Transoral C2 biopsy and vertebroplasty

Pathologic fractures involving the C2 vertebral body and odontoid process pose a unique dilemma, as the surgical approach for direct odontoid process screw fixation has several limitations. There have been a small number of transoral approach C2 vertebroplasty or kyphoplasty reported in the literature. Previous attempts were performed utilizing fluoroscopy or CT guidance. We report a case of a fluoroscopically guided transor-al approach vertebroplasty in a patient with a lytic lesion involving the C2 vertebral body, extending into the odontoid process with an underlying pathologic fracture. This case is unique as two separate punctures were required in order to adequately stabilize the pathologic fracture, CTA was performed preoperatively to better evaluate regional vasculature, and a post-procedure rotational flat panel CT was performed to assess cement placement.

Significance of preoperative MRI in establishing levels of augmentation for percutaneous vertebroplasty

Objectives

To determine whether X-ray, computed tomography (CT), bone scan, and clinical impression accurately reflect the level of vertebral fracture in patients about to undergo vertebroplasty.

Design

Retrospective observational study, utilizing patient inpatient notes, referral correspondence, and clinicians’ private notes.

Setting

Single center – all patients referred to one pain medicine physician for vertebroplasty who subsequently had the procedure.

Participants

All patients referred to a pain physician (PJG) over a 4-year period, who had a presumptive diagnosis of vertebral fracture(s) from the referring consultant physician, based on imaging other than magnetic resonance imaging (MRI) and clinical impression. Participants then had an MRI and subsequent vertebroplasty under the care of the pain physician. Participants were identified retrospectively from the vertebroplasty procedure list.

Intervention

Nil.

Main outcome measure

Number of cases in which the MRI identified a different level of pathology than X-ray, CT, bone scan, and clinical impression.

Results

In 50% (28/56) of patients MRI identified a fracture at a different level to that which was presumed to be the cause of patient pain on the basis of X-ray, CT, and clinical impression.

Conclusion

MRI is an essential investigation to determine accurately the level of fracture in osteoporotic patients. Studies on the effectiveness of treatment of vertebral fractures that do not utilize MRI in every case are unlikely to be accurate.

Repeat vertebroplasty for the subsequent refracture of procedured vertebra

Vertebroplasty (VP) can effectively treat pain and immobility caused by vertebral compression fracture. Because of complications such as extravasation of bone cement (polymethylmethacrylate, PMMA) and adjacent vertebral fractures, some practitioners prefer to inject a small volume of PMMA. In that case, however, insufficient augmentation or a subsequent refracture of the treated vertebrae can occur. A 65-year-old woman visited our clinic complaining of unrelieved severe low back and bilateral flank pain even after she had undergone VP on the 1(st) and 4(th) (L1 and L4) lumbar vertebrae a month earlier. Radiologic findings showed the refracture of L1. We successfully performed the repeat VP by filling the vertebra with a sufficient volume of PMMA, and no complications occurred. The patient's pain and immobility resolved completely three days after the procedure and she remained symptom-free a month later. In conclusion, VP with small volume cement impaction may fail to relieve fracture-induced symptoms, and the refracture of an augmented vertebral body may occur. In this case, repeat VP can effectively resolve both the persistent symptoms and problems of new onset resulting from refracture of the augmented vertebral body due to insufficient volume of bone cement.

Posterior decompression and short segmental pedicle screw fixation combined with vertebroplasty for Kümmell's disease with neurological deficits

The aim of this study was to investigate the treatment of Kümmell’s disease with neurological deficits and to determine whether intravertebral clefts are a pathognomonic sign of Kümmell’s disease. A total of 17 patients who had initially been diagnosed with Kümmell’s disease were admitted, one patient was excluded from this study. Posterior decompression and vertebroplasty for the affected vertebrae were conducted. Pedicle screw fixation and posterolateral bone grafts were performed one level above and one level below the affected vertebrae. Vertebral tissue was extracted for histopathological examination. The mean time of follow-up was 22 months (range, 18 to 42 months). The anterior and middle vertebral heights were measured on standing lateral radiographs prior to surgery, one day postoperatively and at final follow-up. The Cobb angle, the visual analog scale (VAS) and the Frankel classification were used to evaluate the effects of the surgery. The VAS, anterior and middle vertebral heights and the Cobb angle were improved significantly one day postoperatively and at the final follow-up compared with the preoperative examinations (P<0.05). No significant differences were observed between the one-day postoperative results and those at final follow-up (P>0.05). The neurological function of all patients was improved by at least one Frankel grade. All patients in this study exhibited intravertebral clefts, and postoperative pathology revealed bone necrosis. One patient (not included in this study) showed an intravertebral cleft, but the pathology report indicated a non-Hodgkin’s lymphoma. The intravertebral cleft sign is not pathognomonic of Kümmell’s disease. Posterior decompression with short-segment fixation and fusion combined with vertebroplasty is an effective treatment for Kümmell’s disease with neurological deficits.

Pulmonary cement embolism after pedicle screw vertebral stabilization

Pulmonary arterial embolization of polymethylmethacrylate cement, most usually occurring after vertebroplasty or kyphoplasty, is very uncommon following vertebral stabilization procedures. Unenhanced CT scans viewed at lung window settings allow confident identification of cement emboli in the pulmonary circulation along with possible associate parenchymal changes, whereas hyperdense emboli may be less conspicuous on CT-angiographic studies with high-flow contrast medium injection. Although clinical manifestations are largely variable from asymptomatic cases to severe respiratory distress, most cases are treated with anticoagulation.

Prospective comparison of the therapeutic effect of teriparatide with that of combined vertebroplasty with antiresorptive agents for the treatment of new-onset adjacent vertebral compression fracture after percutaneous vertebroplasty

Most post-vertebroplasty new-onset adjacent vertebral compression fractures (VCFs) occur within 2-3 months, and antiresorptive agents do not significantly reduce the risk of their occurrence. In opposite mechanism, teriparatide directly stimulates bone formation and improves bone strength and quality faster. The therapeutic effect of teriparatide is better than that of vertebroplasty combined with an antiresorptive treatment and is a potentially useful therapy for new-onset adjacent VCFs after vertebroplasty.

INTRODUCTION

Following vertebroplasty, patients are at increased risk of new-onset adjacent-level VCFs. The therapeutic effect of antiresorptive agents is too slow, and they are associated with the risk of new VCFs. Teriparatide markedly increases bone formation and strength and reduces the incidence of new-onset VCFs. This prospective cohort study compared the therapeutic effects of teriparatide with those of combined vertebroplasty and an anti-resorber for treating new-onset adjacent VCFs after vertebroplasty.

METHODS

Fifty patients with adjacent VCFs were randomly assigned to two groups: teriparatide only (group A) and additional vertebroplasty combined with an antiresorptive agent (group B). Relevant clinical data of the two groups were prospectively compared.

RESULTS

The 22 patients in group A were at higher risk of new VCFs than those in group B (22 patients); they were older and had more pre-existing fractures (p < 0.05). Patients treated with teriparatide had a significantly lower incidence of new-onset VCFs (odds ratio = 0.21; 95% confidence interval, 0.02-2.10). Teriparatide-mediated VCF reduction was 78.57%, which was markedly better than that of group B. The teriparatide group had a significant decrease in the visual analog scale and an increase in the Japanese Orthopedic Association low back pain score after 6 months of treatment (p < 0.05). The increase in lumbar spine BMD was marked in the teriparatide group (21.70% vs. 6.87%) after an 18-month treatment.

CONCLUSIONS

Treatment of post-vertebroplasty adjacent VCFs with teriparatide (no new vertebroplasty) was more effective than that of repeated vertebroplasties combined with an anti-resorber.

Effectiveness of a bone substitute (CERAMENT™) as an alternative to PMMA in percutaneous vertebroplasty: 1-year follow-up on clinical outcome

PURPOSE

The aim of the study was to evaluate the efficacy of an injectable and partly absorbable calcium bone cement (CERAMENT™, Bone Support, Sweden) in the treatment of osteoporotic or traumatic vertebral fractures by percutaneous vertebroplasty.

METHODS

From March 2009 to October 2010 an open, prospective study in two centres was performed. 33 patients with symptomatic vertebral fractures were enrolled. Patients were included based on evaluation by X-ray, CT, and MRI. Clinical evaluation by Visual Analogue Scale (VAS, 0-10) and Oswestry Disability index test (ODI, 0-100 %) was performed before the operation as well as 1, 6 and 12 months after the procedure. Radiology assessment post-procedure was carried out by X-ray, CT, and MRI at 1, 6 and 12 months post-op. Intake of analgesic medications pre- and post-procedure was monitored.

RESULTS

66 vertebral bodies underwent percutaneous vertebroplasty. VAS score demonstrated a significant decrease from 8.61 (SD 19.8) pre-operatively to 2.48 (SD 2.36) at 1 month. The score was 2.76 (SD 2.68) at 6 months and 1.36 (SD 1.33) at the latest follow up. ODI score dropped significantly from 58.86 pre-op to 26.94 at 6 months and further down to 7.61 at 12 months. No re-fractures or adjacent level fractures were reported.

CONCLUSION

Data show that CERAMENT can be a substitute of PMMA in the treatment of osteoporotic and traumatic vertebral fractures, especially in young patients.

Strategy for bone metastases treatment in patients with impending cord compression or vertebral fractures: a pilot study

Impending spinal cord compression and vertebral fractures are considered contraindications for radionuclide bone pain palliation therapy. However, most of the patients with widespread bone metastases already have weakened vertebral segments that may be broken. Therefore, local field external-beam radiotherapy or percutaneous vertebroplasty (VP) should be considered to improve the patient's quality of life and to institute subsequent appropriate treatment, including radionuclide therapy for bone pain palliation. The objective of this study was to develop a strategy for an effective treatment of bone metastases in patients with widespread bone metastases and intolerable pain, associated with impending cord compression or vertebral fractures. Eleven patients (5 females and 6 males, aged 32-62 years; mean age 53.8 ± 2.7 years) with multiple skeletal metastases from carcinomas of prostate (n = 3), breast (n = 3) and lung (n = 5) were studied. Their mean pain score measured on a visual analogue scale of 10 was found to be 8.64 ± 0.15 (range 8-9) and the mean number of levels with impending cord compression or vertebral fracture was 2.64 ± 0.34 (range 1-4). All patients underwent vertebroplasty and after 3-7 days received Sm-153 ethylene diamine tetra methylene phosphonic acid (EDTMP) therapy. Sm-153 EDTMP was administered according to the recommended standard bone palliation dose of 37 MBq/kg body weight. Whole body (WB) bone scan, computed tomography and magnetic resonance imaging (MRI) were performed before and after treatment in all patients. Pain relief due to stabilization of vertebrae after VP occurred within the first 12 hours (mean 4.8 ± 1.2 hours; range 0.5-12 hours), and the mean pain score was reduced to 4.36 ± 0.39 (range 2-6). Subsequent to Sm-153 EDTMP treatment, further pain relief occurred after 3.91 ± 0.39 days (range 2-6 days) and the pain score decreased to 0.55 ± 0.21 (range 0-2). The responses to treatment were found to be statistically significant (P < 0.0001). Based on the results on this limited patient population, we conclude that spinal stabilization using VP in patients with widespread bone metastases and impending cord compression is an effective way to decrease disability with pain and to facilitate subsequent systemic palliation of painful skeletal metastases by Sm-153 EDTMP therapy.

Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club

This consensus article reviews the various aspects of the non-pharmacological management of osteoporosis, including the effects of nutriments, physical exercise, lifestyle, fall prevention, and hip protectors. Vertebroplasty is also briefly reviewed. Non-pharmacological management of osteoporosis is a broad concept. It must be viewed as an essential part of the prevention of fractures from childhood through adulthood and the old age. The topic also includes surgical procedures for the treatment of peripheral and vertebral fractures and the post-fracture rehabilitation. The present document is the result of a consensus, based on a systematic review and a critical appraisal of the literature. Diets deficient in calcium, proteins or vitamin D impair skeletal integrity. The effect of other nutriments is less clear, although an excessive consumption of sodium, caffeine, or fibres exerts negative effects on calcium balance. The deleterious effects of tobacco, excessive alcohol consumption and a low BMI are well accepted. Physical activity is of primary importance to reach optimal peak bone mass but, if numerous studies have shown the beneficial effects of various types of exercise on bone mass, fracture data as an endpoint are scanty. Fall prevention strategies are especially efficient in the community setting, but less evidence is available about their effectiveness in preventing fall-related injuries and fractures. The efficacy of hip protectors remains controversial. This is also true for vertebroplasty and kyphoplasty. Several randomized controlled studies had reported a short-term advantage of vertebroplasty over medical treatment for pain relief, but these findings have been questioned by recent sham-controlled randomized clinical studies.

Incremental benefit of SPECT + CT bone scans over conventional planar and SPECT bone scans in vertebroplasty

Study design:

Planar bone scans with SPECT and SPECT + CT were performed in those patients who underwent peri-operative evaluation for vertebroplasty. The scans were evaluated separately to identify the “culprit” vertebra (e) by two readers and their results were analyzed.

Objective:

Use of planar and SPECT bone scan for identifying the “culprit” vertebra (e) for vertebroplasty is well established. SPECT + CT is a relatively recent imaging tool providing co-registered fused images. Theoretical advantages of SPECT + CT over conventional SPECT imaging needs to be evaluated and documented.

Summary of Background Data:

Percutaneous stabilization of collapsed vertebra by bone cement has now become a standard procedure. However, it is essential to localize the correct vertebra. Imaging modalities like CT scan provides structural or anatomical information where as bone scan (planar + SPECT images) provides more functional or physiological information. Combination of these two imaging modalities is expected to provide much more than information obtained by any one imaging modality separately. To the best our knowledge, there is no reference available in the literature adopting this approach.

Materials and Methods:

Two expert readers, blinded to patient history, evaluated the scans. They independently analyzed planar + SPECT only images followed by SPECT/CT fused images with the aim to identify the acutely fractured vertebra for vertebroplasty.

Results:

Interpretations changed, on average, 50% of the time as a result of the additional information provided by SPECT + CT. SPECT + CT more precisely localizes tracer abnormalities in the vertebra compared to SPECT imaging alone

Conclusion:

The greatest value of co-registered SPECT + CT bone scan lies in the accurate localization of affected vertebrae in complicated cases of multiple collapsed vertebrae of different ages as well as in the post-vertebroplasty setting

Investigation of polymethylmethacrylate pulmonary embolus in a patient ten years following vertebroplasty

Percutaneous vertebroplasty (PV) is a procedure commonly used for the treatment of vertebral compression fractures, and the number of procedures has been steadily increasing over the past decade. We report a case of an 81 year old female with a history of breast cancer that developed two vertebral body compression fractures and was subsequently treated with PV. The patient developed a subsegmental pulmonary polymethylmethacrylate (PMMA) embolus as a complication of the procedure. Ten years following the procedure, she remained asymptomatic with the PMMA embolus being discovered incidentally during workup for a suspected chronic obstructive pulmonary disease (COPD) exacerbation. In reviewing the case, we describe the typical presentation of a pulmonary PMMA embolus and consider methods to decrease the incidence of this complication.

Kyphoplasty

The advent of the use of kyphoplasty in 1998 was the result of the expected evolution of materials and methods related to the successful introduction of vertebroplasty as a valid treatment of painful vertebral compression fractures. Kyphoplasty introduced a method of creating bilateral bone voids and in many cases elevation (reduction) of depressed end plates with variable degrees of height restoration. This was achieved by using bilateral balloon bone tamps capable of pressures significantly higher than conventional angioplasty balloons. This allows creation of bilateral bone voids, resulting in the ability to apply a much thicker cement mixture. This is felt to be the reason for fewer cement-related complications compared with vertebroplasty including extravasation and embolization. Although the procedural cost presently is higher for kyphoplasty, this is expected to decrease as patents expire and industry competition increases. Kyphoplasty indications include all those of vertebroplasty plus additional ones either contraindicated or not recommended for treatment with vertebroplasty. Kyphoplasty achieves the same degree of pain relief as vertebroplasty but may offer additional benefits of fewer complications, more indications, better biopsy specimens, and potential for height restoration of compression fractures of the spine. Further studies regarding potential benefits are warranted to assess any added value of kyphoplasty compared with vertebroplasty.

Percutaneous cementoplasty

Cementoplasty includes percutaneous procedures like vertebroplasty, kyphoplasty, osteoplasty, and sacroplasty. Bone packing with cement aims to treat or prevent vertebral and extraspinal pathological fractures and relieve pain in patients with osteoporosis and bone metastases. The authors outline the accepted and newer indications for patient selection and present the fundamentals of image-guided lesion access and cement injection. Practitioners should evaluate each patient carefully and have a thorough knowledge of the anatomy, the technique, the expected outcomes, and the potential complications. Detailed informed consent and multidisciplinary decision making are recommended. Understanding of the particular advantages and limitations of the various modern filler materials is also crucial for a successful and uncomplicated procedure. Future developments include new mechanical devices for effective restoration of vertebral height, as well as the introduction of osteoconductive and osteoinductive cements that will be able to promote more physiological bone healing.

Percutaneous bone tumor management

Interventional radiology plays a major role in the management of bone tumors. Many different percutaneous techniques are available. Some aim to treat pain and consolidate a pathological bone (cementoplasty); others aim to ablate tumor or reduce its volume (sclerotherapy, thermal ablation). In this article, image-guided techniques of primary and secondary bone tumors with vertebroplasty, ethanol injection, radiofrequency ablation, laser photocoagulation, cryoablation, and radiofrequency ionization (coblation) will be reviewed. For each modality, the principles, the indications, and the results will be presented. The technical choice depends on the therapeutic intent-curative or palliative-and the need for consolidation, but also on the general status of the patient and the other therapeutic options. For the most complex cases, combined treatments can be required. However, the less disabling technique should always be considered first.

Fibrous dysplasia in axis treated with vertebroplasty

Vertebroplasty of the axis is a challenging procedure, and little is known about its therapeutic outcome. Cervical fibrous dysplasia with a distinct cyst is a rare entity and few cases have been reported in the literature. A 55-year-old man with fibrous dysplasia of axis presented with severe neck pain and left arm since six months. Computed tomography and magnetic resonance imaging revealed an expansile, destructive lesion involving the axis, and no spinal cord. He was submitted to retropharyngeal surgery and the lesion was fulled by vertebroplasty. Microscopic examination was consistent with the diagnosis of monostotic fibrous dysplasia. After the surgery no recurrence was observed. The patient had remarkable improvement in clinical relief of neck pain at 1-year follow-up. Although there are descriptions of vertebral fibrous dysplasia, this is the 13th case of monostotic fibrous dysplasia of the cervical spine, and the 3rd case of the axis described in the literature. The unique case who had treated with ope vertebroplasty.

Lumbar vertebral haemangioma causing pathological fracture, epidural haemorrhage, and cord compression: a case report and review of literature

CONTEXT

Vertebral haemangiomas are recognized to be one of the commonest benign tumours of the vertebral column, occurring mostly in the thoracic spine. The vast majority of these are asymptomatic. Infrequently, these can turn symptomatic and cause neurological deficit (cord compression) through any of four reported mechanisms: (1) epidural extension; (2) expansion of the involved vertebra(e) causing spinal canal stenosis; (3) spontaneous epidural haemorrhage; (4) pathological burst fracture. Thoracic haemangiomas have been reported to be more likely to produce cord compression than lumbar haemangiomas.

FINDINGS

A forty-nine year old male with acute onset spinal cord compression from a pathological fracture in a first lumbar vertebral haemangioma. An MRI delineated the haemangioma and extent of bleeding that caused the cord compression. These were confirmed during surgery and the haematoma was evacuated. The spine was instrumented from T12 to L2, and a cement vertebroplasty was performed intra-operatively. Written consent for publication was obtained from the patient.

CLINICAL RELEVANCE

The junctional location of the first lumbar vertebra, and the structural weakness from normal bone being replaced by the haemangioma, probably caused it to fracture under axial loading. This pathological fracture caused bleeding from the vascularized bone, resulting in cord compression.

Computed tomography-guided vertebroplasty using a stereotactic guidance system (stereo-guide)

Background

In order to make it easy to perform computed tomography (CT)-guided vertebroplasty a stereotactic guidance system called the "stereo-guide" was designed. A method to perform CT-guided vertebroplasty using this system is described.

Methods

The device is a rectangular flat plastic block. One of the flat surfaces of the block has deeply grooved protractor markings at 5-degree intervals; ranging from 0 to 30 degrees. The procedure is performed on the CT table. Based on distances and angle measurements obtained from CT images the device is placed on an appropriate location on the back of the patient and the needle is advanced to the target through the pedicle guided by the grooves on the device. Ten procedures were performed in nine patients with lumbar and thoracic pathology.

Results

The system was easy to use and proved to be accurate. No complication resulted from the procedure.

Conclusion

The stereo-guide proved to be simple and easy to use. Intraoperative scans helped to plan the trajectory and follow the injection of the cement.

Morphological changes of injected calcium phosphate cement in osteoporotic compressed vertebral bodies

SUMMARY

This study was undertaken to investigate the radiologic and clinical outcomes of vertebroplasty with calcium phosphate (CaP) cement in patients with osteoporotic vertebral compression fractures. The morphological changes of injected CaP cement in osteoporotic compressed vertebral bodies were variable and unpredictable. We suggest that the practice of vertebroplasty using CaP should be reconsidered.

INTRODUCTION

Recently, CaP, an osteoconductive filler material, has been used in the treatment of osteoporotic compression fractures. However, the clinical results of CaP-cement-augmented vertebrae are still not well established. The purpose of this study is to assess the clinical results of vertebroplasty with CaP by evaluating the morphological changes of CaP cement in compressed vertebral bodies.

METHODS

Fourteen patients have been followed for more than 2 years after vertebroplasty. The following parameters were reviewed: age, sex, T score, compliance with osteoporosis medications, visual analog scale score, compression ratio, subsequent compression fractures, and any morphological changes in the filler material.

RESULTS

The morphological changes of injected CaP included reabsorption, condensation, bone formation (osteogenesis), fracture of the CaP solid hump, and heterotopic ossification. Out of 14 patients, 11 (78.6%) developed progression of the compression of the CaP-augmented vertebral bodies after vertebroplasty.

CONCLUSIONS

The morphological changes of the injected CaP cement in the vertebral bodies were variable and unpredictable. The compression of the CaP-augmented vertebrae progressed continuously for 2 years or more. The findings of this study suggest that vertebroplasty using CaP cement should be reconsidered.

The effect of pulsed jet lavage in vertebroplasty on injection forces of PMMA bone cement: an animal study

Percutaneous vertebroplasty, comprising of the injection of polymethylmethacrylate (PMMA) into vertebral bodies, is an efficient procedure to stabilize osteoporotic compression fractures as well as other weakening lesions. Besides fat embolism, cement leakage is considered to be one of the major and most severe complications during percutaneous vertebroplasty. The viscosity of the PMMA during injection plays a key role in this context. It was shown in vitro that the best way to lower the risk of cement leakage is to inject the cement at higher viscosity, which is requires high injection forces. Injection forces can be reduced by applying a newly developed lavage technique as it was shown in vitro using human cadaver vertebrae. The purpose of this study was to prove the in vitro results in an in vivo model. The investigation was incorporated in an animal study that was performed to evaluate the cardiovascular reaction on cement augmentation using the lavage technique. Injection forces were measured with instrumentation for 1 cc syringes, additionally acquiring plunger displacement. Averaged injection forces measured, ranged from 12 to 130 N and from 28 to 140 N for the lavage group and the control group, respectively. Normalized injection forces (by viscosity and injection speed) showed a trend to be lower for the lavage group in comparison to the control group (P = 0.073). In conclusion, the clinical relevance on the investigated lavage technique concerning lowering injection forces was only shown by trend in the performed animal study. However, it might well be that the effect is more pronounced for osteoporotic vertebral bodies.

Interventional radiology in the elderly

Interventional radiological percutaneous procedures are becoming all the more important in the curative or palliative management of elderly frail patients with multiple underlying comorbidities. They may serve either as alternative primary minimally invasive therapies or adjuncts to traditional surgical treatments. The present report provides a concise review of the most important interventional radiological procedures with a special focus on the treatment of the primary debilitating pathologies of the elderly population. The authors elaborate on the scientific evidence and latest developments of thermoablation of solid organ malignancies, palliative stent placement for gastrointestinal tract cancer, airway stenting for tracheobronchial strictures, endovascular management of aortic and peripheral arterial vascular disease, and cement stabilization of osteoporotic vertebral fractures. The added benefits of high technical and clinical success coupled with lower procedural mortality and morbidity are highlighted.

Osteoporotic vertebral compression fractures and vertebral augmentation

Vertebral fractures account for ~27% of all osteoporotic fractures in both men and women. The economic burden is substantial and growing: osteoporosis is expected to affect 14 million people by the year 2020. There is substantial morbidity associated with osteoporotic vertebral compression fractures (VCFs) including decreased quality of life, reduced pulmonary function, and increased mortality. Relatively recent additions to the treatment armamentarium include vertebral augmentation using vertebroplasty and kyphoplasty. Numerous retrospective and case studies demonstrate short-term efficacy and low complication rates of vertebroplasty and kyphoplasty in the treatment of osteoporotic VCFs, but controlled trials are needed for validation. The pathophysiology, risk factors, consequences, characteristics, and imaging of osteoporotic VCFs are presented in detail along with a discussion of treatment options and patient selection. Vertebral augmentation is comprehensively reviewed, including the technical aspects of the procedures, contraindications, complications, and clinical outcomes.

Costs and state-specific rates of thoracic and lumbar vertebroplasty, 2001-2005

STUDY DESIGN

Sequential cross-sectional analysis.

OBJECTIVE

To document vertebroplasty rates and costs.

SUMMARY OF BACKGROUND DATA

Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty.

METHODS

Using specific CPT-4 billing codes, we reviewed aggregate Medicare Part B fee-for-service claims data (cross-stratified by physician specialty and treatment setting) on thoracolumbar vertebroplasties performed from 2001-2005. Vertebroplasty rates for individual states were expressed per 100,000 Part B fee-for-service enrollees. Nation-wide facility and physician charges (combining expected contributions from all sources) allowed by Medicare for vertebroplasties and associated imaging guidance procedures were applied to observed vertebroplasty volumes. These charges (reflecting direct medical costs from an all-payer perspective) were expressed in 2005 dollars using the Producer Price Index.

RESULTS

Vertebroplasty rates for individual states rose but varied considerably, ranging from 0.0 to 515.6/100,000 Medicare Part B fee-for-service enrollees in 2001 (median state rate = 35.4), and from 9.8 to 849.5 in 2005 (median state rate = 75.0). On average, 1.3 vertebral levels were treated per procedure, varying by treatment site and physician specialty. Fluoroscopic rather than computed tomography guidance was used in 98.7% of cases. Total nation-wide inflation-adjusted charges rose from $76.0 million for 14,142 cases performed in 2001 to $152.3 million for 29,090 cases in 2005. While vertebroplasty was predominantly an outpatient procedure, inpatient cases generated most of the charges. Increasing volumes and costs were associated with cases performed in ambulatory surgery centers and physicians' offices.

CONCLUSION

Nation-wide vertebroplasty volumes and inflation-adjusted charges doubled from 2001 to 2005 in this Medicare population. Procedure rates varied considerablyby state. Almost all cases involved fluoroscopic guidance; procedures treating multiple vertebral levels were not uncommon. Procedures performed in free-standing facilities are of growing importance. Given the issues surrounding appropriate vertebroplasty use, future practice patterns and outcomes should be closely tracked.

Adjacent vertebral failure after vertebroplasty: a biomechanical study of low-modulus PMMA cement

PMMA is the most common bone substitute used for vertebroplasty. An increased fracture rate of the adjacent vertebrae has been observed after vertebroplasty. Decreased failure strength has been noted in a laboratory study of augmented functional spine units (FSUs), where the adjacent, non-augmented vertebral body always failed. This may provide evidence that rigid cement augmentation may facilitate the subsequent collapse of the adjacent vertebrae. The purpose of this study was to evaluate whether the decrease in failure strength of augmented FSUs can be avoided using low-modulus PMMA bone cement. In cadaveric FSUs, overall stiffness, failure strength and stiffness of the two vertebral bodies were determined under compression for both the treated and untreated specimens. Augmentation was performed on the caudal vertebrae with either regular or low-modulus PMMA. Endplate and wedge-shaped fractures occurred in the cranial and caudal vertebrae in the ratios endplate:wedge (cranial:caudal): 3:8 (5:6), 4:7 (7:4) and 10:1 (10:1) for control, low-modulus and regular cement group, respectively. The mean failure strength was 3.3 +/- 1 MPa with low-modulus cement, 2.9 +/- 1.2 MPa with regular cement and 3.6 +/- 1.3 MPa for the control group. Differences between the groups were not significant (p = 0.754 and p = 0.375, respectively, for low-modulus cement vs. control and regular cement vs. control). Overall FSU stiffness was not significantly affected by augmentation. Significant differences were observed for the stiffness differences of the cranial to the caudal vertebral body for the regular PMMA group to the other groups (p < 0.003). The individual vertebral stiffness values clearly showed the stiffening effect of the regular cement and the lesser alteration of the stiffness of the augmented vertebrae using the low-modulus PMMA compared to the control group (p = 0.999). In vitro biomechanical study and biomechanical evaluation of the hypothesis state that the failure strength of augmented functional spine units could be better preserved using low-modulus PMMA in comparison to regular PMMA cement.

The effect of pre-vertebroplasty tumor ablation using laser-induced thermotherapy on biomechanical stability and cement fill in the metastatic spine

A biomechanical study comparing simulated lytic vertebral metastases treated with laser-induced thermotherapy (LITT) and vertebroplasty versus vertebroplasty alone. To investigate the effect of tumor ablation using LITT prior to vertebroplasty on biomechanical stability and cement fill patterns in a standardized model of spinal metastatic disease. Vertebroplasty in the metastatic spine is aimed at reducing pain, but is associated with risk of cement extravasation in up to 10%. Six pairs of fresh-frozen cadaveric thoracolumbar spinal motion segments were tested in axial compression intact, with simulated metastases and following percutaneous vertebroplasty with or without LITT. Canal narrowing under load, pattern of cement fill, load to failure, and LITT temperature and pressure generation were collected. In all LITT specimens, cement filled the defect without extravasation. The canal extravasation rate was 33% in specimens treated without LITT. LITT and vertebroplasty yielded a trend toward improved posterior wall stability (P = 0.095) as compared to vertebroplasty alone. Moderate rises in temperature and minimal pressure generation was seen during LITT. In this model, elimination of tumor by LITT, facilitates cement fill, enhances biomechanical stability and reduces the risk of cement extravasation.

Transpedicle body augmenter in painful osteoporotic compression fractures

Osteoporotic compression fractures (VCFs) can result in progressive kyphosis and chronic pain. Polymethylmethacrylate has been used for augmentation of VCFs; however, there are cement complications, and long-term fracture healing is unknown. The transpedicle body augmenter (TpBA), a porous titanium spacer, has been reported as an internal support to reconstruct the vertebral body combining short segment fixation in burst fracture. We retrospectively reviewed radiographic and clinical results of TpBA vertebroplasty for single symptomatic VCF in 80 patients. Manual reduction and TpBA vertebroplasty via a paramedian incision with blunt dissection was done. Mean age was 72.3 years (range 51-87 years), and female-male ratio was 66:14. The mean symptom duration was 5 months, and follow-up 44 months. Peri-operative variables and radiographic and clinical results were evaluated. The average operation time was 26.1 min, blood loss 92 cc, and hospitalization 2.3 days. No patient had neurological deterioration. TpBA was found sinking into vertebral body initially, then locked by residual cortex, and finally stabilized within the vertebra. There was no dislodgement of TpBA in the final visit. Sixty-two patients (77.5%) could walk within 3-6 h after operation and the others within 24 h. The anterior vertebral restoration was 8.0 mm initially and 6.1 mm at final follow-up. Wedge angle correction was 11.5 degrees initially and 9.4 degrees at final follow-up. Pain, by the visual analog scale, was 8.6 pre-operatively, 2.5 at day 7 follow-up, and 2.9 at final follow-up. By the questionnaire, 72 of 76 respondents reported a decrease in discomfort after TpBA vertebroplasty, and 63 of 76 patients reported a return to normal activity after operation. The final satisfaction rate was 93.4%. TpBA vertebroplasty led to early and medium-term clinical improvement and anatomic restoration of painful VCFs.