title: Complicated surgical resection of malignant tumors in the upper cervical spine after failed ion-beam radiation therapy.
abstract: METHODS
  Case report.
  
  
  OBJECTIVE
  To report 3 cases of malignant tumors in the upper cervical spine that were treated surgically by a combination of posterior tumor resection and stabilization and anterior tumor resection through a mandible-splitting approach after failed ion-beam radiation therapy.
  
  
  BACKGROUND
  Few clinical reports have described in detail the postoperative complications associated with transoral surgical resection of tumors in the upper cervical spine after unsuccessful ion-beam radiation therapy.
  
  
  METHODS
  Three patients with malignant tumors in the upper cervical spine who had undergone ion-beam radiotherapy and experienced tumor recurrence were treated by a combination of posterior and anterior surgery through a mandible-splitting approach. One patient (patient 1, a 32-year-old man) had a hemangioendothelioma at the C2 and C3 level, whereas the other 2 patients (patient 2, a 66-year-old woman and patient 3, a 65-year-old man) had a chordoma at the C2 and C3 level.
  
  
  RESULTS
  The intralesional but macroscopic total resection of the tumors was achieved in all 3 patients. However, serious complications developed after surgery, including deep wound infection, cerebrospinal fluid leakage, and meningitis in patient 1, prolonged swallowing difficulty, subsidence of the strut graft, and recurrence in patient 2, and deep wound infection and discitis causing progressive paralysis in patient 3. All patients underwent salvage surgery, including debridement of the wound in patient 1, posterior reinforcement using instrumentation and posterior tumor resection for the recurrent tumor in patient 2, and anterior debridement of the wound with a pedicle flap using the pectoral major muscle in patient 3 to address these problems. Patients 1 and 3 had no signs of recurrence at the time of a follow-up examination.
  
  
  CONCLUSIONS
  Severe complications, mainly associated with the disturbance in healing of the retropharyngeal wall, were observed in all 3 patients. A preventive method, such as primary repair of the retropharyngeal wall using muscular/musculocutaneous flaps, should be considered for patients undergoing resection through a transoral approach after ion-beam irradiation.
authors.affiliation: Departments of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan. morio@sc.itc.keio.ac.jp
authors.forename: Morio
authors.initials: M
authors.lastname: Matsumoto
authors.forename: Kota
authors.initials: K
authors.lastname: Watanabe
authors.forename: Ken
authors.initials: K
authors.lastname: Ishii
authors.forename: Takashi
authors.initials: T
authors.lastname: Tsuji
authors.forename: Hironari
authors.initials: H
authors.lastname: Takaishi
authors.forename: Masaya
authors.initials: M
authors.lastname: Nakamura
authors.forename: Yoshiaki
authors.initials: Y
authors.lastname: Toyama
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Chiba
authors.forename: Yorihisa
authors.initials: Y
authors.lastname: Imanishi
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kishi
authors.forename: Hiromasa
authors.initials: H
authors.lastname: Kawana
mesh_terms: D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000473:pathology / Q000601:surgery*; D002817:Chordoma / Q000473:pathology / Q000601:surgery*; D005260:Female; D006390:Hemangioendothelioma / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D019637:Orthopedic Procedures / Q000009:adverse effects; D019651:Plastic Surgery Procedures; D012086:Reoperation; D013123:Spinal Fusion; D013125:Spinal Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome