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VERTEBROPLASTYVERTEBROPLASTY(except the hands-on)(except the hands-on)

Kirkland W. Davis, M.D.Kirkland W. Davis, M.D.Division of Musculoskeletal Radiology

University of Wisconsin Madison, Wisconsin

BACKGROUND

Vertebroplasty: Introduction

• “New” treatment for painful pathologic vertebrae

• X-ray guided spine augmentation: “Internal Splint”

Vertebroplasty: Introduction• Vertebroplasty is an effective,

minimally invasive procedure in which bone cement (PMMA) is injected into a vertebral body to relieve pain

Pathologic Vertebral Compression Fracture

• Primary osteoporosis– Elderly patient– Female>male

• Secondary osteoporosis– Young patient– Steroid use

• Asthma, vasculitis, transplant, inflammatory bowel disease, tumor treatment

Pathologic Vertebra (+/- Compression Fracture)

• Neoplasm–Primary

•Hemangioma•Myeloma

–Secondary•Metastasis (5%/yr, 30% overall)

•Lymphoma

Osteoporotic Vertebral Compression Fractures

• More common in females than in males–2 female:1 male–Prevalence as high as 26% in

females > 50 years of age

Osteoporotic Fractures: Economics

• 1.5 million osteoporotic fractures annually in the United States– 700,000 vertebral fractures

• In 1995, osteoporotic fractures accounted for– 2.5 million physician visits– 432,000 hospital admissions– 180,000 thousand nursing home admissions– $13.5 billion in direct medical expenses

• Fracture incidence predicted to quadruple next 50 years

Osteoporotic Fractures: Actual Costs May Be Under-Reported

– Pain– Diminished

mobility– Loss of

employment– Narcotic

addiction– Urinary retention– Constipation

–Insomnia–Depression–Spinal cord

compression–Kyphosis– Pulmonary

restriction– GI disturbances

Osteoporotic Compression Fractures: Traditional Management• Analgesics

–Temporary–Side effects

• Bed rest–Deep venous

thrombosis–Pneumonia

• Immobilization–Variable success–May cause

further demineralization

• Surgery–Challenging–For neuro

compromise

Osteoporotic Compression Fractures: Traditional

Management

• Some do not heal–Chronically

disabling

• Side effects of traditional management can be significant

Objective

• To provide relief from a painful vertebra– Osteoporotic fracture

• Primary• Secondary

– Neoplasm• Benign or malignant• Fractured or not

• To provide stability

Objective• To prevent further

vertebral collapse that would–Lead to further

loss of height–Result in

kyphosis–Be associated

with fractures at adjacent levels

Early Intervention May Reduce:

• Duration of acute pain

• Medication use• Duration of

immobilization• Occurrence of

chronic back pain

• Further collapse of the treated vertebral body

• Height loss• Kyphosis• Incidence of

pulmonary embolism and pneumonia

Benefits of Vertebroplasty

• Pain relief–Quick–Complete: osteoporosis >

neoplasia• Improved mobility

–Patient able to stand and walk within first 24 hours

History

• Acrylic cements have been used for bone augmentation for over 3 decades–Stabilization of large defects after

tumor excision (Vidal, 1969)–Hip replacement (Chamley, 1970)

History

• First reported case of percutaneous vertebroplasty in Amiens, France –Galibert and Deramond, 1984–50 year-old female with neck pain

due to a cervical (C2) hemangioma

Efficacy of VertebroplastyZoarski et al.

• Osteoporotic compression fracture–75-90% of patients experience

dramatic or complete relief of pain within several to 72 hours

• Neoplastic compression fracture–59-86% of patients experience

marked reduction in narcotic requirements or complete pain relief

Efficacy of VertebroplastyZoarski et al.

• 30 pts, 54 fractures• MODEMS questionnaire pre- and 2 weeks

post-procedure• 80% improved• Treatment expectations: success

(P<0.0001); improved pain and disability (P<0.0001), physical function (P=0.0004), and mental function (P=0.0009).

• 15-18 month follow-up: 22 of 23 patients reported continued pain relief and satisfaction with procedure. Pain improved (P<0.0001)

Efficacy of VertebroplastyEvans et al.

• 488 patients, 245 responding (40 deceased, 75 wrong #, 118 unreachable multiple attempts, 10 other)

• Phone interview average 7 months post-procedure

• Pain: 8.93.4 (P<0.001)• Impaired ambulation: 72%28% (P<0.001)• Ability to perform ADL improved (P<0.001)• Consistent results across subgroups: time from

procedure to questionnaire, one versus multiple fractures, acute versus chronic fractures

Efficacy of VertebroplastyFourney et al.

• MD Anderson• 56 patients (21 myeloma, 35 other)• 97 procedures, all fractures• Recorded:

–VAS: pain–Medication use–Neurologic status–Preop; postop; 1, 3, 6, 9, 12 months

Efficacy of VertebroplastyFourney et al.

• Improvement or complete pain relief 84%

• No change 9%• Not available 7%• None worse

Efficacy of VertebroplastyFourney et al.

• Median pre-op VAS 7• Median post-op VAS 2 (p<0.001)• Pain reduction significant at

each follow-up interval through one year

Efficacy of VertebroplastyWeill et al.

• France• 37 patients with mets (no

myeloma)• 52 procedures• Treated painful vertebra or

lesions that threaten stability of spine

Efficacy of VertebroplastyWeill et al.

• Pain– 73% clear improvement in pain– 21% moderate improvement– 6% no improvement– Statistical estimates:

• 6 months 73% pain relief• 1 year 65% pain relief

– Pain recurrence usually due to new lesions

Efficacy of VertebroplastyWeill et al.

• Stabilization: no loss of height in 11 vertebrae treated for stabilization–Mean follow-up 13.0 months

Efficacy of Vertebroplasty

• UW experience: mostly osteoporosis

• 12 months• 27 patients, 25 with accurate

documentation• 20/25 pain improved or resolved =

80%

Why Does Vertebroplasty Alleviate Pain?

• Stabilizes fracture• Allows healing to occur• Prevents further collapse of the treated

vertebral body• Tumors??

– Thermal effect– Toxic effect– Mass effect– Stabilizes microfractures and

macrofractures

THE PROCEDURE

Indications• Painful vertebra

from:–Osteoporotic

fracture–Neoplastic

fracture–Tumor

infiltration–Trauma?

Patient Selection• Patients who tend to respond best

–Single level or only a couple of levels–Focal pain and tenderness

corresponding to the level of edema by MRI

–Fracture present <2 months or recent worsening of fracture

–Fracture limits activity–No sclerosis of fractured vertebra

Patient Selection• Patients who are less likely to

respond–Fracture present for >1 year–Other causes for back pain are

present•Disc herniation, spinal stenosis, facet or sacroiliac joint disease

–Radicular pain related to disc herniation

Neoplastic Compression Fracture

• Treat to alleviate pain• Stabilize vulnerable vertebrae• Opportunity to obtain biopsy• Amount of pain reduction may be

less than what is achieved in the treatment of osteoporotic compression fractures

• Greater risk for complications

Contraindications:

• Uncorrected coagulopathy–Pathologic–Iatrogenic

• Infection –Spine–Elsewhere

Contraindications:• Moderate or

severe retropulsion of the posterior vertebral body cortex into the spinal canal

• Vertebral height loss >70%

Patient Selection Criteria

• Painful fracture not responding after 4 weeks of treatment (?)

• Acute or subacute compression fracture(s) on plain radiographs or MRI

• Pain corresponding to level of the fracture

Pre-procedure Consultation

• Pain history–Location–Severity–Duration–Radiation–Pain diagram

Pre-procedure Consultation

• Alteration of lifestyle due to fracture?–Activities of daily living

• Analgesic use–Types–Frequency

• Orthotic use

Pre-procedure Consultation

• Past medical history• Past surgical history

–Spine surgery?• Medications

–Anticoagulants

Pre-procedure Consultation

• Allergies–{Iodine contrast agents}–Antibiotics

• Laboratory–{Hct/Hgb}, PT/PTT/INR,

Platelets, {Bun/Creat}• Imaging studies

Pre-procedure Imaging

• Radiographs–Compare with

any prior studies

Pre-procedure Imaging• Magnetic

resonance imaging– T1, T2, STIR

sequences– Assess for

vertebral body marrow edema

– Exclude stenosis due to disc and/or facet disease

Pre-procedure Imaging

• Computed tomography– If MRI

contraindicated– Assesses cortical

integrity of posterior vertebral body and pedicles

Pre-procedure Imaging• Bone scan

–If MRI contraindicated

–With SPECT–Often

performed as part of a metastatic work-up

Pre-procedure Consultation• Examination under

fluoroscopy– Establish

concordance between painful sites and levels of vertebral body compression

– Occasionally needed

• Informed consent

Complications

• Incidence–Minor complications: 1-5%–Major complications: <<1%–Higher for metastases: 10%

• Majority of complications are transient and self-limited

• Steroid therapy or surgery are rarely required

Complications• Spinal cord or nerve root injury

–<1%–Direct

•Puncture–Indirect

•Compression•Hematoma•Ischemia

Complications

• Hemorrhage–Rare

• Infection–Rare

• Pulmonary embolism

• Fracture–Lamina–Pedicle

• Increased pain–1-2%

• Death

Complications

• Symptomatic cement extravasation–Incidence: depends upon

etiology of fracture•Osteoporosis 1-2%•Neoplasm 5-10%

Complications: Cement Extravasation

• Location–Epidural–Foraminal–Paravertebral–Disc

Pre-procedure Care: Day of Procedure

• NPO after midnight• Informed consent• Antibiotics

Procedure: Specifics

• Performed with biplane fluoro• Patient in prone position: comfort is

our goal• Strict sterile technique

Procedure: Anesthesia

• Intravenous sedation–Sedation: midazolam–Analgesia: fentanyl

• Local–1% Lidocaine–0.5% Bupivicaine on bone

• General anesthesia–Rarely required

Procedure: Patient Monitoring

• Nursing• Intravenous line• Continuous monitoring

Procedure

• High quality fluoroscopy suite

• One to two hours• Prone position,

padded table• Cement injected

via needles placed percutaneously

Procedure: Needle Insertion• Needle insertion:

unilateral or bilateral

Procedure: Cement Mixture• Polymer powder• Liquid monomer• Opacifying agent

–Barium sulfate powder–Tungsten–Tantalum

• Optional additive: antibiotic powder (Tobramycin)

Procedure: Cement Injection• Meticulous

fluoroscopic monitoring during the injection process

• Liquefied cement is injected into the vertebral body

Procedure: Cement Injection

• Termination of injection– Cement in

posterior 1/4 of vertebral body on lateral projection

– Cement extending outside vertebra

Conclusions

• Vertebroplasty is –Safe–Effective

• Indications–Osteoporotic fracture–Neoplastic fracture–Painful neoplastic involvement–Stabilization

Conclusions• Vertebroplasty is a palliative

procedure and does not correct the underlying cause of the vertebral fracture

• Appropriate management of osteoporosis or malignancy must therefore be initiated and continued

• Vertebroplasty can be combined with other therapies

Selected References: Vertebroplasty

1. Fourney DR, et al. Percutaneous Vertebroplasty and Kyphoplasty for Painful Vertebral Body Fractures in Cancer Patients. J Neurosurg (Spine 1) 2003; 98:21-30.

2. Jensen ME, Kallmes DF. Percutaneous Vertebroplasty in the Treatment of Malignant Spine Disease. Cancer J 2002; 8:194-206.

3. Weill A, et al. Spinal Metastases: Indications for and Results of Percutaneous Injection of Acrylic Surgical Cement. Radiology 1996; 199:241-247.

4. Zoarski GH, et al. Percutaneous Vertebroplasty for Osteoporotic Compression Fractures: Quantitative Prospective Evaluation of Long-Term Outcomes. J Vasc Interv Radiol 2002; 13:139-148.

Selected References: Kyphoplasty

1. Dudeney S, et al. Kyphoplasty in the Treatment of Osteolytic Vertebral Compression Fractures as a Result of Multiple Myeloma. J Clin Onc 2002; 20:2382-2387.

2. Ledlie JT, Renfro M. Balloon Kyphoplasty: One-Year Outcomes in Vertebral Body Height Restoration, Chronic Pain, and Activity Levels. J Neurosurg:Spine 2003; 98:36-42.

3. Lieberman IH, et al. Initial Outcome and Efficacy of “Kyphoplasty” in the Treatment of Painful Osteoporotic Vertebral Compression Fractures. Spine 2001; 26:1631-1638.

4. Ortiz AO, et al. Kyphoplasty. Techniques in Vascular and Interventional Radiology 2002; 5:239-249.

5. Phillips FM, et al. Minimally Invasive Treatments of Osteoporotic Vertebral Compression Fractures: Vertebroplasty and Kyphoplasty. AAOS Instruct Course Lect 2003; 52:559-567.

THANKS!