Percutaneous intervention of the C2 vertebral body using a CT-guided posterolateral approach

Vertebroplasty of C2 Pathologic Fracture: A Unique Case Report Using a Curved-Needle Technique

Minimally invasive vertebroplasty has arisen as a viable alternative treatment for pathologic vertebral body fractures. Vertebroplasty is well documented in the thoracic and lumbar spine from the posterolateral approach, but is rarely employed in the cervical spine in consideration of numerous critical neural and vascular structures that must be avoided. Careful technique and usage of imaging is necessary to maneuver crucial structures and minimize risk of complication. In the posterolateral approach, the lesion has to lie in the trajectory of a straight needle, in the lateral aspect of the C2 vertebra. This approach may limit adequate treatment of lesions that are located more medially. We describe a unique case report of successful and safe posterolateral approach treatment of a destructive medial C2 vertebra metastatic lesion using a curved needle.

Combined Percutaneous Kyphoplasty/Pediculoplasty by Posterolateral Transpedicular Approach for Painful Cervical Spine Metastases: A Single-Center Prospective Study

Purpose

In patients requiring percutaneous kyphoplasty (PKP) for painful cervical spine metastases (PCSMs), the surgical approach is of utmost importance. Anterolateral and transoral routes are generally used at present, whereas PKP as well as percutaneous pediculoplasty (PPP) via posterolateral transpedicular approach (PTPA) has yet to be pursued in the treatment of PCSMs. The study was designed to evaluate safety and efficacy of PKP procedures combined with PPP via PTPA as treatment of PCSMs.

Patients and Methods

The patients with PCSMs were enrolled and housed in a database. The pain intensity of enrolled patients was gauged by Visual Analog Scale (VAS), ranging from 0 (none) to 10 (extreme). After preprocedural imaging assessment, combined PKP/PPP via PTPA was performed under the guidance of CT and fluoroscopic monitoring. Postprocedural VAS scores, complications, cement dosage, and hospitalization were recorded in the database for analysis. All cases were followed up for 6 months.

Results

Adult enrollees (7 women, 4 men) with PCSMs successfully underwent PKP/PPP via PTPA between February 2019 and January 2020, injected with 3.7±0.7 mL (range, 2.5-4.8 mL) of cement on average. Other than a single instance of asymptomatic cement leakage into paravertebral soft tissues, no complications ensued. Significant analgesic effects observed 24 hours after procedures were sustained for up to 6 months in follow-up surveys. Postprocedural hospitalizations were as brief as 2.2±0.8 days.

Conclusion

Combined PKP/PPP via PTPA is safe and effective as treatment of PCSMs, enabling quick pain relief and patient recovery.

Percutaneous vertebroplasty of the cervical spine performed via a posterior trans-pedicular approach

OBJECTIVES

Percutaneous vertebroplasty (PV) of the cervical spine has been traditionally performed with a trans-oral or antero-lateral approach. The posterior trans-pedicular approach (PTPA) has been sporadically reported. Therefore, the aim of this study is to retrospectively assess the technical feasibility, safety, and clinical outcomes of cervical PV performed with a PTPA.

METHODS

All consecutive patients undergoing PV in cervical levels with PTPA (under general anesthesia and computed tomography [CT] guidance) from January 2008 to November 2019 were identified. The following data were collected: patients' demographics; indication for PV; vertebral level features; procedure-related variables; and clinical outcomes including complications and pain relief.

RESULTS

Thirty-two patients (18 females, 14 males; mean age 61.1 ± 13.2 years, range 36-88) were included accounting for 36 vertebrae. Three vertebrae (3/36, 8%) were referred due to an underlying traumatic fracture, the remaining (33/36, 92%) due to a painful lytic tumor. Technical success was 97% (35/36 levels). Mean time required to deploy the trocar was 23 ± 11 min (range 7-60). Extra-vertebral asymptomatic cement leakage was observed in 3/35 (9%) vertebral levels. One patient (1/32, 3%) developed an acute cardiogenic pulmonary edema requiring admission in the intensive care unit; another patient (1/32, 3%) developed localized infection to the skin entry site, which was managed conservatively. At 1-month follow-up, the mean pain in the study population was 1.0 ± 1.1 (range 0-4/10) vs 6.2 ± 1.4 (range 4-9/10) at baseline (p < 0.05).

CONCLUSIONS

Cervical PV performed via a CT-guided PTPA is technically feasible, safe, and results in effective pain relief.

KEY POINTS

• Percutaneous vertebroplasty (PV) is a well-established technique for the treatment of benign and malignant compression fractures. • Common PV approaches used for cervical vertebrae include the trans-oral, antero-lateral, lateral, and sporadically the posterior trans-pedicular approach. • Retrospective analysis of our 11-year experience with the posterior trans-pedicular approach used for cervical vertebrae proved that such approach was safe and effective.

Percutaneous Treatments of Benign Bone Tumors

Benign bone tumors consist of a wide variety of neoplasms that do not metastasize but can still cause local complications. Historical management of these tumors has included surgical treatment for lesion resection and possible mechanical stabilization. Initial percutaneous ablation techniques were described for osteoid osteoma management. The successful experience from these resulted in further percutaneous image-guided techniques being attempted, and in other benign bone tumor types. In this article, we present the most common benign bone tumors and describe the available results for the percutaneous treatment of these lesions.

Percutaneous radiofrequency-targeted vertebral augmentation of unstable metastatic C2 and C3 lesions using a CT-guided posterolateral approach and ultra-high-viscosity cement

STUDY DESIGN

Case report.

OBJECTIVE

To report the first technical note describing radio frequency-targeted C2 and C3 vertebral augmentation using a posterolateral approach and high-viscosity cement.

SUMMARY OF BACKGROUND DATA

Percutaneous vertebral augmentation is a minimally invasive procedure used for stabilization and pain control in vertebral compression fractures. Its use in the cervical spine, especially the upper cervical spine, is very limited mainly due to technical challenges.

METHODS

We report the first use of an ultra-high-viscosity cement and posterolateral approach with computed tomography (CT) guidance and computed tomographic fluoroscopy in a patient with lytic lesions in C2 and C3 and a pathologic fracture of C2 for the purpose of stabilization and pain palliation.

RESULTS

Technically successful vertebral augmentation of the C2 and C3 vertebral bodies was achieved. There were no complications. The patient reported pain relief and improved range of motion after treatment and the hard cervical collar was removed.

CONCLUSION

Computed tomography-guided radiofrequency-targeted vertebral augmentation of the cervical spine using a posterolateral approach and ultra-high-viscosity cement is a technically feasible procedure that may be used in patients with advanced osteolytic cervical spine metastases who are not surgical candidates for the purpose of pain palliation and fracture stabilization.

LEVEL OF EVIDENCE

N/A.

C1-C2 pigmented villonodular synovitis and clear cell carcinoma: unexpected presentation of a rare disease and a review of the literature

INTRODUCTION

Pigmented Villonodular synovitis (PVNS) is a rare vertebral pathology--around 50 reports, only 3 concerning C1-C2 location.

CASE REPORT

A 64-year-old man, submitted to a right nephrectomy for a clear cell carcinoma, presented with an asymptomatic osteolytic C1-C2 lesion. Even though the diagnosis of metastatic disease was the most probable, the presence of a solitary lesion without other osseous or systemic localization and the predicted low risk of recurrence imposed a surgical biopsy. A pigmented villonodular synovitis diagnosis was made, a rare vertebral pathology--around 50 reports, only 3 concerning C1-C2 location. No further treatment was assigned precluding the iatrogenic consequences of empirical treatments based on clinical diagnosis with no histopathological support. The patient remains stable at 18 months of follow-up.

CONCLUSION

A large differential diagnosis should be made when the typical findings for metastatic disease are absent precluding the iatrogenic consequences of empirical treatments based on clinical diagnosis with no histopathological support.

The use of calcium phosphate cement in vertebroplasty of the base of odontoid process

The authors describe the use of bone cement containing calcium phosphate for vertebroplasty of the cavity in the base of odontoid process. A 23-year-old female patient was operated on by incision in lateral cervical area (anterior open access). After a blunt dissection, the working cannula (Kyphon) was introduced under fluoroscopic guidance through the C2 vertebral body to the cavity in the base of the odontoid process. Intraoperatively, biopsy of the lesion was taken and histo-pathological examination excluded the presence of neoplasm. The cavity, presumably haemangioma, was successfully filled with calcium phosphate bone cement KyphOsTM FS (Ky-phon). The proper filling without paravertebral cement leak was confirmed by postoperative computed tomography (CT). The CT and magnetic resonance imaging performed 9 months after the procedure showed that cement was still present in the cavity. This is the first use of calcium phosphate cement to conduct the vertebroplasty of C2 vertebra.

Percutaneous CT-guided vertebral bone biopsy in children

BACKGROUND

Few published series are dedicated solely to CT-guided vertebral bone biopsy in children.

OBJECTIVE

The objective of our study was to review the diagnostic yield of CT-guided vertebral bone biopsy in children.

MATERIALS AND METHODS

A retrospective review of 26 consecutive CT-guided vertebral bone biopsies during a 7-year period in 24 children (16 girls and 8 boys), mean age 8.8 years (range 1-16 years) was performed at our institution. Procedures were reviewed for diagnostic accuracy, biopsy location, complications and final diagnosis.

RESULTS

Twenty-five of 26 biopsies (96%) were technically successful. Twenty-one of 26 biopsies were diagnostic (81%); 2/26 (8%) were false-negative removing non-lesional tissue, 2/26 (8%) were nondiagnostic, and 1/26 (4%) was technically unsuccessful. The diagnoses were as follows: 12/26 biopsies (46%) were osteomyelitis, 3/26 (11%) biopsies were Langerhans cell histiocytosis, 3/26 biopsies (11%) were normal bone, 2/26 (8%) biopsies were malignant tumors, and 1/26 (4%) biopsies was osteoblastoma. There was one self-limited, procedure-related complication: a small right-sided pneumothorax occurred in the setting of attempting to create a protective extrapleural biopsy window.

CONCLUSION

Percutaneous CT-guided vertebral bone biopsy can be performed safely in children with a high degree of diagnostic accuracy.

Percutaneous vertebroplasty for treatment of osteolytic metastases of the C2 vertebral body using anterolateral and posterolateral approach

Percutaneous vertebroplasty (PVP) of C2 vertebral body is a challenging procedure. The aim of this retrospective study was to evaluate the feasibility, safety, and efficacy of PVP for the C2 osteolytic metastases using anterolateral and posterolateral approaches. Ten patients (8 male, 2 female) with C2 metastases were treated with PVP under local anesthesia. Anterolateral route was used under the guidance of fluoroscopy in 9 cases, and posterolateral route was used under the guidance of CT in 1 case. Pain intensity was scored on a scale ranging from 0/10 (no pain) to 10/10 (maximum pain intensity). The mean volume of cement injected was 3 +/- 0.8 mL (range, 2.0-4.0 mL), with average vertebral filling of more than 70%. Cement leakage was detected in 4 treated vertebrae. Pain improvement and spine stability were achieved in all patients. In conclusion, PVP of C2 using anterolateral approach is a feasible and minimal invasive procedure for treatment of patients with C2 osteolytic metastases. Posterolateral approach is a safe and effective option for PVP of C2 when hyperextension of the cervical spine is contraindicated or difficult to achieve.