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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 29-31

Minimally invasive percutaneous C1–C2 transarticular screw fixation as a palliative management option in C2 metastases

1 Department of Neurosurgery, Saint John Regional Hospital; Division of Neurosurgery, Dalhousie University, Saint John, New Brunswick, Canada
2 Department of Biological Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
3 Canada East Spine Centre, Saint John, New Brunswick, Canada
4 Department of Neurosurgery, Saint John Regional Hospital; Division of Neurosurgery, Dalhousie University; Canada East Spine Centre, Saint John, New Brunswick, Canada

Date of Submission29-Aug-2019
Date of Acceptance31-Jan-2020
Date of Web Publication12-Mar-2020

Correspondence Address:
Dr. Najmedden Attabib
400 University Ave. P. O. Box 2100, Saint John, New Brunswick
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_49_19

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Bone metastasis in patients with esophageal carcinoma is rare but serious, often resulting in structural complications of the spine such as atlantoaxial instability and C2 metastases. Atlantoaxial instability is usually managed surgically using screw-rod constructs; however, in patients undergoing radiotherapy, surgical wound healing is a concern. We present a technical note involving a terminally ill patient diagnosed with esophageal carcinoma who suffered from a metastatic lytic lesion of C2 and mechanical neck pain. Due to the patient starting palliative radiotherapy, a percutaneous approach and transarticular screws were used to achieve atlantoaxial fixation and minimize the surgical wound while maintaining the midline tension band. Significant clinical improvement was found. Our patient was able to begin palliative radiotherapy within 1 week of surgery, without surgical and wound complications. This report provides unique insight into the utilization of a minimally invasive approach for pain management and stabilization of the cervical spine for oncology patients.

Keywords: Atlantoaxial, metastatic esophageal carcinoma, minimally invasive, palliative radiotherapy, transarticular

How to cite this article:
Craig M, Kroetsch S, El-Mughayyar D, Attabib N. Minimally invasive percutaneous C1–C2 transarticular screw fixation as a palliative management option in C2 metastases. Libyan J Med Sci 2020;4:29-31

How to cite this URL:
Craig M, Kroetsch S, El-Mughayyar D, Attabib N. Minimally invasive percutaneous C1–C2 transarticular screw fixation as a palliative management option in C2 metastases. Libyan J Med Sci [serial online] 2020 [cited 2022 Oct 7];4:29-31. Available from: https://www.ljmsonline.com/text.asp?2020/4/1/29/280565

  Introduction Top

Esophageal carcinoma is the fifth most fatal cancer in males aged 40–59 years.[1] The prognosis of individuals with metastatic esophageal carcinoma (MES) is poor, with a 5-year survival rate of <5%.[2] Palliative treatment is used in managing advanced esophageal carcinoma while controlling cancer-related symptoms and maintaining the patient's quality of life.

We report a rare case of minimally invasive percutaneous C1–C2 transarticular screw fixation in a patient with a pathological fracture of C2 undergoing palliative radiotherapy to treat MES. This is the first-reported literature describing this surgical technique as a management option for atlantoaxial instability secondary to C2 metastases.

  Case Report Top

A 57-year-old male was referred for neurosurgical service because he could not begin palliative radiotherapy for MES due to the instability of his cervical spine. Full consent was obtained. This patient had known skeletal metastases and developed debilitating mechanical neck pain and stiffness. The patient had no neurological symptoms or neurological deficits on physical examination. A computed tomography (CT) scan of the cervical spine [Figure 1] showed a lytic lesion involving the body of C2 with an extension into the odontoid base. There was an associated C2 fracture with a mild 3-mm anterior displacement of the odontoid relative to the C2 body. No evidence of spinal cord compression was visible.
Figure 1: Computed tomography in the axial (left) and sagittal (right) planes showing a lytic fracture of C2, with 3-mm anterior displacement of the odontoid

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Posterior C1–C2 fixation was offered as a palliative measure for alleviation of neck pain and stiffness to prevent further displacement of the C2 fracture and to prevent neurological decline. The patient planned to begin a radiotherapy regimen, which is safer with a stable cervical spine. With these goals in mind and with the knowledge that the patient was terminally ill, a minimally invasive posterior approach with transarticular screws was selected. This was done to avoid disturbance of the craniocervical tension band and to minimize any surgical wound, expediting the patient's treatment with palliative radiotherapy. The course of the vertebral artery was considered during surgical planning. The patient provided consent to the senior author for minimally invasive C1–C2 fixation. The patient was prepared for surgery and given intravenous prophylactic antibiotics. The patient was intubated using a fiber optic laryngoscope to minimize neck hyperextension. After general anesthesia induction, the patient was fitted in a 3-point head holder and was carefully positioned prone. The area was prepped with Povidone-iodine solution, with the head positioned in flexion to accommodate the steep angle of the planned screw path. Local anesthetic was applied to the area, and incisions were made. Sequential tubular dilatation and muscle splitting resulted in #7 × 18 final tubular retractors resting on the C2–C3 junction inferior to the C2 pars on each side, attached to the flex arm mounted on the bed rails. Biplanar AP and lateral fluoroscopic guidance were used. The soft tissue overlying the bony elements was dissected with the monopolar cautery. Guidewires were inserted under biplanar fluoroscopic guidance, and the screw lengths were measured. Then, a 42-mm fully threaded transarticular screw was inserted through the pars of C2 into the lateral mass of C1. Similar steps were followed to insert the transarticular screw on the contralateral side. The patient tolerated the procedure well, with minimal blood loss. Intraoperative and postoperative radiographies are shown in [Figure 2]. Each incision was <2 cm and was closed with absorbable subcuticular sutures.
Figure 2: Intraoperative fluoroscopy showing guidewire placement (a), transarticular screw trajectory through the C2 pedicle and into the C1 lateral mass (b), and the final position of each screw (c). Postoperative radiography confirms screw placement (d)

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The procedure was done safely with no neurovascular complications. The patient reported significant relief of neck pain and stiffness as evidenced through a reduction of seven points on the Numeric Rating Scale for neck pain. The patient was discharged home on postoperative day 3, without the need for external orthosis. The patient was able to begin palliative radiotherapy starting on postoperative day 7. Several areas were irradiated, including the cervical spine; this was tolerated well, with no wound complications. Six weeks postoperatively, a repeat CT scan showed progression of the C2 lytic lesion, with some retropulsion of the C2 posterior endplate 4 mm into the spinal canal [Figure 3]. Sagittal views did not reveal any cord compression, and the patient remained neurologically intact. Five months postoperatively, CT scan showed no progression of the lesion or any further instability. The patient maintained reduced neck pain (NRS-N = 2) and received palliative care. His cancer progressed and he developed lytic lesions of the ribs, shoulder, and thoracic spine. The patient expired 7 months postoperatively due to respiratory disease related to primary cancer.
Figure 3: Computed tomography 6 weeks after surgery. There is a progression of the lytic lesion, as seen in axial (a) and midsagittal (b) views, with 4-mm retropulsion of the C2 endplate but without evidence of spinal cord compression. Parasagittal view (c) shows transarticular screw fixation in place

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  Discussion Top

Minimally invasive spine surgery (MISS) has gained popularity and is thought to reduce approach-related morbidity. MISS techniques have been explored in the atlantoaxial region. Atlantoaxial instability can cause severe morbidity, including mechanical neck pain, stiffness, and neurological deficit.[3] An effective strategy for the management of atlantoaxial instability is posterior arthrodesis. Cadaveric studies have described the feasibility of the minimally invasive surgical approach to C1–C2. In addition, a recent report of MISS percutaneous lateral mass screw insertion has supported the feasibility of MISS in treating cervical fractures.[4]

The use of percutaneous transarticular screw fixation offered particular utility in our terminally ill patient. A minimal surgical wound was desired with the smallest amount of soft-tissue disturbance to avoid the delay of palliative radiotherapy needed to treat additional tumors. Our patient did not suffer vertebral artery injury, screw malposition, or nonunion and experienced relief of his neck pain and stiffness. He was able to undergo palliative radiotherapy, as planned within 7 days of surgery.

In conclusion, minimally invasive percutaneous transarticular C1–C2 fixation is a reasonable option when wound healing is a significant concern, such as in terminally ill patients undergoing palliative radiotherapy. The short life expectancy of our patient highlights the increased importance of pain reduction and minimal surgical wound morbidity with the long-term viability of the spinal construct being a lower priority.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin 2017;67:7-30.  Back to cited text no. 1
Wu SG, Zhang WW, He ZY, Sun JY, Chen YX, Guo L. Sites of metastasis and overall survival in esophageal cancer: A population-based study. Cancer Manag Res 2017;9:781-8.  Back to cited text no. 2
Huang DG, Hao DJ, He BR, Wu QN, Liu TJ, Wang XD, et al. Posterior atlantoaxial fixation: A review of all techniques. Spine J 2015;15:2271-81.  Back to cited text no. 3
Kantelhardt SR, Keric N, Conrad J, Archavlis E, Giese A. Minimally invasive instrumentation of uncomplicated cervical fractures. Eur Spine J 2016;25:127-33.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3]


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