The value of routinely performing a bone biopsy during percutaneous vertebroplasty in treatment of osteoporotic vertebral compression fractures

Rate of Unexpected Malignancy in Patients Undergoing Percutaneous Vertebroplasty after Implementing a New Scanning Protocol

STUDY DESIGN

Retrospective quality improvement study.

OBJECTIVE

To investigate if the rate of unsuspected malignancy in biopsies in patients with VCF who underwent percutaneous vertebroplasty (PVP) at the same orthopedic department has changed after the implementation of a new MRI scanning protocol.

SUMMARY OF BACKGROUND DATA

Discrimination between benign and malign vertebral compression fracture (VCF) can be difficult. However, early diagnosis of malignant VCF is crucial to further treatment and prognosis. An earlier study at an orthopedic department reported a rate of unsuspected malignancy of 4.9% in patients with VCF who underwent PVP when biopsies were obtained during the procedure. The MRI scanning protocol was changed in this period.

METHODS

Retrospective on 427 patients with vertebral compression fracture undergoing PVP from April 28, 2017 to April 28, 2022, identifying operated patients from the Danish national DaneSpine registry. Subsequently, individual clinical information was collected in journal records.

RESULTS

The rate of unsuspected malignancy was 0.9% (4/427), and the overestimation of malignant VCF was 50% (16/32).

CONCLUSION

During the last 5 years, the rate of unsuspected malignancy in patients with VCF undergoing PVP has improved considerably from 4.9% to 0.9%. Furthermore, MRI is over-diagnosing malignancies. Thus, the new scanning procedure is effective in differentiating between benign and malign VCFs.

LEVEL OF EVIDENCE

3.

Clinical Oversight and Delayed Diagnosis of a Pathological Compression Fracture Causing Paraplegia

While osteoporosis is the primary cause of vertebral compression fractures (VCFs), it's crucial to promptly recognize pathological fractures through comprehensive diagnostic tests, including vertebral biopsies, to determine the exact etiology. For instance, a 66-year-old male with osteoporosis experienced worsening lower limb weakness and back pain after an initial vertebroplasty for a T12 compression fracture. Subsequent MRI revealed severe circumferential extradural compression at T12, leading to further surgeries that eventually uncovered metastatic adenocarcinoma from a pancreatic tumor. This case highlights the importance of precise diagnosis through vertebral biopsy and the necessity of sufficient ventral decompression or corpectomy, coupled with extensive laminectomy, to address severe neurological impairments like paraplegia. Prompt and accurate interventions can significantly improve patient outcomes and quality of life.

[Value of routine transpedicular biopsies in kyphoplasty and vertebroplasty for vertebral compression fractures : A survey among 250 spine surgeons]

BACKGROUND

Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma.

OBJECTIVE

To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures.

MATERIAL AND METHODS

A web-based (UmfrageOnline®) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU).

RESULTS

Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained.

DISCUSSION

Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The role of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures in the detection of malignant diseases: a systematic review

INTRODUCTION

Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures.

METHODS

A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.).

RESULTS

Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4-6% of the cases.

CONCLUSION

Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4-6% of the patients, even though the definition of "unexpected" varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear.

Risk factor analysis of bone cement leakage for polymethylmethacrylate-augmented cannulated pedicle screw fixation in spinal disorders

Objective

To investigate the risk factors of cement leakage (CL) for polymethylmethacrylate-augmented cannulated pedicle screw (CPS) in spinal degenerative diseases and provided technical guidance for clinical surgery.

Methods

This study enrolled 276 patients with spinal degenerative disease and osteoporosis who were augmented using CPSs (835 screws in total) from May 2011 to June 2018 in our hospital. The patients' age, sex, bone mineral density (BMD), diagnosis, augmented positions, number of CPS implanted, and CL during surgery were recorded. CL was observed by postoperative computed tomography (CT) and was classified by Yeom typing.

Results

A total of 74 (74/835, 8.9%) CPSs in 64 patients leaked (64/276, 23.2%). CL was significantly correlated with the number and position of screws (P < 0.05), but not with sex, age, and BMD (P > 0.05). The position, number of CPSs, fracture, degenerative scoliosis, ankylosing spondylitis, and revision surgery were risk factors for CL (P < 0.05). Augmentation of the thoracic vertebral body, fracture, and ankylosing spondylitis were independent risk factors for Type S. Augmentation of the lumbar vertebral body, lumbar disc herniation, and lumbar spondylolisthesis were independent risk factors for Type B (P < 0.05).

Conclusions

CL has a high incidence in clinical practice. High-risk factors for leakage should be addressed to avoid serious complications. Particularly, it is necessary to develop alternative solutions once CPSs can't be used in surgery caused by CL.

Evaluation of biopsy results during vertebral augmentation in patients with a known history of malignancy

OBJECTIVES

To evaluate biopsy results during vertebral augmentation in vertebral compression fracture (VCF) patients with a known history of malignancy.

METHODS

An analysis of vertebral augmentation between 2012 and 2021 was performed retrospectively. Each level of VCF was biopsied, and all biopsies were sent for histopathological analyses. Imaging evaluation was performed in collaboration with an oncologist, a spine surgeon, and a radiologist. Patients were divided into two groups based on the preoperative imaging findings. Malignant VCF (MVCF) was presumed in group A, while osteoporotic VCF (OVCF) was presumed in group B.

RESULTS

One hundred and fifty-six VCF patients with a known history of malignancy were included. Group A included 91 patients with preoperative imaging findings suspicious for MVCF. And 73 patients were finally diagnosed as MVCF, with biopsy results confirming imaging findings. The incidence of MVCF was 46.8%. Group B included 65 patients with imaging evidence of OVCF. And all biopsy results were negative for malignancy. The sensitivity of imaging evaluation for finding MVCF was 100%, and the specificity was 78.3%.

CONCLUSION

A combination of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) is sufficient to distinguish MVCF from OVCF. Biopsy is not required to confirm the diagnosis during vertebral augmentation, if the imaging findings do not indicate MVCF in patients with a known history of malignancy. It is recommended to perform a biopsy in patients with preoperative imaging findings suspicious for MVCF.

KEY POINTS

• A combination of X-ray, CT, and MRI is sufficient to distinguish MVCF from OVCF. • Biopsy is not required in patients without imaging signs of MVCF. • Biopsy is recommended in patients with imaging findings suspicious for MVCF.

Minimally invasive surgery for spinal fractures due to multiple myeloma

Background:

Multiple myeloma (MM) presents with spinal lesions in 60% of cases. The combination of osteolytic lesions with multifactorial osteopenia raises specific surgical treatment challenges. Minimally invasive spine surgery (MISS) could be a potential option for MM spinal lesions treatment.

Objective:

The objective of this study is to evaluate MISS techniques to treat patients presenting with spine fractures due to MM

Methods:

Retrospective analysis of consecutive patients with histology-proven pathological fractures caused by MM treated with MISS between 2009 and 2018. We collected the data from the clinical records on epidemiology, topography of spine lesions, surgical techniques, blood loss, operation time, complications, mean in-hospital time, and clinical evolution.

Results:

Twenty-one patients were studied – 13 males and 8 females, with a mean age of 64 years (range 43–83). Mean preoperative spinal instability neoplastic score was 9.8 ± 6 (range 5–16). All cases had a thoracolumbar location – 15 patients underwent kyphoplasty (KP) or vertebroplasty (VP) and 6 were treated with other more complex procedures. All patients had a reduction of pain and/or analgesic load. Vertebral body height increased by a mean of 2.9 mm after VP/KP. Mean hospital stay was 1.3 days for KP/VP and 5.0 days for other MISS procedures. Three patients had complications.

Conclusions:

The heterogeneity of techniques used reflected the variety of spine involvement by MM. KP and VP led to shorter hospital stays and less complications, being adequate for lesions without major instability. More complex MISS techniques offer an effective treatment with short delay for starting MM adjuvant treatment.

The Diagnostic Value of Magnetic Resonance Imaging in Identifying Unsuspected Malignancy in Patients Undergoing Percutaneous Vertebral Augmentation for Vertebral Compression Fractures

Background

The aim of this study was to identify the rate of unsuspected malignancy in vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation procedures (PVAPs).

Methods

From 2004-2015, 410 patients with VCFs underwent PVAPs with biopsy in a single tertiary hospital. All patients had preoperative magnetic resonance imaging (MRI) read by consultant radiologists and reviewed by the performing surgeon prior to PVAPs. All procedures were performed by fellowship-trained spine surgeons. A patient was considered to have an unsuspected malignancy if preoperative MRI was negative for malignancy but histology from the operative biopsy was positive.

Results

A total of 44 of 45 patients (97.8%) were identified to have malignancy on preoperative MRI. One patient had a negative MRI but positive biopsy (myeloma). This patient also had a positive myeloma panel. A total of 41 of 44 patients with suspicious MRI preoperatively had a history of malignancy with histology consistent with metastatic spread from the known primary. Two patients had a new diagnosis of malignancy (1 breast carcinoma, 1 metastatic cancer likely of breast or gastrointestinal origin). Younger patients were more likely to have a VCF due to malignancy (odds ratio, 28.33 in age < 60 years).

Conclusions

Almost 98% of patients with malignancy (44 of 45 patients) could be successfully identified with a preoperative MRI. The addition of a myeloma panel to MRI identified all patients with malignancies prior to PVAP in our study. We recommend MRI and myeloma panel for all patients with VCFs to be treated with PVAPs. For patients who undergo a PVAP, routine biopsy should be performed.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures

Vertebral compression fractures (VCFs) have various causes, including osteoporosis, neoplasms, and acute trauma. As painful VCFs may contribute to general physical deconditioning, management of painful VCFs has the potential for improving quality of life and preventing superimposed medical complications. Various imaging modalities can be used to evaluate a VCF to help determine the etiology and guide intervention. The first-line treatment of painful VCFs has been nonoperative or conservative management as most VCFs show gradual improvement in pain over 2 to 12 weeks, with variable return of function. There is evidence that vertebral augmentation (VA) is associated with better pain relief and improved functional outcomes compared to conservative therapy for osteoporotic VCFs. A multidisciplinary approach is necessary for the management of painful pathologic VCFs, with management strategies including medications to affect bone turnover, radiation therapy, and interventions such as VA and percutaneous thermal ablation to alleviate symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vertebral Fractures of Unknown Origin: Role of Computed Tomography-Guided Biopsy

Background

We performed a retrospective evaluation of histological and imaging results of patients submitted to computed tomography (CT)-guided biopsy for vertebral fractures (VFs) of unknown etiology to evaluate the pathological causes of fractures and also to observe the diagnostic results of imaging studies available.

Methods

We retrospectively reviewed all the CT-guided vertebral biopsies performed in our institution in the last 2 years, selecting patients with VF of unknown etiology. We reviewed clinical records, imaging studies, and histological examination results. We compared diagnostic performance of the 2 most sensitive imaging modalities for detection of malignancy on the collapsed vertebral body: magnetic resonance imaging (MRI) and positron emission tomography-CT (PET-CT). Anatomopathological results have been considered the gold standard to assess the diagnostic performance of imaging studies. Age stratification has been performed to understand the distribution of different anatomopathological diagnoses in age groups.

Results

Among 282 CT-guided vertebral biopsies, 36 (12.8%) have been performed to diagnose the etiology of VF of unknown origin. In 26/32 (81.3%), the vertebral biopsy was diagnostic: 8 osteopenia, 6 multiple myelomas, 4 osteomyelitis, 2 eosinophilic granuloma, 3 metastases, 1 mastocytosis, 1 Paget's disease, and 1 dysmielopoiesis. In 6 cases, the anatomopathological diagnosis was normal bone structure, most likely excluding malignancy. There were no statistically significance differences between MRI and PET-CT results (P = 1.0000).

Conclusions

Multiple myeloma and osteopenia represent the most frequent causes of this condition in adult patients, while eosinophilic granuloma and osteomyelitis in pediatric patients. Computed tomography-guided biopsy permits one to reach diagnosis in most of cases. Both PET and MRI could be insufficient to discriminate benign from malignant causes of fractures. Computed tomography-guided biopsy is needed when the etiology of fracture remains unclear.

Which one is more effective for the treatment of very severe osteoporotic vertebral compression fractures: PVP or PKP?

PURPOSE

The purpose of this study was to compare the clinical efficacy and safety of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of the elderly with very severe osteoporotic vertebral compression fractures (vsOVCFs).

METHODS

From September 2012 to September 2015, 57 patients with vsOVCFs who had undergone PVP and PKP surgeries at our medical center were reviewed retrospectively, at least 2 years follow-up. All patients were divided into PVP group (n=31) and PKP group (n=26). Clinical data including clinical and radiological evaluation results were performed pre- and postoperatively.

RESULTS

The operation time of PVP group (29.6±3.3 minutes) was less than that of PKP group (37.4±4.2 minutes), with significant differences (P<0.05). Compared with preoperative data, the VAS scores, Oswestry disability index (ODI) scores, and local kyphotic angle were improved with significant differences at 1 day after surgery and the last follow-up in two groups (P<0.05). However, there were no differences in VAS and ODI scores between the two groups (P>0.05). The local kyphotic angle of PVP group was more than that of PKP group after surgery, with significant differences (P<0.05). At 1 day after surgery and the last follow-up, the anterior height of vertebrae fractured was significantly improved compared with preoperative in PKP group (P<0.05), and there was no statistical difference compared with preoperative in PVP group (P>0.05). However, there were no significant differences between the two groups in the leakage rate of bone cement (P>0.05) and incidence of adjacent-level vertebra fracture (P>0.05).

CONCLUSION

Both PVP and PKP can significantly relieve the pain of the patients with vsOVCFs. Restoring the vertebral height and local kyphotic angle corrections of PKP are comparatively better than those of PVP. However, the operation time of PKP is significantly longer than that of PVP and PKP is not superior in the leakage rate of bone cement and incidence of adjacent-level vertebra fracture compared to PVP.

Potential risks of using cement-augmented screws for spinal fusion in patients with low bone quality

BACKGROUND CONTEXT

Dramatic increases in the average life expectancy have led to increases in the variety of degenerative changes and deformities observed in the aging spine. The elderly population can present challenges for spine surgeons, not only because of increased comorbidities, but also because of the quality of their bones. Pedicle screws are the implants used most commonly in spinal surgery for fixation, but their efficacy depends directly on bone quality. Although polymethyl methacrylate (PMMA)-augmented screws represent an alternative for patients with osteoporotic vertebrae, their use has raised some concerns because of the possible association between cement leakages (CLs) and other morbidities.

PURPOSE

To analyze potential complications related to the use of cement-augmented screws for spinal fusion and to investigate the effectiveness of using these screws in the treatment of patients with low bone quality.

STUDY DESIGN

A retrospective single-center study.

PATIENT SAMPLE

This study included 313 consecutive patients who underwent spinal fusion using a total of 1,780 cement-augmented screws.

METHODS AND OUTCOME MEASURES

We analyzed potential complications related to the use of cement-augmented screws, including CL, vascular injury, infection, screw extraction problems, revision surgery, and instrument failure. There are no financial conflicts of interest to report.

RESULTS

A total of 1,043 vertebrae were instrumented. Cement leakage was observed in 650 vertebrae (62.3%). There were no major clinical complications related to CL, but two patients (0.6%) had radicular pain related to CL at the S1 foramina. Of the 13 patients (4.1%) who developed deep infections requiring surgical debridement, two with chronic infections had possible spondylitis that required instrument removal. All patients responded well to antibiotic therapy. Revision surgery was performed in 56 patients (17.9%), most of whom had long construction. A total of 180 screws were removed as a result of revision. There were no problems with screw extraction.

CONCLUSIONS

These results demonstrate the efficacy and safety of cement-augmented screws for the treatment of patients with low bone mineral density.

Role of Transpedicular Percutaneous Vertebral Biopsy for Diagnosis of Pathology in Vertebral Compression Fractures

Study Design

Retrospective observational study.

Purpose

To identify the role of percutaneous vertebral biopsy in histopathological diagnosis of vertebral compression fractures and to identify the frequency of unexpected malignancy in vertebral compression fractures.

Overview of Literature

Vertebral compression fractures are common in the Indian population. Magnetic resonance imaging and nuclear imaging have some limitations in the diagnosis of definitive pathology of vertebral compression fractures. Therefore, histological confirmation is necessary for definitive diagnosis and to plan appropriate management for patient.

Methods

A retrospective observational study was conducted involving 84 patients who underwent percutaneous vertebral biopsy between 2010 and 2014. We performed C-arm guided percutaneous transpedicular core vertebral biopsy of vertebral compression fractures under combination of local anesthesia and intravenous conscious sedation.

Results

Sufficient biopsy material was obtained in 79 of the 84 cases. In the other five cases, biopsy material was not sufficient for reporting. Out of the 79 cases, osteoporotic pathology was detected in 69 patients, malignancy was detected in 8 patients and no pathology was found in 2 patients. Two patients with distant metastases to vertebra were identified. Primary spinal malignancy was detected in 6 patients (1 unsuspected plasmacytoma, 5 diagnosed malignancy preoperatively). So, the frequency of unsuspected malignancy of this study was 1.19% (1/84). None of the patients had any complications.

Conclusions

C-arm guided percutaneous transpedicular vertebral biopsy is useful in obtaining definitive histopathological diagnosis of vertebral compression fractures, especially in differentiating malignant and non-malignant vertebral compression fractures and helping plan appropriate management of patients. The rate of unexpected malignancy in vertebral compression fracture was 1.19%.

Role of Percutaneous Image Guided Biopsy in Spinal Lesions: Adequacy and Correlation with MRI Findings

INTRODUCTION

Although, MRI has increased our understanding of spinal pathologies, accurate diagnosis of spinal lesions need biopsy, so that early treatment can be initiated.

AIM

To evaluate the accuracy of biopsy, safety and yield of percutaneously done image guided spinal biopsy using a large bore needle and correlate between MRI findings and biopsy as well as the importance of various MRI findings in establishing the diagnosis.

MATERIALS AND METHODS

All spinal lesions after clinical and MRI evaluation were subjected to Jamshidi Needle biopsy using 11 gauge needles. Biopsy material was sent for culture/sensitivity, AFB smear and histopathological examination. The outcome assessment included percentage of patients in whom diagnosis was changed after biopsy, yield in biopsy and complications of biopsy. MRI findings, biopsy findings and final diagnosis were correlated to know the sensitivity and specificity of MRI and biopsy diagnosis. Logistic regression analysis was used to study the importance of each of MRI findings in making a diagnosis.

RESULTS

Forty five patients with spinal lesions underwent biopsy using an 11 gauge Jamshidi needle. Initial biopsy was inconclusive in 4 patients giving a positive yield in about 91.2% of cases and a repeat biopsy ensured conclusive report in all cases. Following biopsy there was a change in diagnosis in 8% cases. MRI showed sensitivity of 85.71% and specificity of 93.54% for the diagnosis of malignancy and sensitivity of 85.71% and specificity of 86.48% for the diagnosis of tuberculosis. In contrast, initial biopsy had sensitivity of 92.85% and specificity of 100% for the diagnosis of malignancy and sensitivity of 71.42% and specificity of 100 % for the diagnosis of infection. Logistic regression analysis showed good correlation between malignancy and posterior bugle in the vertebral body in the absence of a fracture (p = 0.007), involvement of pedicles and posterior elements (p = 0.001) and soft tissue extension (p = 0.002); there was good correlation between infection and epidural abscess (p<0.001) as well as paradiscal involvement (p<0.001).

CONCLUSION

Image guided biopsy done with good technique helps in accuracy of diagnosis thus ensuring the correct treatment at the earliest and has minimal complications. This study also shows that presence of epidural abscess and paradiscal involvement in MRI are highly suggestive of infection, while pedicle involvement and posterior bulge of vertebral body before the onset of pathological fracture are suggestive of malignancy, but all spinal lesions should be biopsied to confirm the diagnosis.

Rate of Unsuspected Malignancy in Patients With Vertebral Compression Fracture Undergoing Percutaneous Vertebroplasty

STUDY DESIGN

Retrospective study.

OBJECTIVE

To determine the malignancy rate and histology in bone biopsies obtained during PVP for VCF.

SUMMARY OF BACKGROUND DATA

Osteoporotic vertebral compression fractures (VCF) affect approximately 20% of postmenopausal women and can lead to long-term disability. Percutaneous vertebroplasty (PVP) is a minimally invasive procedure, primarily used in patients with severe pain after VCF. Even with a thorough clinical examination, magnetic resonance imaging (MRI) scans, and blood samples, some fractures maybe caused by an underlying malignant disease.

METHODS

144 consecutive patients underwent PVP for painful VCF, at the Center for Spine Surgery and Research, Middelfart Hospital. All patients had bone biopsies obtained during the PVP, and these biopsies were sent to the Department for Pathology at Vejle Sygehus for histologic diagnosis.

RESULTS

About 144 patients were included in this study. The majority of the biopsy specimens (137, 95.1%) were acceptable for histological diagnosis. One hundred and twenty nine (89.6%) biopsies showed no signs of malignancy. Seven (4.9 %) were positive for malignancy. One biopsy was positive for MGUS. Seven (4.9 %) of the biopsies were unsuitable for histologic diagnosis.

CONCLUSION

Our study shows an incidence of unsuspected malignancy in biopsies during PVP of 4.9%. Conservative treatment with analgesics and brace can potentially delay diagnosis and treatment of underlying malignant disease. We recommend biopsy during PVP as a standard procedure, to insure not to overlook any underlying malignancy despite the MRI-scan, blood analysis, and clinical examination being inconspicuous.

CONTROVERSIES ON VERTEBROPLASTY AND KYPHOPLASTY FOR VERTEBRAL COMPRESSION FRACTURES

Vertebroplasty and kyphoplasty are widely used for osteoporotic and cancer-related vertebral compression fractures refractory to medical treatment. Many aspects of these procedures have been extensively discussed in the literature during the last few years. In this article, we perform a critical appraisal of current evidence on effectiveness and ongoing controversies regarding surgical technique, indications and contraindications, clinical outcomes and potential complications of these procedures.

Controversial issues in kyphoplasty and vertebroplasty in malignant vertebral fractures

BACKGROUND

Kyphoplasty (KP) and vertebroplasty (VP) have been successfully employed in the treatment of pathological vertebral fractures.

METHODS

A critical review of the medical literature was performed and controversial issues were analyzed.

RESULTS

Evidence supports KP as the treatment of choice to control fracture pain and the possible restoration of sagittal balance, provided that no overt instability or myelopathy is present, the fracture is painful and other pain generators have been excluded, and positive radiological findings are present. Unilateral procedures yield similar results to bilateral ones and should be pursued whenever feasible. Biopsy should be routinely performed and 3 to 4 levels may be augmented in a single operation. Higher cement filling appears to yield better results. Radiotherapy is complementary with KP and VP but must be individualized.

CONCLUSIONS

In cases of painful cancer fractures, if overt instability or myelopathy is not present, unilateral KP should be pursued, whenever feasible, followed by radiotherapy. The technological advances in hardware and biomaterials, as well as combining KP with other modalities, will help ensure a safe and more effective procedure. Address.

The value of routine biopsy during percutaneous kyphoplasty for vertebral compression fractures

Objective

Percutaneous kyphoplasty (PKP) is now widely performed to treat VCF, which is usually caused by osteoporosis. Previous researches have reported unsuspected malignancies found by biopsy. However, the safety and cost-effective profiles of routine biopsy during PKP are unclear. The purpose of this study was to evaluate the feasibility of routine biopsy during PKP in treatment of VCF.

Methods

Ninety-three patients (September 2007–November 2010) undergoing PKP without biopsy were reviewed as the control group. One hundred and three consecutive patients (November 2010–September 2013) undergoing PKP with biopsy of every operated vertebral level were prospectively enrolled as the biopsy group. The rate of unsuspected lesions was reported, and the severe adverse events, surgical duration, cement leakage rate and pain control were compared between the two groups.

Results

No statistically significant differences were found between the two groups, regarding the severe adverse events, surgical duration, cement leakage rate and pain control. Four unsuspected lesions were found in the biopsy group, three of which were malignancies with a 2.9% (3/103) unsuspected malignancy rate. The economic analysis showed that routine biopsy was cost-effective in finding new malignancies comparing with a routine cancer screening campaign.

Conclusions

Routine biopsy during PKP was safe and cost-effective in finding unsuspected malignancies. We advocate routine biopsy in every operated vertebral level during PKP for VCF patients.

Utility of routine biopsy at vertebroplasty in the management of vertebral compression fractures: a tertiary center experience

OBJECT

The authors assess the utility of routine biopsy at vertebroplasty for vertebral compression fracture (VCF) as a tool in the early detection of malignancy in presumed benign VCF.

METHODS

A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty over a 5-year period between April 2006 and March 2011 at the Royal London Hospital. Polymethylmethacrylate cement injection was used in every procedure. Intraoperative vertebral body biopsy was performed routinely at every level of VCF. Pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage, and complications were recorded preoperatively and at 1 day, 1 week, 1 month, 6 months, and 1 year postoperatively.

RESULTS

A total of 202 levels were augmented in 147 patients. The most common levels augmented were T-12 (17%), L-1 (18%), and L-4 (10%). Analysis of 184 routine vertebral biopsies in 135 patients revealed that in 86 patients with presumed osteoporosis and no prior cancer diagnosis, 4 (4.7%) had a malignant VCF. In 20 known cancer patients presumed to be in remission, 2 (10%) had a malignant VCF. Routine vertebral biopsy returned an overall cancer diagnosis rate of 5.5% (6 of 109) when combining the 2 groups (patients with no prior history of cancer or cancer thought to be in remission). In these 6 patients, history, examination, laboratory tests, and preprocedure imaging all failed to suggest malignancy diagnosed at routine biopsy. Significant reductions in pain VAS and ODI scores were evident at Day 1 and were sustained at up to 1 year postoperatively (p < 0.001). They were not dependent on the level of fracture (T3-10, T11-L2, or L3-S1) (p > 0.05), number of levels treated (single level, 2 levels, or > 2 levels) (p > 0.05), or etiology of VCF (p > 0.05). The complication rate was 6% (9 of 147). There were 5 deaths, none of which were directly related to surgery.

CONCLUSIONS

Routine vertebral biopsy performed at vertebroplasty may demonstrate cancer-related VCFs in unsuspected patients with no previous cancer diagnosis or active malignancy in patients previously thought to be in remission. This early diagnosis of cancer or relapsed disease will play an important role in expediting patients' subsequent cancer management. In cases of multiple-level VCF, the authors advocate biopsy at each level to maximize the diagnostic yield from the specimens and to avoid missing a malignancy at a single level.

Treatment of multiple osteoporotic vertebral compression fractures by percutaneous cement augmentation

PURPOSE

Vertebral compression fractures cause significant pain and some patients are debilitated by the pain due to the fracture. Conventional surgery carries a high risk and has a poor outcome. Vertebroplasty is a minimally invasive surgical procedure, which in vertebral fractures restores stability and diminishes pain. The aim of the study was to analyse the effectiveness and safety of vertebroplasty in multiple vertebral compression fractures with a 24-month follow-up.

METHODS

Vertebroplasty was performed in 160 patients with multiple osteoporotic compression fractures under local anaesthesia, using a unilateral transpedicular approach. The level of pain was assessed according to a 10-cm visual analogue scale. The patients were observed for 24 months after surgery.

RESULTS

Vertebroplasty significantly diminished the level of pain in 90% of patients, and half of them were free of pain within 12 hours after surgery. Only 4% of the patients did not benefit from this type of treatment. During the 24-month follow-up these results changed only slightly, and after two years almost 80% still benefited, while the number of unsatisfactory results changed from 6 to 9%. No serious clinical complications were noted; in three patients new fractures appeared during the two year observation period.

CONCLUSIONS

Vertebroplasty should be seriously taken into account as a primary method of treatment in patients with multiple osteoporotic vertebral compression fractures.

Value of forceps biopsy and kyphoplasty in Kümmell's disease

The diagnosis of Kümmell's disease mainly depends on clinical and radiologic findings. However, these are not the gold standards for diagnosing this disease; bone biopsy is required. The authors performed modified bone biopsy and cement-filling techniques during kyphoplasty and investigated the feasibility and efficacy of kyphoplasty for the treatment of Kümmell's disease. This study included 28 patients (9 men and 19 women; average age, 71.9 years) with Kümmell's disease. All patients underwent the modified biopsy procedure and kyphoplasty with the modified cement-filling technique. Treatment efficacy was evaluated using visual analog scale pain scores, Oswestry Disability Index scores, vertebral height, and Cobb angles pre- and postoperatively and at final follow-up. All patients tolerated the procedure well and had immediate back pain relief after kyphoplasty. Biopsy examination revealed necrotic bone in 24 patients and sparse cancellous bone in 2; it was unsuccessful in 2 patients. No severe complication occurred in any patient. Two patients had cement leakage but no clinical symptoms. All efficacy measures were significantly better at the postoperative assessments than the preoperative assessments (P<.05) but were similar at the postoperative and final follow-up assessments. Kyphoplasty is a relatively effective and safe method for treating Kümmell's disease when modified techniques are performed to prevent cement leakage, and forceps biopsy can be used in the differential diagnosis of this condition.

Histological evaluation of bone biopsy results during PVP or PKP of vertebral compression fractures

Percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) is utilized for the treatment of vertebral compression fractures (VCFs). The present study was conducted to evaluate biopsy results obtained from VCFs during PVP or PKP. Between January 2003 and December 2011, 692 vertebral body biopsies were obtained from 546 patients (442 females and 104 males; mean age, 72.3 years), who underwent PVP or PKP for treatment of VCFs. A history of malignancy was identified in 44 patients. Histological/immunohistochemical evaluations were performed by experienced pathologists and 89.9% of biopsies obtained from 546 patients were suitable for histological/immunohistochemical evaluation. The biopsy results of 398 patients were in good agreement with the diagnosis of osteoporotic VCFs. Among the 44 patients with a history of malignancy, malignancy was identified in 25 patients, while osteoporosis was identified in 16 patients. Biopsies of the other 3 patients were not suitable for pathological examination. There were only 2 patients with previously undiagnosed malignancy. One patient was diagnosed with multiple myeloma, while another patient was diagnosed with metastatic carcinoma. In the present study, the rate of unsuspected malignancy was 0.4%. No symptomatic complications occurred as a result of biopsy. The results indicate that biopsy is safely performed during PVP or PKP and it is an efficacious procedure that verifies the pathological process and assists in identifying previously unsuspected processes responsible for VCFs. We recommend obtaining the biopsy of every collapsed vertebral body during PVP or PKP procedures.

The added challenges of bone metastases treatment in elderly patients

Most cancers occur in those older than the age of 65 years. As the population of the world ages and life expectancies continue to increase, it is important to address treatment challenges for elderly patients. This narrative review details the challenges of palliative radiotherapy treatment for elderly patients with bone metastases. We begin with the definition of elderly and its appropriateness, outlining recent demographic data of patients with cancer. The current status of elderly participation in clinical trials is discussed by reviewing the recent literature and clinical trial data. Factors affecting enrolment of the elderly are assessed, with a focus on palliative radiotherapy trials, and what we can do to improve accrual in this data-driven setting. At present, there is a lack of level 1 evidence that evaluates the optimal treatment for elderly patients with bone metastases. Therefore, a review of safety and efficacy is given based on previously published reports. Palliative radiotherapy for elderly patients is a worthwhile treatment and should be recommended regardless of age, as supported by available evidence. Patient, family and physician concerns about physical burden may be reduced as single treatments (that often can be done in a single visit) are as beneficial as multiple treatments for painful bone metastases. In elderly patients, radiotherapy may even be the best treatment for these cases as opioid-related adverse events are amplified in this group and often dosages are more difficult to titrate. Clinicians should continue to encourage the enrolment of elderly patients on to clinical trials as these data form the basis of optimal treatment guidelines. Radiation oncologists are encouraged to reduce the physical burden for elderly patients by offering single treatments where appropriate and completing consultation, treatment simulation and treatment in a single clinical visit.

Coaxial biopsy during percutaneous vertebroplasty in patients with presumed osteoporotic vertebral compression fractures: retrospective review of biopsy results

PURPOSE

This study retrospectively analysed the results of biopsies obtained during percutaneous vertebroplasty (PVP) in patients with presumed osteoporotic vertebral compression fractures, with a view to highlighting the importance of coaxial biopsy in determining the aetiology of vertebral fractures and planning subsequent treatment.

MATERIALS AND METHODS

Between November 2003 and March 2009, 98 patients (78 women; 20 men) with a clinical and imaging suspicion of osteoporotic vertebral compression fractures underwent coaxial biopsy in conjunction with PVP of the thoracic and lumbar vertebrae. Mean age at the time of the procedure was 72.6 years. A pathologist interpreted all the biopsy samples.

RESULTS

In 83 patients, the biopsy results were consistent with the presumed osteoporotic aetiology. In two patients, a malignancy was identified. Biopsy samples from 13 patients were considered insufficient or unsuitable by the pathologist for evaluation.

CONCLUSIONS

Despite the number of biopsy samples considered insufficient or unsuitable, coaxial biopsy during PVP is useful in verifying the presumed aetiology of vertebral compression fractures, which is often unclear on the basis of clinical and imaging examinations. It is therefore both convenient and advisable to perform a vertebral coaxial biopsy in all patients undergoing a PVP.