Osteoradionecrosis of the cervical spine resulting from radiotherapy for primary head and neck malignancies: operative and nonoperative management

Abstract

Osteoradionecrosis is a process of dysvascular bone necrosis and fibrous replacement following exposure to high doses of radiation. The poorly vascularized necrotic tissue may cause pain and/or instability, and it cannot resist infection well, which may result in secondary osteomyelitis. When these processes affect the cervical spine, the resulting instability and neurological deficits can be devastating, and immediate reestablishment of spinal stability is paramount. Reconstruction of the cervical spine can be particularly challenging in this subgroup of patients in whom the spine is poorly vascularized after radical surgery, high-dose irradiation, and infection. The authors report three cases of cervical spine osteoradionecrosis following radiotherapy for primary head and neck malignancies. Two patients suffered secondary osteomyelitis, severe spinal deformity, and spinal cord compression. These patients underwent surgery in which a vascularized fibular graft and instrumentation were used to reconstruct the cervical spine; subsequently hyperbaric oxygen (HBO) therapy was instituted. Fusion occurred, spinal stability was restored, and neurological dysfunction resolved at the 2- and 4-year follow-up examinations, respectively. The third patient experienced pain and dysphagia but did not have osteomyelitis, spinal instability, or neurological deficits. He underwent HBO therapy alone, with improved symptoms and imaging findings. Hyperbaric oxygen is an essential part of treatment for osteoradionecrosis and may be sufficient by itself for uncomplicated cases, but surgery is required for patients with spinal instability, spinal cord compression, and/or infection. A vascularized fibular bone graft is a very helpful adjunct in these patients because it adds little morbidity and may increase the rate of spinal fusion.

Radiation-induced vertebral compression fracture following spine stereotactic radiosurgery: clinicopathological correlation

“…23 The onset of osteoradionecrosis has been described to range from 6 months to 3 years posttreatment, and even up to 25 years after radiation therapy. 10 With respect to the spine, there have been few specific reports of osteoradionecrosis, 3,10,19,21 and ours is the first report specific to spine SRS. Ultimately, the histopathological analysis of these 2 cases supports our previously postulated mechanism of action that high-dose radiation is a factor in develop- ing VCF post-SRS, as opposed to strictly anatomical or tumor-related structural factors.…”

Cervical vertebral osteoradionecrosis: surgical management, complications and flap coverage—a case report and brief review of the literature

“…When it does occur, it is more typically located in the upper or lower jaw [7]. The involvement of cervical vertebrae appears to be rare and the existing reports are succinct [2,7,11]. Criteria used to define ORN have changed over time [3,8,16].…”

“…Consequently, it was reasoned that an isolated anterior approach would permit us to address all the mechanical aspects of this patient's disorder with relatively little soft tissue sacrifice. However, in reference to a series [2], albeit small, that showed a strong tendency for infection and failure to consolidate if surgical management is employed, one should consider long isolated posterior or circumferential stabilization as the primary procedure to use in this type of patient. Although controversial, some physicians advocate associating hyperbaric oxygen therapy with surgery to stimulate tissue vascularization and wound healing [7,9].…”

Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas

“…Like ORN of the mandible, the presentation of ORN of the cervical spine exists on a spectrum that includes pain, kyphosis, neuropathy, myelopathy, osteomyelitis (OM) and cord compression. 5,7,8 As in advanced ORN of the mandible, maxilla and upper cervical spine, we focus on OM and discitis as the end-stage manifestation of subaxial cervical spine ORN, a pattern that should be recognized by radiologists to avoid misdiagnosis. 2,8 We report imaging findings of four cases of ORN of the subaxial cervical spine following surgery and RT for head and neck cancer and a review of 12 cases in the literature.…”

“…5,7,8 As in advanced ORN of the mandible, maxilla and upper cervical spine, we focus on OM and discitis as the end-stage manifestation of subaxial cervical spine ORN, a pattern that should be recognized by radiologists to avoid misdiagnosis. 2,8 We report imaging findings of four cases of ORN of the subaxial cervical spine following surgery and RT for head and neck cancer and a review of 12 cases in the literature. [7][8][9][10][11][12] METHODS AND MATERIALS Records from January 2000 through January 2013 pertaining to patients diagnosed and treated for ORN of the subaxial cervical spine following treatment for head and neck cancer were reviewed following exempt status from the local institutional review board.…”