Percutaneous vertebroplasty at C2: case report of a patient with multiple myeloma and a literature review

Abstract

Percutaneous vertebroplasty (PVP) of the axis is a challenging procedure which may be performed by a percutaneous or a transoral approach. There are few reports of PVP at the C2 level. We report a case of unstable C2 fracture treated with the percutaneous approach. The fracture was the first manifestation of multiple myeloma in a previously healthy 47-year-old woman. After local radiotherapy and chemotherapy, the fracture was still unstable and the patient had been continuously wearing a stiff cervical collar for 9 months. Complication-free PVP resulted in pain relief and stabilization and use of the cervical collar could be discontinued. At 18 months follow-up the patient remained free from pain, the fracture was stable and she had returned to work. The purpose of this article is to present the technical facts and to highlight the benefits and potential complications of the procedure. The technical characteristics of the procedure, the indication and results of the present case are discussed together with previously reported cases of PVP treatment at C2.

Vertebroplasty in Multiple Myeloma: Outcomes in a Large Patient Series

“…Several small studies and case series have demonstrated a beneficial effect, 1,2,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] but the largest sample size is composed of only 18 patients. Many barriers prevent the accumulation of a large patient cohort in the myeloma population, and these include reduced survival time of myeloma patients, the relative rarity of vertebroplasty treatment in myelomatous fractures, and a higher threshold of treatment criteria for patients with diffuse disease.…”

Minimally invasive anterior vertebroplasty for C-2 metastatic lesions

“…Furthermore, the axis is a crucial part of a complex biomechanical system which participates in flexion, extension, rotation, lateral bending, and axial loading as well as distraction. 14,20,25 Hence, arthrodesis or fixation may not be clinically acceptable due to restricted range of motion. Percutaneous vertebroplasty allows the option of preserving the mobility of the upper cervical spine, although surgical stabilization is required if vertebroplasty fails to provide sufficient stability.…”

“…As in patients with aneurysmal bone cysts, hemangiomas, myelomas, and fibrous dysplasias, transoral vertebroplasty has been reported to alleviate cervical pain in patients with osteoporotic fractures and osteolytic metastases in a rapid and durable manner. 5,6,10,[25][26][27] The anterolateral approach for upper cervical spine vertebroplasty has gained popularity because it can be performed without general anesthesia or endotracheal intubation. The anterolateral route entails less risk of infection as the needle does not traverse the oral cavity.…”

“…8,20,27 The minimally invasive surgical technique presented in this paper allows vertebroplasty to be performed under direct vision, thereby avoiding complications such as neurovascular and submandibular gland injury, with a lower chance of cement leakage through the entry site. 25 This procedure would facilitate adequate bone biopsy and has the advantage of minimizing intraprocedural hyperextension of the spine. Hemostasis, which is critically important for airway protection, is easier to achieve in potentially bleeding metastatic bone with the minimally invasive surgical technique presented in this paper than with a closed percutaneous procedure.…”

Percutaneous vertebroplasty to treat painful myelomatous vertebral deposits—long-term efficacy outcomes

“…[23][24][25] We employed a postero-lateral approach, although novel approaches including anterior and even trans-oral access of the cervical spine have been reported.…”