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VERTEBROPLASTYVERTEBROPLASTY(except the hands-on)(except the hands-on)
Kirkland W. Davis, M.D.Kirkland W. Davis, M.D.Division of Musculoskeletal Radiology
University of Wisconsin Madison, Wisconsin
Vertebroplasty: Introduction
• “New” treatment for painful pathologic vertebrae
• X-ray guided spine augmentation: “Internal Splint”
Vertebroplasty: Introduction• Vertebroplasty is an effective,
minimally invasive procedure in which bone cement (PMMA) is injected into a vertebral body to relieve pain
Pathologic Vertebral Compression Fracture
• Primary osteoporosis– Elderly patient– Female>male
• Secondary osteoporosis– Young patient– Steroid use
• Asthma, vasculitis, transplant, inflammatory bowel disease, tumor treatment
Pathologic Vertebra (+/- Compression Fracture)
• Neoplasm–Primary
•Hemangioma•Myeloma
–Secondary•Metastasis (5%/yr, 30% overall)
•Lymphoma
Osteoporotic Vertebral Compression Fractures
• More common in females than in males–2 female:1 male–Prevalence as high as 26% in
females > 50 years of age
Osteoporotic Fractures: Economics
• 1.5 million osteoporotic fractures annually in the United States– 700,000 vertebral fractures
• In 1995, osteoporotic fractures accounted for– 2.5 million physician visits– 432,000 hospital admissions– 180,000 thousand nursing home admissions– $13.5 billion in direct medical expenses
• Fracture incidence predicted to quadruple next 50 years
Osteoporotic Fractures: Actual Costs May Be Under-Reported
– Pain– Diminished
mobility– Loss of
employment– Narcotic
addiction– Urinary retention– Constipation
–Insomnia–Depression–Spinal cord
compression–Kyphosis– Pulmonary
restriction– GI disturbances
Osteoporotic Compression Fractures: Traditional Management• Analgesics
–Temporary–Side effects
• Bed rest–Deep venous
thrombosis–Pneumonia
• Immobilization–Variable success–May cause
further demineralization
• Surgery–Challenging–For neuro
compromise
Osteoporotic Compression Fractures: Traditional
Management
• Some do not heal–Chronically
disabling
• Side effects of traditional management can be significant
Objective
• To provide relief from a painful vertebra– Osteoporotic fracture
• Primary• Secondary
– Neoplasm• Benign or malignant• Fractured or not
• To provide stability
Objective• To prevent further
vertebral collapse that would–Lead to further
loss of height–Result in
kyphosis–Be associated
with fractures at adjacent levels
Early Intervention May Reduce:
• Duration of acute pain
• Medication use• Duration of
immobilization• Occurrence of
chronic back pain
• Further collapse of the treated vertebral body
• Height loss• Kyphosis• Incidence of
pulmonary embolism and pneumonia
Benefits of Vertebroplasty
• Pain relief–Quick–Complete: osteoporosis >
neoplasia• Improved mobility
–Patient able to stand and walk within first 24 hours
History
• Acrylic cements have been used for bone augmentation for over 3 decades–Stabilization of large defects after
tumor excision (Vidal, 1969)–Hip replacement (Chamley, 1970)
History
• First reported case of percutaneous vertebroplasty in Amiens, France –Galibert and Deramond, 1984–50 year-old female with neck pain
due to a cervical (C2) hemangioma
Efficacy of VertebroplastyZoarski et al.
• Osteoporotic compression fracture–75-90% of patients experience
dramatic or complete relief of pain within several to 72 hours
• Neoplastic compression fracture–59-86% of patients experience
marked reduction in narcotic requirements or complete pain relief
Efficacy of VertebroplastyZoarski et al.
• 30 pts, 54 fractures• MODEMS questionnaire pre- and 2 weeks
post-procedure• 80% improved• Treatment expectations: success
(P<0.0001); improved pain and disability (P<0.0001), physical function (P=0.0004), and mental function (P=0.0009).
• 15-18 month follow-up: 22 of 23 patients reported continued pain relief and satisfaction with procedure. Pain improved (P<0.0001)
Efficacy of VertebroplastyEvans et al.
• 488 patients, 245 responding (40 deceased, 75 wrong #, 118 unreachable multiple attempts, 10 other)
• Phone interview average 7 months post-procedure
• Pain: 8.93.4 (P<0.001)• Impaired ambulation: 72%28% (P<0.001)• Ability to perform ADL improved (P<0.001)• Consistent results across subgroups: time from
procedure to questionnaire, one versus multiple fractures, acute versus chronic fractures
Efficacy of VertebroplastyFourney et al.
• MD Anderson• 56 patients (21 myeloma, 35 other)• 97 procedures, all fractures• Recorded:
–VAS: pain–Medication use–Neurologic status–Preop; postop; 1, 3, 6, 9, 12 months
Efficacy of VertebroplastyFourney et al.
• Improvement or complete pain relief 84%
• No change 9%• Not available 7%• None worse
Efficacy of VertebroplastyFourney et al.
• Median pre-op VAS 7• Median post-op VAS 2 (p<0.001)• Pain reduction significant at
each follow-up interval through one year
Efficacy of VertebroplastyWeill et al.
• France• 37 patients with mets (no
myeloma)• 52 procedures• Treated painful vertebra or
lesions that threaten stability of spine
Efficacy of VertebroplastyWeill et al.
• Pain– 73% clear improvement in pain– 21% moderate improvement– 6% no improvement– Statistical estimates:
• 6 months 73% pain relief• 1 year 65% pain relief
– Pain recurrence usually due to new lesions
Efficacy of VertebroplastyWeill et al.
• Stabilization: no loss of height in 11 vertebrae treated for stabilization–Mean follow-up 13.0 months
Efficacy of Vertebroplasty
• UW experience: mostly osteoporosis
• 12 months• 27 patients, 25 with accurate
documentation• 20/25 pain improved or resolved =
80%
Why Does Vertebroplasty Alleviate Pain?
• Stabilizes fracture• Allows healing to occur• Prevents further collapse of the treated
vertebral body• Tumors??
– Thermal effect– Toxic effect– Mass effect– Stabilizes microfractures and
macrofractures
Indications• Painful vertebra
from:–Osteoporotic
fracture–Neoplastic
fracture–Tumor
infiltration–Trauma?
Patient Selection• Patients who tend to respond best
–Single level or only a couple of levels–Focal pain and tenderness
corresponding to the level of edema by MRI
–Fracture present <2 months or recent worsening of fracture
–Fracture limits activity–No sclerosis of fractured vertebra
Patient Selection• Patients who are less likely to
respond–Fracture present for >1 year–Other causes for back pain are
present•Disc herniation, spinal stenosis, facet or sacroiliac joint disease
–Radicular pain related to disc herniation
Neoplastic Compression Fracture
• Treat to alleviate pain• Stabilize vulnerable vertebrae• Opportunity to obtain biopsy• Amount of pain reduction may be
less than what is achieved in the treatment of osteoporotic compression fractures
• Greater risk for complications
Contraindications:• Moderate or
severe retropulsion of the posterior vertebral body cortex into the spinal canal
• Vertebral height loss >70%
Patient Selection Criteria
• Painful fracture not responding after 4 weeks of treatment (?)
• Acute or subacute compression fracture(s) on plain radiographs or MRI
• Pain corresponding to level of the fracture
Pre-procedure Consultation
• Alteration of lifestyle due to fracture?–Activities of daily living
• Analgesic use–Types–Frequency
• Orthotic use
Pre-procedure Consultation
• Past medical history• Past surgical history
–Spine surgery?• Medications
–Anticoagulants
Pre-procedure Consultation
• Allergies–{Iodine contrast agents}–Antibiotics
• Laboratory–{Hct/Hgb}, PT/PTT/INR,
Platelets, {Bun/Creat}• Imaging studies
Pre-procedure Imaging• Magnetic
resonance imaging– T1, T2, STIR
sequences– Assess for
vertebral body marrow edema
– Exclude stenosis due to disc and/or facet disease
Pre-procedure Imaging
• Computed tomography– If MRI
contraindicated– Assesses cortical
integrity of posterior vertebral body and pedicles
Pre-procedure Imaging• Bone scan
–If MRI contraindicated
–With SPECT–Often
performed as part of a metastatic work-up
Pre-procedure Consultation• Examination under
fluoroscopy– Establish
concordance between painful sites and levels of vertebral body compression
– Occasionally needed
• Informed consent
Complications
• Incidence–Minor complications: 1-5%–Major complications: <<1%–Higher for metastases: 10%
• Majority of complications are transient and self-limited
• Steroid therapy or surgery are rarely required
Complications• Spinal cord or nerve root injury
–<1%–Direct
•Puncture–Indirect
•Compression•Hematoma•Ischemia
Complications
• Hemorrhage–Rare
• Infection–Rare
• Pulmonary embolism
• Fracture–Lamina–Pedicle
• Increased pain–1-2%
• Death
Complications
• Symptomatic cement extravasation–Incidence: depends upon
etiology of fracture•Osteoporosis 1-2%•Neoplasm 5-10%
Procedure: Specifics
• Performed with biplane fluoro• Patient in prone position: comfort is
our goal• Strict sterile technique
Procedure: Anesthesia
• Intravenous sedation–Sedation: midazolam–Analgesia: fentanyl
• Local–1% Lidocaine–0.5% Bupivicaine on bone
• General anesthesia–Rarely required
Procedure
• High quality fluoroscopy suite
• One to two hours• Prone position,
padded table• Cement injected
via needles placed percutaneously
Procedure: Cement Mixture• Polymer powder• Liquid monomer• Opacifying agent
–Barium sulfate powder–Tungsten–Tantalum
• Optional additive: antibiotic powder (Tobramycin)
Procedure: Cement Injection• Meticulous
fluoroscopic monitoring during the injection process
• Liquefied cement is injected into the vertebral body
Procedure: Cement Injection
• Termination of injection– Cement in
posterior 1/4 of vertebral body on lateral projection
– Cement extending outside vertebra
Conclusions
• Vertebroplasty is –Safe–Effective
• Indications–Osteoporotic fracture–Neoplastic fracture–Painful neoplastic involvement–Stabilization
Conclusions• Vertebroplasty is a palliative
procedure and does not correct the underlying cause of the vertebral fracture
• Appropriate management of osteoporosis or malignancy must therefore be initiated and continued
• Vertebroplasty can be combined with other therapies
Selected References: Vertebroplasty
1. Fourney DR, et al. Percutaneous Vertebroplasty and Kyphoplasty for Painful Vertebral Body Fractures in Cancer Patients. J Neurosurg (Spine 1) 2003; 98:21-30.
2. Jensen ME, Kallmes DF. Percutaneous Vertebroplasty in the Treatment of Malignant Spine Disease. Cancer J 2002; 8:194-206.
3. Weill A, et al. Spinal Metastases: Indications for and Results of Percutaneous Injection of Acrylic Surgical Cement. Radiology 1996; 199:241-247.
4. Zoarski GH, et al. Percutaneous Vertebroplasty for Osteoporotic Compression Fractures: Quantitative Prospective Evaluation of Long-Term Outcomes. J Vasc Interv Radiol 2002; 13:139-148.
Selected References: Kyphoplasty
1. Dudeney S, et al. Kyphoplasty in the Treatment of Osteolytic Vertebral Compression Fractures as a Result of Multiple Myeloma. J Clin Onc 2002; 20:2382-2387.
2. Ledlie JT, Renfro M. Balloon Kyphoplasty: One-Year Outcomes in Vertebral Body Height Restoration, Chronic Pain, and Activity Levels. J Neurosurg:Spine 2003; 98:36-42.
3. Lieberman IH, et al. Initial Outcome and Efficacy of “Kyphoplasty” in the Treatment of Painful Osteoporotic Vertebral Compression Fractures. Spine 2001; 26:1631-1638.
4. Ortiz AO, et al. Kyphoplasty. Techniques in Vascular and Interventional Radiology 2002; 5:239-249.
5. Phillips FM, et al. Minimally Invasive Treatments of Osteoporotic Vertebral Compression Fractures: Vertebroplasty and Kyphoplasty. AAOS Instruct Course Lect 2003; 52:559-567.