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Transoral Approach to Cervical Vertebroplasty for Multiple Myeloma

¹ Department of Radiology, Emory University, 1364 Clifton Rd. N.E., Atlanta, GA 30322.
² Department of Neurosurgery, Emory University, Atlanta, GA 30322.

Received November 22, 1999; accepted after revision April 12, 2000.

 
Address correspondence to F. C. Tong.

Introduction

Top Introduction Subject and Methods Results Discussion References

 
Percutaneous vertebroplasty is being used increasingly to treat patients with painful compression fractures from osteoporosis, osteolytic metastasis, and multiple myeloma [1, 2]. This technique consists of percutaneous needle placement into the vertebral body followed by injection of opacified methylmethacrylate polymer under fluoroscopic guidance, resulting in reduction of pain and strengthening of the bone [1, 2]. In the thoracic and lumbar spines, the needle is placed primarily using a transpedicular approach. This is not possible in the upper cervical spine where the cervical pedicles are small, with the vertebral arteries in close proximity. A paravertebral approach is risky because vascular, nervous, and pharyngeal structures block access to the vertebral body. High cervical vertebral bodies may be treated with vertebroplasty using an inferior anterolateral approach, which involves placing a needle under the mandible. The needle is then directed cephalad and anteromedially into the vertebral body with manual traction of the adjacent vascular and nervous structures [2]. This approach is relatively difficult at the C2 level. We describe a case in which a transoral approach was used to perform vertebroplasty at C2 in a patient with multiple myeloma.

Subject and Methods

Top Introduction Subject and Methods Results Discussion References

 
A 76-year-old woman was initially diagnosed in 1988 with multiple myeloma involving the C2 and T4 vertebral bodies. She was successfully treated with chemotherapy and radiotherapy at an outside institution, with resulting disappearance of her Bence Jones proteins. The patient later presented with symptoms of upper cervical spine pain, which were reliably reproduced with manual palpation of the C2 spinous process and axial loading. She had no focal neurologic symptoms, and current outside MR images and CT scans showed an extensive osteolytic tumor of the C2 vertebral body and dens (Fig. 1A). The patient was placed in a hard cervical collar by her neurosurgeon, who thought the vertebra was sufficiently weakened to warrant a stabilizing procedure. Pain relief with fortification of the vertebral body with polymethylmethacrylate injection was considered in an effort to avoid extensive and invasive cervical stabilization surgery. After the neurosurgeon consulted the patient, a decision was made to perform vertebroplasty of the C2 lesion via a transoral approach to provide pain relief and to improve stability.

View larger version (184K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —76-year-old woman with previously treated multiple myeloma who presented with upper cervical spine pain and instability. Coronal T1-weighted MR image of upper cervical spine shows extensive signal abnormality within body and dens of C2.

The patient was premedicated with IV antibiotics (1 gm of vancomycin hydrochloride and 100 mg of gentamycin immediately before the procedure). General anesthesia was administered with placement of a flexible reinforced endotracheal tube. A self-retaining pharyngeal retractor (Dingman; V. Mueller, Cleveland, OH) was then placed for tongue depression and displacement of the endotracheal tube from the sterile field (Fig. 1B). An 18-French Foley catheter was passed through the nasopharynx into the oropharyngeal cavity and sutured to the uvula with 2-0 silk. Gentle elevation of the soft palate was achieved with retraction of the Foley catheter. The oral cavity and posterior oropharynx were then cleansed with povidone-iodine, and the overlying areas were draped.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —76-year-old woman with previously treated multiple myeloma who presented with upper cervical spine pain and instability. Frontal photograph of Dingman retractor (Dingman; V. Mueller, Cleveland, OH) shows semirigid endotracheal tube positioned below tongue retractor. Uvula is sutured to Foley catheter, which has been retracted for access to posterior oropharynx.

With biplane fluoroscopy, the osteolytic C2 lesion was seen in the anteroposterior and lateral planes. A disposable 11-gauge bone biopsy needle (Jamshidi; MD Tech, Northbrook, IL) was placed through the posterior oropharyngeal wall into the mid C2 vertebral body under fluoroscopic guidance. Polymethylmethacrylate cement was prepared in the previously described way, including the addition of 1.2 g of tobramycin to the mixture [1].

Four milliliters of thin (pancake batter consistency) polymethylmethacrylate was carefully injected under fluoroscopic guidance, thereby filling the C2 vertebral body and dens (Fig. 1C). The Jamshidi needle was then removed, the suture in the Foley catheter and uvula was cut, and the catheter and Dingman retractor were removed. The patient was awakened from anesthesia and underwent extubation, and unenhanced CT of the upper cervical spine showed satisfactory placement of polymethylmethacrylate in the C2 vertebral body and dens (Fig. 1D). The patient received one dose of 750 mg of IV vancomycin hydrochloride in addition to 1 g of IV aztreonam every 12 hr.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —76-year-old woman with previously treated multiple myeloma who presented with upper cervical spine pain and instability. Frontal radiograph reveals placement of 11-gauge Jamshidi needle (MD Tech, Northbrook, IL) in C2 vertebral body. Note injection of opacified polymethylmethacrylate mixture.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —76-year-old woman with previously treated multiple myeloma who presented with upper cervical spine pain and instability. Coronal reformatted CT scan shows polymethylmethacrylate placement in body and dens of C2, which corresponds to areas of signal abnormality seen on A.

Results

Top Introduction Subject and Methods Results Discussion References

 
Six hours after the procedure, the patient had significant reduction in upper cervical spine pain and no significant pharyngeal pain. Twenty-four hours after the procedure, the patient was pain free and was discharged. A 5-day course of 150 mg of oral clindamycin every 6 hr was prescribed. The patient's local physician discontinued the cervical collar 3 days after discharge, and 6 months after discharge the patient was free of pain and infection.

Discussion

Top Introduction Subject and Methods Results Discussion References

 
High cervical spine lesions have been treated with vertebroplasty using the anterolateral approach [2]. This approach requires manual retraction of the carotid artery and jugular vein, with placement of the needle between the vessels and the pharyngolarynx. The needle path originates below the mandible, ascending in the medial direction. This approach places many neurovascular structures at risk, requiring navigation of the needle around the vagus, spinal accessory, lingual, hypoglossal, marginal, and laryngeal nerves, in addition to the internal jugular vein and vertebral and carotid arteries [3]. Our patient was treated along a direct path using the transoral approach through the posterior oropharynx.

Anatomically, only a thin layer of pharyngeal constrictor muscles, pharyngobasilar fascia, and anterior longitudinal ligament separates the posterior oropharyngeal mucosa from the upper cervical spine. The transoral surgical approach has been used in both otolaryngologic and neurosurgical procedures to reach abnormalities at the craniocervical junction. Adequate surgical exposure can be obtained from the mid clivus from C2-C3 using the transoral approach [4]. This approach is used to treat a variety of extradural (tumor, rheumatoid disease, atlantoaxial instability) and intradural (posterior circulation aneurysms, schwannomas) processes.

Historically, infection has been one of the primary concerns with transoral surgical techniques, with documented complications including pharyngeal wound breakdown, meningitis, vertebral artery injuries, and cerebrospinal fistulas. Overall, the rate of infection in transoral surgery has declined in recent years, which may coincide with improved antibiotic therapies. In 1964, Fang et al. [5] described six cases of transoral C1-C2 surgery, with four patients developing pharyngeal wound infections and one patient ultimately dying from encephalomeningitis. More recent reports list the risk of wound infection at between 0% and 2% [4, 6, 7] and the risk of meningitis at 4.5% [7] for cervicovertebral spine surgery.

Transoral vertebroplasty may have a lower infection rate than transoral surgery given minimal disruption of the posterior oropharyngeal tissues by the needle. The transoral approach allows precise placement of the needle into the C2 vertebral body in a controlled and direct fashion using biplane fluoroscopy, which minimizes needle excursion. This effectively eliminates the risk of neurovascular complications. No cases of infection with vertebroplasty have been documented to date [1]. Our patient was treated with perioperative and postoperative antibiotics for infection prophylaxis, and the posterior oropharynx was prepped with povidone-iodine. In addition, tobramycin was added to the polymethylmethacrylate mixture to minimize the risk of infection, as previously described [1].

The transoral surgical approach has been recognized as a safe and effective method of surgically treating patients with selected craniocervical conditions. Although this method requires intubation of patients with potentially unstable cervical spines, the safety of orotracheal intubation with manual cervical stabilization [8, 9] or fiberoptic intubation [10] has been documented in patients with unstable cervical fractures. Vertebroplasty has been shown to be beneficial for pain control and stabilization of multiple conditions, including osteoporotic fracture, metastasis, aggressive hemangioma, and multiple myeloma. The benefits of transoral vertebroplasty include precise needle placement and decreased risk to adjacent neurovascular structures. In this case, transoral access to the C2 vertebral body with adequate cementation resulted in complete pain relief and stabilization of the vertebra.

References

Top Introduction Subject and Methods Results Discussion References

 

1. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR 1997;18:1897 -1904[Abstract]
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5. Fang HS, Ong GB, Hodgson AR. Anterior spinal fusion: the operative approaches. Clin Orthop 1964;35:16 -33[Medline]
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