PMC4671139_01
Preoperative coronal (a), sagittal (b and c), and axial (d) computed tomography scan showing the bony lesion involving the bodies of C2 and C3, as well as the left C2 and C3 transverse foramina, which are widened. Computed tomography-angiogram (e) confirms the left vertebral artery which is a patent at both C2 and C3 and pushed anteriorly by the tumor
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F1
The lesion encased the left VA, and extended foraminally into the epidural space [Figures 1 and 2].
Preoperative sagittal T2-weighted image (a and b) showing the extension of the tumor from the left C2 and C3 vertebral body to the left epidural space. Axial T1-weighted magnetic resonance imaging with gadolinium (c) shows the left C2-C3 tumor involving the left C3 pedicle and transverse foramina
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F2
The lesion encased the left VA, and extended foraminally into the epidural space [Figures 1 and 2].
After preoperative embolization of left vertebral artery and posterior approach with C2-C3 laminectomy, left facetectomy and sectioning of the left C2 and C3 nerve roots and occipito-cervico-thoracic fusion, the patient underwent an anterior approach. Intraoperative photographs demonstrating the transoral/transmandibular/extended anterior cervical approach. A submental flap was included in the incision and later used to cover the hardware (a). The subaxial cervical spine was exposed following the mandibulotomy, submandibular gland resection, with the preservation of the lingual, hypoglossal and glossopharyngeal nerves (b). The upper cervical spine was exposed following the soft palate and posterior pharyngeal wall incision and retraction. With the synframe retractor in place, a wide anterior exposure extending from the mid-clivus to the level of C5 inferiorly was obtained (c). Following en bloc removal of the tumor (d), the anterior column was reconstructed with a titanium T-shaped Harms (e) which was fixed to the lateral masses of C1 with screws and buttressed in place on the body of C4 with an anterior plate extending from C4 to C5
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F3
Protection of the instrumentation with a submental flap, and refixation of the split mandible was followed by closure of the posterior pharyngeal wall and the neck incision [Figures 3-5].
Lateral (a) anteroposterior (b) and oblique (c) cervical radiographs demonstrating the posterior occipito-cervico-thoracic instrumentation and anterior reconstruction with titanium mesh cage and C4-C5 anterior plate. The embolized left vertebral artery has been removed with the tumor expert for coils above and below the points of ligation (d) Computed tomography scan showing the C1 lateral mass screw through the T-shaped titanium cage (e) and C1 lateral mass
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F4
Protection of the instrumentation with a submental flap, and refixation of the split mandible was followed by closure of the posterior pharyngeal wall and the neck incision [Figures 3-5].
Medical illustration demonstrating the final anterior and posterior constructs. The nerve root and vertebral artery sacrifice are seen
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F5
Protection of the instrumentation with a submental flap, and refixation of the split mandible was followed by closure of the posterior pharyngeal wall and the neck incision [Figures 3-5].