Presented by: Dr David Lisle — Radiologist Event: Challenges in the Ageing Spine - 2014

1. Percutaneous vertebroplasty
Dr David Lisle
Brisbane Private Imaging
Royal Brisbane Hospital
University of Queensland

2. • 85 year old female
• Severe acute mechanical back pain
– Pain not managed with high dose therapy
– Can’t sleep
– Limited walking to only a few steps
• Spontaneous onset
• No known trauma
• No known malignancy

5. Vertebral compression fracture
• Radiographic or symptomatic clinical event
• Radiographic: 26% women >50 years
• USA/year: 150,000 hospital admissions;
5,000,000 restricted days
• ↓ VC and FEV
• ↑ mortality
– ≥ 1 # : 1.23 x age adjusted
– ≥ 5 # : >2 x age adjusted
Mathis AJNR 2001;22:373-381

8. Indications
• Painful crush fracture
– Osteoporosis
– Acute: 4-6 weeks
• Malignant crush fracture
– +/- biopsy
• Haemangioma
– Galibert Neurochirurgie 1987;33:166-8

9. Patient selection = key to success
• Back pain
– Sudden onset
– May radiate anteriorly
– NOT sciatica
– Mechanical
– Restricted activity
– Poor sleep
• Local tenderness
• Imaging

10. Patient selection
• Purposes of pre-procedure imaging:
– Confirm presence of crush fracture
– Confirm that crush fracture is acute
– Diagnose other acute levels
– Integrity of spinal canal
– Accurately localise level

11. Imaging techniques
• Plain films:
– Confirm presence of crush fracture
– Confirm that crush fracture is acute
– Diagnose other acute levels
– Integrity of spinal canal
– Accurately localise level

13. 24/3/2001

14. 24/3/2001 16/12/2000

15. Imaging techniques
• MRI:
– Confirm presence of crush fracture
– Confirm that crush fracture is acute
– Diagnose other acute levels
– Integrity of spinal canal
– Accurately localise level

16. MRI pre-vertebroplasty
• Sagittal plane
• T1 for anatomy
• T2 fat saturation or
STIR
– Marrow black
– Oedema white
STIR

17. MRI
2
3
2
3
T1 STIR

18. Procedure

19. Patient preparation
• Ensure MRI done and available
• (Coagulation profile)
• Pre-sedation fast
• Sedation and pain relief
– iv cannula
– Fentanyl + Midazolam
• Sterile swab and drape

20. Needle placement: Thoracic

23. Needle placement: Lumbar

25. Cement preparation

30. Cement injection

31. Post procedure care
• Lie prone for 20 minutes
• Bed rest for 2-3 hours
• CT to document cement placement
• Discharge if well
– Post-sedation instructions
– Rest 24 hours
– Mobilize according to pain
• Advise re muscle pain
• Follow-up phone call(s)

32. Complications: rare
• Mild fever; nausea for 24 hours
• Rib fracture
• Foraminal leak
• Spinal canal leak
• Venous emboli

35. Literature
• Amar Neurosurg 2001;49:1105
– 97 pat., 258 levels
– ‘better life’ 74%
• Narcotic/analgesic use
• Mobility
• Better sleep
• Evans Radiology 2003;226:366
– 488 pat, 245 follow-up
– Pain scale 8.9 → 3.4
– Impaired ambulation:
• 72% pre → 28% post

36. Literature
• Diamond MJA 2006;184:113-117
– Conservative Rx vs PCV (non-randomised)
– Acute pain 1-6 weeks, not relieved analgesics
– MRI: acute fracture(s)
– 3 factors: pain (VAS); physical function;
hospital days
– 24 hours and 6 weeks: 60% ↓ pain scores;
29% ↑ physical function; 43% ↓ hospital days
– Similar clinical outcomes at 6/12, 12/12, 24/12.

37. My results
• Audit of first 250 patients, 2001 to 2006
• Complete or near complete response
– No or minimal pain
– Good return of activity level
– 83.0 %
• Moderate response
– Still suffer pain, though noticeably reduced
– Some return of activity, though still restricted
– 12.0 %
• No response
– 5.0 %

38. Percutaneous vertebroplasty
Keys to success
• Patient selection
– Early referral
– MRI
• High quality fluoroscopy
– Accurate needle placement
– Cement injection
• Nursing care
– Cement preparation
– Patient care: pre and post

39. Percutaneous vertebroplasty
• Indications
• Patient selection
– Clinical assessment
– Imaging
• Technique
– Needle placement
– Post-procedure care
• Results

40. MBS funding September 2005

41. So, what happened?
• Buchbinder NEJM 2009;361:557-68
– Multicentre, randomized, double blind
– Vertebroplasty vs placebo ‘sham’
procedure
– N = 78: 38 vertebroplasty, 40 sham
– No difference in pain scales or quality of
life
• MJA (Editorial) 2009;191:476-7
– ‘Percutaneous vertebroplasty is not an
effective treatment for acute osteoporotic
vertebral fractures’

42. • Patient selection
– Up to 12 months pain
• Recruitment
– Majority of eligible
patients not recruited
• Technique
– Up to 3ml cement
– Stopped injection if
leaking

43. MBS funding withdrawn 2011

44. Where are we now?
• Uncommon in most places
• Ongoing studies
– eg randomised trial in Sydney for acute
fractures; recruitment very slow
• Included in appropriateness guidelines
in UK and USA
– http://www.nice.org.uk/guidance/IPG12/chapter/1-
Guidance
– http://www.acr.org/
• No Medicare rebate
• Our cost: 1400 + day bed about 700

46. Thank you