Results of vertebroplastynumber Levels treated Duration of FU Pain im-proved % Complications/remarks Prospective case series Perez-Higueras [77] 13 27 60 months 12/13 2 transitory neuri
Trang 1Table 12 Results of vertebroplasty
number
Levels treated
Duration of FU Pain
im-proved (%) Complications/remarks
Prospective case series
Perez-Higueras [77] 13 27 60 months 12/13 2 transitory neuritis, local leakage 48 %,
3 adjacent fractures
insignificant
44 % of patients
Retrospective case series
(1 – 24)
86 71 % local leakage without clinical sequelae
(6 – 28)
80 fractures older than 12 months
level fracture
activity level = predictive for outcome
lapse [37] Even in older fractures, VP can still be effective [9] In patients with
severe osteoporosis and rapidly developing fractures, the reinforcement of
multi-ple levels is an efficient means to preserve posture and prevent further collapse
(Fig 4) [36] A non-union after a VBCF can occur in up to 40 % of patients [66].
In these situations cementing of the defect provides stability (Fig 6).
Vertebroplasty improves pain in about 80 – 90 %
of patients
The treatment of osteoporotic VBCF by percutaneous cement injection has
become a well established treatment option Several prospective case series have
been published and confirm a rapid and lasting pain relief in 80 – 90 % of patients
( Table 11 ) [4, 23, 36 – 38, 77] In fresh fractures the pain improvement is seen in
93 % of patients [63] But also in older lesions the treatment can be effective in as
many as 80 % of patients ( Table 12 ) [9, 48].
The scientific evidence for the superiority of vertebroplasty compared
to non-operative care
is still lacking
However, there are no randomized controlled trial (RCT) studies to compare
this treatment with conservative measures Besides the rapid pain reduction, an
important aspect of vertebroplasty is the prevention of further collapse of the VB
[36] Restoration of lordosis after a VBFC can be attempted if the fracture is still
mobile [100] This is applicable in non-unions, which can occur in up to 40 % [66]
just by placing the patient in hyperextension Furthermore, this can be achieved
in fractures that are up to 2 months old.
Pitfalls of Cement Reinforcement
Complications ( Table 13 ) related to percutaneous cement reinforcement may
occur due to:
) Positioning of the patient (fragility fractures of the rib, prone position
alone)
Trang 2Table 13 Complications reported for vertebroplasty and kyphoplasty
Rib and sternal fractures few case reports [41, 56, 64]
Technical complications pedicle fractures [21, 44]
fracture of transverse process [21]
spinal cord injury during cannula placement [26]
Infection 4 case reports [44, 88, 101, 104]
Cement leakage severe complication after pulmonary cement embolism [11,
25, 69, 93, 94, 97]
oligosymptomatic cement embolism [5, 7, 74, 79]
neurological complication [12, 53, 91, 103]
renal cement embolism [13]
cerebral cement embolization [90]
Fat embolism fatal outcome due to fat embolism [94]
Adjacent fractures increased risk after VP [6, 30, 50, 57, 98]
not significantly increased [54, 95]
) Anesthesia ) Placement of cannula ) Cement injection
The inherent problems associated with any percutaneous cement injection
tech-nique are:
) cement extravasation with compromise of neural structures ) cement embolization
Although local cement leakage is well tolerated in most cases, if cement leaks into the spinal canal, it is potentially deleterious and the resulting neural damage often irreversible Furthermore systemic reactions during cement injection can occur which might be related to the leaking of the toxic cement monomer in the blood circulation In the literature many reports of complications can be found [7, 32, 75, 81, 86, 90, 97, 99, 103].
Cement leakage into
the spinal canal is the most
serious complication
The frequency of local cement leakage in vertebroplasty is reported to be
between 3 % and 75 % [80] This wide variance depends on technique of assess-ment, i.e., radiographs are less reliable than CT [89].
In order to minimize the extravasation risk, it is strongly advocated to respect strictly the following recommendations:
) use of large diameter cannulas ) inject cement with enhanced radiopacity ) be aware of the key factor cement viscosity [8]
The surgical guidelines
must be strictly respected
The use of small syringes allows direct control of the cement flow [3] Any suspi-cious cement flow behavior must lead to immediate discontinuation of injection The filling behavior is changing with increasing viscosity – if the cement flow does not behave as expected, one should pause for 45 s and reinject a small amount of cement.
Pulmonary cement embolism is a potentially
lethal complication
Reinforcement of the osteoporotic VB means substitution of the bone marrow with cement The fatty bone marrow is expelled into the circulation and is cleared
in the lungs [94] Therefore the maximal amount of cement that is injected per
session is restricted to 25 cc; in other words not more than six levels should be
reinforced per session [36].
Trang 3Risk of Adjacent Vertebral Fractures
The risk of adjacent level fractures appears to be increased after vertebroplasty
The risk of a fracture in the adjacent levels seems to be increased after cement
rein-forcement [6, 30, 50, 98] However, the natural history of osteoporotic VBCF needs
to be taken into consideration, as the risk of a new fracture rises exponentially with
increasing number of fractures [58, 84] Therefore patients and their
post-treat-ment doctors should be informed about controlling the situation if new pain does
appear In such cases, reinforcement of the adjacent vertebrae should be performed.
Of course, during the placement of the cannula itself there is the potential risk
of an injury of the neural structures Familiarity with the spinal anatomy and
experience with open surgery is therefore mandatory The occurrence of rib
frac-tures during positioning might occur Complications associated with local
anes-thetic can occur in very rare instances.
Kyphoplasty and Lordoplasty
Kyphoplasty aims to correct kyphosis and height loss
Vertebroplasty does not per se allow the restoration of the kyphotic deformity
(unless the positioning itself provides some correction; Fig 6) VP stabilizes the
fractured vertebral body in situ Kyphoplasty was therefore promoted to restore
the VB height and correct the kyphotic deformity and realign the spine [26, 102].
Lordotic positioning
is an important component
of kyphoplasty
Height restoration and decrease in cement leakage are the main points that
dif-ferentiate this technique from vertebroplasty [70, 78] However, the potential of
kyphosis reduction appears to be moderate The absolute correction of the
kyphotic angle is reported with an average of 8.5 degrees [35, 56] without taking
into consideration the spontaneous correction due to positioning [100] ( Table 14 ).
Table 14 Comparison of kyphoplasty and lordoplasty
Kyphoplasty Lordoplasty
Average kyphosis correction 8.5° (47 %) 14° (68 %)
Based on a prospective case series [73]
Its excessive cost and more complex procedure on one hand and the improved
surgical technique in vertebroplasty by injecting high viscosity cement, with a
rate of leakage no different from that of kyphoplasty on the other hand, place a
questionmark over its usefulness Its indications are restricted to selected cases
where height loss is associated with a spinal stenosis and its restoration can
relieve the symptoms or in cases of traumatic fractures where the repositioning
of the endplate is attempted (Case Introduction) Furthermore the cavity
forma-tion might be of help in difficult indicaforma-tions for tumorous lesions [31, 35, 62, 70].
Lordoplasty is an effective alternative to kyphoplasty
Alternatively, a lordoplasty procedure can be performed Analogous to the
established principle of the “fixateur interne,” an indirect reduction maneuver is
performed [22] The vertebral bodies above and below the fracture are
instru-mented with cannulas and reinforced in a classical technique After curing of the
cement, the cannulas are used as a lever and the collapsed VB is reduced and
maintained in this position until the cement is injected and cured in the fractured
vertebra [35] This principle might be combined with a kyphoplasty procedure
and help to overcome a shortcoming of kyphoplasty, i.e., the partial loss of initial
reduction after deflation of the balloons [100] The resulting segmental kyphosis
correction was 14° on average measured one year postoperatively in a
prospec-tive series of 31 patients for the lordoplasty procedure and 8.5° for kyphoplasty
Trang 4( Table 14 ) [73] The indication for this procedure is given if a relevant kyphotic deformity is present that still has a potential for reduction.
Combined Procedures
Cases of VBCF with subsequent neural compromise due to a deformity (thoracic kyphosis) or instability (lumbar spinal stenosis, Fig 4d) are seen with increasing
frequency [33, 34, 49, 52, 72] Displaced fragments may narrow the spinal canal with subsequent compression of the myelon or nerves Due to the height loss, a foraminal narrowing may lead to nerve root compression The fact of increasing incidence of spinal stenosis per se and the high risk of osteoporotic fractures seems to boost the frequency of acute exacerbation of these groups of patients where only open surgery with decompression and stabilization can help to solve the problem [14, 40, 42, 71].
Pedicle screw fixation with
cement reinforcement
allows even fragile vertebrae to be stabilized
A surgical decompression procedure only, without stabilization, provides unsatisfactory results for this kind of problem – the decompressive measure will further compromise the mechanical stability [49, 71] Any closed measures with cement reinforcement will not relieve symptoms derived from a spinal stenosis
as long as the collapsed segment cannot be restored (see below) An open proce-dure with decompression of the spinal canal and internal fixation and fusion is
usually required However, the problem of anchoring the implants in the
osteo-porotic bone on one hand and the risk of new fractures adjacent to the stabilized part of the spine needs to be addressed Combined internal fixation with cemen-ted screws and the reinforcement of adjacent levels can help to overcome the troubles associated with these osteoporotic spines and allow the same technical principles to be applied as in healthy bone The combination of internal fixation and cement reinforcement appears extremely helpful.
Prophylactic vertebroplasty
of an adjacent vertebra
must be considered
However, in our series of 21 patients who were treated in this manner, five out
of eight who received only a cement fixation of screws showed a fracture of the adjacent vertebrae within 2 – 6 weeks after the stabilization, and needed an
exten-sion of the fixation Therefore it appears mandatory to reinforce the adjacent ver-tebrae in order to prevent this complication.
Recapitulation
Epidemiology. Osteoporotic vertebral body
com-pression fractures (VBCFs) are the hallmark of
oste-oporosis and are frequent Approximately 30 – 50 %
of women and 20 – 30 % of men will develop
verte-bral fractures during their life, and half of them will
develop multiple fractures The socioeconomic
costs of this problem are enormous.
Pathogenesis and classification. Osteoporosis is the
result of an imbalance between bone formation and
bone loss Osteoporosis can be either primary or
sec-ondary Primary osteoporosis is either
postmeno-pausal (type 1) or senile osteoporosis (type 2)
Sec-ondary osteoporosis can be due to diseases, medical
treatments, or lifestyle (diet, smoking) Osteoporosis
is defined as a bone mineral density below 2.5 SD of
the mean for a young adult reference population.
Clinical presentation. Patients who acquire a
frac-ture can be asymptomatic The cardinal symptoms
of acute osteoporotic vertebral fractures are acute, sharp girdle like pain that can be breathtaking ini-tially The pain is often misconceived as back strain and is not further diagnosed unless more severe problems occur The physical findings are almost al-ways non-specific However, neurologic assessment
is mandatory to rule out neural compromise.
Diagnostic work-up. The assessment of patients with VBCFs should include a formal evaluation of the underlying osteoporosis as a systemic disease (laboratory testing, DEXA scan) A tumorous lesion
or secondary osteoporosis must be excluded Stan-dard radiographs remain the method of choice in the diagnostic work-up An MRI scan is necessary to
Trang 5determine whether a fracture is acute or has
already healed by using a fluid-sensitive sequence
(e.g STIR) A CT scan is helpful to better assess the
fracture type and anatomy.
Non-operative treatment. Medical treatment of
the osteoporosis is mandatory after a thorough
osteologic assessment The majority of patients
with osteoporotic vertebral fractures become pain
free within a few days or weeks Bed rest for a few
days may be necessary Painkillers should be
pre-scribed Non-operative treatment means careful
follow-up of the patients Severe pain that is
persist-ing means a progression of vertebral collapse and
patients should obtain a follow-up X-ray examina-tion.
Operative treatment Vertebroplasty is the
treat-ment of choice for severely painful fractures This leads to immediate pain relief in up to 90 % of cases and prevents further collapse of the vertebrae while helping to preserve spinal alignment and bal-ance If a complex fracture is present, which means
a concomitant neurological compression and/or a
severe spinal deformity, open surgical treatment is
advocated In these cases a combination of cement reinforcement and internal fixation might be neces-sary in order to achieve sufficient stability.
Key Articles
Delmas PD ( 2002) Treatment of postmenopausal osteoporosis Lancet 359:2018–26
Excellent review on the medical treatment of osteoporosis
Hodler J, Peck D, Gilula LA ( 2003) Midterm outcome after vertebroplasty: predictive
value of technical and patient-related factors Radiology 227:662–668
This study evaluated different types of polymethylmethacrylate (PMMA) leakage and
patient-related factors in relation to clinical midterm (1 – 24 month) outcome after
verte-broplasty Standardized four-view radiographs obtained during 363 vertebroplasties in
181 treatment sessions in 152 patients were reviewed (121 patients with osteoporotic
frac-tures, 30 with malignant disease, and one with hemangioma) Four types of PMMA
leak-age and other potential predictors were related to postprocedural pain response and
mid-term outcome after vertebroplasty The mean follow-up period was 8.8 months (range
1 – 24 months) At the time of discharge after the procedure, pain was absent after 106 of
the 181 sessions (58.5 %), better after 50 (27.6 %), and the same after 25 (13.8 %) In 258 of
the 363 treated vertebral levels, at least one type of leakage was found None of the
evalu-ated factors was relevalu-ated significantly to postprocedural pain response, including PMMA
leakage The authors concluded that small to moderate amounts of PMMA may escape
from the vertebral body with no significant effect on therapeutic success Immediate
postprocedural pain relief was regarded as the best predictor of midterm clinical outcome
after vertebroplasty
Alvarez L, Alcaraz M, Perez-Higueras A, Granizo JJ, de Miguel I, Rossi RE, Quinones D
( 2006) Percutaneous vertebroplasty: functional improvement in patients with
osteopo-rotic compression fractures Spine 31:1113–8
In this prospective, double-cohort study on the outcome of vertebral compression
frac-tures, 101 consecutive patients who underwent percutaneous vertebroplasty (PV) were
compared to 27 patients who refused PV treatment and were managed conservatively
Patients elected for PV as a treatment had significantly more pain and functional
impair-ment before the procedure than the patients of the conservative group (P< 0.001) The
pain, functional, and general health scores of the PV group were improved from the
pre-operative mean values (P< 0.001) in all postpre-operative periods Compared with the
conser-vative treatment group, there was a significant difference at month 3 However, no
statis-tical differences on function were observed between these groups at 6 months and 1 year
post-treatment The authors concluded that PV demonstrated a rapid and significant
relief of pain and improved the quality of life
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Trang 10Primary Tumors of the Spine
Bruno Fuchs, Norbert Boos
Core Messages
✔ Primary spine tumors are relatively rare
✔ Cancer is a genetic disease
✔ The acquired capabilities of cancer are:
self-suf-ficiency to growth signals, insensitivity to
anti-growth signals, tissue invasion and metastasis,
limitless replicative potential, sustained
angio-genesis, evading apoptosis
✔ Spine tumors are classified based on the
histol-ogy
✔ Pain, spinal deformity, and neurologic deficits
frequently are presenting symptoms
✔ Age and location are important parameters for
establishing a differential diagnosis
✔ CT and MRI are essential for systemic and
surgi-cal staging
✔ Biopsy is required to establish the tissue diagnosis
✔ The biopsy has to be placed so that it does not
compromise subsequent surgical resection
✔ Do not rely completely on the result of the
biopsy – the final histology may be different
✔ The “wait and see” approach is very rarely
indi-cated
✔ Conservative treatment is only indicated for
benign tumors and in asymptomatic patients
✔ Malignant tumors in general are treated
surgi-cally
✔ In sensitive tumors, chemo- and radiotherapy are
considered as an adjuvant treatment
✔ The goal of surgery is to remove the primary
tumor in its entirety followed by stable recon-struction of the spine
Epidemiology
Primary spinal tumors are rare
Approximately 2 000 new cases of bone cancer and 6 000 new cases of soft tissue
tumor are diagnosed in the United States each year [30] Of these, only about 5 %
involve the spine The incidence of primary spinal tumors has been estimated at
2.5 – 8.5 per 100 000 people per year [15] Tumors of the lymphoid system, e.g.,
Plasmocytomas are tumors
of the lymphoreticular system
plasmocytoma, are generally considered in the discussion of spine tumors
although they are tumors of the lymphoreticular system Some bone tumors
have a special predilection for the vertebral column (e.g., osteoblastoma), while
others occur exclusively in the spine (e.g., chordoma) There are two important
clinical features to be considered when evaluating the potential of malignancy of
a spine lesion, i.e.:
) age
) location
In children younger than 6 years of age, most spinal tumors are malignant, e.g.:
) neuroblastoma
) astrocytoma
) sarcoma (less commonly)
However, benign spinal tumors outnumber malignant tumors by a ratio of 2 : 1
among children of all ages.