Percutaneous vertebroplasty

Dr David Lisle

Brisbane Private Imaging Royal Brisbane Hospital University of Queensland

•  85 year old female •  Severe acute mechanical back pain

– Pain not managed with high dose therapy – Can’t sleep – Limited walking to only a few steps

•  Spontaneous onset •  No known trauma •  No known malignancy

Vertebral compression fracture

•  Radiographic or symptomatic clinical event •  Radiographic: 26% women >50 years •  USA/year: 150,000 hospital admissions;

5,000,000 restricted days •  ↓ VC and FEV •  ↑ mortality

–  ≥ 1 # : 1.23 x age adjusted –  ≥ 5 # : >2 x age adjusted

Mathis AJNR 2001;22:373-381

Indications

•  Painful crush fracture – Osteoporosis – Acute: 4-6 weeks

•  Malignant crush fracture – +/- biopsy

•  Haemangioma – Galibert Neurochirurgie 1987;33:166-8

Patient selection = key to success

•  Back pain – Sudden onset – May radiate anteriorly – NOT sciatica – Mechanical – Restricted activity – Poor sleep

•  Local tenderness •  Imaging

Patient selection

•  Purposes of pre-procedure imaging: – Confirm presence of crush fracture – Confirm that crush fracture is acute – Diagnose other acute levels –  Integrity of spinal canal – Accurately localise level

Imaging techniques

•  Plain films: – Confirm presence of crush fracture – Confirm that crush fracture is acute – Diagnose other acute levels –  Integrity of spinal canal – Accurately localise level

24/3/2001

24/3/2001 16/12/2000

Imaging techniques

•  MRI: – Confirm presence of crush fracture – Confirm that crush fracture is acute – Diagnose other acute levels –  Integrity of spinal canal – Accurately localise level

MRI pre-vertebroplasty

•  Sagittal plane •  T1 for anatomy •  T2 fat saturation or

STIR – Marrow black – Oedema white

STIR

MRI

2

3

2

3

T1 STIR

Procedure

Patient preparation

•  Ensure MRI done and available •  (Coagulation profile) •  Pre-sedation fast •  Sedation and pain relief

–  iv cannula – Fentanyl + Midazolam

•  Sterile swab and drape

Needle placement: Thoracic

Needle placement: Lumbar

Cement preparation

Cement injection

Post procedure care

•  Lie prone for 20 minutes •  Bed rest for 2-3 hours •  CT to document cement placement •  Discharge if well

– Post-sedation instructions – Rest 24 hours – Mobilize according to pain

•  Advise re muscle pain •  Follow-up phone call(s)

Complications: rare

•  Mild fever; nausea for 24 hours •  Rib fracture •  Foraminal leak •  Spinal canal leak •  Venous emboli

Literature

•  Amar Neurosurg 2001;49:1105 –  97 pat., 258 levels –  ‘better life’ 74%

•  Narcotic/analgesic use •  Mobility •  Better sleep

•  Evans Radiology 2003;226:366 –  488 pat, 245 follow-up –  Pain scale 8.9 → 3.4 –  Impaired ambulation:

•  72% pre → 28% post

Literature

•  Diamond MJA 2006;184:113-117 – Conservative Rx vs PCV (non-randomised) – Acute pain 1-6 weeks, not relieved analgesics – MRI: acute fracture(s) – 3 factors: pain (VAS); physical function;

hospital days – 24 hours and 6 weeks: 60% ↓ pain scores;

29% ↑ physical function; 43% ↓ hospital days – Similar clinical outcomes at 6/12, 12/12, 24/12.

My results

•  Audit of first 250 patients, 2001 to 2006 •  Complete or near complete response

–  No or minimal pain –  Good return of activity level –  83.0 %

•  Moderate response –  Still suffer pain, though noticeably reduced –  Some return of activity, though still restricted –  12.0 %

•  No response –  5.0 %

Percutaneous vertebroplasty Keys to success

•  Patient selection – Early referral – MRI

•  High quality fluoroscopy – Accurate needle placement – Cement injection

•  Nursing care – Cement preparation – Patient care: pre and post

Percutaneous vertebroplasty

•  Indications •  Patient selection

– Clinical assessment –  Imaging

•  Technique – Needle placement – Post-procedure care

•  Results

MBS funding September 2005

So, what happened?

•  Buchbinder NEJM 2009;361:557-68 – Multicentre, randomized, double blind – Vertebroplasty vs placebo ‘sham’

procedure – N = 78: 38 vertebroplasty, 40 sham – No difference in pain scales or quality of

life •  MJA (Editorial) 2009;191:476-7

–  ‘Percutaneous vertebroplasty is not an effective treatment for acute osteoporotic vertebral fractures’

•  Patient selection –  Up to 12 months pain

•  Recruitment –  Majority of eligible

patients not recruited •  Technique

–  Up to 3ml cement –  Stopped injection if

leaking

MBS funding withdrawn 2011

Where are we now? •  Uncommon in most places •  Ongoing studies

– eg randomised trial in Sydney for acute fractures; recruitment very slow

•  Included in appropriateness guidelines in UK and USA –  http://www.nice.org.uk/guidance/IPG12/chapter/1-

Guidance –  http://www.acr.org/

•  No Medicare rebate •  Our cost: 1400 + day bed about 700

Thank you