Onyx injection by direct puncture for the treatment of hypervascular spinal metastases close to the anterior spinal artery: initial experience

Report of 2 cases

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Presurgical devascularization of hypervascular spinal metastases has been shown to be effective in preventing major blood loss during open surgery. Most often, embolization can be performed using polyvinyl alcohol (PVA) microparticles. However, in some cases, the close relationship between the feeders of the metastases and the feeders of the anterior spinal artery (ASA) poses a risk of spinal cord ischemia when PVA microparticle embolization is performed.

The authors present their early experience in the treatment of spinal metastases close to the ASA; in 2 cases they injected Onyx-18, by direct puncture, into hypervascular posterior arch spinal metastases situated close to the ASA.

Two women, one 36 and the other 55 years of age, who presented with spinal lesions (at the posterior arch of C-4 and T-6, respectively) from thyroid and a kidney tumors, were sent to the authors' department to undergo presurgical embolization. After having performed a complete spinal digital subtraction angiography study, a regular angiography catheter was positioned at the ostium of the artery that mainly supplied the lesion. Then, with the patient in the left lateral decubitus position, direct puncture with 18-gauge needles of the lesion was performed using roadmap guidance. Onyx-18 was injected through the needles under biplanar fluoroscopy.

Satisfactory devascularization of the lesions was obtained; the ASA remained patent in both cases. The metastases were surgically removed in both cases within the 48 hours after the embolization and major blood loss did not occur.

Presurgical devascularization of hypervascular spinal metastases close the ASA by direct puncture with Onyx-18 seems to be an effective technique and appears to be safe in terms of the preserving the ASA's patency.

Abbreviations used in this paper:AP = anteroposterior; ASA = anterior spinal artery; DSA = digital subtraction angiography; PSA = posterior spinal artery; PVA = polyvinyl alcohol.

Article Information

Address correspondence to: Frédéric Clarençon, M.D., Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47, Boulevard de l'Hôpital, 75013 Paris, France. email: fredclare5@msn.com.

Please include this information when citing this paper: published online April 19, 2013; DOI: 10.3171/2013.3.SPINE12832.

© AANS, except where prohibited by US copyright law.

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    Case 1. This 36-year-old woman presented with a recurrence of a C-4 posterior arch metastasis 4 years after treatment. A and B: Sagittal T2-weighted (A) and axial T1-weighted (B) 3-T MR images obtained after Gd injection. A posterior arch oval lesion is seen at C-4 that produced a slight hyperintense signal on T2-weighted imaging and strongly enhanced after Gd injection (arrows). This lesion is responsible for reducing the size of the cervical canal; no hyperintense signal is seen within the spinal cord. Note the presence of a hypointense area within the C-4 vertebral body, corresponding to bone cement from a previous percutaneous vertebroplasty (arrowheads). CE: Preembolization spinal angiograms: Right ascending cervical artery injection, lateral projection (C); right vertebral artery, lateral projection (D); and left vertebral artery, AP projection (E). Marked tumor blush of the C-4 posterior arch lesion and of the vertebral body is seen, fed by both ascending cervical arteries (right side in C; left side not shown), both deep cervical arteries (not shown), and both vertebral arteries (D and E). Note the branches with posterior orientation arising from the right vertebral artery (arrows in D), for which attempts at catheterization were first made to perform microparticle embolization of the lesion. Also note the ASA supplied by the radiculomedullary branches from the left vertebral artery (arrowheads in E). F: Selective contrast media injection via the 18-gauge needles positioned within the lesion. G: Onyx injection via the needles positioned in the posterior arch lesion (large arrow). Note the proximal markers (thin single arrows in F and G) and the distal markers (thin double arrows in F and G) of the balloon protection positioned in the right vertebral artery. H and I: Control digital subtraction angiograms after Onyx injection into the lesion showing a total disappearance of the tumor blush of the posterior arch lesion (right ascending cervical artery, lateral projection [H] and right vertebral artery, lateral projection [I]). J and K: Postprocedure axial and sagittal reconstruction with bone windowing. Satisfactory filling of the lesion by the cast of Onyx is seen (arrows). Note the presence of bone cement within the vertebral body, related to a previous percutaneous vertebroplasty (arrowheads).

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    Case 1. Drawing of the positioning of the patient for the direct puncture of a posterior arch lesion. The patient is placed in a left lateral decubitus position. Direct puncture of the lesion is performed under a roadmap guidance obtained through the angiogram catheter via the femoral access.

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    Case 2. This 55-year-old woman presented with a compressive T-6 spine metastasis from a kidney tumor. A: Unenhanced axial CT scan showing a huge osteolytic lesion (arrows) involving the left aspect of the posterior arch of T-6, the left pedicle, and extending to the vertebral body. Note the extension in the spinal canal. B and C: Preembolization spinal angiograms of the left T-6 intercostal artery (AP projection [B]) and left T-5 intercostal artery (AP projection [C]). Both left T-5 and T-6 intercostal arteries feed the huge tumor blush (black arrowheads). The left T-6 intercostal artery gives rise to a radiculomedullary artery (white arrow) that supplies the ASA (white arrowheads in B); the left T-5 intercostal artery also feeds the PSA (white arrowheads in C). D and E: Unsubtracted snapshots (AP [D] and lateral [E] projections) after Onyx injection through multiple 18-gauge needles positioned in the lesion (arrowheads). Note the voluminous cast of Onyx (black arrows) and the coils positioned in the left T-5 and T-6 intercostal arteries (white arrows). F and G: Left T-6 intercostal artery control DSA image obtained after Onyx injection. Only the blush that involved the vertebral body remains; the posterior aspect of the blush has been satisfactorily embolized. Note the preservation of the patency of the ASA (white arrowheads). H and I: Unenhanced axial CT scan and sagittal reconstruction with bone windowing after Onyx injection. A satisfactory distribution of the Onyx in the posterior aspect of the lesion is seen (arrows).

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