title: [The clinical outcome after occipitocervical fusion due to metastases of the upper cervical spine: a consecutive case series and a systematic review of the literature].
abstract: BACKGROUND
  Increasing incidences of osseous metastatic malignancies and higher life expectancy in patients are resulting in a raise of occipitocervical metastases. Those patients with infaust prognosis have a significantly reduced quality of life. In Germany, between 800 and 1680 new cases per year are expected. Treatment algorithms include the evaluation of the general condition, the operability of visceral metastases, the tumor localization, the sensitivity to chemo-/radiotherapy, the fracture risk and the extent of neurological deficits and myelopathies.
  
  
  METHODS
  A systematic review on clinical studies or case series in posterior occipitocervical fusions due to metastases to the craniocervical transition yielded nine publications with 48 patients without neurological deficit. The mean survival time in the given follow-up was 6.44 months (n = 26; SD: 5,28; 95 % CI: 4.3-8.57). When measured, the clinical outcome was improved towards the VAS, the DENIS Pain Scale and the quality of life through the activities of daily living (ADL). We searched our clinical database for occipitocervical stabilizations in patients with craniocervical metastases. The prospectively collected data included the preoperative Tokuhashi score, SIN score, neurological status, length of hospitalization, perioperative course/loss of blood/complication rate, as well as the Karnofsky- index and pain measured by VAS preoperatively and in follow-up.
  
  
  RESULTS
  Six patients were treated in this consecutive case series. The median age was 72 years (min./max.: 65/82), the average BMI 31.75 (min./max.: 19.3/38.1). The mean preoperative Karnofsky-index was 35 % (min./max.: 23.99/46.01; 95 % CI: 8.39) the mean preoperative Tokuhashi-score 7 (min./max.: 4/10), the mean preoperative VAS7 (min./max.: 4.8/9.2; 95 % CI: 1.68). There were no perioperative complications. In the follow-up, one patient showed a loosening of the screws in the osteolytic massae laterales and one patient suffered from a construct failure after fall.
  
  
  CONCLUSIONS
  Metastases of the craniocervical transition are rare. The initial treatment of instability includes the application of a rigid Miami-J-collar or a Halo fixator. The decision for an operative procedure must accurately assess the individual patient characteristics to provide him a balanced concept between operational risk and clinical benefit. The assessment should be based on the life expectation and the expected quality of life in dependency of the respective therapeutic concept and its risks. The sole posterior stabilization of craniocervical instability through occipitocervical fusion leads to a reduction of pain, has a low perioperative risk, and may prevent a hospitalization. It is justified for selected patients to receive this treatment to help alleviate pain and to improve their quality of life. From our experience, rare cases of pain without instability should undergo conservative treatment in the first line. Due to the low availability of data on the manifestation and the clinical course of craniocervical metastases, there is a need for the collection of both the descriptive patient data include the radiographic findings as well as the clinical outcome and socio-economic factors using appropriate scoring systems.
authors.affiliation: Sektion für Orthopädie, Universitätsklinikum Schleswig-Holstein, Lübeck.
authors.forename: R
authors.initials: R
authors.lastname: Kirchner
authors.affiliation: Sektion für Orthopädie, Universitätsklinikum Schleswig-Holstein, Lübeck.
authors.forename: B
authors.initials: B
authors.lastname: Himpe
authors.affiliation: Sektion für Orthopädie, Universitätsklinikum Schleswig-Holstein, Lübeck.
authors.forename: B
authors.initials: B
authors.lastname: Schweder
authors.affiliation: Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, Berufsgenossenschaftliches Unfallkrankenhaus Hamburg.
authors.forename: C
authors.initials: C
authors.lastname: Jürgens
authors.affiliation: Unfall- und Wiederherstellungschirurgie, BG-Unfallkrankenhaus Hamburg.
authors.forename: J J
authors.initials: JJ
authors.lastname: Gille
authors.affiliation: Abteilung für Unfallchirurgie, Orthopädie und Sporttraumatologie, Berufsgenossenschaftliches Unfallkrankenhaus Hamburg.
authors.forename: M
authors.initials: M
authors.lastname: Faschingbauer
mesh_terms: D000203:Activities of Daily Living / Q000145:classification; D000368:Aged; D000465:Algorithms; D002574:Cervical Vertebrae / Q000601:surgery*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D009777:Occipital Bone / Q000601:surgery*; D010147:Pain Measurement; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D013123:Spinal Fusion / Q000379:methods*; D013125:Spinal Neoplasms / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D016019:Survival Analysis