VertebroplastyVertebroplasty

Introduction– Percutaneous spine intervention. – Image guided.– Treatment of painful pathologic vertebral

compression fractures.

VertebroplastyVertebroplasty

Introduction– Vertebroplasty is an effective, minimally

invasive spine procedure where acrylic bone cement is injected into a painful pathologically compressed vertebral body.

VertebroplastyVertebroplasty

Objective– Provide instant pain relief.

– Prevent further vertebral collapse.

VertebroplastyVertebroplasty

History– Acrylic cement used as jeep windshields in WWII.– European total joint surgery in 1960.– FDA approved for total hips 1971.– FDA approved for total knees in 1973.– FDA approved for pathological fractures 1973 (Simplex P).– Used in Vertebroplasty (Simplex P) 1984.

Deramond 50 year old female with neck pain due to hemangioma.

VertebroplastyVertebroplastyVertebral Body Compression Fracture

Primary osteoporosis

-Elderly females

Secondary osteoporosis

-Young, steroid users

VertebroplastyVertebroplastyVertebral Body Compression Fracture

Neoplasm Primary

-Hemangioma

-Myeloma

Secondary

-Metastasis

-Lymphoma

VertebroplastyVertebroplastyOsteoporotic Fractures

– More common in females than males.– 1.5 Million osteoporotic fractures annually in the US.

500,000 – 700,000 vertebral fractures

– 1995 osteoporotic fracture data 2.5 million physician visits 432,000 hospital admissions 180,000 nursing home admissions $13.5 billion in direct medical costs

VertebroplastyVertebroplasty Osteoporotic/Metastatic Fractures

-Pain-Pulmonary Compromise-Insomnia-Immobility-Depression-Narcotic Dependence-Spinal Cord Compression-Kyphosis

VertebroplastyVertebroplastyTraditional Vertebral Body Compression Fracture

Management

-Analgesics -Bed RestTemporary DVTSide Effects Pneumonia

-Immobilization -SurgeryVariable success High failure ratesDemineralization

VertebroplastyVertebroplastyEarly Intervention May Reduce:

Duration of acute pain Height loss

Duration of immobilization Use of analgesics

Occurrence of chronic pain Incidence of pneumonia

Further collapse of the treated vertebral body

Benefits Of VertebroplastyPain Relief Improved Mobility

-Quick -Mobility within 24 hrs

-Complete

VertebroplastyVertebroplastyEfficacy

Osteoporotic compression fracture 80-90% of patients experience dramatic or complete relief of

pain immediately or within 72 hours.

Neoplastic compression fractures 70% of patients experience marked reduction in narcotic

requirements or complete pain relief.

VertebroplastyVertebroplastyIndications

Pain related to vertebral compression fracturesassociated with osteoporosis or tumor infiltration.

ContraindicationsUncorrected coagulpathy or systemic or spinalinfection. Moderate to severe retropulsion of the posteriorvertebral body cortex into the spinal canal.Height loss>70%

VertebroplastyVertebroplastyPatient Selection

– Patients who tend to respond the best One to three levels of fractures. Focal pain and tenderness corresponding to the level of edema

by MRI. Fracture present < 2 months. Recent worsening of fracture. No sclerosis of fractured vertebra.

VertebroplastyVertebroplasty Patient Consultation

Alteration of lifestyle due to fracture. Analgesic use. Orthotic use. Past medical history Past surgical history.

Spine Medications.

Anticoagulants Allergies

– Iodine contrast agents and antibiotics Laboratory

– Hct/Hgt, PT/PTT/INR, Platelets

VertebroplastyVertebroplasty Patient Consultation

Plain Radiographs.– Compare with any prior studies

MRI.– T1, T2, STIR sequence.– Assess for vertebral body marrow edema.

CT.– If MRI contraindicated.– Assess cortical integrity of posterior

vertebral body and pedicles. Skeletal Seintigraphy

– With SPECT– Often performed as part of a metastatic

work-up

VertebroplastyVertebroplasty Complications

Incidence.– Minor complications <3%– Major complications <1%

Majority are transient and self limiting. Steroid therapy or surgery are rarely required. Spinal cord or nerve root injury <1%. Hemorrhage, infection and PE – Rare Fracture

– Lamina– Pedicle

Increased pain. Death.

VertebroplastyVertebroplastyComplications

Symptomatic cement extravasation.– Incidence depends upon etiology of fracture.

• Osteoporosis 1-2%• Neoplasm 5-10%

Location– Epidural– Foraminal– Paravertebral– Disc

VertebroplastyVertebroplastyPre-Procedure Care

Antibiotics– Optional.

– Recommended for immune compromised patients.

– Systemic.

– Local.• Added to cement.

Patient Positioning and Draping– Patient prone.

– Strict sterile technique.

VertebroplastyVertebroplasty Pre-Procedure Care

Anesthesia– Intravenous sedation

• Sedation: Versed• Analgesia: Fentanyl

– Local• 1% Lidocaine• Bipivicaine

– General Anesthesia • Rarely required

Patient Monitoring– Nursing– Intravenous line– Continuous Monitoring– Parameters

• Vital signs• Oxygen saturation

VertebroplastyVertebroplastyImaging

– High quality fluoroscopy Biplane Single plane C-arm

– Computed tomography CT and fluoroscopy

VertebroplastyVertebroplastyProcedure

– Localize symptomatic vertebral body level prior to prepping the skin.

– Choose approach. Transpedicular Parapedicular

– Anesthetize skin and subcutaneous tissues down to the level of the periosteum.

25 and 22 gauge needles 20 or 22 gauge spinal needles

– Deratotomy #11 scalpel blade or equivalent

VertebroplastyVertebroplastyProcedure: Needle Insertion

– Locate bony landmarks and advance needle to desired location within the vertebral body using imaging guidance.

VertebroplastyVertebroplastyProcedure: Venogram

– Injection of contrast through needle.

– Visualize vertebral body and epidural and paraspinal veins.

– May predict pattern of cement injection.

– Will identify a direct venous communication.

– May interfere with visualization of opacified cement.

VertebroplastyVertebroplastyProcedure: Cement

Mixture– Polymer powder.– Liquid monomer.– Opacifying agent.

Barium sulfate powder.

– Vacuum mixer

VertebroplastyVertebroplastyProcedure: Cement Prep

– Limited working time. 10-15 minutes depending on temperature and cement mixture.

– Injection devices Luer-Lok syringes “Jack-screw” hydraulic injector.

VertebroplastyVertebroplasty Procedure: Cement Injection

– Meticulous fluoroscopic monitoring during the injection process.

– Liquefied cement is injected into the vertebral body.

– Termination of injection. Cement in posterior 1/3 vertebral body on

lateral projection. Cement extruding into epidural, foraminal

or paraspinal veins. Significant disk space penetration. Posterior 1/3.

VertebroplastyVertebroplastyCase #1: Painful

osteoporotic compression fracture T8.

VertebroplastyVertebroplastyCase #1: Painful

osteoporotic compression fracture.

– Complete symptomatic relief within 24 hrs.

VertebroplastyVertebroplasty Case #2: Painful osteoporotic compression fracture L3.

– Complete symptomatic relief in 24 hrs.

VertebroplastyVertebroplasty Case #3: Painful osteoporotic compression fracture T12.

– Complete symptomatic relief in 24 hrs.

VertebroplastyVertebroplasty Case #4: Painful metastatic fracture T12.

– Complete symptomatic relief in 24 hrs.

Pre-Op Post Vertebroplasty

VertebroplastyVertebroplasty Case #5: Destruction Of Posterior Wall

Pre-Op Post Vertebroplasty

VertebroplastyVertebroplasty Post Operative Care

– Dressing at needle site.– Strict bed rest for 2-3 hours post vertebroplasty.– Monitor vital signs.– Monitor neurologic examination.

Patient Follow-up– Patient Instructed to call for

New back pain Chest pain Lower extremity weakness Fever >100 degrees

– Follow-up at 24 hours and 1 week.

VertebroplastyVertebroplasty Results

F. Grados, C. Depriester, G. Cayrolle, N. Hardy, H. Dermond and P.Fardellone Long-term Observations Of Vertebral Osteoporotic Fractures Treated By Percutaneous Vertebroplasty

– 34 levels in 25 patients.– Follow-up 12-84 months (mean 48).– No severe complications.– No progression of vertebral deformity in any injected vertebral body.

M. Jensen, A. Evans, J. Mathis, D. Kallmes, H. Cloft and J. Dion Percutaneous Polymethlymethacrylate Vertebroplasty in the Treatment of osteoporotic Vertebral Body Compression Fractures: Technical Aspects

– 47 levels in 29 patients.– No severe complications.– 90% significant immediate pain relief.

VertebroplastyVertebroplasty Results

Deramond, Percutaneous Vertebroplasty With Polymethylmethacrylate: Technique, Indications, and Results, Musculoskeletal Radiology, 5/98

– 80 Osteoporotic pts, 90% complete pain relief– 101Tumor pts, 80% complete pain relief4 levels in 25 patients.

Martin, Vertebroplasty: Clinical Experience and Follow-up Results, Bone, 8/99– 40 pts, 68 levels– 80% complete pain relief

VertebroplastyVertebroplasty Conclusions

– In experienced hands and with appropriate patient selection, vertebroplasty is a safe and efficacious procedure for the treatment of pain and disability associated with osteoporotic compression fractures.

– The procedure has a low complication rate and a very high success rate.

– Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture.

– Medical management of osteoporosis or malignancy must therefore be initiated and continued.