gms | German Medical Science

Objective: Percutaneous vertebroplasty for metastatic destruction of the axis is effective but exhibits the hazard of cement leakage: Local compression of nerve roots and myelon or embolization of material into the vessels of the cranio-cervical junction with severe deficits and even fatal outcome are described in the literature. We describe alternative microsurgical procedure suitable for patients suffering from axis osteolysis who are considered to be at high risk of cement leakage.

Method: Seven patients presented with new onset of excruciating neck pain due to osteolytic destruction of the axis vertebra. Imaging with X-ray, CT and MRI showed osteolysis of the C2 body and destruction of the cortical bone layer. Pain control, stability and limited treatment with short hospital stay was the primary goal. An open treatment strategy via an antero-lateral approach was performed. Under biplanar fluoroscopic control the soft tumour tissue was resected out of the vertebral body through a drilled entry in the anterior wall using a forceps and a sharp spoon. After this excavation procedure the resection cavity was filled without pressure with bone cement. All patients received postsurgical local radiation therapy of the axis (40 Gy).

Results: In five patients the cancer was known before (2 prostate, 1 mamma, 1 lung, 1 kidney), while two patients presented with CUP. Mean age was 69 years and all patients suffered from severe spontaneous neck pain VAS 8.7 (range 7 to 10) with head-motion depending pain exacerbation.

Mean duration of the operative procedure was 50 minutes, there was no relevant blood loss (< 200 ml) and histology revealed diagnosis of cancer metastasis in all cases. On average 1.9 ml PMMA bone cement was placed within the vertebral body and no cement leakage was observed in postoperative CT and X-ray controls. Besides two cases of mild transient swallowing disturbances there was no approach or treatment related morbidity. Mean hospital stay was 5 days (range 3 to 7).

All patients experienced immediate pain relief at day 1 after the procedure (VAS 3,9; range 2 to 6) and further decrease of pain activity was observed at week 6 after completion of the radiation therapy (VAS 2,2; range 0 to 5).

Conclusions: In special cases of metastatic axis destruction with high risk of cement leakage a tumour excavation via a minimal invasive antero-lateral approach and subsequent bone cement filling of the resection cavity offers an effective and safe alternative to percutaneous approaches.