| Home | E-Submission | Sitemap | Contact Us |  
The Nerve > Volume 5(1); 2019 > Article
Kim, Yoon, Kwon, and Gwak: Transoral Vertebroplasty for Osteolytic C2 Metastasis: Report of 2 Cases


Herein we reported 2 cases of vertebroplasty (VP) via the transoral route for osteolytic painful odontoid (C2) metastasis from non-small cell lung cancer. A 52-year-old man, who was diagnosed with non-small cell lung cancer a year ago, presented neck pain, which was aggravated on swallowing in September, 2015. Neuroimaging revealed osteolytic metastasis of C2 with atlanto-axial joint invasion and of C4 without compression. The metastatic cancer of multiple bone and soft tissues progressed despite the chemotherapy; hence, minimally invasive palliative therapy was needed for immediate relief of the patient’s pain. Another patient, 54-year-old man, also diagnosed non-small cell lung cancer revealed neck pain in May, 2018. He had stopped systemic chemotherapy 6 months ago due to lack of effective available regimen and received stereotactic radiosurgery for multiple brain metastases 3 months ago. Spinal computed tomography revealed C2 osteolytic lesion and we performed transoral VP for pain control. Based on our experience, transoral VP for C2 osteolytic metastasis could be performed safely and resulted in significant and immediate pain relief.


Vertebroplasty (VP) is the most common treatment choice for patients with osteolytic spine bone metastasis to relieve pain and restore stability in metastatic spinal disease [2]. Usually, VP is performed to treat thoracolumbar vertebral metastatic lesion via the transpedicular route. Multiple randomized and nonrandomized reports have demonstrated its effectiveness [2]. However, fractures in the cervical spine are relatively rare, and VP has been applied less commonly in the treatment of cervical metastases due to the complex anatomy of the cervical spine [7]. Percutaneous VP for cervical osteolytic metastases reported as effective but is mainly applied to the mid-cervical lesion. Transoral VP to treat the odontoid (C2) has been described in only a few case reports. We performed VP for 2 patients with osteolytic C2 metastatic lesion via transoral route under general anesthesia without any complications.


A 52-year-old man was diagnosed with non-small cell lung cancer in February, 2014. Staging work-up revealed no metastatic lesion. However, the mass lesion of lung had already invaded regional lymph nodes and caused endotracheal narrowing; hence, pneumonectomy was deferred. The patient was treated with concurrent chemo-radiation therapy with erlotinib (Tarceva) after confirmation of epidermal growth factor receptor (EGFR) mutation. Despite partial remission at the 6-months follow-up imaging, the 15-months follow-up revealed that the lung cancer had progressed to the whole body (both adrenal glands, multiple bones and soft-tissue metastases) In September, 2015, the patient felt neck pain that was exacerbated on swallowing and neck motion. Computed tomography (CT) scan of the cervical spine demonstrated osteolytic lesion involving the C2 and C4 vertebral bodies (Fig. 1A). As the patient pain was not tolerable despite of opioid analgesia and Philadelphia brace, we decided to treat this lesion with more stabilizing method. And, pre-operative magnetic resonance imaging showed paravertebral invasion of metastatic lesion with diffuse posterior wall invasion (Fig. 1B), we could assume that painful swallowing possibly came from his osteolytic metastasis violate the C4 cortex to invade posterior pharyngeal wall, which moved along with glottis on swallowing (Fig. 1B). Considering patients’ disseminated cancer lesions, we chose percutaneous VP for C4 metastasis and plan to apply VP for C2 lesion via transoral approach. All procedure was conducted under general anesthesia. First, percutaneous VP for C4 lesion was performed routinely with C-arm without difficulty. Subsequently, the Dingman mouth retractor was applied and the posterior pharyngeal wall was washed 3 times with Betadine solution (Fig. 2). Under the C-arm guide, we located C2 osteolytic lesion with spinal needle as uvula for midline guidance. After confirmation of proper needle location, a 13 G VP needle was inserted into the C2 osteolytic cavity and a total of 2.5 cc bone cement was injected with the pusher (Fig. 1B). No leakage was observed and the operation time was approximately 1 hour in total. After the procedure, patients could eat with little difficulty until he expired 1 month later due to pneumonia from endotracheal narrowing of lung cancer progression.
Another patient, 54-year-old man complaints progressive neck pain since 3 months ago. He was diagnosed with nonsmall cell lung cancer with multiple bone metastases in July, 2012. As his lung cancer did not have the EGFR mutation, he had received several times of radiation therapy and 5 times of cytotoxic chemotherapy. As the last radiation treatment, he received fractionated stereotactic radiation therapy for painful C2 vertebral metastases 2 months ago (3,200 cGy/4 fraction). However, his neck pain continued, and spinal CT revealed osteolytic lesion of C2 (Fig. 3A). We performed transoral VP as same method. Under the C-arm guide, a 13 G VP needle was inserted into the C2 osteolytic cavity as uvula for midline and C2 body locator (Fig. 4A). And a total of 1.9 cc bone cement was injected with the pusher on lateral view (Fig. 4B). After VP, patient neck pain was much improved and post-operative CT revealed filling of osteolytic lesion with bone cement (Fig. 4B).


VP is a widely performed minimally invasive procedure, that is relatively safe and effective in the treatment of osteoporotic and malignancy-related fractures of the thoracolumbar spine [2]. Recently, in cervical spine lesions, systematic review and meta-analysis revealed that VP for metastatic cervical spine lesion was effective in significant reduction of pain (89%) with a low risk (4%) of complications [5]. But VP for the cervical spine is technically difficult and has potential complications due to the complex anatomy around the cervical spine [11]. Especially, the anterolateral approach used for subaxial cervical VP is risky to apply for C2 due to possible injuries of many neurovascular structures —including the spinal accessory, lingual, hypoglossal, vagus, marginal, and laryngeal nerves as well as carotid and vertebral arteries [1]. Anselmetti et al. [1] reported the outcome of transoral VP under general anesthesia for 25 patients with C2 malignant involvement like our cases. They achieved immediate pain reduction in 96% of patients without clinically significant complications. And 96% of patients had been free from worsening of the pain for 1 year since procedure [1]. Thus, transoral approach is suggested to be relatively safe method to alternate anterior approach for VP at C2 osteolytic metastases. In other way, Kordecki et al. [8] a successful treatment of C2 metastasis via anterolateral approach. They inserted the needle under local anesthesia with palpation of common carotid artery to avoid at C4-C5 level and advanced superiorly [8]. The advantages of transoral VP could be a more direct needle insertion, and decreased risk to adjacent neurovascular structures [1,17].
In the transoral approach, surgical site infection is a major concern because the procedure is performed through the contaminated field. Infection rates for open transoral procedures vary widely from 0.1% to 13% [9,12,16]. However, to our best knowledge, no case of surgical site infection related to transoral VP or kyphoplasty has been reported previously [1,4,6,10,11,13-15,17]. Transoral VP has a lower risk of infection due to minimizing tissue disruption by using the relatively fine needle [1,6,17]. The perioperative intravenous antibiotics, antibiotics within the polymethyl methacrylate mixture, and post-procedural antibiotics could further reduce the infection risk [1,6,14]. We paid particular attention to preparing the surgical field and keeping the needle aseptic during the procedure, and procedure-related infection did not occur in our case.
Several studies indicate that cervical VP has a high technical success rate combined with a low complication rate, while providing immediate pain relief, that lasts for a long-term; in addition, the use of analgesic drugs is reduced [1,3,11,13]. Our patient also showed dramatic pain reduction after the procedure, which continued until he died due to pneumonia aggravation 1 month later.


We could suggest that for painful osteolytic C2 metastasis, transoral VP could be applied as a palliative method to stabilize the vertebra and to improve pain immediately at a little cost of procedure related complication.


No potential conflict of interest relevant to this article was reported.

Fig. 1.
(A) Pre-operative computed tomography (CT) scan revealed osteolytic metastasis of C2 and C4 vertebral body on sagittal. (B) Pre-operative magnetic resonance imaging with gadolinium enhancement showed multiple cervical spine metastases with posterior pharyngeal wall invasion. (C) Post-operative CT scan showed bone cement filling the osteolytic gap of cervical vertebrae.
Fig. 2.
Dingman mouth retractor is applied to expose posterior pharyngeal wall to insert vertebroplasty needle into C2 vertebral body directly alongside of uvula.
Fig. 3.
(A) Pre-operative 3-dimensional (3D) computed tomography (CT) scan revealed osteolytic metastasis of C2 vertebral body, (B) post-operative 3D CT scan showed bone cement filling the osteolytic gap odontoid process.
Fig. 4.
Fluoroscopic image shows that 13G vertebroplasty needle was inserted into the C2 osteolytic cavity (A) and bone cement was injected with the pusher (B).


1. Anselmetti GC, Manca A, Montemurro F, Tutton S, Chiara G, Battistella M, et al.: Vertebroplasty using transoral approach in painful malignant involvement of the second cervical vertebra (C2): a single-institution series of 25 patients. Pain Physician 15:35-42, 2012
crossref pmid
2. Bae JW, Gwak HS, Kim S, Joo J, Shin SH, Yoo H, et al.: Percutaneous vertebroplasty for patients with metastatic compression fractures of the thoracolumbar spine: clinical and radiological factors affecting functional outcomes. Spine J 16:355-364, 2016
crossref pmid
3. Bao L, Jia P, Li J, Chen H, Dong Y, Feng F, et al.: Percutaneous vertebroplasty relieves pain in cervical spine metastases. Pain Res Manag 2017:3926318, 2017
crossref pdf
4. Brage L, Roldán H, Plata-Bello J, Martel D, García-Marín V: Transoral vertebroplasty for a C2 aneurysmal bone cyst. Spine J 16:e473-e477, 2016
5. De la Garza-Ramos R, Benvenutti-Regato M, Caro-Osorio E: Vertebroplasty and kyphoplasty for cervical spine metastases: a systematic review and meta-analysis. Int J Spine Surg 10:7, 2016
crossref pmid pmc
6. Kaminsky IA, Härtl R, Sigounas D, Mlot S, Patsalides A: Transoral C2 biopsy and vertebroplasty. Interv Med Appl Sci 5:76-80, 2013
crossref pmid pmc
7. Kim SK, Chung JY, Cho CB, Choi HC: Percutaneous anterolateral vertebroplasty for a myelomatous pathologic fracture of the subaxial cervical spine: A case report. Korean J Spine 8:225-228, 2011
8. Kordecki K, Lewszuk A, Puławska-Stalmach M, Michalak P, Łukasiewicz A, Sackiewicz I, et al.: Vertebroplasty of cervical vertebra. Pol J Radiol 80:51-56, 2015
crossref pmid pmc
9. Laborde G, Gilsbach J, Bertalanffy H, Harders A, Hardenack M: Limits of the transoral approach in craniospinal malformations. Skull Base Surg 2:6-10, 1992
crossref pmid pmc pdf
10. Martin JB, Gailloud P, Dietrich PY, Luciani ME, Somon T, Sappino PA, et al.: Direct transoral approach to C2 for percutaneous vertebroplasty. Cardiovasc Intervent Radiol 25:517-519, 2002
crossref pmid
11. Masala S, Anselmetti GC, Muto M, Mammucari M, Volpi T, Simonetti G: Percutaneous vertebroplasty relieves pain in metastatic cervical fractures. Clin Orthop Relat Res 469:715-722, 2011
12. Menezes AH: Surgical approaches: postoperative care and complications “transoral-transpalatopharyngeal approach to the craniocervical junction”. Childs Nerv Syst 24:1187-1193, 2008
crossref pmid pdf
13. Monterumici DA, Narne S, Nena U, Sinigaglia R: Transoral kyphoplasty for tumors in C2. Spine J 7:666-670, 2007
crossref pmid
14. Reddy AS, Dinobile D, Orgeta JE, Peri N: Transoral approach to CT-guided C2 interventions. Pain Physician 12:253-258, 2009
15. Sachs DC, Inamasu J, Mendel EE, Guiot BH: Transoral vertebroplasty for renal cell metastasis involving the axis: case report. Spine (Phila Pa 1976) 31:E925-E928, 2006
16. Shousha M, Mosafer A, Boehm H: Infection rate after transoral approach for the upper cervical spine. Spine (Phila Pa 1976) 39:1578-1583, 2014
crossref pmid
17. Tong FC, Cloft HJ, Joseph GJ, Rodts GR, Dion JE: Transoral approach to cervical vertebroplasty for multiple myeloma. AJR Am J Roentgenol 175:1322-1324, 2000
crossref pmid
PDF Links  PDF Links
PubReader  PubReader
ePub Link  ePub Link
XML Download  XML Download
Full text via DOI  Full text via DOI
Download Citation  Download Citation
Related article
Editorial Office
Department of Neurosurgery, Dankook University Hospital
201, Manghyang-ro, Dongnam-gu, Cheonan-si, Chungcheongnam-do 31116, South Korea
TEL: +0082-41-550-6280   FAX: +82-41-556-0524   
E-mail: spine1225@naver.com , mousehunt7@naver.com
About |  Browse Articles |  Current Issue |  For Authors and Reviewers
Copyright © The Korean Society of Peripheral Nervous System.                 Developed in M2PI