Surgical outcomes of occipitocervical fusion for metastatic disease at the craniocervical junction: 24 years of experience at a tertiary cancer referral center.

Abstract

Metastatic disease at the craniocervical junction is rare. Typically, patients present with disabling neck pain and instability. To date, limited data exist to guide treatment strategies. In this study, the authors review 24 years of occipitocervical fusion outcomes at a tertiary cancer center with the aim of evaluating effectiveness with pain control and risk factors for complications. Adult patients who underwent occipitocervical fusion for metastatic disease at a single institution between 2001 and 2024 were identified from a prospectively maintained database. Cases involving nonmetastatic conditions were excluded. Collected preoperative variables included patient demographics, baseline performance status, prior radiation treatments, lesion location, pathology type, and the degree of epidural spinal cord compression. The primary outcome was pain control, evaluated using the neck visual analog scale (VAS) and morphine milligram equivalents (MME) at immediate, 6-week, 3-month, and final follow-up intervals. Complications were extracted from electronic medical records and analyzed for associations with predisposing risk factors. A total of 126 patients underwent occipitocervical fusion, 57 of whom were treated for metastatic disease. Pain (mechanical or occipital neuralgia) was the most common presenting symptom (94.6%). Renal cell carcinoma (35.1%) was the most frequent metastatic histology. Pain outcomes showed significant improvement, with neck VAS scores decreasing from a median of 8 (IQR 5-10) preoperatively to 5 (IQR 3-7) by postoperative day 1, and further reductions to scores of 3 (IQR 0-4) at 6 weeks, 1 (IQR 0-3) at 3 months, and 1 (IQR 0-3) by the final follow-up. MME decreased from a median of 88.8 preoperatively to 53.5 at the last follow-up. The overall complication rate was 10.5%, with 7.0% attributed to wound healing disturbances. Only 3 patients required revision surgery. Age > 60 years trended toward increased complication risk (p = 0.06), although other factors were not significantly associated with complications. Occipitocervical fusion is a safe, effective option for managing painful metastases at the craniocervical junction, showing an acceptable complication rate and significant pain relief. This series is the largest reported on this condition.