Computed Tomography (CT) and Flouroscopy-guided Vertebroplasty: Results and Complications in 187 Patients

The burden of percutaneous vertebroplasty: an epidemiological nationwide study in Italy from 2009 to 2015

PURPOSE

Percutaneous vertebroplasty (PV) is a minimally invasive technique requiring the injection of polymethylmethacrylate cement into a collapsed or weakened vertebral body to stabilize the fracture. The present study aims to determine the trends in PV procedures over the recent years. The longitudinal analysis of national registers may help to understand the yearly trends and the economic burden of PV. The evaluation of the yearly national costs of this procedure is essential to surgeons, policymaker, hospital administrator and the healthcare system. Moreover, to observe possible variation in the trend of hospitalization between countries, the data of the present study were compared to the US population.

METHODS

Data of this study were collected from the National Hospital Discharge Reports reported at the Italian Ministry of Health regarding the years of this paper (2009-2015). The yearly number of hospital admission for PV, sex, age, days of hospitalization and primary diagnoses in the whole Italian population were calculated.

RESULTS

31,887 vertebroplasties were performed in Italy, with an incidence of 8.8 procedures for every 100,000 inhabitants. Females represented the majority of patients undergoing PV. The median length of hospital stay was 4.15 days. The mean hospital reimbursement was 4,629€ for each PV hospitalization.

CONCLUSION

The burden of vertebral fracture is relevant in the Italian population, and PV constitutes a rapid and effective treatment. Compared to other countries, the costs of PV in Italy are relatively lower; however, it is important to define the incidence of this procedure to understand the economic trend of PV.

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.

[Kyphoplasty-Vertebroplasty. A critical assessment]

CLINICAL ISSUE

Painful vertebral compression fractures.

STANDARD TREATMENT

Analgesia.

TREATMENT INNOVATIONS

Osteoplastic procedures, such as kyphoplasty and vertebroplasty.

DIAGNOSTIC WORKUP

Anamnestic and radiological associations of clinical complaints with the radiomorphological findings of vertebral compression fractures are required for an adequate consideration to assess whether an osteoplastic procedure should be carried out. A computed tomography (CT) scan allows a reliable judgement whether an osteoplastic procedure is technically feasible and promising to improve the local vertebral fracture-associated pain.

PERFORMANCE

Prospective controlled trials have demonstrated a satisfactory improvement of back pain associated with vertebral fractures and parameters of quality of life by osteoplastic interventions.

ACHIEVEMENTS

No prospective, truly sham-controlled blind trials are currently available which demonstrate an advantage of osteoplastic interventions compared to standard pain treatment; however, the currently published prospective controlled trials show a satisfactory pain reduction by osteoplastic interventions, such as kyphoplasty and vertebroplasty.

PRACTICAL RECOMMENDATIONS

Painful vertebral fractures and progressive loss of vertebral height of compression fractures should be evaluated in an interdisciplinary team consisting of radiologists, spinal surgeons and internists to assess whether an osteoplastic procedure is technically feasible and promising to improve local pain and immobility associated with vertebral fractures.

Is there a stable vertebral height restoration with the new radiofrequency kyphoplasty? A clinical and radiological study

PURPOSE

The aim of this study is to evaluate whether radiofrequency kyphoplasty can restore vertebral body height in osteoporotic vertebral fractures and whether restoration of vertebral height correlates with decreased pain.

METHODS

In a prospective study from December 2010 to October 2011, 25 patients underwent RF kyphoplasty for 30 fresh osteoporotic vertebral fractures. The parameter demographics, pain relief, restoration of vertebral body height (mean vertebral body height, kyphosis angle, anterior/posterior edge height) and all complications were recorded.

RESULTS

Mean age of patients was 73.8 ± 9.6 (range, 55-83); time from initial painful fracture to treatment was 3.0 weeks ± 1.2; average operative time was 23.5 min (range, 15-41). Average pain index score decreased significantly from 69 ± 8.5 preoperatively to 34.4 ± 5.9 postoperatively (p < 0.001), and to 30 ± 6.3 (p < 0.001) after 3 months. Mean vertebral body height, anterior edge height and kyphosis angle showed significant increases postoperatively and at 3-month follow-up (p < 0.05). In two vertebrae (6.6 %), minimal, asymptomatic cement leakage occurred in the upper disc. After 2 months, one new fracture (3.3 %) was identified in the directly adjacent segment that was also successfully treated with radiofrequency kyphoplasty. There was a preliminary correlation between mean vertebral body height elevation and cement volume (r = 0.533).

CONCLUSION

Radiofrequency kyphoplasty achieves rapid and lasting improvement in clinical symptoms. There was stable restoration of vertebral body height with a mean cement volume of 3.0 ml ± 0.6. There was no correlation between restoration of vertebral body height and pain relief.

Comparison of vertebroplasty and kyphoplasty for complications

Vertebroplasty (VP) and kyphoplasty (KP) have been proven equally effective in providing pain relief in patients with vertebral compression fractures (VCF). Both have been reported to have multiple complications which, though rare, are potentially devastating. This literature review focuses on comparing the incidence of various types of complication of VP and KP. Local cement leakage and pulmonary cement embolism have been reported more commonly after VP than KP. It is questionable whether the relative risk of developing an adjacent level new fracture after VP is greater than after KP The relationship between a new VCF and each of these procedures has also not been clearly established. Although the majority of complications are clinically silent, their potential risks, which include a fatal outcome, should always be kept in mind by the practitioner.

Heat distribution of polymerisation temperature of bone cement on the spinal canal during vertebroplasty

PURPOSE

In the last 15 years, vertebroplasty and kyphoplasty have become established operative procedures for treating osteoporotic vertebral-body fractures and vertebral bodies afflicted with metastases. These procedures are quickly performed with few personnel and material resources and have a low rate of complications. However, cases of neurological impairment are reported in the scientific literature. We analysed whether potentially harmful heat is radiated/conducted by the polymerisation temperature of polymethylmethacrylate (PMMA) bone cement in the spinal canal.

METHODS

We performed vertebroplasty on 25 vertebral bodies and measured the temperature distribution during polymerisation of bone cement within the spinal canal using heat probes placed in the respective areas. The vertebral bodies were located in a circulating water bath at 37°C.

RESULTS

During polymerisation of the bone cement, a temperature rise was measured. The peak temperature was reached after few minutes. Temperature curves differed; a maximum temperature of up to 43.16°C was detected for a few seconds only.

CONCLUSION

When vertebroplasty is performed correctly, there is no temperature development that could eventually damage the spinal cord or spinal nerves.

Current perspectives on percutaneous vertebroplasty: current evidence/controversies, patient selection and assessment, and technique and complications

Osteoporotic-associated vertebral compression fractures are a major public health concern, dwarfing even hip fractures in incidence in the United States. These fractures carry a significant morbidity and mortality burden and also represent a major growing source of consumption of scarce heath resources. Percutaneous vertebroplasty remains a commonly used and safe technique for the symptomatic treatment of vertebral compression fractures, both osteoporotic- and neoplastic-induced. By carefully selecting appropriate patients who are referred promptly, vertebroplasty can provide significant and durable pain relief over traditional conservative therapy. Recent controversies surrounding the evidence for vertebroplasty in osteoporotic-associated vertebral compression fractures are reviewed. A comprehensive step-by-step practical guide to performing vertebroplasty is then described. A brief description of patient selection, workup, as well as complications is also provided.

Therapeutic effects of percutaneous vertebroplasty for vertebral metastases

PURPOSE

We have performed percutaneous vertebroplasty (PV) using polymethylmethacrylate (PMMA) for patients with vertebral metastases since 2002. This study investigated the therapeutic effects of PV on vertebral metastases.

MATERIALS AND METHODS

A retrospective (2002-2008) review was conducted for 69 consecutive patients with 141 metastatic vertebrae treated with PV using PMMA. The clinical background of the patients, visual analog scale (VAS), improvement rate, outcomes, and complications were evaluated.

RESULTS

The mean preoperative VAS score was 7.3 and significantly improved to 1.9 postoperatively (at discharge), with a mean improvement rate of 73.3%. With regard to complications, no new fractures of adjacent vertebral bodies were encountered, but cement leakage was seen in 49% of the patients. Most patients were asymptomatic during the postoperative course, although two patients (3%) experienced dyspnea that was suspected to be adult respiratory distress syndrome or a pulmonary embolism.

CONCLUSION

PV can offer pain relief to patients with painful vertebral metastases and short life expectancy whose general condition makes surgery difficult.

Osteoplastic procedures for the treatment of vertebral complications in multiple myeloma patients

Pain induced by vertebral fracture in multiple myeloma can be treated by an osteoplastic procedure. The magnitude of the pain reduction by the procedure depends on the presence of additional causes for pain as spondylosis deformans, osteochondrosis, stenosis of the spinal canal, or intervertebral nerve compression. To identify additional reasons for pain apart from a vertebral fracture-induced pain, a detailed preoperative analysis of the patients complaints is crucial for the outcome after an osteoplastic procedure. In addition, the technical aspects for performing the procedure and potential complications have to be considered as well as the stability of the cortical bone of the respective vertebral body. A complete collapse of the vertebra (vertebra plana) is an unfavorable situation for any osteoplastic procedure. In case of inflammatory or infectious vertebral lesions (e.g. spondylodiscitis) osteoplastic procedures are contraindicated. An interdisciplinary discussion of the individual case among oncologists, radiotherapists, trauma/spien surgeons, radiologists, and osteologists/endocrinologists is a prerequisite for the identification of patients who will truly benefit from an osteoplastic procedure and to avoid overtreatment of the patient and economical exploitation of healthcare providers.

Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners

OBJECTIVE

This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain.

METHODS

This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered.

CONCLUSIONS

It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.

Efficacy and safety of vertebroplasty for treatment of painful osteoporotic vertebral fractures: a randomised controlled trial [ACTRN012605000079640]

Background

Vertebroplasty is a promising but as yet unproven treatment for painful osteoporotic vertebral fractures. It involves radiographic-guided injection of various types of bone cement directly into the vertebral fracture site. Uncontrolled studies and two controlled quasi-experimental before-after studies comparing volunteers who were offered treatment to those who refused it, have suggested an early benefit including rapid pain relief and improved function. Conversely, several uncontrolled studies and one of the controlled before-after studies have also suggested that vertebroplasty may increase the risk of subsequent vertebral fractures, particularly in vertebrae adjacent to treated levels or if cement leakage into the adjacent disc has occurred. As yet, there are no completed randomised controlled trials of vertebroplasty for osteoporotic vertebral fractures. The aims of this participant and outcome assessor-blinded randomised placebo-controlled trial are to i) determine the short-term efficacy and safety (3 months) of vertebroplasty for alleviating pain and improving function for painful osteoporotic vertebral fractures; and ii) determine its medium to longer-term efficacy and safety, particularly the risk of further fracture over 2 years.

Design

A double-blind randomised controlled trial of 200 participants with one or two recent painful osteoporotic vertebral fractures. Participants will be stratified by duration of symptoms (< and ≥ 6 weeks), gender and treating radiologist and randomly allocated to either the treatment or placebo. Outcomes will be assessed at baseline, 1 week, 1, 3, 6, 12 and 24 months. Outcome measures include overall, night and rest pain on 10 cm visual analogue scales, quality of life measured by the Assessment of Quality of Life, Osteoporosis Quality of Life and EQ-5D questionnaires; participant perceived recovery on a 7-point ordinal scale ranging from 'a great deal worse' to 'a great deal better'; disability measured by the Roland-Morris Disability Questionnaire; timed 'Up and Go' test; and adverse effects. The presence of new fractures will be assessed by radiographs of the thoracic and lumbar spine performed at 12 and 24 months.

Discussion

The results of this trial will be of major international importance and findings will be immediately translatable into clinical practice.

Trial registration

Australian Clinical Trial Register # [ACTRN012605000079640]

Minimally invasive anterior vertebroplasty for C-2 metastatic lesions

The authors describe a technique for minimally invasive anterior vertebroplasty for treating metastatic disease of the C-2 vertebra and discuss its application in 2 cases. After a 2-cm lateral neck incision is made, blunt dissection is performed toward the anterior inferior endplate of the C-2 vertebra. An 11-gauge needle is introduced through a tubular sheath and tapped into the inferior endplate of C-2, with biplanar fluoroscopy being performed to confirm position. The needle is subsequently advanced across the fracture line and into the odontoid process. Under fluoroscopic guidance, 2 ml of methylmethacrylate is injected into the odontoid process and vertebral body. This method is advantageous as 1) hyperextension of the neck is not performed, 2) the chance of inadvertent neurovascular or submandibular gland injury is minimized, 3) the possibility of cement leakage is decreased, and 4) hemostasis is better achieved under direct vision.

Vertebroplasty using real-time, fluoroscopy-controlled, catheter-assisted, low-viscosity cement injection

STUDY DESIGN

Case series.

OBJECTIVE

Evaluation of new vertebroplasty technique.

SUMMARY OF BACKGROUND DATA

Viscous polymethylmethacrylate cement is frequently used to avoid leakage in vertebroplasty. However, the large force required to inject the cement can require the use of special equipment or the direct injection of the cement without a cannula. In addition, injection under fluoroscopic guidance with a short or absent cannula is associated with a higher intraoperative radiation dose. A method using an angiographic catheter for thin cement injection is presented.

METHODS

Real-time, fluoroscopy-controlled, catheter-assisted, thin cement injection was used for 102 vertebroplasty sessions (84 patients, 148 vertebrae). Leakage was monitored in 85 procedures via computed tomography.

RESULTS

All vertebral bodies were successfully and satisfactorily filled with bone cement. Cement leakage was evident in 50% of the 85 asymptomatic cases (25 paraspinal, 29 epidural, and 30 intradisc space). On follow-up, new compression fractures were noted in the same (n = 5) or adjacent (n = 16) vertebral body, and elsewhere (n = 10). Vertebroplasty provided pain relief in >90% of cases. Recurrent compression fracture occurred in 5 vertebrae of 4 patients after vertebroplasty. New compression fractures occurred in 16 adjacent vertebral bodies of 11 patients and in 10 vertebral bodies remote from the site. One patient who developed osteomyelitis was successfully treated with antibiotics alone.

CONCLUSION

Real-time, fluoroscopy-controlled, catheter-assisted, low-viscosity cement injection is a safe and feasible method for vertebroplasty, and produces a comparable outcome as high-viscosity cements.

Height gain of vertebral bodies and stabilization of vertebral geometry over one year after vertebroplasty of osteoporotic vertebral fractures

The height gain of vertebral bodies after vertebroplasty and geometrical stability was evaluated over a one-year period. Osteoporotic fractures were treated with vertebroplasty. The vertebral geometry and disc spaces were analysed using reformatted computed tomography (CT) images: heights of the anterior, posterior, and lateral vertebral walls, disc spaces, endplate angles, and minimal endplate distances. Vertebrae were assigned to group I [severe compression (anterior height/posterior height) <0.75] and group II (moderate compression index >0.75). A total of 102 vertebral bodies in 40 patients (12 men, 28 women, age 70.3 +/- 9.5) were treated with vertebroplasty and prospectively followed for 12 months. Group I showed a greater benefit compared with group II with respect to anterior height gain (+2.1 +/- 1.9 vs +0.7 +/- 1.6 mm, P < 0.001), reduction of endplate angle (-3.6 +/- 4.2 vs -0.8 +/- 2.3 degrees , P < 0.001), and compression index (+0.09 +/- 0.11 vs +0.01 +/- 0.06, P < 0.001). At one-year follow-up, group I demonstrated preserved anterior height gain (+1.5 +/- 2.8 mm, P < 0.015) and improved endplate angle (-3.4 +/- 4.9 degrees , P < 0.001). In group II, the vertebral heights returned to and were fixed at the pre-interventional levels. Vertebroplasty provided vertebral height gain over one year, particularly in cases with severe compression. Vertebrae with moderate compression were fixed and stabilized at the pre-treatment level over one year.

Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty

STUDY DESIGN

Literature review concerning pulmonary embolism of polymethylmethacrylate (PMMA) material following percutaneous vertebroplasty and a report on 2 new cases.

OBJECTIVE

To inform clinicians about delayed clinical manifestation of pulmonary embolism of polymethylmethacrylate material after percutaneous vertebroplasty, pathophysiology, precautions, and therapeutic management of this complication.

SUMMARY OF BACKGROUND DATA

Percutaneous vertebroplasty is a minimal invasive intervention used to treat vertebral fractures, which yields good therapeutic results and rarely produces complications. Nevertheless, serious complications may occur. Pulmonary PMMA embolism, which has been recently reported in some cases, is one of these.

METHODS AND RESULTS

We report on 2 cases of pulmonary embolism of PMMA material after percutaneous vertebroplasty. In the case of a 45-year-old female patient, symptoms of pulmonary embolism arose with a delay of 3 days following percutaneous vertebroplasty. A therapy with low-molecular-weight heparin, Enoxaparin, enabled recovery from pulmonary failure. The second case occurred without detection of any cement leakage into the paravertebral venous system, neither intraoperatively nor perioperatively. The existence of PMMA in pulmonary vessels was detected 1 year later and remained asymptomatic.

CONCLUSION

These 2 cases allow us to conclude that the risk of pulmonary embolism of PMMA might be underestimated. We propose routine chest radiograph following every vertebroplasty, in order to detect pulmonary PMMA embolism and thereby prevent serious delayed cardiopulmonary failures.

CT-guided vertebroplasty in osteoprotic vertebral fractures: incidence of secondary fractures and impact of intradiscal cement leakages during follow-up

The purpose of this study was to analyse the number and types of secondary fractures, and to investigate the impact of intradiscal cement leaks for adjacent vertebral fractures. Patients with osteoporotic vertebral fractures were treated with vertebroplasty. Results were documented and prospectively followed by means of computed tomography (CT) and magnetic resonance imaging. The frequency and the types of cement leakages were analysed from multiplanar CT images and secondary fractures were characterised as follows: (1) adjacent fracture in the immediate vicinity of an augmented vertebra; (2) sandwich fracture, fracture of an untreated vertebra between two vertebrae that had been previously augmented, and (3) distant fractures not in the vicinity of augmented vertebrae. A total of 385 osteoporotic vertebral fractures were treated in 191 patients (61 men, 130 women, age 70.7 +/- 9.7 years). The overall rate of cement leaks was 55.6%, including all leaks detectable by CT. Intradiscal leaks through the upper, the lower, and both endplates occurred in 18.2%, 6.8%, and 2.6%, respectively. In 39 patients (20.4%), a total of 72 secondary fractures occurred: 30 adjacent fractures in 23 patients (12.0%) with a time to fracture of 2 months [median; 1.0/4.0 months, first/third quartile (Q1/Q3)]; 11 secondary sandwich fractures in 11 patients (5.8%) after 1.5 months (median; 0.25/7.5 months, Q1/Q3); and 31 distant fractures in 20 patients (10.5%) after 5 months (median; 2.0/8.0 months, Q1/Q3). Ten of 30 adjacent fractures occurred in the presence of pre-existing intradiscal cement leaks and 20 where there was no leakage. Six of 11 sandwich fractures occurred in the presence of intradiscal leaks (five leaks in both adjacent disc spaces, one leak in the lower disc space) and five where there was no leakage. The rate of secondary adjacent and non-adjacent fractures is quite similar and there is no specific impact of intradiscal leakages on the occurrence of adjacent secondary fractures. Adjacent fractures occur sooner than distant secondary fractures. Sandwich fractures are associated with specific biomechanical conditions, with a 37.9% fracture rate in sandwich constellations.

Percutaneous vertebroplasty and kyphoplasty for the stand-alone augmentation of osteoporosis-induced vertebral compression fractures: Present status and future directions

Enormous research efforts are being expended on two minimally invasive procedures: percutaneous vertebroplasty (VP) and kyphoplasty (KP). The present report, which is a detailed critical review of VP and KP that emphasizes their biomechanics aspects, is divided into six parts. In the first two parts, succinct descriptions are given of osteoporosis-induced vertebral body (VB) compression fractures as the underlying pathology to be treated with VP and KP, the theory of VP and KP, and the techniques used in performing these procedures. Concerns about VP and KP, such as the high radiation exposure burden that may be imposed on both patient and medical personnel and extravasation of the injectable bone cement, are discussed in the third part. Detailed discussions of fourteen issues/questions, such as the extent to which VP or KP affects various biomechanical measures of the augmented VB and those adjacent to it and the appropriate volume of the cement to use, are presented in the fourth part. Ideas for future research, such as development of a new generation of injectable bone cements and identification of an appropriate animal model, are covered in the fifth part. The final section contains a summary of the most salient points/observations made in the report.

Unsuspected lymphoma diagnosed with use of biopsy during kyphoplasty

BACKGROUND

Vertebral augmentation procedures are currently widely performed to treat vertebral compression fractures. In selecting appropriate patients for these procedures, it is important to distinguish the pain caused by a fracture from other causes of back pain. The purpose of this study was to determine the frequency of underlying, previously unrecognized malignant tumors in a consecutive series of patients undergoing kyphoplasty to treat vertebral compression fractures. Our hypothesis was that an unsuspected malignant tumor will exist and that a bone-marrow aspiration from the iliac crest would enhance our ability to detect a malignant tumor.

METHODS

A prospective histological evaluation of vertebral body biopsy specimens from presumed osteoporotic vertebral compression fractures and a concurrent bone-marrow aspiration from the iliac crest were performed in order to identify latent hematopoietic dyscrasias. Over a four-year period, vertebral body biopsies from 523 vertebral levels as well as iliac crest bone-marrow aspirations were performed in 238 patients. Both specimens were evaluated histologically, and the prevalence of an underlying occult malignant neoplasm was determined.

RESULTS

All specimens from the vertebral bodies showed signs of bone-remodeling and/or fracture-healing. However, in three patients, both the bone biopsy specimen and the bone-marrow aspirate showed evidence of B-cell lymphoma. The bone-marrow aspirate did not provide any additional information compared with the vertebral body biopsy specimen, and multiple myeloma was not identified in any patient.

CONCLUSIONS

Lymphoma is an uncommon cause of a vertebral compression fracture, but on the basis of our experience in this series, we recommend that vertebral body biopsy specimens be obtained in all patients managed with kyphoplasty and vertebroplasty to rule out an unsuspected malignant tumor. However, we do not recommend the routine use of an additional bone-marrow aspiration from the iliac crest during vertebral augmentation procedures because doing so did not appear to enhance our ability to detect a malignant tumor.

Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures

STUDY DESIGN

Prospective, double-cohort study.

OBJECTIVE

To evaluate conservative and percutaneous vertebroplasty (PV) management of osteoporotic vertebral fractures.

SUMMARY OF BACKGROUND DATA

PV is an elective alternative to conservative management for the treatment of a painful osteoporotic vertebral fracture.

METHODS

We performed a prospective study consisting of 101 consecutive patients who underwent PV and 27 patients who refused PV treatment and were managed conservatively. We used a data evaluation and outcomes system that was developed to evaluate the outcomes of surgical intervention.

RESULTS

Patients that elected for PV as a treatment of their fractures had significantly more pain and functional impairment before the procedure than the patients of the conservative group (P < 0.001). The pain, functional, and general health scores of the PV group were improved from the preoperative mean values (P < 0.001) in all postoperative periods. Compared with the conservative treatment group, there was a significant difference at month 3. However, no statistical differences on function were observed between these groups at 6 months and 1 year posttreatment.

CONCLUSIONS

PV demonstrated a rapid and significant relief of pain and improved the quality of life. PV election for treatment of painful osteoporotic vertebral fracture after 6 weeks of conservative treatment was based on pain and functional impairment.

Kyphoplasty treatment of vertebral fractures: 2-year outcomes show sustained benefits

STUDY DESIGN

Retrospective single-center consecutive case series with two [corrected] year follow-up.

OBJECTIVES

To examine kyphoplasty [corrected] patients for long-lasting clinical and radiological outcomes [corrected] including effects on [corrected] vertebral body shape.

SUMMARY OF BACKGROUND DATA

Kyphoplasty is the minimally-invasive [corrected] reduction and stabilization of vertebral body fractures [corrected] resulting in pain relief and improved physical function as described in our previously published one-year outcomes report [corrected]

METHODS

Safety (complications and cement extravasation) was monitored in all 117 patients (151 fractures) treated through December 2001. Preoperative and postoperative VAS [corrected] pain scores, analgesia usage, and ambulatory status were compared in 77 [corrected] of these patients with at least two-year [corrected] follow-up. Anterior, midline, posterior vertebral body heights, and height ratios from this cohort were assessed pre-operatively, [corrected] immediately postoperative [corrected] and after 2 years of follow-up.

RESULTS

Pain scores, patient ability to ambulate independently and without difficulty, and need for prescription pain medications improved significantly (P < 0.001) after kyphoplasty [corrected] and remained unchanged or improved at 2 years [corrected] Vertebral heights significantly (P < 0.001) [corrected] increased at all postoperative intervals, with > or = 10% height increases in 84% [corrected] of fractures. Morphometric height ratios for treated fractures also significantly increased (P < 0.001): 0.67 +/- 0.24 to 0.81 +/- 0.21 and 0.64 +/- 0.24 [corrected] to 0.83 +/- 0.11. Asymptomatic cement extravasation occurred in 11.3% of fractures, and during the follow-up period [corrected] additional fractures occurred in previously untreated levels at a rate of 4.5% per year. There were no kyphoplasty-related [corrected] complications.

CONCLUSIONS

Kyphoplasty markedly improves clinical outcome [corrected] and results in significant vertebral height restoration and normalization of morphologic shape indices [corrected] that remain stable for at least two [corrected] years following treatment.

Fatal pulmonary cement embolism following percutaneous vertebroplasty (PVP)

A case of fatal pulmonary embolism with acrylic cement occuring during a percutaneous vertebroplasty on account of a fracture of L1 is described. Autopsy confirmed the presence of large amounts of surgical cement in the paravertebral venous system and in the pulmonary arteries. This rare complication occurred because perivertebral venous cement migration was not recognized during vertebroplasty. To our knowledge, this is the first case of fatal pulmonary embolism caused by surgical cement following a percutaneous vertebroplasty.

Percutaneous vertebroplasty: An update

Percutaneous vertebroplasty is an imaging-guided interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a painful compressed vertebral body. This technique is safe and effective, and provides increased strength and pain relief in vertebrae weakened by bone diseases. Among the current indications for vertebroplasty are intractable nonradicular pain caused by compression fractures due to osteoporosis, myeloma, metastasis, and aggressive vertebral hemangioma. Contraindications include bleeding disorder, unstable fracture, and lack of definable vertebral collapse. The preprocedural evaluation, technique, complications, and expected results of performing this procedure are also reviewed.

Percutaneous treatment of vertebral body pathology

Percutaneous vertebral body injection procedures currently are used to stabilize and reinforce weakened or fractured bone resulting from metastatic disease and severe osteoporosis. Both vertebroplasty and kyphoplasty can reinforce the structure of a vertebral body and provide pain relief, but the procedures have technical differences. Kyphoplasty improves vertebral height to varying degrees in nearly three quarters of patients. Kyphosis is improved more effectively when the procedure is performed within 3 months from the onset of fracture pain. To date, it is unknown whether vertebroplasty with preprocedure postural reduction can provide similar improvement of deformity. Complications are relatively infrequent with both vertebroplasty and kyphoplasty. Cement leakage from the vertebral body is more likely with vertebroplasty than with kyphoplasty. Leakage is more common in the treatment of pathologic fractures resulting from metastatic disease. Clinical complications caused by cement leakage and neural compression are infrequent. Specific indications for these injection procedures need to be more clearly refined. Long-term outcomes, including the fate of the injected material and the effect on adjacent vertebrae, have yet to be determined.

Predictors of outcomes of percutaneous vertebroplasty for osteoporotic vertebral fractures

STUDY DESIGN

Retrospective review of all percutaneous vertebroplasties performed in the authors' institution from November 1994 to June 2002. OBJECTIVE.: To determine the factors affecting the outcome of percutaneous vertebroplasty for the treatment of persistent painful osteoporotic fractures.

SUMMARY OF BACKGROUND DATA

Percutaneous vertebroplasty is an efficient procedure to treat pain due to osteoporotic vertebral fracture. However, the patient population that is most likely to benefit from this procedure is uncertain, and the inclusion and exclusion criteria for an ideal candidate have varied widely in the literature.

METHODS

A retrospective review of 278 percutaneous vertebroplasty procedures for osteoporotic fractures at 423 levels was performed. Sociodemographic, clinical, radiologic, and procedural data were analyzed as parameters for prognosis significance by univariate and multivariate analysis with logistic regression to estimate the strength of influence of each variable.

RESULTS

The presence of two or less symptomatic vertebrae (P < 0.03), the American Society of Anesthesiologists status I (P < 0.001), the presence of signal changes on magnetic resonance imaging (P < 0001), and the collapse of the vertebral body less than 70% (P < 0.001) were assessed as parameters for prognostic significance. Multivariate analysis also showed a significant correlation between the American Society of Anesthesiologists score and height loss of the vertebral body and the final outcome. The presence of signal changes on magnetic resonance imaging showed the highest odds ratio adjusted.

CONCLUSIONS

Appropriate patient selection is essential for achieving clinical success. Better results can be expected in patients with an American Society of Anesthesiologists score of I and when the level managed is confirmed by magnetic resonance imaging and the vertebral body height loss is less than 70%.

[Pulmonary embolism of cement during vertebroplasty]

A 62-year-old woman with severe osteoporosis experienced pulmonary embolism by polymethylmethacrylate after percutaneous vertebroplasty. The patient immediately developed respiratory and cardiac distress, and a computed tomographic scan revealed the presence of cement in the pulmonary circulation. Proper techniques can minimize the risk of pulmonary embolism during percutaneous vertebroplasty: adequate preparation of cement and fluoroscopy during the procedure are recommended.

Percutaneous vertebroplasty: history, technique and current perspectives

Percutaneous vertebroplasty is a safe and efficacious technique for the treatment of persistent pain from a fractured vertebral body. Injection of cement into the vertebral body is made after insertion of a large-bore needle, frequently by a trans-pedicular approach. Vertebroplasty is most commonly used to treat painful osteoporotic fracture resistant to conservative therapy, but may be helpful in other conditions such as malignant collapse. NICE guidelines are now available for this procedure, which is relatively new in the UK, but has been performed for more than 15 years in continental Europe.

The biomechanics of vertebroplasty: a review

Percutaneous vertebroplasty and kyphoplasty are being used extensively in the United States for the treatment of osteoporotic vertebral compression fractures. Although short-term clinical outcomes appear favourable, long-term data are not yet available and it is becoming increasingly important to understand how the underlying biomechanics of the spine are altered by the procedure. In vitro experimental studies have investigated the effect of cement augmentation on individual vertebra and short spinal segments. For individual vertebra, vertebroplasty appears to increase or return strength to the prefracture level, whereas the stiffness is not always restored. However for multiple-vertebra segments, the strength of the unit as a whole appears to decrease, with failure occurring in the non-augmented vertebrae. Both finite element (FE) and experimental studies have shown that the volume of cement injected affects the restoration of strength and stiffness. The type of cement appears to have less of an effect. Although biomechanical studies of the vertebroplasty process have indicated that the procedure has the potential to restore vertebral strength and stiffness, further work is necessary to understand fully the effects of the augmentation process on the surrounding structures if the treatment is to be fully optimized. This paper is a review of the biomechanical data available on vertebroplasty.

[Percutaneous vertebroplasty: technique and early results in 25 procedures]

Vertebroplasty procedure which involves percutaneous injection of bone cement into a collapsed vertebra using fluoroscopic guidance, has been introduced not only for treatment of osteoporotic patients, who have prolonged long lasting pain following vertebral fracture, but also for osteolytic vertebral compression fractures, to restore its loadbearing capacity and stiffness. Our result suggest that vertebroplasty is associated with pain relief in almost 100% of cases. Proper patient selection and a good technique should minimize complications.

Percutaneous vertebroplasty: indications, technique, and results

The authors describe a dedicated therapeutic vertebroplasty technique that uses newly designed instruments, acrylic cement, and dual guidance with ultrasonography and computed tomography for pain control in patients with bone failure, and report their experience. Between 1990 and 2002, they performed 868 percutaneous cementoplasty procedures in patients with severe osteoporosis, vertebral tumors, and symptomatic hemangiomas. In patients with osteoporosis, satisfactory results were obtained in 78% of cases; in patients with vertebral tumors, satisfactory results were obtained in 83% of cases; and in patients with hemangiomas, satisfactory results were obtained in 73% of cases. In the global series of 868 cementoplasties, an epidural leak was observed in 15 cases, which caused neuralgia in only three patients without spinal cord compression. In two patients, an asymptomatic pulmonary embolism was detected. The needle of the new vertebroplasty set is designed with side wings for easier rotation and removal. The screw syringe increases the precision of injection. The risk of leak is substantially reduced. The system is safe, reduces the cement manipulation time, and allows excellent control of the injection. The authors performed 130 vertebroplasties with this system without major complications.

The use of a side-opening injection cannula in vertebroplasty: a technical note

STUDY DESIGN

A human cadaveric investigation was conducted to determine the effect that a side-opening injection cannula in monopedicular percutaneous vertebroplasty had on the vertebrae filling pattern.

OBJECTIVES

To assess the filling pattern in vertebroplasty using a monopedicular technique, and to compare a standard front-opening filling cannula with a side-opening cannula.

SUMMARY OF BACKGROUND DATA

Vertebroplasty is an effective treatment for osteoporotic vertebral fractures. Clinical and biomechanical investigations show its efficacy even in asymmetrical filling patterns. However, the risk of cement extravasation is a major concern with this technique.

METHODS

Two different bone cement-injecting cannulas were compared: a standard front-opening cannula (8 gauge, 6 inches long) and a cannula of the same dimensions with a side-opening at its distal end. Eight pairs of osteoporotic nonfractured cadaver vertebrae (T10-T11) were augmented with low-viscosity polymethylmethacrylate under axial C-arm control. The filling pattern was assessed semiquantitatively. The cross-section in its lateral extension was divided into four equal bands, and the appearance of the cement in each respective zone was assessed after cement injections of 2, 4, and 8 mL. The extravasation of bone cement also was monitored.

RESULTS

With the side-opening cannula, the cement flow reached Zone 3 in six of eight cases, whereas with the front-opening cannula, the polymethylmethacrylate was observed in Zone 3 in only three cases. In no case was the cement observed in Zone 4. In five of eight cases using front-opening cannulas, extravasation into the vessels was observed after 3 to 4 mL of bone cement had been injected. No extravasation was noted with the use of the side-opening cannula unless the amount of cement exceeded 8 mL.

CONCLUSIONS

A side-opening cannula can improve the cement-filling pattern in monopedicular vertebroplasty, as compared with a standard front-opening cannula. The risk of extravasation is diminished if the cement flow is directed medially.