EVERYTHING YOU WANTED TO KNOW ABOUT VERTEBROPLASTY (except the hands-on)

1. EVERYTHING YOU WANTED TO KNOW ABOUT VERTEBROPLASTY(except the hands-on) Kirkland W. Davis, M.D. Division of Musculoskeletal Radiology University of Wisconsin Madison, Wisconsin

2. BACKGROUND

3. Vertebroplasty: Introduction • “New” treatment for painful pathologic vertebrae • X-ray guided spine augmentation: “Internal Splint”

4. Vertebroplasty: Introduction • Vertebroplasty is an effective, minimally invasive procedure in which bone cement (PMMA) is injected into a vertebral body to relieve pain

5. Pathologic Vertebral Compression Fracture • Primary osteoporosis • Elderly patient • Female>male • Secondary osteoporosis • Young patient • Steroid use • Asthma, vasculitis, transplant, inflammatory bowel disease, tumor treatment

6. Pathologic Vertebra (+/- Compression Fracture) • Neoplasm • Primary • Hemangioma • Myeloma • Secondary • Metastasis (5%/yr, 30% overall) • Lymphoma

7. 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

8. 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

9. 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

10. 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

11. Osteoporotic Compression Fractures: Traditional Management Some do not heal Chronically disabling Side effects of traditional management can be significant

12. Objective • To provide relief from a painful vertebra • Osteoporotic fracture • Primary • Secondary • Neoplasm • Benign or malignant • Fractured or not • To provide stability

13. Objective • To prevent further vertebral collapse that would • Lead to further loss of height • Result in kyphosis • Be associated with fractures at adjacent levels

14. 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

15. Benefits of Vertebroplasty • Pain relief • Quick • Complete: osteoporosis > neoplasia • Improved mobility • Patient able to stand and walk within first 24 hours

16. 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)

17. 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

18. 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

19. 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)

20. 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: 8.93.4 (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

21. 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

22. Efficacy of VertebroplastyFourney et al. • Improvement or complete pain relief 84% • No change 9% • Not available 7% • None worse

23. 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

24. Efficacy of VertebroplastyWeill et al. • France • 37 patients with mets (no myeloma) • 52 procedures • Treated painful vertebra or lesions that threaten stability of spine

25. 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

26. Efficacy of VertebroplastyWeill et al. • Stabilization: no loss of height in 11 vertebrae treated for stabilization • Mean follow-up 13.0 months

27. Efficacy of Vertebroplasty • UW experience: mostly osteoporosis • 12 months • 27 patients, 25 with accurate documentation • 20/25 pain improved or resolved = 80%

28. 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

29. THE PROCEDURE

30. Indications • Painful vertebra from: • Osteoporotic fracture • Neoplastic fracture • Tumor infiltration • Trauma?

31. 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

32. 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

33. 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

34. Contraindications: • Uncorrected coagulopathy • Pathologic • Iatrogenic • Infection • Spine • Elsewhere

35. Contraindications: • Moderate or severe retropulsion of the posterior vertebral body cortex into the spinal canal • Vertebral height loss >70%

36. 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

37. Pre-procedure Consultation • Pain history • Location • Severity • Duration • Radiation • Pain diagram

38. Pre-procedure Consultation • Alteration of lifestyle due to fracture? • Activities of daily living • Analgesic use • Types • Frequency • Orthotic use

39. Pre-procedure Consultation • Past medical history • Past surgical history • Spine surgery? • Medications • Anticoagulants

40. Pre-procedure Consultation • Allergies • {Iodine contrast agents} • Antibiotics • Laboratory • {Hct/Hgb}, PT/PTT/INR, Platelets, {Bun/Creat} • Imaging studies

41. Pre-procedure Imaging • Radiographs • Compare with any prior studies

42. 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

43. Pre-procedure Imaging • Computed tomography • If MRI contraindicated • Assesses cortical integrity of posterior vertebral body and pedicles

44. Pre-procedure Imaging • Bone scan • If MRI contraindicated • With SPECT • Often performed as part of a metastatic work-up

45. Pre-procedure Consultation • Examination under fluoroscopy • Establish concordance between painful sites and levels of vertebral body compression • Occasionally needed • Informed consent

46. 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

47. Complications • Spinal cord or nerve root injury • <1% • Direct • Puncture • Indirect • Compression • Hematoma • Ischemia

48. Complications Hemorrhage Rare Infection Rare Pulmonary embolism Fracture Lamina Pedicle Increased pain 1-2% Death

49. Complications • Symptomatic cement extravasation • Incidence: depends upon etiology of fracture • Osteoporosis 1-2% • Neoplasm 5-10%

50. Complications: Cement Extravasation • Location • Epidural • Foraminal • Paravertebral • Disc