Open microsurgical tumor excavation and vertebroplasty for metastatic destruction of the second cervical vertebra—outcome in seven cases

Background contextMetastatic osteolytic involvement of the second cervical vertebra (C2) is rare, but usually very painful. Percutaneous vertebroplasty has shown to be effective regarding pain control, but carries the risk of cement leakage.PurposeTo describe an alternative microsurgical procedure suitable for patients suffering from C2 osteolysis who are considered to be high risk with respect to cement leakage.Study designA technical report.Patient sampleIt included seven patients.Outcome measuresThey include the assessment of clinical safety regarding approach- and procedure-related morbidity and radiologic safety regarding extravertebral cement leakage and the assessment of clinical efficacy by monitoring the pain activity using the visual analog scale (VAS).Materials and methodsSeven patients (five men, two women; mean age 70 years) presented with an acute onset of excruciating neck pain (VAS>6) due to osteolytic destruction of the axis vertebra. There was no neurologic deficit and no compression of the spinal cord preoperatively requiring surgical decompression or stabilization in any of the cases. An open treatment strategy via an anterolateral microsurgical approach was performed. Under biplanar fluoroscopic control, the soft tumor tissue was resected out of the vertebral body through a drilled entry in the anterior wall. After the excavation procedure, the resection cavity was filled with minimal pressure with polymethylmethacrylate bone cement.ResultsAll patients suffered from severe spontaneous neck pain (mean VAS 8.1, range 6–9), with head motion-dependent pain exacerbation despite high dose of opiates and fixation of the head with a brace.Mean duration of the operative procedure was 51 minutes. Histologic analysis revealed a diagnosis of cancer metastasis in all cases. On average, 1.9 mL cement was placed within the vertebral body, and no cement leakage was observed in postoperative computed tomography and X-ray controls. All patients experienced immediate pain relief at Day 1 after the procedure (mean VAS 4.0, range 2–6), and a further decrease of pain levels was observed at Week 6 after the completion of radiation therapy (mean VAS 2.0, range 0–5).ConclusionsIn cases of metastatic C2 destruction, tumor excavation via an anterolateral approach and subsequent filling of the resection cavity with bone cement offers a safe and effective alternative to percutaneous approaches.     

Vertebral compression fractures in patients under treatment with denosumab: a contraindication for percutaneous vertebroplasty?

Background contextDenosumab (XGeva) is a receptor activator of nuclear factor-κB ligand (RANKL)–antibody that was approved by the Food and Drug Administration (FDA) in 2010 for the prevention of skeletal fractures in patients with bone metastases from solid tumors. Although there is a widespread use of such drug in patients under risk of pathological fractures, the compatibility of denosumab therapy with percutaneous vertebroplasty (an interventional procedure commonly used for pain control in such population) has not yet been established.PurposeTo present the serial imaging findings and technical report of an attempted percutaneous vertebroplasty in a patient with refractory pain and a lytic pathological vertebral fracture related to small cell lung cancer spinal metastasis and who was actively under medical treatment with denosumab.Study designRetrospective review and case report.MethodsThe authors present the imaging findings and technical report of an attempted percutaneous vertebroplasty in the only patient found to be actively under treatment with denosumab after a retrospective review of the databank of patients with pathological fractures referred to the Department of Radiology of the Ohio State University for percutaneous vertebroplasty (a total sample of 20 patients) since the FDA approval of denosumab (November 2010) until June 2013 (a 30-month period).ResultsAlthough the computed tomography scan of the thoracic spine, performed 6 weeks after the initiation of the treatment with denosumab, presented a remarkable remodeling of the previously lytic vertebral lesion (which became markedly sclerotic in appearance), the clinical response in terms of pain improvement was not satisfactory. At the time of the percutaneous vertebroplasty (which was indicated for pain control), after advancing the 11-gauge needle through the pedicle with extreme difficulty, the needle repeatedly deviated laterally and, despite several attempts, it was not possible to penetrate the vertebral body and perform the cement injection.ConclusionsThis is the first report of the technical peculiarities of percutaneous vertebroplasty in patients under medical treatment with denosumab. According to our experience, because of its RANKL-mediated effects on osteoclasts activity, denosumab has been shown to induce a fast and marked sclerotic response on vertebral bodies that may not be accompanied by a satisfactory improvement in pain control (especially in patients with mechanical type of pain) and which may actually prevent the successful performance of percutaneous vertebroplasty. Therefore, it is of paramount importance that future studies evaluating patients with vertebral fractures under treatment with denosumab include long-term pain outcome measures. Additionally, further investigation is warranted to determine the optimal order of treatment and the best timeframe for combining percutaneous vertebroplasty and denosumab therapy in patients presenting with acute vertebral compression fractures and refractory axial pain.     

Bow hunter's stroke associated with atlantooccipital assimilation--case report

A 39-year-old male presented with bow hunter's stroke manifesting as repeated vertebrobasilar ischemic attacks induced by head rotation 45 degrees to the left. Three-dimensional computed tomography angiography clearly showed the occluded right vertebral artery (VA) between the axis and atlas. Single photon emission computed tomography study showed diffuse hypoperfusion of the brain stem and bilateral cerebellar hemispheres, suggesting hemodynamic compromise of these regions. He refused surgery and was treated conservatively. The most likely mechanism is that the affected VA was fixed by the ossification of the atlantooccipital membrane, vascular groove, and transverse foramen of the atlas, and therefore became elongated and compressed by head-turning.     

Minimally invasive vertebroplasty in the treatment of pain induced by spinal metastatic tumor

Spinal metastatic tumor is a common problem and represents a challenging problem in oncology practice. Patients with osteolytic metastases often suffer from intractable local and/or radicular pain. Percutaneous vertebroplasty is a minimally invasive, radiologically guided procedure whereby bone cement is injected into structurally weakened vertebrae to provide immediate biomechanical stability. Vertebroplasty is also used to relieve pain by stabilizing metastatically compromised vertebrae that are at risk of pathological burst fracture. In this retrospective study, a total of 57 patients (78 vertebrae) with spinal metastatic tumor were treated with PMMA vertebroplasty. The mean value of the visual analogue scale (VAS) was 8.1 +/- 0.67 preoperatively, and significantly decreased to 3.8 +/- 1.9 (1-8, p < 0.015) one day after vertebroplasty. The mean VAS value 6 months after vertebroplsty was 2.8 +/- 2.0 (p < 0.001). Mean injected bone cement amount in our study is 5.16 +/- 1.6 mL. The complication rate is about 21.8%, bone cement extravasation without neurological deficit is the most common complication. No new or adjacent vertebral fracture has occurred in more than 2 years follow-up. Percutaneous vertebroplasty is a minimally invasive procedure that offers a remarkable advantage of effective and immediate pain relief with few complications.     

Case of unifocal orbital langerhans cell histiocytosis in an adult

A 34-year-old man had a 3-month history of left upper eyelid swelling and pain. Computed tomography showed osteolytic lesion of the left frontal bone. Magnetic resonance imaging (MRI) revealed a mass lesion with heterogeneously gadolinium enhancement and extension to both the lateral orbit and the frontal base. We performed mass resection via left frontotemporal craniotomy to diagnose the lesion. Pathological findings of the specimen were Langerhans cell histiocytosis (LCH). Systemic investigations revealed no sign of the disease elsewhere. The patient was diagnosed with unifocal orbital LCH and received neither chemotherapy nor radiotherapy. Follow-up MRI has shown no recurrences 2 years after surgery. Although orbital LCH rarely occurs in adults, it should be considered in differential diagnosis of orbital tumor. The patients with unifocal orbital LCH required no treatment in addition to mass resection.     

A comparison between one- and two-fluoroscopic techniques in percutaneous vertebroplasty

Background  

Percutaneous vertebroplasty (PV) is generally performed under fluoroscopic guidance. Technically, single fluoroscope is considered sufficient for effectively monitoring PV. However, single fluoroscopic technique might be time-consuming in rotating the C-arm of the fluoroscope for either antero-posterior (AP) or lateral radiographic view, and causing delay in detecting cement leakage that can occur if the correct sight is not given. The aim of the current investigation was to compare the efficacy and safety of performing PV using one or two sets of fluoroscope.     

Herniated disc of lumbar spine caused by bone cement leakage after kyphoplasty – A case report and literature review

Introduction and importanceTo describe an unusual case with herniated disc caused by bone cement leaking to disc space after kyphoplasty.Case presentationWe reported a 72-year-old woman with L4 osteoporotic compression fracture. New-onset of left sciatica, numbness and intermittent claudication suffered her immediate after kyphoplasty. Herniated disc caused by bone cement leaking to disc space after kyphoplasty. The patient was post decompressive operation of L34 and the symptoms subsided well then.Clinical discussionPercutaneous vertebroplasty (PVP) was a common procedure today. Especially to back pain caused by osteoporotic fracture, reported pain relief rate was satisfactory. Current studies about bone cement leakage showed kyphoplasty less than vertebroplasty. However, for the mechanism and stress effect of balloon expansion, new weak points and cracks over endplate was created, which may cause bone cement leakage to disc space and related symptoms.ConclusionKyphoplasty was a common, effective and minimal invasive operation for patients with compression fracture of spine. Cement leakage to intervertebral disc space was generally asymptomatic, but it should be avoided as much as possible. The leakage could affect the stability and weight-bearing of spinal column. Accelerated degenerative process of disc would be found and newly herniated disc would be noted. It should be ceased the procedure when relative amount of bone cement leakage to disc space during kyphoplasty.     

经皮椎体成形术治疗脊柱转移癌

目的探讨经皮椎体成形术治疗脊柱转移癌的效果。方法对17例脊柱转移癌患者的共33个椎体进行椎体成形手术,观察其疗效及并发症。结果33个椎体均穿刺成功,每个椎体平均注入骨水泥3.5ml,4例发生渗漏,渗漏率为12.1%(4/33),术后患者疼痛迅速缓解,均恢复日常生活。结论椎体成形术是一种治疗脊柱转移癌的安全、有效的方法,止痛效果满意,可以明显提高患者的生活质量。     

Anterior decompression of persistent vertebral artery occlusion caused by the cervical facet joint originated osteophyte

BackgroundPersistent vertebral artery occlusion caused by compression of cervical facet joint originated osteophyte is exceptional rare. The authors sought to achieve adequate decompression of the vertebral artery (VA) with less stability decrease and movement restriction via the anterior approach, and to the authors'' knowledge, no case of anterior decompression of this condition has been reported, and combination of intraoperative indocyanine green (ICG) angiography in the setting of VA decompression is also rare.Case presentationA 77‐year‐old man presented continuous vertigo, unsteady gait and dysphagia with no relationship to the head movement. Preoperative computed tomography angiography (CTA) and digital substraction angiography (DSA) examination revealed the left vertebral artery was severely compressed at C_4‐5 level with approximately 95% occlusion due to a left C_4‐5 facet joint originated large osteophyte. Successful anterior decompression was performed without fusion and intraoperative ICG fluorescence angiography proved excellent blood flow. After surgery, vertebrobasilar insufficiency symptoms remarkably improved with no neurological deficits and no recurrence at 12 months'' follow‐up.ConclusionsThe authors'' therapeutic strategy of anterior decompression was successful in treating VA compression due to facet joint overgrowth with adequate exposure, no stability decrease and movement restriction, and lower rates of neck pain and blood loss.     

Stability of the metastatic spine pre and post vertebroplasty

OBJECTIVE: Vertebrae with lytic metastases have an elevated risk of burst fracture and resultant neurologic compromise. Prophylactic vertebroplasty has the potential to reduce pain and the risk of burst fracture in the metastatic spine. The purpose of this study was to quantify the ability of vertebroplasty to stabilize metastatically involved vertebrae against the risk of burst fracture initiation with a standardized model of vertebral metastases. METHODS: Metastases were simulated in eight fresh-frozen cadaveric thoracolumbar spinal motion segments by removing a central core of trabecular bone and filling the defect with tumor tissue. Specimens were tested under a physiologic level of axial compression, intact, with a simulated tumor and post-vertebroplasty, and ultimately tested to failure. Axial load induced canal narrowing (CN) was used as a measure of the risk of burst fracture initiation. Following testing, vertebrae were axially sectioned to visualize cement fill. RESULTS: Vertebrae with simulated metastases exhibited significantly higher CN than intact specimens (227%+/-109%; P<0.05). Post vertebroplasty, three vertebrae exhibited reduced CN compared with the simulated tumor configuration, whereas the other five had increased CN. Specimens with reduced CN were found to have cement posterior to the tumor, whereas specimens with an increase in CN had cement anterior and lateral to the tumor only. Percutaneous vertebroplasty is effective in decreasing CN if tumor is surrounded posteriorly with cement. However, injecting cement into the posterior third of the vertebral body is risky due to potential extravasation into the canal. CONCLUSION: Future work aimed at improving cement fill is necessary for safe and consistent stabilization of the metastatic spine with vertebroplasty.     

Gorham disease of the lumbar spine with an abdominal aortic aneurysm: a case report

Background contextReports of Gorham disease of the lumbar spine complicated by abdominal aortic aneurysms are rare.PurposeWe herein report the case of a patient with Gorham disease of the lumber spine involving an abdominal aortic aneurysm (AAA).Study designCase report.MethodsA 49-year-old man had a 1-month history of right leg pain and severe low back pain. Plain lumbar radiography revealed an osteolytic lesion in the L4 vertebral body. Computed tomography images demonstrated the presence of an extensive osteolytic lesion in the L4 vertebral body and an AAA in front of the L4 vertebral body.ResultsThe patient underwent mass resection, spinal reconstruction, and blood vessel prosthesis implantation. During surgery, it was found that the wall of the aorta had completely disappeared and was shielded by the tumor mass; therefore, we speculated that the mass in the lumbar spine had directly invaded the aorta.ConclusionsThe patient was able to walk without right leg or low back pain 1 year after undergoing surgery. No recurrence was demonstrated in the magnetic resonance images taken 1 year and 10 months after surgery.     

Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty.

Percutaneous vertebroplasty is a minimally invasive technique that is used to treat vertebral fractures, tumors and osteolytic vertebral metastases. However, cement leakage to the venous system is a potential source of serious complications after percutaneous vertebroplasty. We report a 65-year-old female patient who demonstrated cardiac perforation, pulmonary cement embolism, and tricuspid regurgitation, and these were all caused by venous leakage of polymethylmethacrylate as a complication of the procedure.     

Occlusion of the vertebral artery secondary to dissection of the subclavian artery--case report

A 34-year-old man presented with occlusion of the left vertebral artery (VA) secondary to dissection of the left subclavian artery manifesting as vertigo, nausea, vomiting, and neck pain. On admission, he was alert with left limb and truncal ataxia. Magnetic resonance (MR) imaging and MR angiography showed left cerebellar infarction and occlusion of the left VA. Conventional angiography and three-dimensional computed tomography (3D-CT) angiography showed stenosis with thrombosed pseudo-lumen of the left subclavian artery, and occlusion of the left VA. Presumably the idiopathic dissection of the left subclavian artery had reached the orifice of the left VA, and an embolism from the dissection had caused occlusion of the VA, leading to cerebellar infarction. After one month, he was discharged without severe neurological deficits. Idiopathic dissection of the subclavian artery is very rare. 3D-CT angiography is very useful for the diagnosis of arterial dissection.     

三种术式治疗骨质疏松性椎体骨折的疗效分析

目的 :探讨经皮空心带侧孔椎弓根钉钉道骨水泥强化术、经皮椎体成形术(percutaneous vertebroplasty,PVP)和经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗骨质疏松性椎体骨折(osteoporotic vertebral compression fractures,OVCF)的临床疗效。方法 :对2012年5月至2013年11月收治的90例OVCF患者的临床资料进行回顾性分析,按手术方法的不同将其分为经皮空心带侧孔椎弓根钉钉道骨水泥强化组(A组)、PVP组(B组)和PKP组(C组),每组30例。术前、术后1 d、3个月、1年采用疼痛视觉模拟评分法(visual analogue scale,VAS)对患者疼痛缓解程度进行评定;通过影像学资料观察责任椎的椎体压缩率、矢状面Cobb角的变化。结果:所有患者手术顺利,无切口感染、深静脉血栓等并发症。末次随访时A组中有2例患者术后留有轻度腰背痛;B组残留中度腰背痛7例,重度腰背痛4例,术后椎体再骨折2例;C组残留中度腰背痛5例,重度腰背痛3例,术后椎体再骨折4例。术后3组VAS评分、责任椎的椎体高度压缩率、Cobb角均较术前明显改善(P0.05)。术后1 d、3个月、1年各项目A组与B、C两组比较差异有统计学意义(P0.05),B组与C组比较差异无统计学意义(P0.05)。术后1 d、3个月、1年各项目在A组内差异无统计学意义(P0.05);在B组与C组内差异有统计学意义(P0.05)。结论:PVP和PKP对OVCF患者术后即刻止痛效果较经皮空心带侧孔椎弓根钉钉道骨水泥强化术明显,但PVP、PKP患者术后随访均残留不同程度腰背痛;经皮空心带侧孔椎弓根钉钉道骨水泥强化术在恢复责任椎前缘高度和矫正椎体后凸畸形、减少术后残余腰背痛方面具有明显的优势。     

Preliminary biomechanical evaluation of prophylactic vertebral reinforcement adjacent to vertebroplasty under cyclic loading

Background ContextPercutaneous vertebroplasty has become a favored treatment option for reducing pain in osteoporotic patients with vertebral compression fractures (VCFs). Short-term results are promising, although longer-term complications may arise from accelerated failure of the adjacent vertebral body.PurposeTo provide a preliminary biomechanical assessment of prophylactic vertebral reinforcement adjacent to vertebroplasty using a three-vertebra cadaveric segment under dynamic loads that represent increasing activity demands. In addition, the effects of reducing the elastic modulus of the cement used in the intact vertebrae were also assessed.Study Design/SettingThree-vertebra cadaveric segments were used to evaluate vertebroplasty with adjacent vertebral reinforcement as an intervention for VCFs.MethodsNine human three-vertebra segments (T12–L2) were prepared and a compression fracture was generated in the superior vertebrae. Vertebroplasty was performed on the fractured T12 vertebra. Subsequently, the adjacent intact L1 vertebra was prophylactically augmented with cement of differing elastic moduli (100–12.5% modulus of the base cement value). After subfailure quasi-static compression tests before and after augmentation, these specimens were subjected to an incrementally increasing dynamic load profile in proportion to patient body weight (BW) to assess the fatigue properties of the construct. Quantitative computed tomography assessments were conducted at several stages in the experimental process to evaluate the vertebral condition and quantify the gross dimensions of the segment.ResultsNo significant difference in construct stiffness was found pre– or postaugmentation (t=1.4, p=.19). Displacement plots recorded during dynamic loading showed little evidence of fracture under normal physiological loads or moderate activity (1–2.5× BW). A third of the specimens continued to endure increasing load demands and were confirmed to have no fracture after testing. In six specimens, however, greater loads induced 11 fractures: 7 in the augmented vertebra (2×T12, 5×L5) and 4 in the adjacent L2 vertebra. A strong correlation was observed between the subsidence in the segmental unit and the incidence of fracture after testing (r_Spearman's=?0.88, p=.002). Altering the modulus of cement in the intact vertebra had no effect on level of segmental compromise.ConclusionsThese preliminary findings suggest that under normal physiological loads associated with moderate physical activity, prophylactic augmentation adjacent to vertebroplasty showed little evidence of inducing fractures, although loads representing more strenuous activities may generate adjacent and peri-augmentation compromise. Reducing the elastic modulus of the cement in the adjacent intact vertebrae appeared to have no significant effect on the incidence or location of the induced fracture or the overall height loss of the vertebral segment.     

Self-designed posterior atlas polyaxial lateral mass screw-plate fixation for unstable atlas fracture

Background contextMost atlas fractures can be effectively treated nonoperatively with external immobilization unless there is an injury to the transverse atlantal ligament. Surgical stabilization is most commonly achieved using a posterior approach with fixation of C1–C2 or C0–C2, but these treatments usually result in loss of the normal motion of the C1–C2 and C0–C1 joints.PurposeTo clinically validate feasibility, safety, and value of open reduction and fixation using an atlas polyaxial lateral mass screw-plate construct in unstable atlas fractures.Study designRetrospective review of patients who sustained unstable atlas fractures treated with polyaxial lateral mass screw-plate construct.Patient sampleTwenty-two patients with unstable atlas fractures who underwent posterior atlas polyaxial lateral mass screw-plate fixation were analyzed.Outcome measuresVisual analog scale, neurologic status, and radiographs for fusion.MethodsFrom January 2011 to September 2012, 22 patients with unstable atlas fractures were treated with this technique. Patients' charts and radiographs were reviewed. Bone fusion, internal fixation placement, and integrity of spinal cord and vertebral arteries were assessed via intraoperative and follow-up imaging. Neurologic function, range of motion, and pain levels were assessed clinically on follow-up.ResultsAll patients were followed up from 12 to 32 months, with an average of 22.5±18.0 months. A total of 22 plates were placed, and all 44 screws were inserted into the atlas lateral masses. The mean duration of the procedure was 86 minutes, and the average estimated blood loss was 120 mL. Computed tomography scans 9 months after surgery confirmed that fusion was achieved in all cases. There was no screw or plate loosening or breakage in any patient. All patients had well-preserved range of motion. No vascular or neurologic complication was noted, and all patients had a good clinical outcome.ConclusionsAn open reduction and posterior internal fixation with atlas polyaxial lateral mass screw-plate is a safe and effective surgical option in the treatment of unstable atlas fractures. This technique can provide immediate reduction and preserve C1–C2 motion.     

Open dorsal vertebroplasty of the axis

Vertebroplasty of the axis is always a challenging procedure. We report the case of a young, HIV-positive patient suffering from an osteolytic metastasis of the axis. An open dorsal vertebroplasty was performed. A leakage of the cement formed a new cortical bone of the massa lateralis of C2, and stabilized the C1–C2 articulation by an arthrodesis-like effect. Durable pain relief and stabilization were obtained. The location of the cement, although atypical, had all desired effects of a conventional vertebroplasty. The intra-articular injection of cement into the facets for stabilization and pain relief could be considered in the future.     

Unicameral bone cyst in the spinous process of a thoracic vertebra

Unicameral bone cysts affecting the spine are extremely rare and tend to be misdiagnosed. We report on a 17-year-old female patient who presented with a 2-year history of persistent low back pain. The radiographic evaluation and bone scan failed to reveal a pathologic process. Magnetic resonance of the painful area and subsequent computed tomography scan showed a well-circumscribed osteolytic lesion originating from the spinous process and extending into both laminae of T9 vertebra. Aneurysmal bone cyst or osteoblastoma was considered to be the most probable diagnosis. The patient underwent excisional biopsy of the tumor. The intraoperative findings were suggestive of solitary bone cyst, a diagnosis that was confirmed histologically. Because the tumor had not invaded the articular facets, no posterolateral spine fusion was required. The patient had an unremarkable postoperative clinical course. Her symptoms resolved and she returned to her previous level of physical activities. Unicameral bone cysts, although uncommon, should be included in the differential diagnosis of an osteolytic lesion involving the spine.