Vertebroplasty Grand Rounds

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Vertebroplasty is an effective, minimally invasive spine procedure where acrylic bone cement is injected into a painful pathologically compressed vertebral body.

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Vertebroplasty Grand Rounds

  1. 1. Vertebroplasty <ul><li>Introduction </li></ul><ul><ul><li>Percutaneous spine intervention. </li></ul></ul><ul><ul><li>Image guided. </li></ul></ul><ul><ul><li>Treatment of painful pathologic vertebral </li></ul></ul><ul><ul><li>compression fractures. </li></ul></ul>
  2. 2. Vertebroplasty <ul><li>Introduction </li></ul><ul><ul><li>Vertebroplasty is an effective, minimally invasive spine procedure where acrylic bone cement is injected into a painful pathologically compressed vertebral body. </li></ul></ul>
  3. 3. Vertebroplasty <ul><li>Objective </li></ul><ul><ul><li>Provide instant pain relief. </li></ul></ul><ul><ul><li>Prevent further vertebral collapse. </li></ul></ul>
  4. 4. Vertebroplasty <ul><li>History </li></ul><ul><ul><li>Acrylic cement used as jeep windshields in WWII. </li></ul></ul><ul><ul><li>European total joint surgery in 1960. </li></ul></ul><ul><ul><li>FDA approved for total hips 1971. </li></ul></ul><ul><ul><li>FDA approved for total knees in 1973. </li></ul></ul><ul><ul><li>FDA approved for pathological fractures 1973 (Simplex P). </li></ul></ul><ul><ul><li>Used in Vertebroplasty (Simplex P) 1984. </li></ul></ul><ul><ul><ul><li>Deramond </li></ul></ul></ul><ul><ul><ul><li>50 year old female with neck pain due to hemangioma. </li></ul></ul></ul>
  5. 5. Vertebroplasty <ul><li>Vertebral Body Compression Fracture </li></ul><ul><ul><li>Primary osteoporosis </li></ul></ul><ul><ul><li>-Elderly females </li></ul></ul><ul><ul><li>Secondary osteoporosis </li></ul></ul><ul><ul><li>-Young, steroid users </li></ul></ul>
  6. 6. Vertebroplasty <ul><li>Vertebral Body Compression Fracture </li></ul><ul><ul><li>Neoplasm </li></ul></ul><ul><ul><ul><li>Primary </li></ul></ul></ul><ul><ul><li>-Hemangioma </li></ul></ul><ul><ul><li>-Myeloma </li></ul></ul><ul><ul><ul><li>Secondary </li></ul></ul></ul><ul><ul><li>-Metastasis </li></ul></ul><ul><ul><li>-Lymphoma </li></ul></ul>
  7. 7. Vertebroplasty <ul><li>Osteoporotic Fractures </li></ul><ul><ul><li>More common in females than males. </li></ul></ul><ul><ul><li>1.5 Million osteoporotic fractures </li></ul></ul><ul><ul><li>annually in the US. </li></ul></ul><ul><ul><ul><li>500,000 – 700,000 vertebral fractures </li></ul></ul></ul><ul><ul><li>1995 osteoporotic fracture data </li></ul></ul><ul><ul><ul><li>2.5 million physician visits </li></ul></ul></ul><ul><ul><ul><li>432,000 hospital admissions </li></ul></ul></ul><ul><ul><ul><li>180,000 nursing home admissions </li></ul></ul></ul><ul><ul><ul><li>$13.5 billion in direct medical costs </li></ul></ul></ul>
  8. 8. Vertebroplasty <ul><li>Osteoporotic/Metastatic Fractures </li></ul><ul><ul><li>-Pain </li></ul></ul><ul><ul><li>-Pulmonary Compromise </li></ul></ul><ul><ul><li>-Insomnia </li></ul></ul><ul><ul><li>-Immobility </li></ul></ul><ul><ul><li>-Depression </li></ul></ul><ul><ul><li>-Narcotic Dependence </li></ul></ul><ul><ul><li>-Spinal Cord Compression </li></ul></ul><ul><ul><li>-Kyphosis </li></ul></ul>
  9. 9. Vertebroplasty <ul><li>Traditional Vertebral Body Compression Fracture Management </li></ul><ul><ul><li>-Analgesics -Bed Rest </li></ul></ul><ul><ul><li>Temporary DVT </li></ul></ul><ul><ul><li>Side Effects Pneumonia </li></ul></ul><ul><ul><li>-Immobilization -Surgery </li></ul></ul><ul><ul><li>Variable success High failure rates </li></ul></ul><ul><ul><li>Demineralization </li></ul></ul>
  10. 10. Vertebroplasty <ul><li>Early Intervention May Reduce: </li></ul><ul><ul><li>Duration of acute pain Height loss </li></ul></ul><ul><ul><li>Duration of immobilization Use of analgesics </li></ul></ul><ul><ul><li>Occurrence of chronic pain Incidence of pneumonia </li></ul></ul><ul><ul><li>Further collapse of the treated vertebral body </li></ul></ul><ul><li>Benefits Of Vertebroplasty </li></ul><ul><ul><li>Pain Relief Improved Mobility </li></ul></ul><ul><ul><li>-Quick -Mobility within 24 hrs </li></ul></ul><ul><ul><li>-Complete </li></ul></ul>
  11. 11. Vertebroplasty <ul><li>Efficacy </li></ul><ul><ul><li>Osteoporotic compression fracture </li></ul></ul><ul><ul><ul><li>80-90% of patients experience dramatic or complete relief of pain immediately or within 72 hours. </li></ul></ul></ul><ul><ul><li>Neoplastic compression fractures </li></ul></ul><ul><ul><ul><li>70% of patients experience marked reduction in narcotic requirements or complete pain relief. </li></ul></ul></ul>
  12. 12. Vertebroplasty <ul><li>Indications </li></ul><ul><ul><ul><li>Pain related to vertebral compression fractures </li></ul></ul></ul><ul><ul><ul><li>associated with osteoporosis or tumor infiltration. </li></ul></ul></ul><ul><li>Contraindications </li></ul><ul><ul><ul><li>Uncorrected coagulpathy or systemic or spinal </li></ul></ul></ul><ul><ul><ul><li>infection. </li></ul></ul></ul><ul><ul><ul><li>Moderate to severe retropulsion of the posterior </li></ul></ul></ul><ul><ul><ul><li>vertebral body cortex into the spinal canal. </li></ul></ul></ul><ul><ul><ul><li>Height loss>70% </li></ul></ul></ul>
  13. 13. Vertebroplasty <ul><li>Patient Selection </li></ul><ul><ul><li>Patients who tend to respond the best </li></ul></ul><ul><ul><ul><li>One to three levels of fractures. </li></ul></ul></ul><ul><ul><ul><li>Focal pain and tenderness corresponding to the level of edema by MRI. </li></ul></ul></ul><ul><ul><ul><li>Fracture present < 2 months. </li></ul></ul></ul><ul><ul><ul><li>Recent worsening of fracture. </li></ul></ul></ul><ul><ul><ul><li>No sclerosis of fractured vertebra. </li></ul></ul></ul>
  14. 14. Vertebroplasty <ul><li>Patient Consultation </li></ul><ul><ul><ul><li>Alteration of lifestyle due to fracture. </li></ul></ul></ul><ul><ul><ul><li>Analgesic use. </li></ul></ul></ul><ul><ul><ul><li>Orthotic use. </li></ul></ul></ul><ul><ul><ul><li>Past medical history </li></ul></ul></ul><ul><ul><ul><li>Past surgical history. </li></ul></ul></ul><ul><ul><ul><ul><li>Spine </li></ul></ul></ul></ul><ul><ul><ul><li>Medications. </li></ul></ul></ul><ul><ul><ul><ul><li>Anticoagulants </li></ul></ul></ul></ul><ul><ul><ul><li>Allergies </li></ul></ul></ul><ul><ul><ul><ul><li>Iodine contrast agents and antibiotics </li></ul></ul></ul></ul><ul><ul><ul><li>Laboratory </li></ul></ul></ul><ul><ul><ul><ul><li>Hct/Hgt, PT/PTT/INR, Platelets </li></ul></ul></ul></ul>
  15. 15. Vertebroplasty <ul><li>Patient Consultation </li></ul><ul><ul><ul><li>Plain Radiographs. </li></ul></ul></ul><ul><ul><ul><ul><li>Compare with any prior studies </li></ul></ul></ul></ul><ul><ul><ul><li>MRI. </li></ul></ul></ul><ul><ul><ul><ul><li>T1, T2, STIR sequence. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Assess for vertebral body marrow edema. </li></ul></ul></ul></ul><ul><ul><ul><li>CT. </li></ul></ul></ul><ul><ul><ul><ul><li>If MRI contraindicated. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Assess cortical integrity of posterior vertebral body and pedicles. </li></ul></ul></ul></ul><ul><ul><ul><li>Skeletal Seintigraphy </li></ul></ul></ul><ul><ul><ul><ul><li>With SPECT </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Often performed as part of a metastatic work-up </li></ul></ul></ul></ul>
  16. 16. Vertebroplasty <ul><li>Complications </li></ul><ul><ul><ul><li>Incidence. </li></ul></ul></ul><ul><ul><ul><ul><li>Minor complications <3% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Major complications <1% </li></ul></ul></ul></ul><ul><ul><ul><li>Majority are transient and self limiting. </li></ul></ul></ul><ul><ul><ul><li>Steroid therapy or surgery are rarely required. </li></ul></ul></ul><ul><ul><ul><li>Spinal cord or nerve root injury <1%. </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage, infection and PE – Rare </li></ul></ul></ul><ul><ul><ul><li>Fracture </li></ul></ul></ul><ul><ul><ul><ul><li>Lamina </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pedicle </li></ul></ul></ul></ul><ul><ul><ul><li>Increased pain. </li></ul></ul></ul><ul><ul><ul><li>Death. </li></ul></ul></ul>
  17. 17. Vertebroplasty <ul><li>Complications </li></ul><ul><ul><ul><li>Symptomatic cement extravasation. </li></ul></ul></ul><ul><ul><ul><ul><li>Incidence depends upon etiology of fracture. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Osteoporosis 1-2% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Neoplasm 5-10% </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><ul><li>Epidural </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Foraminal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Paravertebral </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Disc </li></ul></ul></ul></ul>
  18. 18. Vertebroplasty <ul><li>Pre-Procedure Care </li></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><ul><li>Optional. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Recommended for immune compromised patients. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Systemic. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Local. </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Added to cement. </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Patient Positioning and Draping </li></ul></ul></ul><ul><ul><ul><ul><li>Patient prone. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Strict sterile technique. </li></ul></ul></ul></ul>
  19. 19. Vertebroplasty <ul><li>Pre-Procedure Care </li></ul><ul><ul><ul><li>Anesthesia </li></ul></ul></ul><ul><ul><ul><ul><li>Intravenous sedation </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sedation: Versed </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Analgesia: Fentanyl </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Local </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>1% Lidocaine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bipivicaine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>General Anesthesia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Rarely required </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Patient Monitoring </li></ul></ul></ul><ul><ul><ul><ul><li>Nursing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intravenous line </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Continuous Monitoring </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Parameters </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Vital signs </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Oxygen saturation </li></ul></ul></ul></ul></ul>
  20. 20. Vertebroplasty <ul><li>Imaging </li></ul><ul><ul><li>High quality fluoroscopy </li></ul></ul><ul><ul><ul><li>Biplane </li></ul></ul></ul><ul><ul><ul><li>Single plane </li></ul></ul></ul><ul><ul><ul><li>C-arm </li></ul></ul></ul><ul><ul><li>Computed tomography </li></ul></ul><ul><ul><ul><li>CT and fluoroscopy </li></ul></ul></ul>
  21. 21. Vertebroplasty <ul><li>Procedure </li></ul><ul><ul><li>Localize symptomatic vertebral body level prior to prepping the skin. </li></ul></ul><ul><ul><li>Choose approach. </li></ul></ul><ul><ul><ul><li>Transpedicular </li></ul></ul></ul><ul><ul><ul><li>Parapedicular </li></ul></ul></ul><ul><ul><li>Anesthetize skin and subcutaneous tissues down to the level of the periosteum. </li></ul></ul><ul><ul><ul><li>25 and 22 gauge needles </li></ul></ul></ul><ul><ul><ul><li>20 or 22 gauge spinal needles </li></ul></ul></ul><ul><ul><li>Deratotomy </li></ul></ul><ul><ul><ul><li>#11 scalpel blade or equivalent </li></ul></ul></ul>
  22. 22. Vertebroplasty <ul><li>Procedure: Needle Insertion </li></ul><ul><ul><li>Locate bony landmarks and advance needle to desired location within the vertebral body using imaging guidance. </li></ul></ul>
  23. 23. Vertebroplasty <ul><li>Procedure: Venogram </li></ul><ul><ul><li>Injection of contrast through needle. </li></ul></ul><ul><ul><li>Visualize vertebral body and epidural and paraspinal veins. </li></ul></ul><ul><ul><li>May predict pattern of cement injection. </li></ul></ul><ul><ul><li>Will identify a direct venous communication. </li></ul></ul><ul><ul><li>May interfere with visualization of opacified cement. </li></ul></ul>
  24. 24. Vertebroplasty <ul><li>Procedure: Cement Mixture </li></ul><ul><ul><li>Polymer powder. </li></ul></ul><ul><ul><li>Liquid monomer. </li></ul></ul><ul><ul><li>Opacifying agent. </li></ul></ul><ul><ul><ul><li>Barium sulfate powder. </li></ul></ul></ul><ul><ul><li>Vacuum mixer </li></ul></ul>
  25. 25. Vertebroplasty <ul><li>Procedure: Cement Prep </li></ul><ul><ul><li>Limited working time. </li></ul></ul><ul><ul><ul><li>10-15 minutes depending on temperature and cement mixture. </li></ul></ul></ul><ul><ul><li>Injection devices </li></ul></ul><ul><ul><ul><li>Luer-Lok syringes </li></ul></ul></ul><ul><ul><ul><li>“ Jack-screw” hydraulic injector. </li></ul></ul></ul>
  26. 26. Vertebroplasty <ul><li>Procedure: Cement Injection </li></ul><ul><ul><li>Meticulous fluoroscopic monitoring during the injection process. </li></ul></ul><ul><ul><li>Liquefied cement is injected into the vertebral body. </li></ul></ul><ul><ul><li>Termination of injection. </li></ul></ul><ul><ul><ul><li>Cement in posterior 1/3 vertebral body on lateral projection. </li></ul></ul></ul><ul><ul><ul><li>Cement extruding into epidural, foraminal or paraspinal veins. </li></ul></ul></ul><ul><ul><ul><li>Significant disk space penetration. </li></ul></ul></ul><ul><ul><ul><li>Posterior 1/3. </li></ul></ul></ul>
  27. 27. Vertebroplasty <ul><li>Case #1: Painful osteoporotic compression fracture T8. </li></ul>
  28. 28. Vertebroplasty <ul><li>Case #1: Painful osteoporotic compression fracture. </li></ul><ul><ul><li>Complete symptomatic relief within 24 hrs. </li></ul></ul>
  29. 29. Vertebroplasty <ul><li>Case #2: Painful osteoporotic compression fracture L3. </li></ul><ul><ul><li>Complete symptomatic relief in 24 hrs. </li></ul></ul>
  30. 30. Vertebroplasty <ul><li>Case #3: Painful osteoporotic compression fracture T12. </li></ul><ul><ul><li>Complete symptomatic relief in 24 hrs. </li></ul></ul>
  31. 31. Vertebroplasty <ul><li>Case #4: Painful metastatic fracture T12. </li></ul><ul><ul><li>Complete symptomatic relief in 24 hrs. </li></ul></ul>Pre-Op Post Vertebroplasty
  32. 32. Vertebroplasty <ul><li>Case #5: Destruction Of Posterior Wall </li></ul>Pre-Op Post Vertebroplasty
  33. 33. Vertebroplasty <ul><li>Post Operative Care </li></ul><ul><ul><li>Dressing at needle site. </li></ul></ul><ul><ul><li>Strict bed rest for 2-3 hours post vertebroplasty. </li></ul></ul><ul><ul><li>Monitor vital signs. </li></ul></ul><ul><ul><li>Monitor neurologic examination. </li></ul></ul><ul><li>Patient Follow-up </li></ul><ul><ul><li>Patient Instructed to call for </li></ul></ul><ul><ul><ul><li>New back pain </li></ul></ul></ul><ul><ul><ul><li>Chest pain </li></ul></ul></ul><ul><ul><ul><li>Lower extremity weakness </li></ul></ul></ul><ul><ul><ul><li>Fever >100 degrees </li></ul></ul></ul><ul><ul><li>Follow-up at 24 hours and 1 week. </li></ul></ul>
  34. 34. Vertebroplasty <ul><li>Results </li></ul><ul><ul><li>F. Grados, C. Depriester, G. Cayrolle, N. Hardy, H. Dermond and P.Fardellone Long-term Observations Of Vertebral Osteoporotic Fractures Treated By Percutaneous Vertebroplasty </li></ul></ul><ul><ul><li>34 levels in 25 patients. </li></ul></ul><ul><ul><li>Follow-up 12-84 months (mean 48). </li></ul></ul><ul><ul><li>No severe complications. </li></ul></ul><ul><ul><li>No progression of vertebral deformity in any injected vertebral body. </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>47 levels in 29 patients. </li></ul></ul><ul><ul><li>No severe complications. </li></ul></ul><ul><ul><li>90% significant immediate pain relief. </li></ul></ul>
  35. 35. Vertebroplasty <ul><li>Results </li></ul><ul><ul><li>Deramond, Percutaneous Vertebroplasty With Polymethylmethacrylate: Technique, Indications, and Results , Musculoskeletal Radiology , 5/98 </li></ul></ul><ul><ul><li>80 Osteoporotic pts, 90% complete pain relief </li></ul></ul><ul><ul><li>101Tumor pts, 80% complete pain relief4 levels in 25 patients. </li></ul></ul><ul><ul><li>Martin, Vertebroplasty: Clinical Experience and Follow-up Results , Bone , 8/99 </li></ul></ul><ul><ul><li>40 pts, 68 levels </li></ul></ul><ul><ul><li>80% complete pain relief </li></ul></ul>
  36. 36. Vertebroplasty <ul><li>Conclusions </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>The procedure has a low complication rate and a very high success rate. </li></ul></ul><ul><ul><li>Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. </li></ul></ul><ul><ul><li>Medical management of osteoporosis or malignancy must therefore be initiated and continued. </li></ul></ul>

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