Transoral C2 biopsy and vertebroplasty

Abstract

Pathologic fractures involving the C2 vertebral body and odontoid process pose a unique dilemma, as the surgical approach for direct odontoid process screw fixation has several limitations. There have been a small number of transoral approach C2 vertebroplasty or kyphoplasty reported in the literature. Previous attempts were performed utilizing fluoroscopy or CT guidance. We report a case of a fluoroscopically guided transor-al approach vertebroplasty in a patient with a lytic lesion involving the C2 vertebral body, extending into the odontoid process with an underlying pathologic fracture. This case is unique as two separate punctures were required in order to adequately stabilize the pathologic fracture, CTA was performed preoperatively to better evaluate regional vasculature, and a post-procedure rotational flat panel CT was performed to assess cement placement.

Keywords: C2; biopsy; odontoid; pathologic fracture; spine; transoral; vertebroplasty.

Fig. 1.

Axial contrast enhanced CT image demonstrating a lytic lesion in the body of C2

Fig. 2.

Sagittal contrast enhanced CT image demonstrates the lytic lesion with extension into the odontoid process

Fig. 3.

Coronal contrast enhanced CT image identifying the retropharyngeal course of the right internal carotid artery

Fig. 4.

Color photograph shows the oral fixator in place with red rubber catheters retracting the uvula

Fig. 5.

AP and lateral fluoroscopic images demonstrate the 22-gauge, 5 inch spinal needle used for localization purposes (see also Fig. 6)

Fig. 6.

AP and lateral fluoroscopic images demonstrate the 22-gauge, 5 inch spinal needle used for localization purposes (see also Fig. 5)

Fig. 7.

Lateral fluoroscopic image with the 10-gauge trocar guide needle entering the body of C2

Fig. 8.

Lateral fluorscopic image during coaxial placement of the 12-gauge biopsy needle into the lytic lesion in C2

Fig. 9.

Lateral fluorscopic images during early PMMA injection

Fig. 10.

Lateral fluorscopic images during late PMMA injection

Fig. 11.

Lateral fluorscopic image demonstrating placement of the second 10-gauge trocar guide needle into the odontoid process

Fig. 12.

Lateral fluorscopic image during early PMMA injection through the second guide needle in the odontoid process

Fig. 13.

Sagittal flat panel MIP after completion of PMMA injection

Fig. 14.

Axial and sagittal conventional CT after procedure completion (see also Fig. 15)

Fig. 15.

Axial and sagittal conventional CT after procedure completion (see also Fig. 14)