Lytic Lesion of the C2 Body

History

The patient is a 71-year-old female with progressive neck pain. She has hypertension, and she previously had a cholecystectomy and a knee replacement.

Examination

She is neurologically intact with decreased neck range of motion.

Pre-treatment Images

 
Figure 1: Pre-treatment lateral x-ray showing destruction of the C2 body  

Figure 2A: Pre-treatment sagittal reconstruction CT scan showing destruction of the C2 body and preservation of the odontoid process 

Figure 2B: Pre-treatment axial CT scan showing destruction of the C2 body 

Figure 2C: Pre-treatment coronal reconstruction CT scan showing destruction of the C2 body and preservation of the lateral masses and C1-C2 articulations

Figure 3: Pre-treatment T1-weighted sagittal MRI showing no evidence of spinal cord compression

Diagnosis 

Pre-treatment work-up showed this to be an isolated lesion. A presumptive diagnosis of myeloma was made based on pre-operative testing confirming the presence of Bence Jones proteins, elevated serum protein electrophoresis, and an elevated ESR.

Selected Treatment 

The lesion did not compromise stabilility of the C1-C2 region, and the lateral mass articulations were well-preserved. The patient underwent an anterior C2 vertebroplasty augmented with an odontoid screw.

A standard right-sided anterior cervical approach was utilized, as described for odontoid screw fixation. A long blade right angle retractor was used to gain access to the C2 body, and the tumor was curetted.

Under fluoroscopic guidance, the odontoid screw was placed into the remaining intact dens. The screw was then removed, cement in the putty phase was placed into the C2 body, and the screw was then placed through the still-wet cement through the C2 body and into the dens as shown in the radiograph.

With the preserved odontoid, excellent fixation was achieved with the odontoid screw supplemented with the cement in the vertebral body. This method preserved neck range of motion.

Post-treatment Images

Figure 4: Post-treatment lateral radiograph (left) and open mouth radiograph (right) showing an anterior odontoid screw with C2 vertebroplasty

Outcome

The patient made a quick recovery and went on to have radiation. The lesion was very responsive to the post-operative radiation.

Case Discussion

This is an interesting case that is obviously a neoplastic lesion. The pre-operative workup is very important since the tissue diagnosis has potential ramifications for surgical options. The 2 main issues in most patients with spine tumors include the need for decompression and stabilization. İn this patient, the studies do not demonstrate any spinal cord compression, so it is primarily a case of achieving stability in the face of destruction of the C2 body.

The treatment by the author is a quite satifactory and creative way of achieving stability with an anterior approach only for this patient. Use of an odontoid screw typically requires an incision at the C5-C6 level. This low incision would make it difficult to do an open curettage of the tumor, so I will assume placement of the bone cement was done through a needle injection like a true vertebroplasty. Obviously, great care needs to be taken in these tumor patients to avoid extrusion of cement into the spinal canal. The odontoid screw provides a “steel-reinforced concrete” type of construct. Placement of the odontoid screw requires a stable dens that would not move during placement of the screw. Obviously in this patient, there was enough residual architecture of C2 to allow for this technique despite the tumor. The nice aspect of this surgical treatment option is that it does not need a posterior approach as well.

I do believe the diagnosis is important for choosing this treatment option. For a radio-sensitive tumor (such as myeloma), this technique works well, since residual tumors can be treated with radiation. However, if the tumor was radio-resistant (such as a chordoma), then an open curettage of the lesion might provide for a longer period of time before any local recurrence.

Alternative surgical treatment options would be anterior debridement with essential corpectomy at C2 followed by strut reconstruction from C1-C3 using a cage or allograft construct. Typically, however, this would require a secondary posterior instrumentation and fusion for adequate stability.