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N. ACHOUR, I. NACCACHE, H. RAJHI, F. BEN AMARA, N. MNIF

PERCUTANEOUS VERTEBROPLASTY (PVP) IN THE TREATMENT OF VERTEBRAL FRACTURES CAUSED BY AGGRESSIVE HEMANGIOMAS: A SHORT AND MEDIUM TERM CLINICAL FOLLOW-UP. N. ACHOUR, I. NACCACHE, H. RAJHI, F. BEN AMARA, N. MNIF Radiology service ,Charles Nicolle Hospital. INTV2. INTRODUCTION.

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N. ACHOUR, I. NACCACHE, H. RAJHI, F. BEN AMARA, N. MNIF

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  1. PERCUTANEOUS VERTEBROPLASTY (PVP) IN THE TREATMENT OF VERTEBRAL FRACTURES CAUSED BY AGGRESSIVE HEMANGIOMAS: A SHORT AND MEDIUM TERM CLINICAL FOLLOW-UP N. ACHOUR, I. NACCACHE, H. RAJHI, F. BEN AMARA, N. MNIF Radiology service ,Charles Nicolle Hospital INTV2

  2. INTRODUCTION • Vertebral hemangiomas are benigntumors and mostfrequent in thoracicspine . • The majority of them are asymptomatic and require no treatment ,and lessthan 1℅ of vertebral hemangiomas are agressive and producesymptoms .

  3. INTRODUCTION • Percutaneous vertebroplasty (PV) is a minimally invasive interventional radiology technique where pathological vertebral bodies are filled with acrylic cement to strengthen the bone and relieve pain.

  4. INTRODUCTION • The purpose of the study is to evaluate the efficacy and safety of percutaneous vertebroplasty using polymethylmethacrylate in the treatment of vertebral fractures caused by aggressive hemangiomas. • We report on our preliminary results a short and medium term clinical follow-up.

  5. Materials and methods • A retrospective study of 10 cases was performed between 2006 and 2011in the interventional radiology unit of Charles Nicolle hospital.

  6. Materials and methods • Sociodemographiccharacteristics : age , sex; • Clinicalparameters; • Comorbidity; • Caracteristics of spinal pain : course duration and schedule ; • The repercussion on the physical activity; • Anteriortreatment to VPP.

  7. Materials and methods • Clinicalexamination: • Analgesic attitude ; • Spinal deformation; • Spinal stiffness ; • Pain in the pressure of thornyapophysis ; • Neurologicsymptoms .

  8. Materials and methods • Before VPP: • X ray radiographics: • The importance of the spinal compression • Posteriorarch extension • Spinal deformation • M RI: • Achievement of the vertebral body • Posteriorwallrecession • Posteriorarch extension • CT-scan : • Cortical rupture.

  9. Materials and methods • Technicalprocedure of VPP : Most procedures have been carried out in the interventionnal radiological unit of Charles Nicolle hospitalequippedwith a Philips apparatus (V3000) with a rotative bowaround the examining table in order to secure a better control of the cement injection.

  10. Materials and methods Two patients have benefitedfrom VPP under CT guidance in the CT room of the medicalimagery service of Charles Nicolle hospitalequippedwith a multi detector CT Général Electrique (GE) 16 Bits.

  11. Materials and methods • The VPP procedurecarried out undergeneralanaesthesia or neuroleptanalgesia in rigorousaseptic conditions. • Transpedicular access way. • Three to ten ml of PMMA cementwereinjectedunderscopic or CT control afterhavingplaced an 11G trocart.

  12. Materials and methods • The outcome was measured using a subjective evaluation of the pain before vertebroplasty and the improvement of the pain after the short term (3 -15 days) and the medium term (1-3 months).

  13. RESULTS • Age:18 -68 • Sex: 4 females 6 Males • Kind of pain: mixed ( 4 cases), inflammatory( 6 cases) • Pain average duration: 13, 9±14 months

  14. RESULTS • The initial pain was classified according to: • The analgesic treatment consumption • The repercussion on the physical activity determining this way the stage of the pain that varies from 0 to 3 (0 absent-3 invalidating).

  15. RESULTS Clinicalexamination: • Analgesic attitude: 3 cases • Spinal stiffness :3 cases • Pain in the pressure of thornyapophysis: 5 cases • Neurologicsymptoms : cord compression :3 cases • Bilateral sciatalgy L5 • Paraplegia flask • Spastic paraparesis

  16. RESULTS X ray radiographics: • The angiomatous locations : dorsal spine (9 cases) , lumbar spine (1 case) • Vertebral fractures: (7cases) • Morphological type of the spinal compression: cuneiform ( 5cases) pancake shaped( 5cases) • The semiquantitative classification of GRENANT : rank 1: (8 cases) rank 2:( 1 case) rank 3: (1 case)

  17. X ray radiographics centered on the dorsal and lumbar hinge Showing a cuneiform compression of L1 rank 2 of GRENANT.

  18. RESULTS • CT scan: • Rupture of cortical bone:(4 cases) • Posteriorwallrecession:(2cases) • Typical striated bony appearance: (2 cases) • Posterior arch extension : (5 cases)

  19. RESULTS • MRI: • Posterior arch extension : 2 cases • Posteriorwallrecession :2 cases • Pedicle extension:1 case • Epidural extension :3 cases • Endocanal extension :1 case • Cord compression withoutmarrowsuffering:1 case.

  20. Spinal MRI sagittal T2 ( A ) and sagittal T1 ( B ) of an aggressive hemangiomas of D2 with epidural extension

  21. RESULTS • VPP procedure: • NEUROLEPTANALGESIA:8 cases • Under scopic control: 8 cases : The great majority of the authors (3,4,11) realize vertebroplasties under scopic control • CT control: 2 cases • Transpedicular access way: 9 cases • Three to ten ml of PMMA cementwereinjectedunderscopic or CT control afterhavingplaced a 11G trocart.

  22. VPP of an aggressive hemangioma of D11 by bi pedicular access underscopic control .

  23. RESULTS Technical incidents: • Leak of cement :vascular system ,intra-canalar (1 case), foraminal , intervertebral discs and soft tisssus.

  24. Discussion CT in coronal reconstruction ( A ) and sagittal ( B ) in the immediate fall of a VPP of D3 for an aggressive hemangioma realized under scopic showing an intracanalar leak of acrylic cement. Let us note the presence of intracanalar air bubbles which is possible during this procedure .

  25. RESULTS Improvement of the pain : • the short term: 3-15 days • Total regression :1 case • Partial regression:10% 1st - 30% 3rd day • Medium term 1-3 months • Occasional pains in the prolonged effort • Analgesic treatment on demand :20℅ • Partial regression

  26. DISCUSSION • The vertebral hemangiomas is a frequent benign vascular dysplasia generally asymptomatic. Only 0,9 % to1,2 % of the cases become symptomatic by the appearance of invalidating pains or neurological signs or present signs of aggressiveness in imagery(4) that were described by Laredo (12):the achievement of the vertebral body, the extension in the posterior arc of the vertebra, in neighboring soft tissues and epidural extension .

  27. DISCUSSION • The VPP is an effective therapeutic means in the symptomatic forms of spinal hemangiomas or in the aggressive forms which present a high potential risk of fracture (2,5 ). The objective of the injection of PMMA in the vertebral body is to obtain a definitive hardening of the hemangiomas by a complete filling by the cement ( 1 ). The analgesic effect is immediate and complete in most cases according to the various studies carried out.

  28. DISCUSSION • For example, an immediate complete improvement was obtained in 9cases out of ten in the series of Galibert and Deramond ( 5 -6) and in 11 cases out of 12 in the experience of Chiras and al ( 11 ). • A long-term clinical evaluation of patients handled by VPP for VH realized by Brunot ( 4) demonstrated a long-term symptomatic relief in 90 % of the patients, without premature or late complication bound to the method.

  29. DISCUSSION VPP combines 2 effects: • Vertebralstabilization (5): using PMMA whichis a hard and resistantmaterial • Analgesiceffect: consolidation of micro fractures(7,8) destruction of the nerve endings of the normal bone (10).

  30. DISCUSSION • The results of our series consolidate those of the literature with 100 % of short and medium-term improvement (at least partial improvement) among which 57 % of medium-term total relief.

  31. CONCLUSION • The percutaneous vertebroplasty appears to be an effective and simple technique in the treatment of symptomatic vertebral hemangiomas providing a significant improvement of the pain with biomechanical stability and a low complications rate.

  32. REFERENCES • 1.Chiras J, Barragàn Campos HM, Cormier E, et al. Vertébroplastie: état de l’art. J Radiol 2007;88:1255-60. • 2.Galibert P, Deramond H. Percutaneous acrylic vertebroplasty as a treatment of vertebral angioma as well as painful and debilitating diseases. Chirurgie 1990;116:326-35. • 3.Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolyticmetastases and myeloma: effects of percentage of lesionfilling and the leakage of methylmethacrylateatclinicalfollow up. Radiology 1996;200:525-30. • 4.Brunot S, Berge J, Barreau X, et al. Evaluation clinique à long terme des patients traités par vertébroplastie pour des angiomes vertébraux J Radiol 2005;86:41-7. • 5.Chiras J. Vertébroplasties percutanées. Technique, indications, resultats. Feuillets de Radiologie 2000;40:58-68. • 6.Deramond H, Darrasson R, Galibert P. La vertébroplastie percutanée acrylique dans le traitement des hémangiomes vertébraux agressifs. Le Rachis 1989;1:143-53

  33. REFERENCES • 7. Kaemmerlen P, Thiesse P, Bouvard H, et al. Percutaneous vertebroplasty in the treatment of metastases. Technic and results. J Radiol 1989;70:557-62. • 8.Lapras C, Mottolese C, Deruty R, et al. Injection percutanée de méthylméthacrylate dans le traitement de l’ostéoporose et ostéolyse vertébrale grave. Ann Chir 1989;43:371-6. • 9.Baroud G, Bohner M. Conséquences biomécaniques de la vertébroplastie.Rev Rhum Engl Ed 2006;73:248-55. • 10.Provenzano MJ, Murphy KP, Riley LH. Bonecements: review of theirphysiochemical and biomechanicalproperties in percutaneous vertebroplasty. AJNR Am J Neuroradiol 2004;25:1286-90. • 11.Chiras J, Sola Martinez MT, Weill A, et al. Vertébroplasties percutanées. Rev Med Interne 1995;16:854-9. • 12. Laredo JD, Reizine D, Bard M, Merland JJ. VertebralHemangioma : Radiologicevaluation. Radiology 1986;161:183-9.

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