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Painful Osteolytic Metastasis Involving the Anterior and Posterior Arches of C1: Percutaneous Vertebroplasty with Local Anesthesia

2009; Elsevier BV; Volume: 20; Issue: 12 Linguagem: Inglês

10.1016/j.jvir.2009.08.008

1535-7732

Giovanni Carlo Anselmetti, Antonio Manca, Gabriele Chiara, Daniele Regge,

Spine and Intervertebral Disc Pathology

Percutaneous vertebroplasty is gaining acceptance as the standard of care for patients with painful osteolytic metastases of the spine who do not respond to conventional therapy (1Barragán-Campos H.M. Vallée J.N. Lo D. et al.Percutaneous vertebroplasty for spinal metastases: complications.Radiology. 2006; 238: 354-362Crossref PubMed Scopus (198) Google Scholar). Injection of acrylic cement was proved to be effective in pain relief by stabilizing the vertebral body (2Gangi A. Guth S. Imbert J.P. Marin H. Dietemann J.L. Percutaneous vertebroplasty: indications, technique, and results.Radiographics. 2003; 23: e10Crossref PubMed Scopus (243) Google Scholar); this clinical outcome could also be achieved in difficult cervical vertebrae (3Mont'Alverne F. Vallée J.N. Cormier E. et al.Percutaneous vertebroplasty for metastatic involvement of the axis.Am J Neuroradiol. 2005; 26: 1641-1645PubMed Google Scholar) even if percutaneous vertebroplasty on the body of C1 was previously reported in only two cases (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar). Metastases located on C1 needing stabilization are extremely rare, and the most common surgical option for atlas neoplasms (reported in few case reports and case series most frequently for primary tumors such as chordoma or meningioma) is resection eventually followed by occipitocervical fusion (6Shin H. Barrenechea I.J. Lesser J. Sen C. Perin N.I. Occipitocervical fusion after resection of craniovertebral junction tumors.J Neurosurg Spine. 2006; 4: 137-144Crossref PubMed Scopus (62) Google Scholar).Herein, we describe the use of percutaneous vertebroplasty in a painful osteolytic lesion located in the anterior and posterior left arches of C1 with use of combined fluoroscopic and computed tomographic (CT) guidance and local anesthesia.A 68-year-old woman with diffuse metastatic disease (bones, liver, and lungs) from primary breast cancer, who had previously (2 years earlier) been successfully treated with percutaneous vertebroplasty on T9 and C4, reported a new painful vertebral metastasis on C1. The patient was admitted to our hospital for the treatment of refractory pain in the upper cervical spine. Spiral CT, with two-dimensional reconstruction, showed a wide osteolytic lesion of the atlas involving the left lateral mass, the anterior and the posterior arches of C1 (Figure, a, arrows). Magnetic resonance (MR) imaging did not depict spinal cord tumor involvement despite the significant bone destruction.The patient was deemed unfit for surgery by orthopedic surgeons and neurosurgeons due to high procedural risks, extended bone destruction, left vertebral artery involvement, and short life expectancy. Considering the patient's poor quality of life, the risk of spinal cord injury in case of a pathologic fracture, and the pain refractory to medical treatment, the option of percutaneous vertebroplasty, aiming to achieve stability and pain control, was offered to the patient. After receiving an explanation of the risks and possible procedure benefits, and considering the limited worldwide experience of vertebroplasty on C1 (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar), the patient gave informed consent.Institutional review board approval was not required by our institution for this case because percutaneous vertebroplasty, performed according to the Declaration of Helsinki, was the only option offered to the patient for bone consolidation and pain relief.The procedure was performed with the patient under local anesthesia by injecting 3 mL of 2% lidocaine hydrocloride (Lidosan; Industria Farmaceutica Galenica Senese, Monteroni d'Arbia, Siena, Italy), both at the skin level and deep to include the bone lesion.Vertebroplasty was performed in the CT room (LightSpeed16; GE Medical Systems, Milwaukee, Wisconsin) with a digital mobile fluoroscopy C-arm (BV300; Philips, Amsterdam, the Netherlands) positioned in front of the gantry to allow real-time monitoring of the bone cement injection.The patient was positioned in a right lateral decubitus position on the CT cradle; heart rate and pulse oximetry were monitored continuously throughout the procedure.Prophylactic antibiotic therapy with a third-generation cephalosporin (Rocefin, Roche, Segrate, Italy; 2 g intravenously before the procedure and 1g intramuscularly for 5 days after the procedure) was applied as previously described (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar).The correct needle pathways (to avoid vertebral artery direct puncture) and their intralesional precise positioning were assessed with CT (section thickness, 3 mm; pitch, 1.5; section increment, 2.5 mm). Two thin (15-gauge) beveled vertebroplasty needles (Optimed, Ettlingen, Germany) were inserted in an axial direction, both anterior and posterior to the vertebral artery, into the osteolytic-destroyed anterior and posterior arches of C1 (Figure, b). After the correct needle placement was assessed with CT, 1.5 mL (anterior) and 1 mL (posterior) of bone cement (Opacity plus; Teknimed, Bigorre, France) were slowly injected under fluoroscopic control (Figure, c) in the lateral projection by means of a screw injector (Cemento-RE gun, Optimed). This bone cement is specially designed for percutaneous vertebroplasty, offering high radiopacity, medium viscosity, and a long working time (up to 20 minutes at 21°C). These features enable us to briefly suspend the injection and perform CT to evaluate the absence of significant cement leaks.After CT scans showed adequate filling of the osteolytic lesion (Figure, d), bone cement injection was ended and the needles were withdrawn. Vertebroplasty was concluded successfully without complications within a total time of 45 minutes. No neurologic symptoms or sequelae were observed during the procedure and follow-up. The patient, still living, reported substantial pain relief immediately after the procedure that has been stable for a 13-month follow-up and no longer requires opioid therapy.In the two previous studies in which vertebroplasty of C1 was described (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar), the authors employed a posterolateral approach under fluoroscopy after coil occlusion of the vertebral artery (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar) or a lateral approach under combined CT and fluoroscopic guidance (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar); both procedures were performed with the patient under general anesthesia. In our case, the neoplastic lesion involved both the anterior and posterior arches of C1; therefore, the lateral approach with two needles seemed to be the best choice to achieve bone consolidation. To obtain a precise and safe needle insertion, avoiding direct puncture of vital structures adjacent to the lesion such as main vessels and spinal cord, CT guidance was mandatory as was fluoroscopic monitoring during bone cement injection, as previously reported (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar, 7Gangi A. Kastler B.A. Dietemann J.L. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy.Am J Neuroradiol. 1994; 15: 83-86PubMed Google Scholar). We did not perform vertebral artery coil embolization (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar) because spiral CT guidance can help avoid direct puncture of the artery and thus cement arterial embolization (7Gangi A. Kastler B.A. Dietemann J.L. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy.Am J Neuroradiol. 1994; 15: 83-86PubMed Google Scholar). Unlike the two previously reported cases, percutaneous vertebroplasty on C1 was performed with local anesthesia only. The aim of this was to be able to rule out complications by continuously monitoring vital signs and checking the sensitivity and mobility of the limbs; furthermore, procedural pain was bearable for the patient and she was able to speak to operators during the entire procedure. Thus, any possible neurologic symptom could have been detected early and bone cement injection promptly interrupted. One limit of this management could be individual compliance because the patient is asked to hold still; thus, general anesthesia could be needed in less-cooperative patients. Although percutaneous vertebroplasty was performed in the CT room instead of a surgical room, the sterile conditions necessary for percutaneous procedures were achieved. Our patient reported no septic complications during follow-up. We used radiopaque bone cement, specifically designed for vertebroplasty, which offers a medium viscosity, high-grade opacity, and a long working time (up to 20 minutes); these features enable us to monitor the injection under fluoroscopy and, especially, to obtain "on-the-spot" CT scans during the procedure. CT procedural images were essential for precise evaluation of leaks and for adequate lesion perfusion; this is not possible if injection is carried out under fluoroscopic guidance alone. For this extreme percutaneous vertebroplasty, as we usually do for most of cervical levels, 15-gauge beveled needles were preferred for the lower invasivity, steerability, and sharp cutting edge that allow the penetration of the cortex without hammering. As reported in biomechanical studies (8Belkoff S.M. Mathis J.M. Jasper L.E. et al.The biomechanics of vertebroplasty: the effect of cement volume on mechanical behavior.Spine. 2001; 26: 1537-1541Crossref PubMed Scopus (458) Google Scholar), even a small volume of cement guarantees the restoration of vertebral body integrity and consequent pain relief. In this case, a complete and lasting cervical pain remission was obtained with a total injection of 2.5 mL of bone cement; this is consistent with the previously described cases (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar).As study limitation, the case report presented just gives a further unique demonstration of the feasibility and safety of this extreme application of percutaneous vertebroplasty and was not comparable to other procedures. Procedure modality may vary according to the patients' history and the lesion to treat, but combined CT and fluoroscopic guidance definitely offers the most precise needle placement and bone cement injection. This procedure can be performed with the patient under local anesthesia only, allowing patients' collaboration that can reduce, in our opinion, the risk of major complications. In conclusion, because a satisfactory pain regression could be achieved, percutaneous vertebroplasty might be considered as a treatment option in selected patients with painful metastatic involvement of the atlas not responding to conventional therapy. Percutaneous vertebroplasty is gaining acceptance as the standard of care for patients with painful osteolytic metastases of the spine who do not respond to conventional therapy (1Barragán-Campos H.M. Vallée J.N. Lo D. et al.Percutaneous vertebroplasty for spinal metastases: complications.Radiology. 2006; 238: 354-362Crossref PubMed Scopus (198) Google Scholar). Injection of acrylic cement was proved to be effective in pain relief by stabilizing the vertebral body (2Gangi A. Guth S. Imbert J.P. Marin H. Dietemann J.L. Percutaneous vertebroplasty: indications, technique, and results.Radiographics. 2003; 23: e10Crossref PubMed Scopus (243) Google Scholar); this clinical outcome could also be achieved in difficult cervical vertebrae (3Mont'Alverne F. Vallée J.N. Cormier E. et al.Percutaneous vertebroplasty for metastatic involvement of the axis.Am J Neuroradiol. 2005; 26: 1641-1645PubMed Google Scholar) even if percutaneous vertebroplasty on the body of C1 was previously reported in only two cases (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar). Metastases located on C1 needing stabilization are extremely rare, and the most common surgical option for atlas neoplasms (reported in few case reports and case series most frequently for primary tumors such as chordoma or meningioma) is resection eventually followed by occipitocervical fusion (6Shin H. Barrenechea I.J. Lesser J. Sen C. Perin N.I. Occipitocervical fusion after resection of craniovertebral junction tumors.J Neurosurg Spine. 2006; 4: 137-144Crossref PubMed Scopus (62) Google Scholar). Herein, we describe the use of percutaneous vertebroplasty in a painful osteolytic lesion located in the anterior and posterior left arches of C1 with use of combined fluoroscopic and computed tomographic (CT) guidance and local anesthesia. A 68-year-old woman with diffuse metastatic disease (bones, liver, and lungs) from primary breast cancer, who had previously (2 years earlier) been successfully treated with percutaneous vertebroplasty on T9 and C4, reported a new painful vertebral metastasis on C1. The patient was admitted to our hospital for the treatment of refractory pain in the upper cervical spine. Spiral CT, with two-dimensional reconstruction, showed a wide osteolytic lesion of the atlas involving the left lateral mass, the anterior and the posterior arches of C1 (Figure, a, arrows). Magnetic resonance (MR) imaging did not depict spinal cord tumor involvement despite the significant bone destruction. The patient was deemed unfit for surgery by orthopedic surgeons and neurosurgeons due to high procedural risks, extended bone destruction, left vertebral artery involvement, and short life expectancy. Considering the patient's poor quality of life, the risk of spinal cord injury in case of a pathologic fracture, and the pain refractory to medical treatment, the option of percutaneous vertebroplasty, aiming to achieve stability and pain control, was offered to the patient. After receiving an explanation of the risks and possible procedure benefits, and considering the limited worldwide experience of vertebroplasty on C1 (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar), the patient gave informed consent. Institutional review board approval was not required by our institution for this case because percutaneous vertebroplasty, performed according to the Declaration of Helsinki, was the only option offered to the patient for bone consolidation and pain relief. The procedure was performed with the patient under local anesthesia by injecting 3 mL of 2% lidocaine hydrocloride (Lidosan; Industria Farmaceutica Galenica Senese, Monteroni d'Arbia, Siena, Italy), both at the skin level and deep to include the bone lesion. Vertebroplasty was performed in the CT room (LightSpeed16; GE Medical Systems, Milwaukee, Wisconsin) with a digital mobile fluoroscopy C-arm (BV300; Philips, Amsterdam, the Netherlands) positioned in front of the gantry to allow real-time monitoring of the bone cement injection. The patient was positioned in a right lateral decubitus position on the CT cradle; heart rate and pulse oximetry were monitored continuously throughout the procedure. Prophylactic antibiotic therapy with a third-generation cephalosporin (Rocefin, Roche, Segrate, Italy; 2 g intravenously before the procedure and 1g intramuscularly for 5 days after the procedure) was applied as previously described (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar). The correct needle pathways (to avoid vertebral artery direct puncture) and their intralesional precise positioning were assessed with CT (section thickness, 3 mm; pitch, 1.5; section increment, 2.5 mm). Two thin (15-gauge) beveled vertebroplasty needles (Optimed, Ettlingen, Germany) were inserted in an axial direction, both anterior and posterior to the vertebral artery, into the osteolytic-destroyed anterior and posterior arches of C1 (Figure, b). After the correct needle placement was assessed with CT, 1.5 mL (anterior) and 1 mL (posterior) of bone cement (Opacity plus; Teknimed, Bigorre, France) were slowly injected under fluoroscopic control (Figure, c) in the lateral projection by means of a screw injector (Cemento-RE gun, Optimed). This bone cement is specially designed for percutaneous vertebroplasty, offering high radiopacity, medium viscosity, and a long working time (up to 20 minutes at 21°C). These features enable us to briefly suspend the injection and perform CT to evaluate the absence of significant cement leaks. After CT scans showed adequate filling of the osteolytic lesion (Figure, d), bone cement injection was ended and the needles were withdrawn. Vertebroplasty was concluded successfully without complications within a total time of 45 minutes. No neurologic symptoms or sequelae were observed during the procedure and follow-up. The patient, still living, reported substantial pain relief immediately after the procedure that has been stable for a 13-month follow-up and no longer requires opioid therapy. In the two previous studies in which vertebroplasty of C1 was described (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar), the authors employed a posterolateral approach under fluoroscopy after coil occlusion of the vertebral artery (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar) or a lateral approach under combined CT and fluoroscopic guidance (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar); both procedures were performed with the patient under general anesthesia. In our case, the neoplastic lesion involved both the anterior and posterior arches of C1; therefore, the lateral approach with two needles seemed to be the best choice to achieve bone consolidation. To obtain a precise and safe needle insertion, avoiding direct puncture of vital structures adjacent to the lesion such as main vessels and spinal cord, CT guidance was mandatory as was fluoroscopic monitoring during bone cement injection, as previously reported (5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar, 7Gangi A. Kastler B.A. Dietemann J.L. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy.Am J Neuroradiol. 1994; 15: 83-86PubMed Google Scholar). We did not perform vertebral artery coil embolization (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar) because spiral CT guidance can help avoid direct puncture of the artery and thus cement arterial embolization (7Gangi A. Kastler B.A. Dietemann J.L. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy.Am J Neuroradiol. 1994; 15: 83-86PubMed Google Scholar). Unlike the two previously reported cases, percutaneous vertebroplasty on C1 was performed with local anesthesia only. The aim of this was to be able to rule out complications by continuously monitoring vital signs and checking the sensitivity and mobility of the limbs; furthermore, procedural pain was bearable for the patient and she was able to speak to operators during the entire procedure. Thus, any possible neurologic symptom could have been detected early and bone cement injection promptly interrupted. One limit of this management could be individual compliance because the patient is asked to hold still; thus, general anesthesia could be needed in less-cooperative patients. Although percutaneous vertebroplasty was performed in the CT room instead of a surgical room, the sterile conditions necessary for percutaneous procedures were achieved. Our patient reported no septic complications during follow-up. We used radiopaque bone cement, specifically designed for vertebroplasty, which offers a medium viscosity, high-grade opacity, and a long working time (up to 20 minutes); these features enable us to monitor the injection under fluoroscopy and, especially, to obtain "on-the-spot" CT scans during the procedure. CT procedural images were essential for precise evaluation of leaks and for adequate lesion perfusion; this is not possible if injection is carried out under fluoroscopic guidance alone. For this extreme percutaneous vertebroplasty, as we usually do for most of cervical levels, 15-gauge beveled needles were preferred for the lower invasivity, steerability, and sharp cutting edge that allow the penetration of the cortex without hammering. As reported in biomechanical studies (8Belkoff S.M. Mathis J.M. Jasper L.E. et al.The biomechanics of vertebroplasty: the effect of cement volume on mechanical behavior.Spine. 2001; 26: 1537-1541Crossref PubMed Scopus (458) Google Scholar), even a small volume of cement guarantees the restoration of vertebral body integrity and consequent pain relief. In this case, a complete and lasting cervical pain remission was obtained with a total injection of 2.5 mL of bone cement; this is consistent with the previously described cases (4Wetzel S.G. Martin J.B. Somon T. Wilhelm K. Rufenacht D.A. Painful osteolytic metastasis of the atlas: treatment with percutaneous vertebroplasty.Spine. 2002; 27: E493-E495Crossref PubMed Google Scholar, 5Huegli R.W. Schaeren S. Jacob A.L. Martin J.B. Wetzel S.G. Percutaneous cervical vertebroplasty in a multifunctional image-guided therapy suite: hybrid lateral approach to C1 and C4 under CT and fluoroscopic guidance.Cardiovasc Interv Radiol. 2005; 28: 649-652Crossref PubMed Scopus (27) Google Scholar). As study limitation, the case report presented just gives a further unique demonstration of the feasibility and safety of this extreme application of percutaneous vertebroplasty and was not comparable to other procedures. Procedure modality may vary according to the patients' history and the lesion to treat, but combined CT and fluoroscopic guidance definitely offers the most precise needle placement and bone cement injection. This procedure can be performed with the patient under local anesthesia only, allowing patients' collaboration that can reduce, in our opinion, the risk of major complications. In conclusion, because a satisfactory pain regression could be achieved, percutaneous vertebroplasty might be considered as a treatment option in selected patients with painful metastatic involvement of the atlas not responding to conventional therapy.