Reconstruction of C-1 lateral mass with titanium mesh cage after resection of an aneurysmal bone cyst of the atlas

Reconstruction of C1 lateral mass with an expandable cage in addition to vertebral artery preservation: presenting two cases

PURPOSE

C1 lateral mass reconstruction is recommended, in cases of instability caused by tumor involvement or extensive C1 lateral mass resection. However, because of the anatomical complexity of the area and, most importantly, the proximity to vertebral arteries, few cases of reconstruction have been reported to date. The purpose of this report is to present technical details of C1 lateral mass reconstruction in conjunction with vertebral artery preservation from a posterior approach.

METHODS

Two cases of one stage craniovertebral junction instrumentation and C1 lateral mass reconstruction in conjunction with vertebral artery preservation from a posterior approach are presented.

RESULTS

In both cases of extensive resection of lateral mass due to tumor involvement, an expandable cage was used for C1 lateral mass reconstruction, which has been used only in one patient in literature. Complementary pathological examinations of the two cases indicated two rare tumors that had been reported in the upper cervical region so far. The first case became an unknown origin metastatic cancer and the second was reported to be a primary non- Hodgkin lymphoma.

CONCLUSIONS

C1 lateral mass reconstruction with an expandable cage together with VA preservation is recommended in cases of extensive C1 lateral mass resection to increase the total strength and to shorten the length of the posterior device and probably better fusion. The expandable cage is preferred because of safer placement under compression instead of the lateral mass.

Reconstruction of the cervical lateral mass using 3D-printed prostheses

Objective

This study aimed to investigate the outcome of using 3-dimensional (3D)-printed prostheses to reconstruct a cervical lateral mass to maintain cervical stability.

Methods

We retrospectively analyzed data of 7 patients who underwent cervical lateral mass reconstruction using a 3D-printed prosthesis, comprising axial and subaxial lateral mass reconstruction in 2 and 5 patients, respectively. Bilateral mass was reconstructed in 1 patient and unilateral mass in the remaining 6 patients.

Results

Using a 3D-printed lateral mass prosthesis, internal fixation was stable for all 7 patients postoperatively. No implant-related complications such as prosthesis loosening, displacement, and compression were observed at the last follow-up.

Conclusion

Reconstruction of the lateral mass structure is beneficial in restoring load transfer in the cervical spine under physiological conditions. A 3D-printed prosthesis can be considered a good option for reconstruction of the lateral mass as fusion was achieved, with no subsequent complications observed.

Denosumab: a potential treatment option for aneurysmal bone cyst of the atlas

PURPOSE

Aneurysmal bone cysts (ABCs) of spine are conventionally treated with en-bloc resection or intralesional excision/curettage and reconstruction or filling of defects with bone cement. For the treatment of upper cervical ABCs, en-bloc resections are often not desirable considering the risk/benefit ratio while the risk of recurrence after intralesional excision is high. Hence, alternative management options are often necessary. We describe our clinical experience with one such treatment alternative-denosumab for the treatment of ABC of Atlas.

METHODS AND RESULTS

We present a case of 16-year-old boy who presented with neck pain and restriction of neck movements. A large lytic lesion with multiple fluid-fluid interfaces involving vertebral arch of atlas was identified on further imaging. There was destruction of right lateral mass and the lesion was found encasing the right vertebral artery. Core needle biopsy confirmed the diagnosis of ABC. With no visible CT response after first session of intra-lesional injection of Calcitonin and Methylprednisolone, the patient was treated with denosumab (120 mg SC once-a-month) for a period of 12 months. His symptoms resolved within 7 months of onset of treatment and serial CT scans over 12-month treatment period showed complete ossification of the lesion. Further there was no evidence of recurrence at 12 months after completion of treatment.

CONCLUSION

Our case report contributes to the accruing evidence on the effectiveness of denosumab for the treatment of spinal ABCs. However, long-term safety, risk of recurrence, optimal duration of treatment and consistency of denosumab are yet to be determined.

Use of Intraoperative Navigation for Reconstruction of the C1 Lateral Mass After Resection of Aneurysmal Bone Cyst

BACKGROUND

Aneurysmal bone cysts (ABCs) are rare blood-filled cystic lesions that are found in the long bones and spine. Here, we present a case of an ABC found in the lateral mass and lamina of C1. Lesions in this area provide a surgical challenge because of its difficulty to access as well as its need for reconstruction. We describe a novel use of intraoperative navigation (ION) to assist in the placement of a C1 lateral mass titanium cage.

CASE DESCRIPTION

An 18-year-old female patient presented with headaches and progressive neck pain. Imaging revealed a large cystic lesion involving the C1 lamina and right lateral mass. The patient underwent ION-assisted aggressive intralesional resection of the ABC and reconstruction of the C1 lateral mass with a static titanium cage, supplemented with posterior fusion from the occiput to C3. At 2-year follow-up, there was no evidence of recurrence and the hardware remained intact.

CONCLUSIONS

ION is a useful aid in assessing the extent of tumor resection and performing cage reconstruction of the C1 lateral mass.

Bilateral C-1 lateral mass reconstruction following radical resection of a giant osteoblastoma of the atlas: case report

Osteoblastoma is a rare, benign, osteoid-producing, and slow-growing primary bone tumor, typically arising in long bones or in the spine, with a slight male predominance. This report describes the surgical treatment of a giant C-1 (atlantal) osteoblastoma diagnosed in a young male patient with neurofibromatosis Type 1. The authors describe the clinical presentation, the surgical procedure for complete excision and stabilization, and results as of the 1-year follow-up. They detail a bilateral occipitoaxial spinal interarticular stabilization technique that they used after complete tumor excision. To the best of their knowledge, this is the first case of bilateral C-1 lateral mass reconstruction by this technique to be reported in the literature.

Reconstruction of the C-1 lateral mass with a titanium expandable cage after resection of eosinophilic granuloma in an adult patient

Spinal involvement occurs frequently in cases of eosinophilic granuloma (EG), but surgical treatment is limited primarily to those with spinal instability. Involvement of the cervical spine is rare, but primarily occurs in the vertebral bodies, and is normally amenable to anterior corpectomy and spinal reconstruction. The authors describe a 27-year-old man with pathologically proven EG who presented with complete destruction of the C-1 lateral mass requiring spinal stabilization. A titanium expandable cage was used to reconstruct the weight-bearing column from the occipital condyle to the superior articular surface of C-2 from a posterior approach, with preservation of the traversing vertebral artery. To the authors' knowledge, this is the first reported instance of reconstruction of the C-1 lateral mass using an expandable metal cage, which facilitated preservation of the vertebral artery.

Diagnosis of an aneurysmal bone cyst of the cricoid cartilage: A case report

An aneurysmal bone cyst (ABC) is a type of reactive reparative bone neoplasm that rarely occurs in the head and neck. To date, only a small number of cases have been previously reported. The present study reports the case of a 58-year-old male who presented with a tumor in the laryngeal cricoid cartilage, a rare position for a tumor, who subsequently underwent treatment by surgical resection. Based on the observations of the present study and a literature review, it was concluded that an ABC of the larynx can be identified based on a combination of radiology and postoperative histopathology examinations. However, following a tracheotomy and excision, the difficulty of performing tracheal cannula removal is inevitable. The present study described in detail a rare disease, ABC, occurring in the larynx. More cases are required for follow-up studies.

Fusion following lateral mass reconstruction in the cervical spine

OBJECT

Recently, aggressive surgical techniques and a push toward en bloc resections of certain tumors have resulted in a need for creative spinal column reconstruction. Iatrogenic instability following these resections requires a thoughtful approach to adequately transfer load-bearing forces from the skull and upper cervical spine to the subaxial spine.

METHODS

The authors present a series of 7 cases in which lateral mass reconstruction with a cage or fibular strut graft was used to provide load-bearing support, including 1 case of bilateral cage placement.

RESULTS

The authors discuss the surgical nuances of en bloc resection of high cervical tumors and explain their technique for lateral mass cage placement. Additionally, they provide their rationale for the use of these constructs throughout the craniocervical junction and subaxial spine.

CONCLUSIONS

Lateral mass reconstruction provides a potential alternative or adjuvant method of restoring the load-bearing capabilities of the cervical spine.

Occipitoaxial spinal interarticular stabilization with vertebral artery preservation for atlantal lateral mass failure

The treatment of craniocervical instability caused by diverse conditions remains challenging. Different techniques have been described to stabilize the craniocervical junction. The authors present 2 cases in which tumoral destruction of the C-1 lateral mass caused craniocervical instability. A one-stage occipitoaxial spinal interarticular stabilization (OASIS) technique with titanium cages and posterior occipitocervical instrumentation was used to reconstruct the C-1 lateral mass and stabilize the craniocervical junction. The ipsilateral vertebral artery was preserved. The OASIS technique offers single-stage tumor resection, C-1 lateral mass reconstruction, and stabilization with a loadsharing construct. It could be an option in the treatment of select cases of C-1 lateral mass failure.

Occipitocervical reconstruction through direct lateral and posterior approach for the treatment of primary osteosarcoma in the atlas: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a new surgical technique of the primary cervical osteosarcoma in the atlas.

SUMMARY OF BACKGROUND DATA

Primary osteosarcoma of the atlas is extremely rare. This is the first report that describes a surgical treatment of the primary osteosarcoma in the atlas. Resection of an osteosarcoma in the atlas is very difficult because of the complex and important anatomic structures that surround it, and secure reconstruction of the atlas is difficult as well.

METHODS

A 48-year-old man was referred to our institute with a 10-month history of a palpable painful mass on the right posterior neck. His neck mass was diagnosed as chondroblastic osteosarcoma by open bone biopsy. The plain radiograph of the lateral cervical spine revealed the osteoblastic lesion of the vertebra and an extraosseous mass formation from the C1 to C3 vertebrae. Computed tomography of the cervical spine revealed approximately a 7 × 3 × 7 cm-sized extraosseous calcified mass that originated from the right lateral mass of the atlas. The magnetic resonance imaging of the cervical spine did not show any spinal cord compression.

RESULTS

The patient underwent excision of this tumor using the direct lateral approach and reconstruction of the lateral mass of the atlas. On gross examination of the mass, there was a reactive thin membrane ("pseudomembrane") between soft tissue and tumor. At 3 months after surgery, the computed tomographic scan showed the solid fusion state of the occipitocervical joint. He rarely complained of any problems except for mild limitation of neck motion.

CONCLUSION

We report a rare case of complete excision of an osteosarcoma of the C1 lateral mass in our patient via a direct lateral and posterior approach to secure additional fixation of occipitocervical joint. We describe our technique for reconstructing the lateral mass of the atlas. This reconstruction technique will also be applicable to other resection surgeries involving the occipitocervical junction.

Tumours of the atlas and axis: a 37-year experience with diagnosis and management

PURPOSE

This paper presents a single institution's longterm experience regarding the incidence and management of tumours of the atlas and axis and discusses clinical and imaging findings and treatment options.

MATERIALS AND METHODS

We searched the registry of the Istituto Ortopedico Rizzoli for patients admitted and treated for tumours of the upper cervical spine. We identified 62 patients over 37 years, from July 1973 to October 2010. There were 39 male and 23 female patients, with a mean age of 39.5 (range 5-77) years. For each patient, we collected data on clinical presentation, imaging and treatment. Mean follow-up was 10 years.

RESULTS

Benign bone tumours were diagnosed in 24 (39%) and malignant tumours in 38 (61%) patients. The most common tumours were bone metastases, followed by osteoid osteomas and chordomas. The atlas was involved in six and the axis in 52 patients; in four patients, both the atlas and axis were involved. The most common clinical presentation was pain, torticollis, dysphagia and neurological deficits. Surgical treatment was performed in 35 patients and conservative treatment, including intralesional methylprednisolone injections and halo-vest immobilisation with or without radiation therapy, chemotherapy or embolisation, in the remaining patients. One patient with osteoblastoma of the atlas had local recurrence. All patients with metastatic bone disease had local recurrence; four of the eight patients with plasmacytoma progressed to multiple myeloma within 1-4 years. All patients with chordomas had two to four local recurrences. Patients with osteosarcomas and chondrosarcoma died owing to local and distant disease progression.

CONCLUSIONS

Bone tumours of the cervical spine are rare. However, they should be kept in mind when examining patients with neck pain or neurological symptoms at the extremities. In most cases, only intralesional surgery can be administered. Combined radiation therapy and chemotherapy is indicated for certain tumour histologies.

Atlantoaxial stabilization utilizing atlas translaminar fixation

Atlantoaxial instability is a potentially devastating sequela of tumor invasion to the upper cervical spine. We aim to report an alternative technique for atlantoaxial stabilization. Stabilization is technically demanding due to limited bony elements and proximity of the regional neurovascular structures. While the C1 lateral masses are considered robust points of fixation, one or both of these structures may be destroyed by pathology. A 54-year-old female presented with a lytic, metastatic lesion to one of the C1 lateral masses, which precluded its use for fixation. We utilized the contralateral hemilamina of the atlas for screw fixation and devised a stable construct that provided immediate stability. Thus, atlas translaminar fixation is a feasible option when the lateral masses cannot be utilized.