Future directions in percutaneous vertebroplasty

Interventional therapeutic procedures to treat degenerative and inflammatory musculoskeletal conditions: state of the art

Imaging-guided interventional procedures have become increasingly popular in the treatment of several pathologic conditions in the musculoskeletal system. Besides oncological treatments, musculoskeletal procedures can be performed to treat different degenerative or inflammatory conditions. This paper is aimed to review clinical indications and technical aspects of these kinds of procedures. In particular, we revise the general aspects common to most procedures and the different imaging-guided interventions which can be performed around joints, soft tissues, and spine.

Percutaneous Selective Vertebroplasty: State of the Art Management in Well-Confined Metastatic Vertebral Lesions

Study Design

Prospective cohort study.

Purpose

To evaluate the clinical and radiological results of percutaneous selective vertebroplasty (PSV) as first-line treatment options in the setting of well-confined spinal metastases.

Overview of Literature

Recent technological advances combined with innovative interventional techniques enable an alternative less invasive treatment option for many patients with malignant vertebral body infiltration. Percutaneous vertebral augmentation procedures offer less invasive but effective pain relief to many patients with symptomatic spinal metastatic disease.

Methods

Eleven patients with 21 well-confined metastatic vertebral lesions that had been treated with PSV were included. Pain was evaluated one week, one month, 3 months and 6 months post-procedure using a 10-point visual analogue scale (VAS). A statistical analysis including repeated measures analysis of variance test was used to collectively indicate the presence of any significant differences between different time sequences. Medication usage and range of mobility were also evaluated.

Results

The 11 patients had an average age of 42 years and 54.5% were male. Highly significant improvements in VAS scores at rest and with activity (p<0.001) were evident. There was a significant decrease in rate of medication consumption post-procedure (p<0.05).

Conclusions

PSV can be used successfully as the first-line treatment for well-confined metastatic vertebral lesions. It is also an effective method to decrease pain, increase mobility, and decrease narcotic administration in such patients.

Application of percutaneous vertebroplasty in the treatment of multiple thoracic metastases

The present study aimed to explore the clinical implications of percutaneous vertebroplasty (PVP) in the treatment of multiple thoracic metastases. A total of 104 involved vertebrae of 28 patients with multiple thoracic metastases underwent PVP and the injection of bone cement. The pain relief rate and activity of daily life were assessed, and the morphological changes of the involved vertebral bodies and the invasiveness of the intraspinal tumor were also observed at 1 week, and 3, 6 and 12 months post-surgery, respectively. The pain relief rate increased at each time-point following PVP. The quality of life scores were also significantly higher than the pre-operative scores. After 12 months of follow-up, the post-operative heights of the anterior border, center and posterior border of the vertebral bodies were not noted to be statistically different from those prior to PVP (P>0.05). The present study concluded that PVP has a good analgesic effect on multiple thoracic metastases. PVP not only improves the quality of life of patients significantly, but also prevents further vertebral collapse and the invasiveness of intraspinal tumors, avoiding the nerve dysfunction caused by spinal cord compression.

Vertebroplasty of cervical vertebra

BACKGROUND

The first vertebroplasty was performed by Harve Deramond in France in 1984 due to a hemangioma of cervical vertebral body. Procedure technique consisted of inserting a needle through the bony palate of the oral cavity. Bone cement injected under pressure not only fills the areas of bone loss. The heat released in the process of crystallization causes denaturation of pathological tissue proteins (metastasis) and disrupts blood supply (hemangiomas). The aim of this study was to evaluate the method of treatment from anterolateral access.

MATERIAL/METHODS

In the years 2007-2012 the procedure was performed in 6 men and 9 women aged from 42 to 71 years (mean age: 56.3 years). In 10 cases the reason for vertebroplasty was the vertebral hemangioma, in another 4 - pathological vertebral fractures due to metastases, and in one case - multiple myeloma. Procedures were performed from anterolateral access, under local anesthesia, under x-ray guidance (fluoroscopy). Bone needle was inserted into the vertebral body, followed by injection of PMMA cement.

RESULTS

In 100% cases pain relief was observed immediately after the procedure and beneficial therapeutic effect was obtained. No life-threatening complications and clinical symptoms were observed. Average length hospital stay amounted to 2.9 days.

CONCLUSIONS

Cervical spine vertebroplasty from anterolateral access seems to be a safe, effective and beneficial method of treatment. It reduces the risk of infection in comparison to the transoral method.

Evaluation of operator radioprotection using a new injection device during vertebroplasty

This study aimed to evaluate the protection granted by a simple device (X'TENS(®), Thiebaud, France) and to provide operators with information on the performance of this new device, which has not yet been assessed. Our assumption is that this device efficiently reduces the radiation dose to the operator. In a prospective clinical study, the radiation dose the operator's hand receives has been assessed using a specific sensor (UNFOR Instrument). Each patient included in the study was to receive at least two injections of cement during the procedure. Exposure was measured with and without the range extender. The data collected were then processed using a Wilcoxon matched pairs test. During 14 interventions, 20 vertebrae were treated with both procedures. Eleven women and three men were included. Seven patients underwent vertebroplasty for metastatic lesions and seven for osteoporotic lesions, bone fractures or vertebral compressions. The average injection time was 1.35 minutes with the device and 1.20 without (p=0.75). The dose to the hand per ml injected was 111.37 vs. 166.91 (p<0.05). Theoretically, the protection granted by the range extender depends on the length of the device. Our results are consistent with the inverse-square law. However, the variations in our results indicate that a proper and rigorous use is mandatory for the device to be effective. Given that radioprotection during fluoroscopy procedures is a frequently raised issue, the need for information for a safer practice increases likewise.

The Efficacy of Percutaneous Vertebroplasty in Pain Relief in Patients with Pathological Vertebral Fractures due to Metastatic Spinal Tumors

BACKGROUND

Metastatic spinal tumors are common and major causes of pathological spinal fractures that result in severe pain, weakness, and progressive neurological deficits. This study aims to evaluate the efficacy of percutaneous vertebroplasty (PVP) in pain-relief in patients with spinal fractures due to metastatic spinal tumors.

METHODS

We evaluated 25 documented cases of metastatic spinal tumors with pathologic vertebral fractures who were suffering from severe pain and underwent vertebroplasty. Degree of pain was measured by visual analog scale (VAS). The symptoms were evaluated 24 hours and 2 months after vertebroplasty regarding the degree of pain relief.Complications such as leakage, embolism and infection were assessed.

RESULTS

MeanVAS score was 8.23 before therapy in the patients that was reduced to 2.12 and 1 in the patients 24 hours and 2 months after vertebroplasty, respectively. The most common complication was cement leakage (44%) and there was no embolism or infection. Data was analyzed by SPSS version 18 software through ANOVA test with Greenhouse-Geisser correction and P-value of 0.00 was obtained in the patients 24 hours and 1 month after surgery.

CONCLUSION

Considering significant decrease in the mean pain severity degree after the treatment, veretebroplasty seems to be significantly effective in pain relief in metastatic spinal tumors.

Interventional radiology and the care of the oncology patient

Interventional Radiology (IR) is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Adequate diagnostic samples can be obtained under image guidance by percutaneous biopsy and needle aspiration in an accurate and minimally invasive manner. IR techniques may be used to place central venous access devices with well-established safety and efficacy. Therapeutic applications of IR in the oncology patient include local tumour treatments such as transarterial chemo-embolisation and radiofrequency ablation, as well as management of complications of malignancy such as pain, organ obstruction, and venous thrombosis.

Percutaneous vertebroplasty relieves pain in metastatic cervical fractures

BACKGROUND

Percutaneous vertebroplasty is currently an alternative for treating vertebral fractures of the thoracic and lumbar spine, providing both pain control and vertebral stabilization. In the cervical spine, however, percutaneous vertebroplasty is technically challenging because of the complex anatomy of this region.

QUESTIONS/PURPOSES

We evaluated the technical feasibility, complication rate, and ability of percutaneous vertebroplasty to provide pain relief in patients with painful metastatic cervical fractures.

METHODS

We retrospectively reviewed 62 patients (24 men) who, between May 2005 and May 2009, underwent vertebroplasty to treat painful metastatic cervical fractures. Each patient was evaluated by a visual analog scale for pain, number of pain analgesics, and CT and MRI before, the day after, and at 3 months after the procedure.

RESULTS

Two of the 62 patients had asymptomatic cement leakage in the soft tissues. We observed no delayed complications. Mean pretreatment and 24-hour posttreatment visual analog scale pain scores were 7.9±1.7 and 1.5±2, respectively. Immediately after surgery, the pain completely disappeared in 25 (40%) patients. Administration of analgesics was suspended in 34 (55%) patients whereas in 27 (39%) patients the median analgesics use decreased from two pills per day (range, 0-3) to 0 (range, 0-3). In two (3%) patients, analgesics administration was continued due to the persistence of pain. At 3 months, the patients reported a mean visual analog scale pain score of 1.7±2.

CONCLUSIONS

Our data suggest, in selected patients, percutaneous vertebroplasty may be performed with a high technical success rate combined with a low complication rate, providing immediate pain relief lasting at least 3 months and a reduction in the use of analgesic drugs.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.