Metastases to the Craniovertebral Junction

OBJECTIVE: This study reviews the relevant literature regarding the management of craniovertebral junction (CVJ) metastases. These rare tumors present significant diagnostic and treatment challenges. METHODS: A PubMed search of cervical spine, cervical spine metastasis, craniovertebral junction, atlantoaxial spine, and metastasis radiation was conducted to define the epidemiology, imaging, and treatment protocols in the management of metastatic CVJ tumors. RESULTS: CVJ tumors represent less than 1% of spinal metastases, and the literature is limited to small case series. CVJ tumors present with flexion, extension, and rotational pain, often associated with occipital neuralgia. Magnetic resonance imaging is the most sensitive imaging modality for the detection of spinal metastases, but plain x-rays, computed tomography, and [F-18] 2-fluoro-2-deoxy-D-glucose play a role in diagnosis and management. Conventional external beam radiation therapy or stereotactic radiosurgery effectively treat the majority of patients with normal spinal alignment or minimal fracture subluxations. Surgery should be considered in patients with fracture subluxations greater than 5 mm, or 3.5 mm subluxation with 11-degree angulation. The palliative goals for surgery favor posterior approaches only including laminectomy for decompression, without the need for anterior approaches with the associated morbidity. Occipitocervical instrumentation using screw-rod systems are effective for irreducible subluxations, but posterior strategies using C1-C2 or C1-C3 can be used for patients with reducible subluxations. CONCLUSION: Effective management of CVJ tumors using radiation and/or surgery results in significant pain and functional improvement in properly selected patients. Advanced surgical techniques and stereotactic radiation may improve outcomes with less morbidity.