Management of a major atlanto-axial instability secondary to a lytic lesion of C2.

Abstract

Management of C1-C2 instability is very challenging, especially when tumoral lesions are involved. We present the case of a 65-year-old male, with a recently discovered small cell lung carcinoma, presenting progressive tetraparesis due to a secondary lesion involving the body of C2 with complete collapse of its anterior part and major C1-C2 instability in all planes. The patient underwent a reconstructive surgery of the upper cervical spine during two sessions. First, an emergency surgery was done by a high anterior cervical approach, where reconstruction of the body of C2 was done by an original technique using a C3 body to odontoid long screw with bone cement filling around the screw at the level of C2, and an anterior buttress plate put from C2 to C4. A posterior surgery was performed after 48 h to stabilize the spine posteriorly with C1 to C5 instrumentation. The patient recovered from his neurological symptoms, and underwent complementary adjuvant radiotherapy with chemotherapy later on. Literature is sparse on the treatment of major C1-C2 instability, especially when a secondary lesion is involved, the current case shows a successful treatment strategy with an original technique that was never described before in the literature. The patient was pain free at 1 year follow-up with a stable construct.