A novel multimodal approach to C2 vertebroplasty in the setting of osteolytic metastases: A case report

Abstract

Image-guided vertebral augmentation effectively treats pathologic vertebral lesions, though managing pathology in the cervical spine presents unique challenges. Posterolateral approaches, while safer, require prone positioning that may not be feasible for all patients. Open anterolateral and transoral approaches increase infection risk and typically require general anesthesia. We present a novel multimodal anterolateral approach using ultrasound, fluoroscopy, and cone-beam CT for percutaneous C2 vertebral augmentation in a patient with metastatic lesions. A 72-year-old man with multiple myeloma presented with a C2 vertebral body lytic lesion at high risk for dislocation. Due to presence of a stabilizing cervical collar and the risk associated with prone positioning, vertebral augmentation access was limited. With the patient in supine position, we utilized cone-beam CT with overlay guidance to plan a right lateral trajectory. Ultrasound identified vital vasculature, enabling targeted hydrodissection to create a safe access path with real-time image-guidance. An 11G trocar needle was advanced under ultrasound guidance, with intermittent cone-beam CT adjustments to ensure precise placement. After confirming access to the right lateral mass of C2 via fluoroscopy, 3.5cc of PMMA cement was successfully injected without extravasation. The patient experienced no complications or neurologic deficits on follow-up and was cleared to remove the cervical collar 10 days postprocedure. This case demonstrates the feasibility and efficacy of a multimodal anterolateral approach for C2 vertebral augmentation when conventional approaches are contraindicated. By integrating ultrasound-guided hydrodissection with advanced imaging, this technique offers a safe alternative for anatomically constrained patients while avoiding the risks associated with traditional approaches.

Keywords: C2; Cervical; Multimodal; Vertebral augmentation; Vertebroplasty.

Fig. 1

Noncontrast coronal (A) and sagittal (B) CT of the cervical spine demonstrates a large, expansile lytic C2 lesion with potential for pathologic fracture and spinal instability.

Fig. 2

Cone beam CT with biopsy guide delineates the planned trajectory for trocar placement, showing a safe anterolateral percutaneous window from the skin surface to the lateral mass of C2 vertebral body while avoiding critical vasculature. This planning was critical for avoiding vascular injury.

Fig. 3

Ultrasound of the right neck with color doppler (A) demonstrates the carotid artery (arrow), vertebral artery (arrowhead) and C2 vertebral body (star). Ultrasound-guided hydrodissection was performed (B) with a micropuncture needle (arrow) to help widen the percutaneous window for safe trocar placement into the C2 vertebral body. This technique was essential for creating a safe corridor between major vessels.

Fig. 4

Cone beam CT was performed to confirm trocar placement following initial insertion under ultrasound guidance (A) and biopsy guidance was then used for incremental re-adjustment of the trocar, to safely progress the needle further into the C2 vertebral body (B and C). These sequential imaging steps ensured precise needle positioning before cement delivery.

Fig. 5

Coronal fluoroscopic images demonstrate access to C2 vertebral body (A) followed by insertion of the cannula (B) prior to cement injection. Real-time fluoroscopy allowed for continuous monitoring of needle position relative to bony landmarks.

Fig. 6

Coronal (A) and Sagittal (B) fluoroscopic spot films of the cervical spine status post C2 cementoplasty demonstrate 3.5cc of radio-opaque PMMA cement within the vertebral body, without evidence of clinically significant extravasation. Note the confined distribution of cement without leakage into dangerous spaces.