Vertebroplasty: theory and practice

Vertebroplasty was first introduced in the United States at the 1988 annual meeting of the Radiological Society of North America (RSNA). Until now, vertebroplasty is little known and only few radiologists perform this procedure but interest in and enthusiasm for vertebroplasty are growing at a surprising rate. The literature on this matter clearly shows how effective this procedure is. This technique allows significant results in pain relief and in bone strengthening. It also provides increased stability in pathological vertebral bodies. This is why we would like to share our knowledge on this procedure that we have closely examined and tested. The main goal of this paper, besides illustrating the technical aspects of vertebroplasty, is to provide anyone intending to approach this procedure with some practical tips on how to handle the technical problems that may arise when performing the procedure.     

经皮椎体成形术的常见并发症及其预防

目的 探讨经皮椎体成形术(PVP)常见的并发症及其发生机理和预防。资料与方法 对PVP术治疗中所发生的并发症进行回顾性分析，包括临床资料及CT、MRI检查。结果 PVP术治疗27例31个椎体，其中23例27个椎体在术中及术后均未见并发症发生，4例骨质疏松性压缩骨折中4个椎体在术中发生聚甲基丙烯酸甲脂(PMMA)渗漏。发生外渗的比率，按病例计算为14．8％(4／27)，按治疗的椎体数计算为12．9％(4／31)。对这4例在术后进行对症治疗并作了随访，以后患者症状基本解除。结论 PMMA的渗漏是PVP术最常见的并发症之一，少量渗漏可以不产生症状。中量渗漏可以产生症状，对症治疗后症状可以减轻。     

Percutaneous Cryoablation and Vertebroplasty: A Case Report

A 70-year-old man with a painful vertebral metastasis was treated with combined percutaneous cryoablation and vertebroplasty therapy (CVT) in one session. The patient was suffering from diffuse visceral metastasized cholangiocarcinoma. After several weeks of back pain, magnetic resonance imaging documented a single L2 bone metastasis. In consultation with the oncologists, palliative combined CVT was administered with the aim of obtaining pain relief and bone stabilization. In our experience this combined treatment is safe and effective for immediate pain relief in painful bone metastases when other standard palliative treatments have failed.     

Vertebroplasty in the mid- and upper thoracic spine

BACKGROUND AND PURPOSE: Vertebroplasty performed in the mid- and upper thoracic spine presents technical challenges that differ from those in the lower thoracic and lumbar region. We herein report results of percutaneous vertebroplasty for treatment of painful, osteoporotic compression fractures in the mid- and upper thoracic spine. METHODS: Retrospective chart review identified vertebroplasty treatments performed for painful osteoporotic compression fractures at T4-T8. The following were catalogued: percentage of vertebral body compression, needle size, surgical approach, clinical outcome, volume of cement injected, and complications. RESULTS: Sixty-three vertebral bodies were treated in 41 patients. Mean percentage of compression was 44%. Bipediculate injections were used in 12 (19%) of 63 treatment levels, and unipediculate injections were used in 51 (81%) of treatments (75 injections performed). Eleven-gauge needles were used for 55 (73%) of the 75 injections, and 13-gauge needles were used for 20 (27%). Clinical follow-up was available for 76% of the patients. Mean pre- and postoperative pain intensity was 9.7 +/- 1.0 and 1.7 +/- 1.9, respectively (P <.0001). Mean pre- and postoperative medication scores were 3.4 +/- 0.7 and 1.7 +/- 1.7, respectively (P =.075). Fracture involving the pedicle used for needle access was noted in one (1.3%) of 75 injections; this pedicle had been traversed using a 13-gauge needle. Staphylococcus epidermidis infection occurred in one case. No cases of pneumothorax were noted. CONCLUSION: Transpedicular vertebroplasty is readily and safely performed using 11-gauge needles in the mid- and upper thoracic regions, yielding excellent pain relief and low complication rates.     

Vertebroplasty in the United States: guidance method and provider distribution, 2001-2003

PURPOSE: To use the nationwide Medicare database to retrospectively evaluate the provider distribution for vertebroplasty, as well as the guidance method used in the United States. MATERIALS AND METHODS: Use of the Medicare database was exempt from Institutional Review Board review and informed consent; regarding HIPAA compliance, the Medicare database lacks unique patient identifiers. Using the 2001, 2002, and 2003 United States Medicare part B claims database, the authors studied CPT-4 (Current Procedural Terminology, fourth edition) procedure codes used for vertebroplasty procedures, including thoracic and lumbar vertebroplasty (22520 and 22521, respectively), treatment of additional levels (22522), and method of radiologic guidance (fluoroscopy, 76012; CT, 76013). For each of these codes, volume and physician specialty participation were tabulated. RESULTS: In 2001, 14 152 vertebroplasty procedures were reimbursed through Medicare. In 2003, the volume increased to 24 558 (+73.5%). In 2001 radiologists performed the majority (9864, 69.7%) of these procedures. The minority were performed by other specialists, mainly orthopedic surgeons (1792, 12.7%), neurosurgeons (1037, 7.3%) and anesthesiologists (736, 5.2%). In 2003, radiologists performed 86.8% more vertebroplasties than in 2001, and participation increased to 75.0% of the total. Radiologists had the greatest increase of all specialties from 2001 to 2003 (+86.8% vs: orthopedic surgery, +58.3%; neurosurgery, +55.7%; other, +46.6%; physiatry, +32.1%; neurology, +15.5%; anesthesiology, -11.8%). From 2001 to 2003, the number of additional levels treated by each of the three highest-volume specialties decreased (radiology, 23.0% to 20.8%; orthopedic surgery, 36.3% to 27.5%; neurosurgery, 28.2% to 27.0%). As a guidance method, fluoroscopy is used almost exclusively (98.7% in 2003). CONCLUSION: Radiologists performed the majority of Medicare-reimbursed vertebroplasty procedures in the United States in 2001-2003. Fluoroscopy is nearly universal as a guidance method.     

Vertebroplasty, first 1000 levels of a single center: evaluation of the outcomes and complications

BACKGROUND AND PURPOSE: Percutaneous polymethylmethacrylate (PMMA) vertebroplasty has become a common procedure for treatment of pain and disability associated with vertebral compression fractures. We reviewed the experience with our first 1000 consecutively treated vertebral compression fractures in an attempt to demonstrate both the short- and long-term safety and efficacy of percutaneous vertebroplasty. MATERIALS AND METHODS: The first 1000 compression fractures treated by vertebroplasty at our institution were identified from a comprehensive prospectively acquired vertebroplasty data base. All patients treated with vertebroplasty were included, regardless of the underlying pathologic cause. Chart reviews of the procedure notes, imaging studies, clinical visits, and follow-up telephone interviews were performed for each patient. Evaluation at each follow-up time point included pain response (subjective and visual analog pain score), change in mobility, change in pain medication usage, and modified Roland-Morris Disability Questionnaire. Statistical analysis was performed on the pain response and change in the Roland-Morris score at each follow-up time point. Significant procedure-related complications that occurred from the time of the procedure were also specifically extracted from the patients' charts. RESULTS: There was a dramatic improvement in all the evaluated parameters following percutaneous vertebroplasty. The improvement in pain, mobility, medication usage, and Roland-Morris score was noticed immediately after the procedure and persisted through the 2-year follow-up. There was a low rate of complications from the procedure, the most common being rib fractures. CONCLUSION: According to our results, practitioners can quote a high success rate and low complication rate for vertebroplasty when making treatment recommendations for painful spinal compression fractures.     

Carbon Dioxide and Gadopentetate Dimeglumine Venography to Guide Percutaneous Vertebroplasty

Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) is an effective procedure for relieving pain due to vertebral body compression fractures. The technique employs iodinated contrast venography to exclude needle placement directly within the basivertebral complex. We present two cases in which carbon dioxide (CO₂) and gadopentetate dimeglumine venography was used to guide percutaneous vertebroplasty in patients with a contraindication to iodinated contrast.     

经皮椎体成形术治疗骨质疏松椎体压缩骨折的综合疗效评价

目的 前瞻性评估经皮椎体成形术(PVP)治疗骨质疏松性椎体压缩骨折患者的生活质量及无症状骨水泥渗漏是否影响远期疗效.资料与方法 用视觉模拟评分法(VAS)、生活自理能力表(ADL)和下腰部活动障碍表(OLBPDQ)前瞻性评价疼痛性椎体压缩骨折126例PVP治疗术前及术后不同时期的综合疗效.结果 平均随访9.9个月(3～24个月),获得完整随访资料有72例.术前、术后1天、1个月、3个月、6个月及1年以上随访时VAS分别为8.53±0.85、3.22±1.20、3.06±1.02、2.06±0.98、1.61±0.85及1.24±0.85,术后1天VAS平均下降了5.31;Barthel指数术前、术后1周、1个月、3个月、6个月及1年以上分别为40.5±16.9、69.4±22.3、78.5 ±20.6、87.3±15.1、91.7±9.7、93.0±7.9,术后1周较术前提高了28.9(71%);ODI指数术前、术后1周、1个月、3个月、6个月及1年以上分别为33.81±5.54、20.90±5.31、16.90±4.78、12.11±6.41、9.71±4.82、8.69±4.81,术后1周较术前下降了12.91(38%).术后CT证实骨水泥在椎旁少量渗漏共有12例18节,其各随访时点VAS、ADL及ODI总分分别与无渗漏的60例同期比较均无显著性差异(P>0.5).结论 PVP治疗疼痛性骨质疏松椎体压缩骨折可迅速缓解患者疼痛和提高生活质量,而且疗效可保持长期稳定;无症状骨水泥渗漏对患者生命质量无影响.     

围手术期护理干预对经皮椎体成形术患者的临床分析

目的：围手术期护理干预对经皮椎体成形术患者的影响。方法选取2013年1月～2014年5月骨科接受了经皮椎体成形术46例患者作为研究对象,通过围手术期的护理干预对提高患者手术前后的生活质量进行观察分析。结果病例顺利完成手术,手术疗效显著,无并发症发生,康复出院。结论围手术期护理干预对老年经皮椎体成形患者手术成功及术后早日康复有着明显效果。     

椎体成形术缓解疼痛和稳定脊柱的影像和临床评价

目的:探讨经皮穿刺椎体成形术治疗脊柱病变对缓解疼痛和稳定脊柱的价值.材料和方法:对45例共62个椎体行经皮穿刺椎体成形术,其中血管瘤4例4个椎体、骨质疏松7例13个椎体、椎体恶性肿瘤34例46个椎体.经CT扫描定位,将不透X线骨水泥(主要成分为粉剂甲基丙烯酸树脂多聚体和液态甲基丙烯酸树脂单体)按粉剂与液体为4:1比例混合调制成糊状,用1ml注射器匀速缓慢注入病变椎体.结果:本组完全缓解(CR)率77.78%,部分缓解(PR)率17.78%,有效率为95.56%.其中7例骨质疏松症所致压缩性骨折者获CR4例,PR3例;4例血管瘤患者3例获CR,1例获PR;34例恶性瘤中28例获CR,4例获PR.止痛作用2周至18个月持续有效.CT和平片随访观察骨水泥密度、形态与术后所见无变化,未见椎体进一步压缩.结论:经皮穿刺椎体成形术适用于椎体血管瘤、骨质疏松、转移瘤等溶骨性病变,具有稳定脊柱和减轻疼痛的作用.     

Clinical Outcome and Safety of Multilevel Vertebroplasty: Clinical Experience and Results

Purpose

To compare safety and efficacy of percutaneous vertebroplasty (PVP) when treating up to three vertebrae or more than three vertebrae per session.

Materials and Methods

We prospectively compared two groups of patients with symptomatic vertebral fractures who had no significant response to conservative therapy. Pathologic substrate included osteoporosis (n = 77), metastasis (n = 24), multiple myeloma (n = 13), hemangioma (n = 15), and lymphoma (n = 1). Group A patients (n = 94) underwent PVP of up to three treated vertebrae (n = 188). Group B patients (n = 36) underwent PVP with more than three treated vertebrae per session (n = 220). Decreased pain and improved mobility were recorded the day after surgery and at 12 and 24 months after surgery per clinical evaluation and the use of numeric visual scales (NVS): the Greek Brief Pain Inventory, a linear analogue self-assessment questionnaire, and a World Health Organization questionnaire.

Results

Group A presented with a mean pain score of 7.9 ± 1.1 NVS units before PVP, which decreased to 2.1 ± 1.6, 2.0 ± 1.5 and 2.0 ± 1.5 NVS units the day after surgery and at 12 and 24 months after surgery, respectively. Group B presented with a mean pain score of 8.1 ± 1.3 NVS units before PVP, which decreased to 2.2 ± 1.3, 2.0 ± 1.5, and 2.1 ± 1.6 NVS units the day after surgery and at 12 and 24 months after surgery, respectively. Overall pain decrease and mobility improvement throughout the follow-up period presented no statistical significance neither between the two groups nor between different underlying aetiology. Reported cement leakages presented no statistical significance between the two groups (p = 0.365).

Conclusion

PVP is an efficient and safe technique for symptomatic vertebral fractures independently of the vertebrae number treated per session.     

经皮椎体成形术治疗椎体骨髓瘤(6例分析)

目的:评价经皮椎体成形术(PVP)治疗多发性骨髓瘤椎体病变的临床疗效,探讨该技术能否作为多发性骨髓瘤椎体病变常规治疗手段。方法:回顾性分析6例多发性脊髓瘤患者共19个椎体(胸椎10个、腰椎9个)在DSA监视下行PVP术的术后疗效,其中5个椎体已发生压缩性骨折。采用视觉模拟评分方法(VAS)评价患者术前和术后的疼痛情况,并采用配对t检验对所得数据进行统计学分析。结果:所有患者手术均获成功,在术后第一天疼痛缓解不显著(P>0.05),术后一周疼痛缓解显著(P<0.05)。5个椎体发生椎旁渗漏,2个椎体发生下椎间盘渗漏,1个椎体发生硬膜外渗漏,但无明显临床症状。术后3个月所有患者平片复查均未见手术椎体发生压缩性骨折或进一步塌陷(术前已发生压缩性骨折的)。结论:经皮椎体成形术是治疗椎体骨髓瘤的有效方法,创伤小且安全可靠,可以考虑作为多发性骨髓瘤椎体病变的常规治疗手段。     

Chordoma of the Lumbar Spine Presenting as Sciatica and Treated with Vertebroplasty

The lumbar spine is a less common location for chordoma. Here we describe a 44-year-old woman presenting with pain due to a L4 vertebral expansile lesion that caused significant canal stenosis and neural foraminal compromise. Vertebroplasty was performed and resulted in immediate pain relief. For patients with painful lumbar chordoma who are unwilling to undergo surgery, vertebroplasty can play a palliative role as in patients with other vertebral lesions. Treating pain and stabilizing vertebra by way of vertebroplasty in a case of chordoma has not yet been reported.     

经皮椎体成形术:手术操作技术与相关问题

本文以作者自己的研究和经验为基础，系统地介绍经皮椎体成形术（PVP）的发展历史和现状，重点对这一技术的手术操作技术作了详细的叙述，并对PVP的适应证与禁忌证、PVP的充填材料、临床疗效及并发症等相关问题进行介绍和讨论。作者认为：PVP可有效地解除椎体肿瘤或骨质疏松症椎体压缩骨折患者的痛苦，提高和改善生活质量，延长生存时间，为一技术操作较简单和实用性极强的介入技术。但是，必须指出：只有熟练掌握PVP的穿刺定位技术，熟悉骨水泥的性状和使用方法才能保证这一技术安全和有效地开展。