Standalone Transoral Vertebroplasty for Treatment of Painful Metastatic C2 Lesion: A Case Report

Abstract

Introduction: Metastatic involvement of the spine may present with pathologic fractures, deformity, neurologic deficit due to vertebral canal compromise, and pain. Pain is usually managed with non-steroidal anti-inflammatory agents, corticosteroid injections, calcitonin, etc. Since the introduction of percutaneous vertebroplasty in 1984, it has proven as an effective armamentarium in the management of painful metastatic spine lesions. Herein, we present a case of breast cancer with osteolytic C2 metastasis, for whom trans-oral vertebroplasty without posterior fusion resulted in long-standing pain control and maintenance of normal motions and stability. Case Presentation: A 41-year-old woman, a known case of breast cancer with severe neck pain for three months, was admitted due to an osteolytic lesion in C2. The pain was incapacitating and resistant to conservative measures. Standalone transoral vertebroplasty resulted in pain control and a three-year follow-up showed durable control of pain. After positioning the patient and insertion of Dingman mouth gag, the oropharynx was prepped and injected with epinephrine/lidocaine solution. Under biplanar fluoroscopic guidance, a needle was introduced into the C2 body through the oropharynx. The lytic lesion was filled with about 2 cc of PMMA cement. The VAS score decreased from 10 prior to operation to 5 immediately after recovery from general anesthesia and improved to 2 after six months. At a 36-month follow-up visit, the VAS score was 0, normal cervical motions were preserved, and lateral neutral and dynamic cervical X-rays disclosed stability. Conclusions: Standalone transoral vertebroplasty can be safely practiced as an effective treatment for painful osteolytic metastases of C2 with normal dynamics.

Can C2 Vertebroplasty Restore Alignment in Pathologic Odontoid Fracture?

“…Solitary plasmacytoma occasionally present with pathologic fractures, pain and neurological deficits secondary to canal compromise. Painful solitary plasmacytoma in any part of the vertebral column can be treated effectively by vertebroplasty [2]. PMMA injection not only can improve the cervical spine biomechanics by augmenting stiffness but also has pain relief effect due to having oncolytic properties and axial load-bearing capacity.…”

“…Not many similar cases of this procedure are presented previously. Farrokhi et al [2] reported transoral vertebroplasty in patients with C2 metastasis for pain palliation. According to their report, this technique led to a significant rise in VAS.…”

“…Early and pain relief up to 90%, is the important benefit of this procedure. The complication rates were reported at 2%-4% [2].…”

“…The patient had local and constant pain which worsened by active neck motion. The pain control consisted of different medications, hormone replacement, oral non-steroidal anti-inflammatory drugs, and osteogenic agents such as bisphosphonates [2].…”

“…In the lower and midcervical part of vertebral column, vertebroplasty performed with the anterolateral approach. By inserting the needle between carotid-jugular vessels laterally and the upper airways medially [2]. There were 2 methods for C2 percutaneous vertebroplasty [4,5] direct trans-oral and transpedicular routes [3].…”