making.”
1. Ahmed R, Menezes AH, Awe OO, et al. Long-term incidence and risk factors for development of spinal deformity following resection of pediatric intramedullary spinal cord tumors. J Neurosurg Pediatr. 2014;13(6):613-621.