|Year : 2006 | Volume
| Issue : 4 | Page : 637-642
|Role of vertebroplasty in non infective vertebral collapse - a review article
Bhawna, R Santosham, S Joseph
FF 1 CASA-XS, Manapakam, Chennai - 600 116, India
Click here for correspondence address and email
|Date of Submission||05-Apr-2006|
|Date of Acceptance||10-Aug-2006|
Keywords: Vertebroplasty, Cement, Fluroscopy
|How to cite this article:|
Bhawna, Santosham R, Joseph S. Role of vertebroplasty in non infective vertebral collapse - a review article. Indian J Radiol Imaging 2006;16:637-42
Vertebroplasty is a simple, minimally invasive, relatively new percutaneous technique of plastic reconstruction of the weakened vertebra by injecting bone cement, which results in pain relief and restoration of biomechanical strength. These may be due to osteoporosis, benign or malignant tumors of the vertebrae. This procedure is effective for treating certain types of painful vertebral compression fractures and some painful or unstable benign and malignant vertebral lesions that fail to respond to the traditional conservative therapies
|How to cite this URL:|
Bhawna, Santosham R, Joseph S. Role of vertebroplasty in non infective vertebral collapse - a review article. Indian J Radiol Imaging [serial online] 2006 [cited 2020 Jan 18];16:637-42. Available from: http://www.ijri.org/text.asp?2006/16/4/637/32287
This is particularly relevant as there is an increase in the life expectancy amongst patients with osteopenia and osteoporosis. This procedure offers a therapeutic option for patients suffering from osteoporotic and tumor-related vertebral fractures and pain.
This technique was introduced into the medical field by a French Neuroradiologist Herve Deramond in 19871 and is presently gaining wide acceptance all over the world.Treatment of aggressive vertebral angiomas was the first indication. PVP has recently been introduced as a therapeutic alternative for the treatment of pain associated with compression fractures.
Initially all the commercially available kits did not have PMMA mixed with Barium sulphate,thus before the procedure sterile Barium sulphate was mixed with PMMA to render the mixture radio-opaque.
Mechanism of Pain Relief
Vertebroplasty offers analgesic effect, biomechanical strength and antitumoral effect . The analgesic effect is due to in situ immobilization of fractures, destruction of nerve endings, cytotoxic effect and exothermic reaction. The antitumoral effect is due to local toxicity of methyl methacrylate (MM).
Polymethyl Methacrylate is the principle component of bone cements used for rapid stable fixation of implants, such as metal and plastic prosthesis placed in living bone during orthopaedic procedures. PMMA is used at present in PVP to fortify a collapsed vertebral body and stabilize the vertebral column.
There have been concerns related to the potential toxicity of the acrylic substances used as bone cement, both for the patient and for the medical personnel who are exposed to the vapor during a percutaneous vertebroplasty procedure.
Cloft et al addressed the issue of occupational exposure using air-sampling pumps during five vertebroplasty procedures. These samples yielded methyl methacrylate vapor levels of less than 5 ppm, well below the recommended maximum exposure of 100 ppm/day.
Several in vitro studies have addressed the question of whether the heat generated by the exothermic reaction during polymerization of the acrylic bone cement could injure tissue surrounding the injection site.
Deramond et al measured the temperature in postmortem vertebrae during injection of two types of bone cement. While the temperature rose above 50°C within the vertebral bodies, the temperature within the spinal canal did not rise above 41°C, the authors concluded that it is unlikely that any thermal damage to the spinal cord would occur during cement polymerization.
In a postmortem examination of the vertebrae of six patients who had undergone percutaneous vertebroplasty, San Millαn Ruνz et al7 found that the bone cement had a necrotizing effect on tumor tissue within and directly around the implant. This effect was particularly prominent with injection of polymethyl-methacrylate (PMMA) compared with N-buyl-cyano-acrylate (NBCA), which these authors hypothesize was due to the increased toxicity of PMMA and the higher degree of exothermic reaction during polymerization.
Percutaneous vertebroplasty is indicated in patients with incapacitating and persistent severe focal back pain due to vertebral body collapse.
Despite recent advances in medical therapy for osteoporosis, osteoporotic vertebral fractures remain a common problem.
Traditional treatment of painful compression fractures included bed rest, oral or parenteral analgesics, muscle relaxants, external back-bracing and physical therapy. Calcitonin also appears to have a variable analgesic effect in osteoporotic compression fractures. The majority of patients respond favorably to traditional treatment; however, there are some patients who fail with conservative therapy and suffer from prolonged pain and immobility, which can persist for life.
60% of post menopausal women will have abnormal bone density on X -ray/CT. 40 % will have osteoporosis related fracture and incapacitating pain. Old age, smoking habits, white females, patients on prolonged immobilization and steroid therapy are additional risk factors.
Initially a trial of conservative management with bed rest and pain medication is given for 4-6 weeks. PVP is indicated if there is no improvement after 4-6 weeks of conservative management. One has to carry out diagnostic studies, plain X-rays or MRI. Percussion of the spine demonstrates the maximally affected vertebrae.
Present day indications for Percutaneous Vertebroplasty in osteoporosis include
- Incapacitating and persistent pain involving a maximum of 3 vertebrae in a patient.
- Vertebroplasty is also indicated in osteoporosis to prevent decubitus complications.
- Indicated in patients above the age of 85 years with focal back pain for more than 2 weeks.
Jensen ME et al showed that 90 percent of patients (29 patients with 47 fractures) with age-related or steroid-induced osteoporosis experienced pain relief and improved mobility at 24 hours post-vertebroplasty. No worsening of pain post procedure was reported.
Coretet B et al showed significant pain reduction and improvement in health profile scores of 16 patients treated at 20 vertebral levels.
Painful destructive vertebral body haemangioma (VH) is relatively rare. Vertebral haemangioma may cause pain due to fracture, mass effect, thecal sac compression or neural foraminal narrowing. The literature supports significant reduction in pain in approximately 80% of patients with hemangiomas treated by vertebroplasty. In fact, the first report of a Percutaneous vertebroplasty being performed was in a patient who presented with haemangioma.
Vertebroplasty is not performed on all hemangiomas seen on MRI or CT, but for aggressive hemangiomas only. The signs of aggressivity are classified into clinical and radiological signs.
The radiological signs of aggressivity are described by Laredo et al.
These signs include:
a) Hemangioma from D3-D9
b) Involvement of the whole vertebral body
c) Neural arch extension
d) Expanded cortex without indistinct margins
e) Irregular honey comb pattern
f) Extra vertebral soft tissue mass
g) Reduced fat content by CT/MR
h) Epidural extension and vertebral collapse.
A lesion is said to be radiologically aggressive if 3 or more of these signs are present and based on these signs we have 4 different groups.
1. Asymptomatic vertebral hemangioma, without radiological signs - no treatment required.
2. Asymptomatic vertebral hemangioma with radiological signs - patients usually require regular follow up, PVP or ethanol injection can be done.
3. Symptomatic vertebral hemangioma without radiological signs - PVP is ideal for this patient.
4. Symptomatic vertebral hemangioma with radiological signs - here again PVP is ideal.
4A. Patients with Acute spinal compression or cauda equina syndrome - PVP plus surgery is indicated.
4B. Patients with progressive myelopathy - PVP and ethanol is ideal.
Deramond et al, Cotton et al and Dousset et al have reported results with group 4A patients.
In patients with hemangioma, epidural and neural arch involvement vertebroplasty can be done for the body followed by glue or alcohol for the neural arch.
Gangi A et al treated 289 vertebrae in 105 patients with percutaneous vertebroplasty for a variety of lesions. They showed favorable outcomes in 78 percent of patients with osteoporotic lesions, 83 percent of patients with malignant lesions and 73 percent of patients with vertebral hemangiomas.
Vertebroplasty in malignant tumors
Indicated in primary tumors like myeloma, plasmocytoma and secondary tumors like oesteolytic metastasis and lymphoma. This is the patient population that benefits most from the rapid and durable reduction in vertebral pain that the technique offers. Conventional therapy for malignant disease consists of bed rest, bracing, anti-inflammatory or opiate medications and radiation therapy. The indication for vertebroplasty depends on number of vertebrae affected, spinal level etc.
Cotten A et al described complete or partial pain relief in 97 percent of patients who were treated for painful metastasis (29 patients) and multiple myeloma (8 patients).
Weill A reported good pain relief in 73 percent of patients with at least a 50 percent reduction in analgesic dose; this study also reported moderate pain relief in 29 percent of patients (37 patients, 52 vertebrae) with painful malignant vertebral lesions.
Chiras et al reported their experience with 33 patients with malignant disease treated with vertebroplasty. Twenty-four of the 33 procedures resulted in clear improvement; 7 of 33 resulted in moderate improvement; and 2 of 33 resulted in no improvement. Improvement was stable in 73% of patients at 6 months.
Cortet et al reported short and long term outcome data in their patients with malignant disease, who experienced severe or excruciatingly severe pain (McGill - Melzack score of 4 or 5) and were unresponsive to narcotics.
The experience of the authors' group at the University of Geneva with 40 patients (11 for osteoporosis, 7 for hemangiomas, 19 for metastases, 2 for myelomas, and 1 for lymphoma) treated at 68 levels has been reported. Early clinical follow-up showed that pain relief occurs mostly within 3 days. There was a minimum of 6-month follow-up and a maximum of 4-year follow-up in 34 patients.
Cotten et al reported that there was no relationship in their series of 40 vertebroplasties performed for metastases (30 cases) and myeloma (10 cases) in 37 patients. Patient selection criteria.
Henceforth Percutaneous vertebroplasty is considered as an appropriate treatment for patients with vertebral lesions resulting from acute trauma, osteolytic vertebral metastasis, vertebral hemangioma and osteoporotic compression fractures.
The following criteria should be taken into consideration before performing percutaneous vertebroplasty:
- Patient does not have neurological compromise.
- Pain is severe and debilitating and is not be relieved by medical therapy.
- Other causes of pain such as herniated intervertebral disc are ruled out by Computed Tomography or Magnetic Resonance Imaging.
- The affected vertebra is not extensively destroyed and is at least one third of its original height.
The procedure is contraindicated in patients with
- Destruction of the posterior wall of the vertebral body.
- Coagulation disorders.
Pre Procedure Workup
History of the patient regarding the severity of pain and disability of the patient is recorded that gives an important clue to the degree of improvement and a battery of the following investigations should be run.
- Plain film of the local site of interest is taken to see the level and degree of vertebral involvement.
- CT is done to reveal the cortical disruption, neural arch and pedicular involvement.
- MRI is done to see for intra & extra spinal component.
- Bone Scan is done to see the active hot spot.
- Chest X-Ray taken in all patients as most of them are elderly and have poor respiratory reserve.
- Routine blood examination and the bleeding and coagulation profile.
- Cardiological evaluation in all patients prior to the procedure.
A physical examination is carried out with special reference to the level of tenderness.
Procedure is performed in four major steps
Step 1- Vertebral puncture
Step 2 - Vertebral biopsy
Step 3 - Injection of bone cement
Step 4 - Removal of the needle
Position of the patient
Patient is put in supine position for cervical level plasty.
For dorsal or lumbar vertebral collapse patients are made to lie prone. A pillow is placed under the stomach, for the patient to be positioned properly for vertebral puncture. Next, the spine of the patient is percussed and the exact level of tenderness noted.
The patients are sedated with neruoleptanalgesia
Following this, under biplane fluoroscopy at the level of affected vertebra the pedicle is localized in both planes and exact point of entry is marked and patient is draped. This is followed by Step 1 of the technique.
Step 1 - Vertebral puncture.
The pedicle is made end on with slight angulations of the tube in AP position and the needle is inserted through the superolateral quadrant of the pedicle into the vertebral body by hammering or through cork screw movement.
Special care is taken not to encroach on the medial wall of the pedicle. In the lateral view when the needle reached the anterior third of the vertebral body, superior or inferior to mid coronal plane, the hammering is stopped.
Step II - Spinal biopsy
Spinal biopsy is taken and sent for histopathological examination. This is done by inserting a bone biopsy needle through the vertebroplasty needle.
A bone cutting needle (15G made by Cook) that gives a good sample of the bone is usually used.
Spinal biopsy should not be attempted in cases of hemangioma .
Step III - Preparation and Injection of bone cement.
Preparation of bone cement
20 grams of bone cement (Osteo-firm) IS taken in a steel bowl and 5-7 ml of the liquid monomer Methyl Methacrylate Is added drop by drop while stirring till the cement reached tooth paste/melting ice cream consistency. Once this Is done only 10 minutes to complete the procedure are available as the polymerization starts immediately.
The mixture made in the bowl is transferred into a 10 ml syringe and through this syringe it is quickly transferred into 1 ml Leur lock syringes.
The 1ml syringe is now connected to the vertebroplasty needle and cement is injected under fluoroscopy in the lateral projection. The end point of the injection is decided when the cement reached the posterior vertebral wall or if paravertebral vein filling is noted.
Step IV - Removal of Needle.
When the endpoint is reached, the needle Is carefully withdrawn by a rotatory motion. A sterile gauze Is applied at the local site.
Following the procedure, the patients is put on analgesic and non steroidal anti-inflammatory drugs. Analgesics are stopped 1-2 days later. The patients are made to sit up after 4 hours and are mobilised after 8 hours. In most patients the pain disappeared instantaneously.
Vertebroplasty Vs Radiotherapy (XRT) in malignant tumors
Pain relief is almost equal in both vertebroplasty and radiation treatment, but the onset of pain relief is immediate following vertebroplasty as compared to 10 to 20 days for XRT. Another advantage of vertebroplasty is biomechanical strength offered to the vertebral body following vertebroplasty, which is not there following XRT. Radiation treatment is complimentary to vertebroplasty. Thus radiation complements the analgesic effects and does not spoil the biomechanical properties of PMMA.
A combination of vertebroplasty, XRT or surgery may be done depending on the clinical conditions. Anterior stabilizations with percutaneous vertebroplasty can be done followed by surgery. The treatment should be ideally done on a consensus opinion with a team of experts consisting of oncologists, radiologists and surgical team.
Coming to vertebroplasty complications, these are few. They can be due to:
- Percutaneous approach - in the cervical region it can produce injury to carotid artery or internal jugular vein and in the dorsal region it can injure the pleura resulting in pneumothorax.
- Improper force on the needle can result in needle breakage.
- Complications due to cement injection include a variety of cement leaks.
- Complications due to condition of the patient, which may be the result of poor pulmonary function, deep vein thrombus and pulmonary embolism.
- Complications due to local injection of PMMA include increasing pain not associated with leaks, which may be due to inflammatory reaction or local ischaemia. Radiculopathy occurs as a result of leak into the neural foramina. The most serious complication is spinal cord compression as a result of epidural extension.
Complications due to vertebroplasty in general are less. Overall complications for vertebroplasty in cases of hemangioma and osteoporosis is around 1-3 %., all of which can be managed conservatively. Complications due to malignant tumors are slightly high, around 10%. So care and caution should be exercised in performing vertebroplasty due to malignant tumors. Complications are directly related to the volume of the cement injected. One should remember that the pain relief has no direct relation with volume of the cement injected. Following guidelines using good techniques and multidisciplinary approach can reduce complications.
Padovani et al, reporting on a case of pulmonary infarction associated with embolism of acrylic material during a Vertebroplasty procedure, hypothesizes that insufficient polymerization of the acrylic at the time of injection can allow migration into the inferior vena cava and the pulmonary arteries.
Gangi et al, in describing the outcome of percutaneous vertebroplasty in a large series of patients, state that the following elements are necessary to avoid complications with the procedure and improve outcome: (1) appropriate patient selection; (2) adequate radiographic and fluoroscopic guidance to ensure correct needle placement; (3) injection of cement at the proper stage of polymerization to avoid leakage or embolism and (4) sufficient operator training.
The mechanism of pain relief experienced by patients who undergo vertebroplasty is primarily due to the mechanical support provided by the bone cement; nerve damage resulting from heat generated during the exothermic polymerization of PMMA or from toxicity caused by the unpolymerized monomer may also play a role in reducing pain perception22.
Percutaneous vertebroplasty has proved to be a valuable remedy in the treatment of vertebral compression fracture due to osteoporosis, acute trauma, metastasis and haemangioma .This procedure results in immediate pain relief and early mobility of patients. As the bone cement and equipment used to perform percutaneous vertebroplasty are improving the procedure is becoming safer and durable day by day.
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FF 1 CASA-XS, Manapakam, Chennai - 600 116
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
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