CT-Guided Percutaneous Vertebroplasty of the Upper Cervical Spine Via a Translateral Approach

Background: The clinical management of spinal hemangiomas and osteolytic metastases involving the upper cervical spine (C1-C3) is challenging. Symptoms vary from simple vertebral pain to progressive neurological deficits. Surgery and radiotherapy have been the treatment options for years. Surgery, however, can result in complications, such as hemorrhage, and may be counter-indicated when the treatment goal is primarily palliative due to multiple metastases, an unfavorable prognosis and/or a poor performance state. On the other hand, radiotherapy carries the risk of inducing secondary sarcomas or producing radionecrosis. Percutaneous vertebroplasty (PVP) was recently introduced as an alternative for treating patients in whom surgery and radiotherapy are counter-indicated. As of yet, there are few PVP case reports. Objective: This study aimed to evaluate the safety and efficacy of PVP using a computed tomography (CT)-guided translateral approach via the space between the carotid sheath and vertebral artery for hemangiomas or metastatic lesions at C1-C3 under local anesthesia. Study Design: CT-guided PVP was performed in 15 patients with hemangiomas or metastatic lesions at C1-C3 and clinical outcomes were evaluated. Setting: An interventional therapy group at a medical center in a major Chinese city. Methods: Fifteen consecutive patients had a total of 15 cervical vertebral bodies treated with CT-guided PVP via a translateral approach. The patients were followed up for a mean postoperative period of 8.3 months (range, 1-40 months). Pain status was assessed using a visual analog scale (VAS). The presence of complications was assessed preoperatively (baseline) and at 24 hours, 2 weeks, and one, 3, 6, 12 and 24 months postoperatively, or until the patient died or was lost to follow-up. Results: Fifteen consecutive patients were successfully treated with CT-guided PVP via a translateral approach. Their mean VAS score decreased from 7.7 ± 2.9 preoperatively to 1.4 ± 1.5 by the 24 hour postoperative time point, and was 1.2 ± 1.3 at 2 weeks, 1.2 ± 1.3 at one month, 1.4 ± 1.3 at 3 months, 0.6 ± 0.9 at 6 months, 0.3 ± 0.5 at 12 months, and 0 at 24 months after the procedure. The mean VAS score at all of the postoperative time points differed significantly from the preoperative baseline score (P < 0.05). No severe complications were observed. Mild complications included 2 cases (13.3%) of asymptomatic cement leakage into the epidural space, one case (6.67%) of anterior leakage from the vertebral body, and 2 cases (13.3%) of paravertebral leakage. Limitations: This was an observational study with a relatively small sample size. Conclusions: The safety and efficacy of CT-guided PVP using a translateral approach via the space between the carotid sheath and vertebral artery were demonstrated in patients with hemangioma or metastasis in the upper cervical spine. CT-guided PVP via a translateral approach should become a treatment option for such patients. Key words: CT-guided percutaneous vertebroplasty, upper cervical spine, translateral approach, hemangioma, osteolytic metastasis, pain