Multiple Myeloma Treatment Challenges: A Case Report of Vertebral Artery Pseudoaneurysm Complicating Occipitocervical Arthrodesis and a Review of the Literature

Abstract

Multiple myeloma is a hematological neoplasm that frequently affects the spinal column. Less than a fifth of this vertebral involvement corresponds to the cervical spine and cranio-cervical junction. When there is instability or neurological involvement due to compression or deformity, approaches for anterior decompression and occipitocervical stabilization are required. The correct managment of vertebral artery aneurysm associated with occipitocervical arthrodesis requires extensive knowledge of anatomy and pathology. We present a case of a vertebral pseudoaneurysm that occurred late after the resection of a C1-C2 vertebral body multiple myeloma lesion managed with endonasal endoscopic approach and posterior occipitocervical arthrodesis as well as a systematic review of the related literature. The patient recovered well, without major neurological deficits.

Keywords: arthrodesis; cervical spine; endovascular treatment; multiple myeloma; spine oncology; surgical complication.

Figure 1. Sagittal (A, B) and axial (C) T2 sequence MRI shows vertebral bodies with heterogeneous signal and uptake throughout the entire spine secondary to multiple myeloma, with greater involvement at levels C1, C2, and C3. In this last segment, the infiltrative tissue involves adjacent paravertebral tissues and extends into the spinal canal, causing a narrow canal and compressing the adjacent spinal cord (C), which shows an increased signal, findings consistent with compression myelopathy. There is involvement of foramina and nerve roots bilaterally at levels C1-C2 and C2-C3. It presents as an osteodestructive lesion in the CT scan (D).

Figure 2. Representative Illustration of the main approaches in this case; via posterior, the occipitocervical fixation and screws can be seen (red line) and via anterior the trajectory of the endonasal endoscopic approach to the odontoid process is visible (dotted lines), as well as their relationship with the vertebral artery in the sagittal plane view.

Figure owned by Manuel Encarnacion Ramirez.

Figure 3. (A) Postoperative X-ray shows occipitocervical arthrodesis. (B) DSA shows a pseudoaneurysm in the V3 segment of the left vertebral artery (red arrow).

DSA: digital subtraction angiography

Figure 4. This illustration depicts the characteristics and localization of the vertebral artery pseudoaneurysm located between the segments V3; also the dilatation of the vessel is illustrated (inset image), including two layers of the vessel as injured layers (intima and media) with the consequent dilatation only of the adventitia layer, forming the pseudoaneurysm, causing a volumetric effect on the surrounding tissues, as well as its turbulent flow content.

Figure owned by Manuel Encarnacion Ramirez.

Figure 5. PRISMA flow diagram.