• Zach Pennington, Erick M Westbroek, Sheng-Fu Larry Lo, and Daniel M Sciubba.
• Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
• World Neurosurg. 2021 Dec 1; 156: e41-e56.

ObjectiveTo propose a surgical approach algorithm for the tumors of the cervicothoracic spine.MethodsAll patients operated for vertebral column tumors involving the occipito-cervicothoracic spine were reviewed. Oncologic characteristics and surgical approach were gathered. Approach was classified by the use of staging and trajectory (posterior, transnasal, transoral, transmandibular, transcervical, transsternal). Angle of attack was defined for the occipitocervical junction tumor as the angle inscribed by the inferior mandibular plane and line connecting the superior tumor pole and mandibular angle. For lesions extending below the thoracic inlet, angle of attack was that inscribed by the plane of the thoracic inlet and the line connecting the jugular notch and inferior tumor pole.ResultsIn total, 115 patients were included (mean age 56.7 years, 64 [56%] male, average size 26.5 cm3, 39 [34%] primary tumors). Sixty-nine (60%) of patients had single-stage procedures (57 [49.6%] posterior-only, 12 [10.4%] anterior-only), 35 (30.4%) had 2-stage procedures, and 11 (9.6%) had 3- or 4-stage approaches. Lesions requiring a combined transmandibular-transcervical approach all involved the C2 and C3 levels and had a significantly steeper angle of attack (42.5 ± 9.5 vs. 6.1 ± 13.3°; P = 0.01) and greater superior tumor extent above the inferior plane of the mandible (3.69 ± 2.18 vs. 0.33 ± 0.78; P = 0.002). Lateral tumor extent, tumor size, nor inferior angle of attack differed significantly between approach groups.ConclusionsHere, we present a preliminary decision-making algorithm for the management of vertebral column tumors of the cervicothoracic spine. Based on this single-center experience, we suggest which patients, assessed via a combination of tumor histology and regional anatomy, may benefit from extended anterior surgical access.Copyright © 2021 Elsevier Inc. All rights reserved.

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