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Neuroradiology, vertebral transfer, cervical vertebroplasty, posterolateral approach, curved needle, interventional neuroradiology, percutaneous vertebroplasty
Cite this article as: Swarnkar A, Zain S, Christie O, et al. (May 29, 2022) Vertebroplasty for pathological C2 fractures: a unique clinical case using the curved needle technique. Cure 14(5): e25463. doi:10.7759/cureus.25463
Minimally invasive vertebroplasty has emerged as a viable alternative treatment for pathological vertebral fractures. Vertebroplasty is well documented in the thoracic and lumbar posterolateral approach, but is rarely used in the cervical spine due to the many important neural and vascular structures that should be avoided. The use of careful technique and imaging is essential to manipulate critical structures and minimize the risk of complications. In a posterolateral approach, the lesion should be located on a straight needle trajectory lateral to the C2 vertebra. This approach may limit adequate treatment of more medially located lesions. We describe a unique clinical case of a successful and safe posterolateral approach for the treatment of destructive medial C2 metastases using a curved needle.
Vertebroplasty involves the replacement of the internal material of the vertebral body to repair fractures or structural instability. Cement is often used as a packaging material, resulting in increased strength of the vertebrae, reduced risk of collapse, and decreased pain, especially in patients with osteoporosis or osteolytic bone lesions [1]. Percutaneous vertebroplasty (PVP) is commonly used as an adjunct to analgesics and radiation therapy to relieve pain in patients with vertebral fractures secondary to malignancy. This procedure is usually performed in the thoracic and lumbar spine through the posterolateral pedicle or extrapedicular approach. PVP is usually not performed in the cervical spine due to the small size of the vertebral body and technical problems associated with the presence of important neurovascular structures in the cervical spine such as the spinal cord, carotid arteries, jugular veins, and cranial nerves. 2]. PVP, especially at the C2 level, is relatively rare or even rarer due to the anatomical complexity and tumor involvement at the C2 level. In the case of unstable osteolytic lesions, vertebroplasty may be performed if the procedure is deemed too complicated. In PVP lesions of the C2 vertebral bodies, a straight needle is usually used from the anterolateral, posterolateral, translational, or transoral (pharyngeal) approach to avoid critical structures [3]. The use of a straight needle indicates that the lesion must follow this trajectory for adequate healing. Lesions outside the direct trajectory may result in limited, inadequate treatment or complete exclusion from appropriate treatment. The curved needle PVP technique has recently been used in the lumbar and thoracic spine with reports of increased maneuverability [4,5]. However, the use of curved needles in the cervical spine has not been reported. We describe a clinical case of a rare C2 pathologic fracture secondary to metastatic pancreatic cancer treated with posterior cervical PVP.
A 65-year-old man presented to the hospital with new onset severe pain in his right shoulder and neck that persisted for 10 days without relief with over-the-counter medications. These symptoms are not associated with any numbness or weakness. He had a significant history of metastatic poorly differentiated pancreatic cancer stage IV, arterial hypertension and severe alcoholism. He completed 6 cycles of FOLFIRINOX (leucovorin/leucovorin, fluorouracil, irinotecan hydrochloride and oxaliplatin) but started a new regimen of gemzar and abraxane two weeks ago due to disease progression. On physical examination, he had no tenderness to palpation of the cervical, thoracic, or lumbar spine. In addition, there were no sensory and motor impairments in the upper and lower extremities. His bilateral reflexes were normal. An out-of-hospital computed tomography (CT) scan of the cervical spine showed osteolytic lesions consistent with metastatic disease involving the right side of the C2 vertebral body, the right C2 mass, the adjacent right vertebral plate, and the depressed side of C2. Upper right articular surface block (Fig. 1). A neurosurgeon consulted, magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine was performed, taking into account metastatic osteolytic lesions. MRI findings showed T2 hyperintensity, T1 isointense soft tissue mass replacing the right side of the C2 vertebral body, with limited diffusion and post-contrast enhancement. He received radiation therapy without any noticeable improvement in pain. The neurosurgical service recommends not performing emergency surgery. Therefore, interventional radiology (IR) was required for further treatment due to severe pain and the risk of instability and possible spinal cord compression. After evaluation, it was decided to perform CT-guided percutaneous C2 spine plasty using a posterolateral approach.
Panel A shows distinct and cortical irregularities (arrows) on the right anterior side of the C2 vertebral body. Asymmetric expansion of the right atlantoaxial joint and cortical irregularity at C2 (thick arrow, B). This, together with the transparency of the mass on the right side of C2, indicates a pathological fracture.
The patient was placed in the right side lying position and 2.5 mg of Versed and 125 μg of fentanyl were administered in divided doses. Initially, the C2 vertebral body was positioned and 50 ml of intravenous contrast was injected to localize the right vertebral artery and plan the access trajectory. Then, an 11-gauge introducer needle was advanced to the posterior-medial part of the vertebral body from the right posterolateral approach (Fig. 2a). A curved Stryker TroFlex® needle was then inserted (Fig. 3) and placed in the lower medial part of the C2 osteolytic lesion (Fig. 2b). Polymethyl methacrylate (PMMA) bone cement was prepared according to standard instructions. At this stage, under intermittent CT-fluoroscopic control, bone cement was injected through a curved needle (Fig. 2c). Once adequate filling of the lower part of the lesion was achieved, the needle was partially withdrawn and rotated to access the upper mid-lesion position (Fig. 2d). There is no resistance to needle repositioning as this lesion is a severe osteolytic lesion. Inject additional PMMA cement over the lesion. Care was taken to avoid leakage of bone cement into the spinal canal or paravertebral soft tissues. After achieving satisfactory filling with cement, the curved needle was removed. Postoperative imaging showed successful PMMA bone cement vertebroplasty (Figures 2e, 2f). Postoperative neurological examination revealed no defects. A few days later the patient was discharged with a cervical collar. His pain, although not completely resolved, was better controlled. The patient tragically died a few months after discharge from the hospital due to complications of invasive pancreatic cancer.
Computed tomography (CT) images depicting the details of the procedure. A) Initially, an 11 gauge external cannula was inserted from the planned right posterolateral approach. B) Insertion of a curved needle (double arrow) through the cannula (single arrow) into the lesion. The tip of the needle is placed lower and more medially. C) Polymethyl methacrylate (PMMA) cement was injected into the bottom of the lesion. D) The bent needle is retracted and re-inserted into the superior medial side, and then the PMMA cement is injected. E) and F) show the distribution of PMMA cement after treatment in the coronal and sagittal planes.
Vertebral metastases are most commonly seen in the breast, prostate, lung, thyroid, kidney cells, bladder, and melanoma, with a lower incidence of skeletal metastases ranging from 5 to 20% in pancreatic cancer [6,7]. Cervical involvement in pancreatic cancer is even rarer, with only four cases reported in the literature, especially those associated with C2 [8-11]. Spinal involvement may be asymptomatic, but when combined with fractures, it can lead to uncontrolled pain and instability that is difficult to control with conservative measures and may predispose the patient to spinal cord compression. Thus, vertebroplasty is an option for spinal stabilization and is associated with pain relief in more than 80% of patients undergoing this procedure [12].
Although the procedure can be successfully performed at the C2 level, the complex anatomy creates technical difficulties and may lead to complications. There are many neurovascular structures adjacent to C2, as it is anterior to the pharynx and larynx, lateral to the carotid space, posterolateral to the vertebral artery and cervical nerve, and posterior to the sac [13]. Currently, four methods are used in PVP: anterolateral, posterolateral, transoral, and translational. The anterolateral approach is usually performed in the supine position and requires hyperextension of the head to elevate the mandible and facilitate C2 access. Therefore, this technique may not be suitable for patients who cannot maintain head hyperextension. The needle is passed through the parapharyngeal, retropharyngeal and prevertebral spaces and the posterolateral structure of the carotid artery sheath is carefully manipulated manually. With this technique, damage to the vertebral artery, carotid artery, jugular vein, submandibular gland, oropharyngeal and IX, X and XI cranial nerves is possible [13]. Cerebellar infarction and C2 neuralgia secondary to cement leakage are also considered complications [14]. The posterolateral approach does not require general anesthesia, can be used in patients who cannot hyperextend the neck, and is usually performed in the supine position. The needle is passed through the posterior cervical space in the anterior, cranial and medial directions, trying not to touch the vertebral artery and its vagina. Thus, complications are associated with damage to the vertebral artery and spinal cord [15]. Transoral access is technically less complicated and involves the introduction of a needle into the pharyngeal wall and pharyngeal space. In addition to potential damage to the vertebral arteries, this method is associated with a higher risk of infection and complications such as pharyngeal abscesses and meningitis. This approach also requires general anesthesia and intubation [13,15]. With lateral access, the needle is inserted into the potential space between the sheaths of the carotid artery and the vertebral artery lateral to the level of C1-C3, while the risk of damage to the main vessels is higher [13]. A possible complication of any approach is the leakage of bone cement, which can lead to compression of the spinal cord or nerve roots [16].
It has been noted that the use of a curved needle in this situation has certain advantages, including increased overall access flexibility and needle maneuverability. The curved needle contributes to: the ability to selectively target different parts of the vertebral body, more reliable midline penetration, reduced procedure time, reduced cement leakage rate, and reduced fluoroscopy time [4,5]. Based on our review of the literature, the use of curved needles in the cervical spine was not reported, and in the cases above, straight needles were used for posterolateral vertebroplasty at the C2 level [15,17-19]. Given the complex anatomy of the neck region, the increased maneuverability of the curved needle approach may be particularly beneficial. As shown in our case, the operation was performed in a comfortable lateral position and we changed the position of the needle to fill several parts of the lesion. In a recent case report, Shah et al. The curved needle left after balloon kyphoplasty was indeed exposed, suggesting a potential complication of the curved needle: the shape of the needle may facilitate its removal [20].
In this context, we demonstrate the successful treatment of unstable pathological fractures of the C2 vertebral body using posterolateral PVP with a curved needle and intermittent CT fluoroscopy, resulting in fracture stabilization and improved pain control. The curved needle technique is an advantage: it allows us to reach the lesion from a safer posterolateral approach and allows us to redirect the needle to all aspects of the lesion and adequately and more completely fill the lesion with PMMA cement. We expect that this technique may limit the use of anesthesia required for transoropharyngeal access and avoid the neurovascular complications associated with anterior and lateral approaches.
Human Subjects: All participants in this study gave or did not give consent. Conflicts of Interest: In accordance with the ICMJE Uniform Disclosure Form, all authors declare the following: Payment/Service Information: All authors declare that they did not receive financial support from any organization for the submitted work. Financial Relationships: All authors declare that they do not currently or within the past three years have financial relationships with any organization that may be interested in the submitted work. Other Relationships: All authors declare that there are no other relationships or activities that may affect the submitted work.
Swarnkar A, Zane S, Christie O, et al. (May 29, 2022) Vertebroplasty for pathological C2 fractures: a unique clinical case using the curved needle technique. Cure 14(5): e25463. doi:10.7759/cureus.25463
© Copyright 2022 Svarnkar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. Unlimited use, distribution, and reproduction in any medium is permitted, provided the original author and source are credited.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the author and source are credited.
Panel A shows distinct and cortical irregularities (arrows) on the right anterior side of the C2 vertebral body. Asymmetric expansion of the right atlantoaxial joint and cortical irregularity at C2 (thick arrow, B). This, together with the transparency of the mass on the right side of C2, indicates a pathological fracture.
Computed tomography (CT) images depicting the details of the procedure. A) Initially, an 11 gauge external cannula was inserted from the planned right posterolateral approach. B) Insertion of a curved needle (double arrow) through the cannula (single arrow) into the lesion. The tip of the needle is placed lower and more medially. C) Polymethyl methacrylate (PMMA) cement was injected into the bottom of the lesion. D) The bent needle is retracted and re-inserted into the superior medial side, and then the PMMA cement is injected. E) and F) show the distribution of PMMA cement after treatment in the coronal and sagittal planes.
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