Combination of Elective Preoperative Vertebral Artery Stenting with O-Arm-Assisted Navigation in Cervical Spine Tumor Excision

Abstract

Introduction The cervical spine is considered the most mobile segment of the spine, most of the movement occurs at the upper cervical. In addition to the flexion–extension movement, a rotational movement is added because of the orientation of lateral masses of C1 and C2 and the unique ligamentous structures which play an integral role in stabilization of the upper cervical spines. In general, primary spinal tumor is not as common as metastatic secondary tumors; the reported incidence is less than 10% of all spinal tumors. The management of cervical spine bony tumors is challenging and different from the rest of the spine, not only the rarity to be affected compared with other spines but also the anatomical regional difficulties that come with it, in addition to the challenge in approach, the proximity to the vertebral artery, and the spinal cord. The mainstay treatment of primary cervical spine tumor is surgical resection, although there have been reports of minimal invasive management with embolization. Vertebral artery injury is a rare complication of cervical spine tumor excision and the sequel of vertebral artery injury varies from arterio-venous fistula, pseudo aneurysm, thrombosis with embolic stroke, or even death. Purpose The purpose of this study is to report our new technique for the management of the cervical spine tumors by combining vertebral artery elective preoperative stenting with O-arm navigation-assisted tumor excision. Materials and Methods For the retrospective analysis of our patient's data for cervical spine tumors, between January 2010 and December 2013, inclusion criteria were: patients with primary cervical spine tumors underwent elective preoperative VA stenting, excision done under O-arm navigation with sufficient follow-up. Exclusion criteria were patients with secondary tumors, patients lost to follow-up, and if surgery was done without navigation. Results A total of 15 patients met our inclusion criteria, 5 were excluded: 2 lost to follow-up, in 1 stenting was not done, and the other 3 were done without navigation. Mean age was 16.4 years, average follow-up period was 16 months, 7 females and 6 males, neck pain was a presenting symptom in 8, neck swelling in 1, and one incidental finding in routine check-up. Diagnosis was aneurysmal bone cyst in 7, osteoblastoma in 2, and giant cell tumor in 1. The level was C2 in 5, C3 in 3, C4 in 1, and C6 in 1. Our results are of 10 case series with different primary bone tumors that were successfully managed by a combination of both techniques. Conclusions Combining both techniques provides successful tumor excision, with several advantages: keeping the patency of the VA, possibility of VA hand feeling during the procedure, and possibility of visualizing the VA at the time of surgery under O-arm navigation.