Published online November 20, 2002, 10.1148/rg.e10
(Radiographics. 2003;23:e10-e10.)
© RSNA, 2003
Percutaneous Vertebroplasty: Indications, Technique, and Results1
Afshin Gangi, MD, PhD,
Stephane Guth, MD,
Jean Pierre Imbert, MD,
Horia Marin, MD and
Jean-Louis Dietemann, MD
1 From the Department of Radiology, University Louis Pasteur, Strasbourg, France. Presented as a scientific exhibit at the 2001 RSNA scientific assembly. Received April 15, 2002, revision requested June 11, revision received and accepted October 13. Address correspondence to S.G., 194 route de Lyon, 67400 Illkirch, France (e-mail: guth.stephane.str@evc.net).
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Abstract
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The authors describe a dedicated therapeutic vertebroplasty technique that uses newly designed instruments, acrylic cement, and dual guidance with ultrasonography and computed tomography for pain control in patients with bone failure, and report their experience. Between 1990 and 2002, they performed 868 percutaneous cementoplasty procedures in patients with severe osteoporosis, vertebral tumors, and symptomatic hemangiomas. In patients with osteoporosis, satisfactory results were obtained in 78% of cases; in patients with vertebral tumors, satisfactory results were obtained in 83% of cases; and in patients with hemangiomas, satisfactory results were obtained in 73% of cases. In the global series of 868 cementoplasties, an epidural leak was observed in 15 cases, which caused neuralgia in only three patients without spinal cord compression. In two patients, an asymptomatic pulmonary embolism was detected. The needle of the new vertebroplasty set is designed with side wings for easier rotation and removal. The screw syringe increases the precision of injection. The risk of leak is substantially reduced. The system is safe, reduces the cement manipulation time, and allows excellent control of the injection. The authors performed 130 vertebroplasties with this system without major complications.
© RSNA, 2002
Index Terms: Computed tomography (CT), guidance, 30.1211 • Fluoroscopy Osteoporosis, 30.56 • Spine, fixation devices, 30.1267, 30.1296 • Spine, hemorrhage, 30.367 • Spine, interventional procedures, 30.1267, 30.1296 • Spine, primary neoplasms, 30.32 • Spine, secondary neoplasms, 30.33
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Introduction
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Percutaneous cementoplasty (also known as vertebral packing or vertebroplasty) with acrylic cement (polymethylmethacrylate [PMMA]) is a procedure aimed at preventing vertebral body collapse and pain in patients with pathologic vertebral bodies. Percutaneous cementoplasty is a promising therapeutic technique for pain control in patients with bone failure. The first percutaneous cementoplasty was performed by Deramond et al, who originated the method in 1984 (1). Since that time, the interest in percutaneous cementoplasty has grown and many technical improvements have been made. Percutaneous cementoplasty has become an accepted procedure and the number of cases published is increasing (2,3)
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Principle
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The analgesic effect of cement cannot be explained by the consolidation of pathologic bone alone (Fig 1). In fact, good pain relief is obtained after injection of only 2 mL of PMMA in metastases. In these cases, the consolidation effect is minimal. The methylmethacrylate is cytotoxic because of its chemical and thermal effects during polymerization. The temperature during polymerization is high enough to produce coagulation of tumoral cells. Therefore, good pain relief can be obtained with a small volume of cement.
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Figure 1a. Drawings in (a) sagittal and (b) axial views demonstrate the principle of percutaneous cementoplasty at the lumbar level, showing vertebral puncture via the posterolateral route and vertebral filling.
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Figure 1b. Drawings in (a) sagittal and (b) axial views demonstrate the principle of percutaneous cementoplasty at the lumbar level, showing vertebral puncture via the posterolateral route and vertebral filling.
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Indications and Contraindications
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Indications for Injection of PMMA
- Symptomatic vertebral angioma.
- Painful vertebral body tumors and acetabular tumors. In cancer patients, percutaneous cementoplasty is used particularly in symptomatic treatment of osteolytic bone metastases and myeloma. As vertebroplasty is intended only to treat pain and consolidate the weight-bearing bone, other specific tumor therapy should be given in conjunction when appropriate. The use of PMMA is reserved for weight-bearing bone because of the consolidation effect. In other locations, pain can be treated with alcohol or thermoablation techniques.
- Severe painful osteoporosis with loss of height and/or with compression fractures of vertebral bodies (2–17). Painful compression fractures in patients with osteoporosis refractory to conservative therapy are excellent indications for vertebroplasty. The ideal candidate for vertebroplasty presents within 4 months of fracture and has midline, nonradiating back pain that increases with weight bearing and can be exacerbated by manual palpation of the spinous process of the involved vertebra. However, many patients have multiple fractures and lack sufficient imaging studies to document the age of some or all of the fractures. Others have several adjacent fractures in which it is difficult to determine, by physical examination, the fracture that is symptomatic. In such instances, magnetic resonance (MR) imaging is helpful, with edema within the marrow space of the vertebral body best visualized on sagittal T2-weighted images. Bone scans can be used to help differentiate the symptomatic level from incidentally discovered fractures.
Contraindications
- Hemorrhagic diathesis.
- Infection.
- Lesions with epidural extension. These require careful injection to prevent epidural overflow and spinal cord compression by the cement or displaced epidural tissue.
The absolute contraindications are hemorrhagic diathesis and infection. Patients with more than five metastases or diffuse metastases are not candidates for vertebroplasty. We have never used this technique in children or adolescents.
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Materials and Methods
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Overview
The procedure is performed with the patient under local anesthesia usually combined with neuroleptanalgesia. The patient is placed in the prone position for the lumbar and thoracic levels and in the supine position for the cervical level. A 15-gauge needle is used for cervical vertebrae and a 10-gauge needle for thoracic and lumbar vertebrae. We use dual-guidance computed tomography (CT) and C-arm fluoroscopy or biplane fluoroscopy. The entry point and the pathway, avoiding the nerve root and visceral structures, are determined with CT. The needle is safely guided under CT or biplane fluoroscopy.
Once the needle is in the optimal position, the imaging mode is switched to fluoroscopy. The acrylic cement mixed with tantalum (to increase radiopacity) has to be injected during its pasty polymerization phase to prevent distal venous migration (Fig 2). The injection of cement is carefully controlled under strict lateral fluoroscopy. The injection of cement is stopped whenever epidural or paravertebral opacification is observed or when the cement reaches the dorsal quarter of the vertebral body.
Sequence of Operations
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Complications
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- The most serious complication is a cement leak.
- The second most serious complication is infection. Strict sterility during the intervention is mandatory.
- Temporary pain can occur after the procedure. Patients are usually free of pain after 24 hours. Postprocedural pain is usually proportional to the volume of cement injected. Most of these patients have good packing of the vertebral body with more than 4 mL of cement injected.
- Allergic reactions and hypertension are limited in these procedures because the quantity of cement injected in percutaneous cementoplasty is far less than that used in orthopedic surgery.
Cement Leaks
- Cement leaks (Figs 3–7) toward the epidural veins, epidural space, and neural foramina can occur. The most serious complication during cement injection is epidural overflow of PMMA with spinal cord compression. This risk is minimized by monitoring the bone filling with a high-quality fluoroscopic unit and by having adequate radiopacity (tantalum) in the cement. Radiculopathy is the major risk with neural foramina leaks. In our series, three instances of a neural foramina leak occurred immediately after cementoplasty: the filling of an epidural vein and neural foramina, causing intercostal neuralgia. This complication can be successfully treated with a series of intercostal steroid infiltrations. In cases of severe complications, orthopedic or neurosurgical support should be available. Epidural vein filling does not necessarily cause neuralgia.
- Cement leaks toward the disk usually do not have clinical consequence; however, these leaks may increase the risk of adjacent vertebral collapse.
- Leak into paravertebral veins can lead to pulmonary cement embolism. In our series, an asymptomatic pulmonary embolism was detected in two cases. In both cases, paravertebral venous opacification was observed. To avoid major pulmonary infarction, the cement should be injected slowly under fluoroscopic control during its pasty polymerization phase, and the injection should be immediately stopped if a venous leak is observed.
- Cement leaks into paravertebral soft tissues have no clinical significance.
- In one case, the control CT scan showed a leak of cement into an intercostal artery. This leak was asymptomatic.
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Results and Discussion
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Between 1990 and 2002, 868 percutaneous cementoplasty interventions in patients ranging in age from 25 to 86 years were performed at our institution. Indications were severe painful osteoporosis, vertebral tumors, and symptomatic hemangiomas. Detailed results are available on our Web site (http://www-ulpmed.u-strasbg.fr/irws/index.html). The average volume of cement injected was 2.8 mL (range, 1.8–6.5 mL). The analgesic effect ocurred within 6–48 hours after the procedure. The results were evaluated according to the reduction of opiate analgesic doses required. In patients with osteoporosis, satisfactory results were obtained in 78% of cases; in patients with vertebral tumors, satisfactory results were obtained in 83% of cases; and in patients with hemangiomas, satisfactory results were obtained in 73% of cases. Other studies agree that percutaneous cementoplasty is a safe and effective technique (2,3,6,9,20).
Percutaneous cementoplasty is a successful technique for pain management and consolidation of pathologic vertebral bodies. The most critical elements for successful vertebroplasty are proper patient selection, correct needle placement, good timing of cement injection, strict fluoroscopic control of injection, and operator's experience. The good pain relief obtained with this technique is not correlated with the volume of cement injected, especially in metastases, where 1.5 mL of cement is usually enough to considerably reduce the patient's pain.
In the global series of 868 cementoplasties, an epidural leak was observed in 15 cases and this caused neuralgia in only three cases, without spinal cord compression. Spinal cord compression is an emergency, and urgent surgery is mandatory to prevent neurologic complications. The injection of acrylic cement should be performed under a high-quality fluoroscopic unit. The injection should be immediately interrupted if the cement reaches the posterior cortex of the vertebral body. Adequate radiopacity of acrylic cement (with the addition of tantalum, barium, or tungsten) is mandatory, and the cement should be injected during its pasty polymerization phase.
Radiculopathy is the major risk with neural foramina leaks. Radiculopathy is particularly difficult to treat at the cervical and lumbar levels. Epidural vein filling does not necessarily cause neuralgia. Significant cement leaks toward the disk were observed in 15 cases; however, these leaks were without clinical consequence, although the risk of adjacent vertebral collapse is increased.
In two cases, an asymptomatic pulmonary embolism was detected. In both cases, paravertebral venous opacification was observed. To prevent major pulmonary infarction, the cement should be injected slowly during its pasty polymerization phase under fluoroscopic control and the injection should be immediately stopped if a venous leak is observed.
In one case, hardening of the cement prevented the reinsertion of the stylet of the needle. After the needle was pulled out, a paravertebral cement leak was detected. Two days later, the cement fragment was extracted percutaneously. The stylet should be repositioned before removal of the needle whenever possible. If the stylet cannot not be reinserted, the needle is removed under fluoroscopic control to allow detection of leaks.
In another case, an asymptomatic intercostal artery injection occurred during vertebroplasty of a hypervascularized breast cancer metastasis. Therefore, hypervascularized lesions should be evaluated by means of phlebography in anteroposterior and lateral views before cementoplasty, particularly in dorsolumbar regions (T11–L1).
Additional references: 21–36.
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Footnotes
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Abbreviations: PMMA = polymethylmethacrylate.
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References
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Abstract
Introduction
