Download radiofrequency ablation of painful musculoskeletal mets

EVERYTHING YOU WANTED
TO KNOW ABOUT
VERTEBROPLASTY
(except the hands-on)
Kirkland W. Davis, M.D.
Division of Musculoskeletal Radiology
University of Wisconsin
Madison, Wisconsin
BACKGROUND
Vertebroplasty: Introduction
• “New” treatment for painful
pathologic vertebrae
• X-ray guided spine augmentation:
“Internal Splint”
Vertebroplasty: Introduction
• Vertebroplasty is an effective,
minimally invasive procedure in
which bone cement (PMMA) is
injected into a vertebral body to
relieve pain
Pathologic Vertebral Compression
Fracture
• Primary osteoporosis
– Elderly patient
– Female>male
• Secondary osteoporosis
– Young patient
– Steroid use
• Asthma, vasculitis,
transplant,
inflammatory bowel
disease, tumor
treatment
Pathologic Vertebra
(+/- Compression Fracture)
• Neoplasm
–Primary
• Hemangioma
• Myeloma
–Secondary
• Metastasis (5%/yr,
30% overall)
• Lymphoma
Osteoporotic Vertebral
Compression Fractures
• More common in females than in
males
–2 female:1 male
–Prevalence as high as 26% in
females > 50 years of age
Osteoporotic Fractures:
Economics
• 1.5 million osteoporotic fractures
annually in the United States
– 700,000 vertebral fractures
• In 1995, osteoporotic fractures
accounted for
– 2.5 million physician visits
– 432,000 hospital admissions
– 180,000 thousand nursing home
admissions
– $13.5 billion in direct medical expenses
• Fracture incidence predicted to
quadruple next 50 years
Osteoporotic Fractures: Actual
Costs May Be Under-Reported
– Pain
– Diminished
mobility
– Loss of
employment
– Narcotic
addiction
– Urinary retention
– Constipation
–Insomnia
–Depression
–Spinal cord
compression
–Kyphosis
– Pulmonary
restriction
– GI disturbances
Osteoporotic Compression
Fractures: Traditional Management
• Analgesics
–Temporary
–Side effects
• Bed rest
–Deep venous
thrombosis
–Pneumonia
• Immobilization
–Variable success
–May cause
further
demineralization
• Surgery
–Challenging
–For neuro
compromise
Osteoporotic Compression
Fractures: Traditional
Management
• Some do not heal
–Chronically
disabling
• Side effects of
traditional
management can
be significant
Objective
• To provide relief from a painful
vertebra
– Osteoporotic fracture
• Primary
• Secondary
– Neoplasm
• Benign or malignant
• Fractured or not
• To provide stability
Objective
• To prevent further
vertebral collapse
that would
–Lead to further
loss of height
–Result in
kyphosis
–Be associated
with fractures at
adjacent levels
Early Intervention May Reduce:
• Duration of
acute pain
• Medication use
• Duration of
immobilization
• Occurrence of
chronic back
pain
• Further collapse of
the treated
vertebral body
• Height loss
• Kyphosis
• Incidence of
pulmonary
embolism and
pneumonia
Benefits of Vertebroplasty
• Pain relief
–Quick
–Complete: osteoporosis >
neoplasia
• Improved mobility
–Patient able to stand and walk
within first 24 hours
History
• Acrylic cements have been used
for bone augmentation for over 3
decades
–Stabilization of large defects after
tumor excision (Vidal, 1969)
–Hip replacement (Chamley, 1970)
History
• First reported case of
percutaneous vertebroplasty in
Amiens, France
–Galibert and Deramond, 1984
–50 year-old female with neck pain
due to a cervical (C2) hemangioma
Efficacy of Vertebroplasty
Zoarski et al.
• Osteoporotic compression fracture
–75-90% of patients experience
dramatic or complete relief of pain
within several to 72 hours
• Neoplastic compression fracture
–59-86% of patients experience
marked reduction in narcotic
requirements or complete pain relief
Efficacy of Vertebroplasty
Zoarski et al.
• 30 pts, 54 fractures
• MODEMS questionnaire pre- and 2 weeks
post-procedure
• 80% improved
• Treatment expectations: success (P<0.0001);
improved pain and disability (P<0.0001),
physical function (P=0.0004), and mental
function (P=0.0009).
• 15-18 month follow-up: 22 of 23 patients
reported continued pain relief and
satisfaction with procedure. Pain improved
(P<0.0001)
Efficacy of Vertebroplasty
Evans et al.
• 488 patients, 245 responding (40 deceased, 75
wrong #, 118 unreachable multiple attempts, 10
other)
• Phone interview average 7 months postprocedure
• Pain: 8.93.4 (P<0.001)
• Impaired ambulation: 72%28% (P<0.001)
• Ability to perform ADL improved (P<0.001)
• Consistent results across subgroups: time from
procedure to questionnaire, one versus multiple
fractures, acute versus chronic fractures
Efficacy of Vertebroplasty
Fourney et al.
• MD Anderson
• 56 patients (21 myeloma, 35 other)
• 97 procedures, all fractures
• Recorded:
–VAS: pain
–Medication use
–Neurologic status
–Preop; postop; 1, 3, 6, 9, 12 months
Efficacy of Vertebroplasty
Fourney et al.
• Improvement or complete pain
relief 84%
• No change 9%
• Not available 7%
• None worse
Efficacy of Vertebroplasty
Fourney et al.
• Median pre-op VAS 7
• Median post-op VAS 2 (p<0.001)
• Pain reduction significant at
each follow-up interval through
one year
Efficacy of Vertebroplasty
Weill et al.
• France
• 37 patients with mets (no
myeloma)
• 52 procedures
• Treated painful vertebra or
lesions that threaten stability of
spine
Efficacy of Vertebroplasty
Weill et al.
• Pain
– 73% clear improvement in pain
– 21% moderate improvement
– 6% no improvement
– Statistical estimates:
• 6 months 73% pain relief
• 1 year 65% pain relief
– Pain recurrence usually due to new
lesions
Efficacy of Vertebroplasty
Weill et al.
• Stabilization: no loss of height in
11 vertebrae treated for
stabilization
–Mean follow-up 13.0 months
Efficacy of Vertebroplasty
• UW experience: mostly
osteoporosis
• 12 months
• 27 patients, 25 with accurate
documentation
• 20/25 pain improved or resolved =
80%
Why Does Vertebroplasty
Alleviate Pain?
• Stabilizes fracture
• Allows healing to occur
• Prevents further collapse of the treated
vertebral body
• Tumors??
– Thermal effect
– Toxic effect
– Mass effect
– Stabilizes microfractures and
macrofractures
THE PROCEDURE
Indications
• Painful vertebra
from:
–Osteoporotic
fracture
–Neoplastic
fracture
–Tumor
infiltration
–Trauma?
Patient Selection
• Patients who tend to respond best
–Single level or only a couple of levels
–Focal pain and tenderness
corresponding to the level of edema
by MRI
–Fracture present <2 months or recent
worsening of fracture
–Fracture limits activity
–No sclerosis of fractured vertebra
Patient Selection
• Patients who are less likely to
respond
–Fracture present for >1 year
–Other causes for back pain are
present
• Disc herniation, spinal stenosis,
facet or sacroiliac joint disease
–Radicular pain related to disc
herniation
Neoplastic Compression
Fracture
• Treat to alleviate pain
• Stabilize vulnerable vertebrae
• Opportunity to obtain biopsy
• Amount of pain reduction may be
less than what is achieved in the
treatment of osteoporotic
compression fractures
• Greater risk for complications
Contraindications:
• Uncorrected coagulopathy
–Pathologic
–Iatrogenic
• Infection
–Spine
–Elsewhere
Contraindications:
• Moderate or
severe
retropulsion of
the posterior
vertebral body
cortex into the
spinal canal
• Vertebral height
loss >70%
Patient Selection Criteria
• Painful fracture not responding
after 4 weeks of treatment (?)
• Acute or subacute compression
fracture(s) on plain radiographs or
MRI
• Pain corresponding to level of the
fracture
Pre-procedure Consultation
• Pain history
–Location
–Severity
–Duration
–Radiation
–Pain diagram
Pre-procedure Consultation
• Alteration of lifestyle due to
fracture?
–Activities of daily living
• Analgesic use
–Types
–Frequency
• Orthotic use
Pre-procedure Consultation
• Past medical history
• Past surgical history
–Spine surgery?
• Medications
–Anticoagulants
Pre-procedure Consultation
• Allergies
–{Iodine contrast agents}
–Antibiotics
• Laboratory
–{Hct/Hgb}, PT/PTT/INR,
Platelets, {Bun/Creat}
• Imaging studies
Pre-procedure Imaging
• Radiographs
–Compare with
any prior
studies
Pre-procedure Imaging
• Magnetic
resonance
imaging
– T1, T2, STIR
sequences
– Assess for
vertebral body
marrow
edema
– Exclude
stenosis due to
disc and/or
facet disease
Pre-procedure Imaging
• Computed
tomography
– If MRI
contraindicated
– Assesses cortical
integrity of
posterior
vertebral body
and pedicles
Pre-procedure Imaging
• Bone scan
–If MRI
contraindicated
–With SPECT
–Often
performed as
part of a
metastatic
work-up
Pre-procedure Consultation
• Examination under
fluoroscopy
– Establish
concordance
between painful
sites and levels of
vertebral body
compression
– Occasionally
needed
• Informed consent
Complications
• Incidence
–Minor complications: 1-5%
–Major complications: <<1%
–Higher for metastases: 10%
• Majority of complications are
transient and self-limited
• Steroid therapy or surgery are
rarely required
Complications
• Spinal cord or nerve root injury
–<1%
–Direct
•Puncture
–Indirect
•Compression
•Hematoma
•Ischemia
Complications
• Hemorrhage
–Rare
• Infection
–Rare
• Pulmonary
embolism
• Fracture
–Lamina
–Pedicle
• Increased pain
–1-2%
• Death
Complications
• Symptomatic cement
extravasation
–Incidence: depends upon
etiology of fracture
• Osteoporosis 1-2%
• Neoplasm
5-10%
Complications:
Cement Extravasation
• Location
–Epidural
–Foraminal
–Paravertebral
–Disc
Pre-procedure Care: Day of
Procedure
• NPO after midnight
• Informed consent
• Antibiotics
Procedure: Specifics
• Performed with biplane fluoro
• Patient in prone position: comfort is
our goal
• Strict sterile technique
Procedure: Anesthesia
• Intravenous sedation
–Sedation: midazolam
–Analgesia: fentanyl
• Local
–1% Lidocaine
–0.5% Bupivicaine on bone
• General anesthesia
–Rarely required
Procedure: Patient Monitoring
• Nursing
• Intravenous line
• Continuous monitoring
Procedure
• High quality
fluoroscopy suite
• One to two hours
• Prone position,
padded table
• Cement injected
via needles placed
percutaneously
Procedure: Needle Insertion
• Needle insertion:
unilateral or
bilateral
Procedure: Cement Mixture
• Polymer powder
• Liquid monomer
• Opacifying agent
–Barium sulfate powder
–Tungsten
–Tantalum
• Optional additive: antibiotic
powder (Tobramycin)
Procedure: Cement Injection
• Meticulous
fluoroscopic
monitoring
during the
injection process
• Liquefied cement
is injected into
the vertebral
body
Procedure: Cement Injection
• Termination of
injection
– Cement in
posterior 1/4 of
vertebral body on
lateral projection
– Cement
extending outside
vertebra
Conclusions
• Vertebroplasty is
–Safe
–Effective
• Indications
–Osteoporotic fracture
–Neoplastic fracture
–Painful neoplastic involvement
–Stabilization
Conclusions
• Vertebroplasty is a palliative
procedure and does not correct the
underlying cause of the vertebral
fracture
• Appropriate management of
osteoporosis or malignancy must
therefore be initiated and
continued
• Vertebroplasty can be combined
with other therapies
Selected References: Vertebroplasty
1.
2.
3.
4.
Fourney DR, et al. Percutaneous Vertebroplasty and
Kyphoplasty for Painful Vertebral Body Fractures in Cancer
Patients. J Neurosurg (Spine 1) 2003; 98:21-30.
Jensen ME, Kallmes DF. Percutaneous Vertebroplasty in the
Treatment of Malignant Spine Disease. Cancer J 2002; 8:194206.
Weill A, et al. Spinal Metastases: Indications for and Results of
Percutaneous Injection of Acrylic Surgical Cement. Radiology
1996; 199:241-247.
Zoarski GH, et al. Percutaneous Vertebroplasty for
Osteoporotic Compression Fractures: Quantitative Prospective
Evaluation of Long-Term Outcomes. J Vasc Interv Radiol
2002; 13:139-148.
Selected References: Kyphoplasty
1.
2.
3.
4.
5.
Dudeney S, et al. Kyphoplasty in the Treatment of Osteolytic
Vertebral Compression Fractures as a Result of Multiple
Myeloma. J Clin Onc 2002; 20:2382-2387.
Ledlie JT, Renfro M. Balloon Kyphoplasty: One-Year
Outcomes in Vertebral Body Height Restoration, Chronic Pain,
and Activity Levels. J Neurosurg:Spine 2003; 98:36-42.
Lieberman IH, et al. Initial Outcome and Efficacy of
“Kyphoplasty” in the Treatment of Painful Osteoporotic
Vertebral Compression Fractures. Spine 2001; 26:1631-1638.
Ortiz AO, et al. Kyphoplasty. Techniques in Vascular and
Interventional Radiology 2002; 5:239-249.
Phillips FM, et al. Minimally Invasive Treatments of
Osteoporotic Vertebral Compression Fractures: Vertebroplasty
and Kyphoplasty. AAOS Instruct Course Lect 2003; 52:559567.
THANKS!