Vertebroplasty

The role of The role of vertebroplastyvertebroplasty in in vertebral fracturesvertebral fractures

Dr Steve ConnorNeuroradiology Department

King’s College Hospital

Basic principles and mechanismsBasic principles and mechanisms

Injection of polymethylmethacrylate(PMMA) into compressed vertebral bodyRelief of pain Strengthening of bone (load bearing and stiffness)

HistoryHistory

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

IndicationsIndications

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

IndicationsIndications

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

IndicationsIndications

NOT :

High energy traumatic fractures

Prophylactic treatment of vertebrae at high risk of fracture

Absolute contraindicationsAbsolute contraindications

Other causes of pain e.g. disc herniation

Clear improvement with medical therapy

Infection

Coagulopathy

Relative contraindicationsRelative contraindications

Marked loss of vertebral height

(?<1/3 of original height)

Relative contraindicationsRelative contraindications

Retropulsion of fracture fragments (?>20%)or marked destruction of posterior vertebra

PrePre--procedural evaluationprocedural 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

PrePre--treatment imagingtreatment imaging

Computed tomography– Pedicle morphology– Bone retropulsion/ posterior wall defects– Mark point of entry

PrePre--treatment imagingtreatment imaging

Magnetic resonance imaging

– Multiple collapses or prolonged pain

PrePre--treatment imagingtreatment imaging

Nuclear medicineSuccessful treatment unlikely ifnegative bone scan Useful if contraindication to MRI

Equipment and materialsEquipment and materials

High quality imaging– Biplane digital angiography suite– CT/ Portable fluoroscopy

Equipment and materialsEquipment and materials

Sterile conditions

Anaesthetic and monitoring equipment

Equipment and materialsEquipment and materials

Vertebroplasty needle

Low viscosity cement

Injection device

AftercareAftercare

Supine for 2 hours (observations)Limit activity for 24 hoursNSAIDs for 2-4 daysExpect pain relief within 24 hours but may be delayed up to one weekFollow up (1,7,30 days)

Mechanism of actionMechanism of action

Stabilising of microfracturesThermal necrosis of liquid monomerChemotoxicity of liquid monomer

Clinical outcome dataClinical 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)

Clinical outcome dataClinical 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)

Clinical outcome dataClinical 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

New developmentsNew developments

Non PMMA cements– Bioactive glass– Hydroxyapatite– Osteoconductive coral granules– Composite cements

Ideal cement volumesVariations of technique

Balloon Balloon kyphoplastykyphoplasty

Restores vertebral body heightHigh pressure balloon followed by cement injection into cavity created by balloon

?fewer complications resulting from cement extravasation?reduction in morbidity of kyphosis

Clinical outcome dataClinical outcome data--balloon balloon kyphoplastykyphoplasty

Five published case seriesLargest 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 therapyPain relief scores similar to those achieved by vertebroplasty

ConclusionConclusion

Vertebroplasty is a viable treatment and possible standard management of the pain and disability of vertebral fractures– Adequate training– Meticulous technique– Careful patient selection