vertebroplasty
TRANSCRIPT
The role of The role of vertebroplastyvertebroplasty in in vertebral fracturesvertebral fractures
Dr Steve ConnorNeuroradiology Department
King’s College Hospital
Basic principles and mechanismsBasic principles and mechanisms
Injection of polymethylmethacrylate(PMMA) into compressed vertebral bodyRelief of pain Strengthening of bone (load bearing and stiffness)
HistoryHistory
First performed in 1984 (Deramond et al 1987)
Widespread use for treatment of painful osteoporotic collapse in 1990s in USA
Not widely available in UK at present
IndicationsIndications
Painful new or progressive osteoporotic collapse – refractory to medical therapy– dosage of analgesia leads to unacceptable side effects
After conservative treatment (6-8 weeks)
Treatment is optimal within 4 months of fracture
Early treatment useful in specific cases– Co-morbid disease – To reduce loss of vertebral height and possibility of continued
collapse
IndicationsIndications
Management of painful vertebral tumours– Benign or malignant– Vertebra not necessarily collapsed
Onset of pain relief more rapid than radiotherapy and does not effect subsequent radiotherapy
IndicationsIndications
NOT :
High energy traumatic fractures
Prophylactic treatment of vertebrae at high risk of fracture
Absolute contraindicationsAbsolute contraindications
Other causes of pain e.g. disc herniation
Clear improvement with medical therapy
Infection
Coagulopathy
Relative contraindicationsRelative contraindications
Marked loss of vertebral height
(?<1/3 of original height)
Relative contraindicationsRelative contraindications
Retropulsion of fracture fragments (?>20%)or marked destruction of posterior vertebra
PrePre--procedural evaluationprocedural evaluation
Careful history, examination and discussion with patient– Residual deep ache worse with standing, bending and alleviated by
rest– Review analgesia requirement and side effects– Pain and mobility assessment– Reproduce pain on palpation
Consent
PrePre--treatment imagingtreatment imaging
Computed tomography– Pedicle morphology– Bone retropulsion/ posterior wall defects– Mark point of entry
PrePre--treatment imagingtreatment imaging
Magnetic resonance imaging
– Multiple collapses or prolonged pain
PrePre--treatment imagingtreatment imaging
Nuclear medicineSuccessful treatment unlikely ifnegative bone scan Useful if contraindication to MRI
Equipment and materialsEquipment and materials
High quality imaging– Biplane digital angiography suite– CT/ Portable fluoroscopy
Equipment and materialsEquipment and materials
Sterile conditions
Anaesthetic and monitoring equipment
Equipment and materialsEquipment and materials
Vertebroplasty needle
Low viscosity cement
Injection device
AftercareAftercare
Supine for 2 hours (observations)Limit activity for 24 hoursNSAIDs for 2-4 daysExpect pain relief within 24 hours but may be delayed up to one weekFollow up (1,7,30 days)
Mechanism of actionMechanism of action
Stabilising of microfracturesThermal necrosis of liquid monomerChemotoxicity of liquid monomer
Clinical outcome dataClinical outcome data
No large randomised controlled trial
One prospective randomised trial underway (acute compression factures)
One non randomised study with long term follow up comparing with conservative treatment (Diamond et al Am J Med 2003)
Clinical outcome dataClinical outcome data
22 published observational studies– Retrospective designs– Short term follow up– Concurrent treatment modalities
Three series of >250 patients– Gangi et al Radiographics 2003(868 patients)
Clinical outcome dataClinical outcome data
Moderate or marked pain relief in 75-95%– Increased energy– Improved quality of life
Longer term follow up data supports long term efficacy
No published studies addressing cost effectiveness
New developmentsNew developments
Non PMMA cements– Bioactive glass– Hydroxyapatite– Osteoconductive coral granules– Composite cements
Ideal cement volumesVariations of technique
Balloon Balloon kyphoplastykyphoplasty
Restores vertebral body heightHigh pressure balloon followed by cement injection into cavity created by balloon
?fewer complications resulting from cement extravasation?reduction in morbidity of kyphosis
Clinical outcome dataClinical outcome data--balloon balloon kyphoplastykyphoplasty
Five published case seriesLargest describes 188 procedures in 78 patients with minimum 1 year follow up(Coumans JV et al J Neurosurg 2003)
No comparisons with vertebroplasty or conservative therapyPain relief scores similar to those achieved by vertebroplasty
ConclusionConclusion
Vertebroplasty is a viable treatment and possible standard management of the pain and disability of vertebral fractures– Adequate training– Meticulous technique– Careful patient selection