Transoral vertebroplasty results promising in treatment of second cervical vertebra

Anselmetti GC. Pain Phys. 2011. 2012;15;35-42

Transoral vertebroplasty yielded satisfactory results in patients with high-grade cervical pain due to “malignant involvement” of the second cervical vertebra, according to Italian researchers.

The researchers performed transoral vertebroplasty (TOV) on 25 consecutive patients — 16 women and nine men. These patients had failed consecutive therapies and did not have surgical indications.

Prospective evaluation occurred through follow-up and the patients underwent clinical interviews.

For the treatment, surgeons manually advanced a beveled vertebroplasty needle up to the posterior odontoid wall and injected bone cement under continuous digital fluoroscopic control. Patients left the hospital the next day after the procedure, according to the study authors.

Pain, as measured with the visual analog scale [VAS], analgesic requirement and use of external cast support were used to evaluate the efficacy of the procedure. The primary end point of the study was safety and efficacy 15 days postoperatively. Further follow-ups occurred at 1 month, 3 months, 6 months and every 6 months thereafter.

According to the study abstract, the median VAS scores dropped significantly from 8 points preoperatively to 0 postoperatively. The investigators found that 20 patients (80%) achieved complete pain relief within 15 days postoperatively. Differences in preoperative and postoperative analgesic therapy use were reported as “significant,” with 23 patients (92%) no longer needing to use a cervical cast.

“At median overall follow-up of 16 months, the projected proportion of patients free from worsening pain at 6, 12 and 24 months was 96%, 96% and 92% respectively,” the authors wrote.

This is a useful article describing the treatment of painful malignancies involving the C2 vertebral body in 25 patients by percutaneous vertebral augmentation. The indications are relatively rare. A more standard approach for treating the pain and/or instability would be posterior stabilization and fusion, perhaps accompanied with transoral debridement and possible "stabilization". This traditional technique has relatively high associated morbidity including infection, blood loss, prolonged healing, etc., in addition to the medical consequences related to anesthesia, positioning, etc.

The technique described involves transoral/transmucosal injection of PMMA through a needle into the involved C2 vertebral body. The authors’ list potential complications, but few occurred with very little leakage of cement, low infection rate, and significant decrease in pain. In the thoraco-lumbar vertebroplasty literature for malignancies there is a relatively high rate of cement leakage, and yet in this very small area (C2) there were little observed, which is confusing; but it appears reliable as the authors used post-op CT for evaluation. Additionally, it would seem difficult to fill C2 and the odontoid through this technique. Yet, the CT scan they show demonstrates nearly a complete fill of C2 and the odontoid.

The article is clear and impressive. It has been described by others, but not with this number of patients. It is a useful technique that should be considered in appropriate patients.

— Steven R. Garfin, MD
Professor and chair
Department of Orthopaedic Surgery at the University of California San Diego