Vertebroplasty

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Vertebroplasty

  1. 1. The role of vertebroplasty in vertebral fractures Dr Steve Connor Neuroradiology Department King’s College Hospital
  2. 2. Basic principles and mechanisms Injection of polymethylmethacrylate (PMMA) into compressed vertebral body Relief of pain Strengthening of bone (load bearing and stiffness)
  3. 3. History First performed in 1984 (Deramond et al 1987) Widespread use for treatment of painful osteoporotic collapse in 1990s in USA Not widely available in UK at present
  4. 4. Indications Painful new or progressive osteoporotic collapse – refractory to medical therapy – dosage of analgesia leads to unacceptable side effects After conservative treatment (6-8 weeks) Treatment is optimal within 4 months of fracture Early treatment useful in specific cases – Co-morbid disease – To reduce loss of vertebral height and possibility of continued collapse
  5. 5. Indications Management of painful vertebral tumours – Benign or malignant – Vertebra not necessarily collapsed Onset of pain relief more rapid than radiotherapy and does not effect subsequent radiotherapy
  6. 6. Indications NOT : High energy traumatic fractures Prophylactic treatment of vertebrae at high risk of fracture
  7. 7. Absolute contraindications Other causes of pain e.g. disc herniation Clear improvement with medical therapy Infection Coagulopathy
  8. 8. Relative contraindications Marked loss of vertebral height (?<1/3 of original height)
  9. 9. Relative contraindications Retropulsion of fracture fragments (?>20%) or marked destruction of posterior vertebra
  10. 10. Pre-procedural evaluation Careful history, examination and discussion with patient – Residual deep ache worse with standing, bending and alleviated by rest – Review analgesia requirement and side effects – Pain and mobility assessment – Reproduce pain on palpation Consent
  11. 11. Pre-treatment imaging Computed tomography – Pedicle morphology – Bone retropulsion/ posterior wall defects – Mark point of entry
  12. 12. Pre-treatment imaging Magnetic resonance imaging – Multiple collapses or prolonged pain
  13. 13. Pre-treatment imaging Nuclear medicine Successful treatment unlikely if negative bone scan Useful if contraindication to MRI
  14. 14. Equipment and materials High quality imaging – Biplane digital angiography suite – CT/ Portable fluoroscopy
  15. 15. Equipment and materials Sterile conditions Anaesthetic and monitoring equipment
  16. 16. Equipment and materials Vertebroplasty needle Low viscosity cement Injection device
  17. 17. Aftercare Supine for 2 hours (observations) Limit activity for 24 hours NSAIDs for 2-4 days Expect pain relief within 24 hours but may be delayed up to one week Follow up (1,7,30 days)
  18. 18. Mechanism of action Stabilising of microfractures Thermal necrosis of liquid monomer Chemotoxicity of liquid monomer
  19. 19. Clinical outcome data No large randomised controlled trial One prospective randomised trial underway (acute compression factures) One non randomised study with long term follow up comparing with conservative treatment (Diamond et al Am J Med 2003)
  20. 20. Clinical outcome data 22 published observational studies – Retrospective designs – Short term follow up – Concurrent treatment modalities Three series of >250 patients – Gangi et al Radiographics 2003(868 patients)
  21. 21. Clinical outcome data Moderate or marked pain relief in 75-95% – Increased energy – Improved quality of life Longer term follow up data supports long term efficacy No published studies addressing cost effectiveness
  22. 22. New developments Non PMMA cements – Bioactive glass – Hydroxyapatite – Osteoconductive coral granules – Composite cements Ideal cement volumes Variations of technique
  23. 23. Balloon kyphoplasty Restores vertebral body height High pressure balloon followed by cement injection into cavity created by balloon
  24. 24. ?fewer complications resulting from cement extravasation ?reduction in morbidity of kyphosis
  25. 25. Clinical outcome data-balloon kyphoplasty Five published case series Largest describes 188 procedures in 78 patients with minimum 1 year follow up (Coumans JV et al J Neurosurg 2003) No comparisons with vertebroplasty or conservative therapy Pain relief scores similar to those achieved by vertebroplasty
  26. 26. Conclusion Vertebroplasty is a viable treatment and possible standard management of the pain and disability of vertebral fractures – Adequate training – Meticulous technique – Careful patient selection

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