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Acta Orthop. Belg., 2005, 71, 00-00
Posterior stabilisation of a malignant cervico-thoracic vertebral bone defect
Benjamin ULMAR, Balkan CAKIR, Klaus HUCH, Wolfhart PUHL, Marcus RICHTER From Department of Orthopedic Surgery and Spinal Cord Injury, University of Ulm, Germany Oesophageal cancer is frequently complicated by
population are affected at younger age (6). In malignant fistulae. Necrosis of the tumour following
oesophageal carcinoma, the prevalence of fistulae radiotherapy or chemotherapy may lead to the devel-
between the oesophagus and the trachea or bron- opment of fistulae between the oesophagus and adja-
chial tree are a relatively common complication (5- cent tissues and organs. We report the expansion of
10%) (2, 3). Communicating fistulae between an extra-luminal oesophageal cancer after resection,
oesophagus and the aorta, pericardium, pleural invading the cervico-thoracic spine, fortunately with-
space and various other intrathoracic or mediastinal out neurological deficit, and leading to instability and
formation of a malignant fistula linking the tracheo-
bronchial tree to the subarachnoidal space. To pre-
radio-chemo-therapy may increase the risk of vent imminent paraplegia and to alleviate severe
pain, we rigidly stabilised the spine at the cervico-
thoracic junction using an angle-stable system

CASE REPORT
through a single posterior approach. Further post-
operative follow-up revealed no signs of neurological

A 60-year-old cachectic white man was referred deterioration. Cervico-thoracic stability was pre-
to our department with a short history of severe served until the patient died nearly five months post-
neck pain, increasing stiffness and conspicuous operatively. This case shows that posterior stabilisa-
hyperkyphosis of the cervico-thoracic spine. Physi- tion and decompression may be a palliative option
cal examination revealed a slight deficit of rotation for patients with imminent paraplegia and severe
to both sites and tenderness at the cervico-thoracic pain due to advanced tumour infiltration of the cer-
vico-thoracic spine.

INTRODUCTION
■ Balkan Cakir, MD, Resident.
■ Klaus Huch, MD, Associate Professor.
Carcinoma of the oesophagus represents about ■ Wolfhart Puhl, MD, Professor, Chairman.
1.5% of all cancers and about 7% of all gastroin- ■ Marcus Richter, MD, Associate Professor.
testinal carcinomas. Worldwide regional differ- Department of Orthopaedic Surgery and Spinal Cord Injury, ences in incidence and age distribution can be Correspondence : Benjamin Ulmar, MD, Rehabilitation found : In the United States the incidence is 10 men Hospital Ulm (RKU), Department of Orthopaedics and Spinal per 100000 population per year, predominantly Cord Injury, University of Ulm, D-89081 Ulm, Germany.
occurring between the fifth and seventh decades of life. In contrast, in Japan, 46.3 men per 100000 Acta Orthopædica Belgica, Vol. 71 - 2 - 2005 B. ULMAR, B. CAKIR, K. HUCH, W. PUHL, M. RICHTER Fig. 2 a-b. — Computertomography : the coughed-up bone
pieces and the air the infiltration of the cervico-thoracic spine
suggest strongly a fistula between the spinal canal and the tra-
chea.
Fig. 1. — Coughed-up bone pieces
spine. The patient had coughed up bone fragments(fig 1). An oesophageal squamous cell carcinoma had been detected 2.5 years earlier. After a neo-adju-vant radio-chemo-therapy (80 Gray combined with4 cycles of CDDP (cisplatin and 5-fluorouracil) thepatient underwent 7 months later an abdomino-tho-racic oesophagectomy. The oesophagus wasmarkedly indurated 5 cm above and 5 cm below thebifurcation. About 4 cm above the bifurcation itwas firmly fixed to the trachea. Quick sectionhistology revealed tumour cells in the resectionmargin. Retrosternal elevation of a stomach-tubeand completion of a collar anastomosis completedthe procedure. Plain radiographs, computer tomography (CT) and magnetic resonance tomography (MRI)showed an osteolytic destruction with collapse ofthe thoracic vertebral bodies I, II and III by anextraluminal tumour recurrence of the oesophagealcarcinoma, resulting in a highly unstable situation Fig. 3. — MRI : tumour infiltration of the spine
and hyperkyphosis (fig 2a, b and 3). The tracheo-bronchial tree was invaded and air was seenbetween the affected vertebrae and in the spinal expectancy was estimated by the surgeons to be canal, suggestive for dural infiltration. A tech- netium bone scan demonstrated increased uptake at To prevent paraplegia with this highly unstable the cervico-thoracic spine and at the right third rib.
situation of the affected vertebrae and to alleviate Plain radiographs and computer-tomography of the pain, we decided to stabilise the spine. A stabilisa- thorax did not reveal further metastases. Life tion was carried out from the cervical vertebral Acta Orthopædica Belgica, Vol. 71 - 2 - 2005 POSTERIOR STABILISATION OF A MALIGNANT CERVICO-THORACIC VERTEBRAL BONE DEFECT Fig. 4. — Intraoperative air bubbles in the spinal canal visible
after laminectomy.
body VII to the thoracic vertebral bodies IV/Vtogether with dorsal decompression by laminecto-my of the thoracic vertebrae II and III. We used theangle-stable modular rod-screw implant system forposterior instrumentation of the occipito-cervicalspine (Neon®, Ulrich Spinal Implants, Ulm,Germany). This implant system has the advantageof a high biomechanical stability without the needof an anterior column support (5). Insertion of thepedicle screws was assisted by a CT-assisted opto-electronic navigation system (BrainLAB® VectorVision Navigation Systems, Germany). After laminectomy we found tumourtissue in the spinal canal at the T II level. Air wasleaking at the site (fig 4). Postoperative CT-scanshowed correct position of the pedicle screws(fig 5). Postoperative follow-up was uncomplicat-ed. Two days postoperatively the patient wasmobilised wearing a rigid cervical collar for14 days. Amoxicillin (Augmentin®) was adminis-tered to prevent infection. The preexisting neck andshoulder pain and the tenderness over the cervi-cothoracic spine disappeared. Histological exami-nation confirmed a squamous cell carcinoma. Twoweeks after the operation the patient left ourdepartment with a soft collar. The patient was seenat the outpatient department 6 weeks and 3 monthsafter the operation. Radiographs showed no Fig. 5. — Computertomography demonstrating the correct
implant failure, no dislocation, osteolysis or screw position of the pedicle screws in vertebrae C7, Th4 and Th5.
Acta Orthopædica Belgica, Vol. 71 - 2 - 2005 B. ULMAR, B. CAKIR, K. HUCH, W. PUHL, M. RICHTER breakdown. Nearly 5 months after the operation the option for patients with imminent paraplegia and patient died in terminal cachexia without any neu- severe pain due to advanced tumour infiltration of rological deficit or clinical signs of vertebral unsta- REFERENCES
DISCUSSION
1. Cornwell J, Walden C, Ghahremani CG. CT demonstra-
tion of fistula between esophageal carcinoma and spinal We describe a case of a fistula between the canal. J Comput Assist Tomogr 1986 ; 10 (5) : 871-873.
tracheobronchial tree and the subarachnoid space 2. Frances PB, Goldstein J. Asymptomatic esophageal carci-
due to a recurrent oesophageal squamous cell noma with esophagopulmonary fistula masquerading as a carcinoma after oesophagectomy. The cervico- primary lung absess. South Med 1979 ; 72 (1) : 75-77.
thoracic spine was unstable due to tumoral invasion 3. Martini N, Goodner JT, D’Angio GJ et al. Tracheo-
esophageal fistula due to cancer. J Thorac Cardiovasc Surg1970 ; 59 (3) : 319-324.
At the first consultation no neurological deficits 4. Moss AA, Schnyder P, Thoeni RF et al. Esophageal car-
could be detected. The risk of surgery and the cinoma : pretherapy staging by computer tomography. AJR relatively short life expectancy of the patient were balanced against the reduced risk for paraplegia 5. Richter M, Wilke HJ, Kluger P et al. Biomechanical
with a successful intervention and the anticipation evaluation of a new modular rod-screw implant system forposterior instrumentation of the occipito-cervical spine : in- of considerable tumour pain reduction. The patient vitro comparison with two established implant systems.
wished to avoid a Milwaukee-brace as an alterna- Eur Spine J 2000 ; 9 (5) : 417-425.
tive and decided for an operation. Until his death 6. Rubin P. Cancer of the gastrointestinal tract : I. Eso-
(nearly 5 months after surgery), he developed no phagus : detection and diagnosis. JAMA 1973 ; 226 (13) : neurological deficit and no signs of spinal instabil- ity. The pain situation was manageable with oral 7. Wippold FJ, Schnapf D, Benett LL et al. Esophago-
subarachnoidal fistula : An unusual complication of eso- analgesics and a cervical collar was not necessary.
phageal carcinoma. J Comput Assist Tomogr 1982 ; 6 (1) :147-149.
CONCLUSION
Posterior stabilisation with the Neon® system in a single posterior approach may be a palliative Acta Orthopædica Belgica, Vol. 71 - 2 - 2005

Source: http://www.joho.de/pdfdownload/KnochenhusterActaOrthopBelg05.pdf

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