Direct anterolateral balloon kyphoplasty for a painful C-2 osteolytic malignant lesion: Case illustration

Balloon kyphoplasty is increasingly used in the treatment of painful malignant and osteoporotic fractures and is usually performed via a posterior percutaneous transpedicular approach. The surgical treatment of an axial unstable malignant lesion is classically done via a posterior approach with occipitocervical fusion. To our knowledge, balloon kyphoplasty via an anterolateral approach for a C-2 osteolytic lesion has never been described and may be a good alternative in the treatment paradigm of this disease.1,2 This 62-year-old man with a 3-year history of lung carcinoma and lumbar metastasis developed a sudden onset of cervical pain that was increased by head motion. His neurological examination revealed normal findings, and a cervical computed tomography (CT) scan disclosed an osteolytic C-2 metastasis eroding the base of the dens but not disrupting its posterior wall (Fig. 1). Because of his poor medical condition, we believed that occipitocervical fusion in the prone position would carry too much of a risk of morbidity. Given that the posterior wall was still intact and there was no spinal cord compression, we thought that balloon kyphoplasty would be a good alternative in achieving satisfactory bone repair and pain control. We opted for a minimally invasive anterolateral approach. After a 2-cm skin incision was made on the anterior edge of the right sternocleidomastoid muscle at the C3‐4 level, medially and cranially oriented blunt dissection on the lateral aspect of the esophagus exposed the caudal end of the C-2 rostrum. A needle was then positioned on the midline and slowly inserted at a 20˚ angle, first into the vertebral body and then into the tumor. The kyphoplasty balloon was then inserted into the tumor under fluoroscopic guidance and was safely inflated (Fig. 2 upper). After removal of the balloon, the space progressively filled with high viscosity cement under low pressure (Fig. 2 lower). The patient returned home the next day with no residual pain. Six weeks later he returned for follow up. Although the patient still suffered from low-back pain related to the lumbar spinal metastases, there was no residual cervical pain and the range of motion of the neck was normal. The patient subsequently underwent radiotherapy with a 60-Gy dose targeting the tumor volume. He eventually died 8 months after the surgery. Although vertebroplasty techniques have been used to treat conditions involving C-2, either by direct transoral approach 3 or by anterolateral approach, 4 we found no other reported case of a C-2 balloon kyphoplasty. This surgical procedure can be safely performed as a palliative treatment in uncontrolled diseases associated with cancer. Kyphoplasty offers minimal risks of cement extrusion, excellent pain control, and motion preservation. Visualization of the cement and control of its application remain the keys to avoiding complications.5