Vertebroplasty presentaion
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Vertebroplasty presentaion Document Transcript

  • 1. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pmThe most rewarding intervention: Vertebroplasty Ramsin Benyamin, MD, DABIPP, FIPP DisclaimerPresident/Medical Director, Millennium Pain Center, Bloomington, IllinoisMedical Director, Millennium Pain Center, Chicago, IllinoisMedical Director, OSF Millennium Pain Center, Normal, IllinoisCo-founder, Millennium Pain Management-Teknon Medical Center, Barcelona, SpainClinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana/ChampaignAdjunct Professor, Department of Biological Sciences, Illinois State UniversityPresident-Elect, ASIPPBoard of Directors, SIPMSBoard of Examiners, ABIPPBoard of Examiners, FIPPMember, Guidelines committee, ASIPPMember, Research committee, ASIPPAssociate Editor, “ Pain Physician”Editorial Board, “ Pain Practice”Editorial Board, “Journal of Opioid Management” Scope of the problemOsteoporosis epidemic: - 200 million worldwide - 40 million in USAWomen over 80: - 80% osteoporosis - 40% VCF9x increased mortality Cauley et al, Osteo Intern, 2000Self-care assistance: >50% of 1-2 VCF (8% in OA/LBP )One VCF: 19.2%Two VCF: 24%more chance of another VCF in next year 1
  • 2. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Most common risk factors Oral glucocorticoid use Early menopause Unintentional weight loss and malnutrition 34% 36% Other factors 10% 20% Tannenbaum C et al. J Clin Endocrin Metab. 2002 Risk of fracture from steroid use • 2.6-fold increase vertebral fracture Risk of Oral glucocorticoid Age- and gender- users matched controls (n=244,235) (n=244,235) Van Staa TP et al. J Bone Miner Res. 2000 Incidence of vertebral fractures in spine T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 1 2 3 4 5 6 7 8 Fracture prevalence (%) Nevitt MC et al. Bone. 1999 2
  • 3. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Consequences of VCF Pain Immobility Kyphosis More Compression Opioid dependence Impact of ImmobilityOsteoporosis(loss of BMD): 2% per weekMuscle wasting: 1-3% per dayLoss of Strength : 50% in 3-5 weeksConstipation, loss of appetite, fecal impactionDepression/ anxietyDecubitus ulcers: 70% in 2 weeks (70& older): 50% more nursing costUTI/ calculiLow FVC: 9% with each VCFAtelectasis, less effective coughing, reduced cilliaryclearance: 25-50% reduced inspiration: PneumoniaDVT: 61% in bed rest: PE in 2-12%: 0.5-10% fatal Benefits of VertebroplastyPain Relief Quick & Complete • Osteoporotic 75-90% complete relief of pain (immediately or within 72 hours) • Neoplastic 59-86% complete relief of pain or marked reduction in opioidsImproved Mobility • within 24 hours, reduced AE (cost) in elderly Brown et al, JAmGerSoc,2004 3
  • 4. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Position Statement · American Society of Interventional and Therapeutic Neuroradiology · Society of Interventional Radiology · American Association of Neurological Surgeons/Congress of Neurological Surgeons · American Society of Spine Radiology Percutaneous vertebral augmentation is a safe, efficacious, and durable procedure in appropriate patients with symptomatic osteoporotic & neoplastic fractures “Benefits far outweigh its risk and the risk of conservative therapy” Jensen et al, Position Statement, JVIR, 2007Vertebroplasty, First 1000 Levels of a Single Center: Evaluation of the Outcomes and Complications Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, Kallmes DF, AJNR 2007 Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, Kallmes DF, AJNR 2007 4
  • 5. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Percutaneous Vertebroplasty for Painful Compression Fractures in a Small Cohort of Patients with a Decreased Expectation-Related Placebo Effect due to Dementia METHODS: 10 patients with dementia who had vertebroplasty RESULTS: Pain with activity decreased or resolved in 80%-100% of patients at each time point, whereas pain at rest decreased or resolved in 78%-100% of all patients at each time point. Improved mobility was reported in 80%-100% of patients at all time points. Pain medication was decreased or stopped in 67% of patients at 1 week and in 100% of patients at 6 months and 1 year. CONCLUSION: Treatment of painful compression fractures in patients with dementia demonstrates a high rate of success regarding pain relief and mobility. This study offers additional evidence that vertebroplasty has true benefit.Lehman VT, Gray LA, Kallmes DF , AJNR Am J Neuroradiol. 2008 Jun 12 Vertebroplasty in multiple myeloma: outcomes in a large patient series Significant improvement in: rest pain (82%) and activity pain (89%) 65% of patients requiring fewer narcotics 70% having improved mobility Vertebroplasty provides significant & durable pain relief McDonald RJ, Trout AT, Gray LA, Dispenzieri A, Thielen KR, Kallmes DF, AJNR 2008 Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels with osteoporotic vertebral compression fractures Out of 334 procedures, 15 patients with unrelieved pain in 4 to 32 days after an initial PV Complete pain relief in 11 (73%) and partial pain relief in 4 patients (27%), in a mean follow-up of 15 months Absent or inadequate filling of cement may be responsible for the unrelieved pain after the initial PV He SC, Teng GJ, Deng G, Fang W, Guo JH, Zhu GY, Li GZ, Spine, 2008 5
  • 6. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Indication “Painful Compression Fracture”Osteoporosis, Trauma, CancerAcute, Sub-acuteNot totally collapsedNo (significant) retropulsionPain consistent with imaging Exam under Fluoroscopy Establish diagnosis Evaluate the view, fracture Decide feasibility: fluoro / CT Plan the approach (? fractured peddicle) Do NOT be a maverick! Preparation Antibiotics: systemic Positioning: padding, self-positioning Anesthesia: MAC + local Strict sterile technique 6
  • 7. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Image Guidance High-quality fluoroscopy • Biplane • Single plane • C-armCT and fluoroscopy Love the Dog!Discography and Intradiscals Facet Joint Medial Branch Vertebroplasty Epidural or Intrathecal Transforaminal Final needle position 7
  • 8. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Vertebral Venous Plexus 8
  • 9. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Posterior leakage Rarely symptomatic Intradural leakage Too medial?? May require Sx Massive Pulmonary Edema•Insufficient polymerisation of the injected cement, probably due to anunbalanced monomer-to-powder ratio?•3 levels (T12, L1 & L2)•15 ml retrieved Monticelli, Forensic Sci Int, 2005 More cases Aortic embolism!: Breast Ca. 6cc Right Laterovertebral artery Asymptomatic Amoretti, Skeletal Radiol 2007 9
  • 10. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm L4 radiculopathy Pedicle fracture No cement in the vertebrae!!! Baumann C. Cardiovasc Intervent Radiol, 2007 10
  • 11. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Safe Deposit Area! Trans-Pedicular approach Vertebroplasty 11
  • 12. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Hammer!Too far medial Too far lateral Blind Spots ! 12
  • 13. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Bi-pedicular technique Cement injection Radio-opaque: 30% Barium Adequate curing time: “tooth-paste” Real-time fluoro in lateral Volume of cement: 2-4ml - not correlated with pain relief - not correlated with strengthening 13
  • 14. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Final X-Ray Finally…….. Vertebroplasty vs. Kyphoplasty Clinical response rate is similar No proven advantage of Kyphoplasty in: - Pain relief - Height restoration - Complication ratePosition Statement, J Vas Interv Radiol, 2007:American Society of Interventional and Therapeutic NeuroradiologySociety of Interventional RadiologyAmerican Association of Neurological Surgeons/Congress of Neurological SurgeonsAmerican Society of Spine Radiology 14
  • 15. Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm Evidence ASIPP Guidelines, 2007 Level of evidence is Moderate Final CommentsBest suited: Interventional Pain Physician (Anesthesia, PM&R, IR, Surgeon)Not : Part-timers (Anesthesiologist, Radiologist, Spine surgeon)- Comprehensive clinic & follow-up- Fluoroscopy/percutaneous- Resuscitation skillsPhysicians (not marketplace): determine patient selection criteriaIt’s not the procedure that changes the outcome, it’s the operator Thanks!benyamin@millenniumpaincenter.com 15