osteoporotic compression fracture and percutaneous vertrebroplasty dr.sandeep c agrawal agrasen...

Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!

Osteoporotic Compression Fracture And Percutaneous Vertebroplasty

Loss of body Height Kyphotic deformity

Dr.Sandeep Agrawal Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital Gondia

Maharashtra

India

www.agrasenortho.com

[email protected]


Osteoporotic Compression Fracture

1.Most can be treated by bed rest, brace, and analgesics

!2.Rarely surgically treated –

High complications rate by implant fixation

!3.Alternative - Minimally Invasive

Method


Percutaneous Vertebroplasty

●Deramond 1984 – Vertebra Hemangioma


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Vertebral Compression Fracture Thoracic: wedge by kyphotic loading

!Lumbar: central endplate cupping

!!

MRI: high sensitivity Bone scan

Sagittal reconstructed CT images


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Imaging guided percutaneous spine intervention.

!For painful benign or malignant, pathologic

vertebral fracture.

Vertebroplasty


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Confirmed by X-ray & MRI !

Pain corresponding to level of the fracture !

Unresponsive to conservative treatment

Patient Selection Criteria


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Contraindications

Uncorrected coagulopathy !

Infection – local or systemic !

Moderate or severe retropulsion of posterior vertebral body cortex into spinal cord

!Vertebra plana: Height loss > 80%


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Procedures

General or local anesthesia !

Prone position (posture reduction) !

Unilateral or bilateral transpedicular approach under fluroscopic control

!Cement - barium sulfate mixture


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Introduction (Percutaneous vertebroplasty )

Galibert and Deramond in 1987 ( vertebral angioma )!

Lapras in 1989 ( osteoporotic compression fracture )!

Decreasing the pain and improving the function !

Benefit from this procedure is uncertain


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Procedure

Route chosen !Cement leakage !

Nonevident!Epidural plexus!

Lumbar venous plexus!Adjacent disc!

Epidural space !Postprocedural complications


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Radiologic

Number of vertebral levels !!

Percentage loss of vertebral height !Distance (endplate to endplate) at center of vertebral body !

!Height of vertebra above fractured vertebra =>!

! Estimation of the prefracture height !

Height lost = (fractured height/estimated prefractured height) × 100


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Radiologic

Location of the vertebral level !T spine :T1 - T10!

TL junction : T11 - L2! L spine : L3 - L5 !

Type of deformity (wedge, biconcave, or compression) and osteonecrosis


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Height loss associated with unfavorable result!

71.4% in vertebrae with a height loss higher than 70%


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Leakage into disc associated with worse result


Imaging Guided Percutaneous Spine Intervention.

!New Treatment for Painful Benign or

Malignant Vertebral Compression Fracture



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85 year male, low back pain after trauma for one year

L1 compression Fracture


T12 compression Fracture with nonunion


74 Year female, T11 T12 L1 Multiple Compression Fractures



Minimal invasive method Stabilize the fracture vertebra Dramatic Decreased back pain => Improved life quality


Pain Relief in Vertebroplasty

Prevention of micromotion !

Mechanical stabilization !

Monomer cytotoxicity or exothermic reaction

- Thomas A. Einhorn. Spine vol 25. no. 9 -


Complications of Vertebroplasty

Cement leakage Adjacent new compression fracture

Pulmonary embolism Infection

● Subcutaneous hematoma

● Neurological deficit


Cement Leakage

34~75% Not generally lead to complications

Possible paraplegia ! ! ! ! ! ! ! - OKU 7 -


Pulmonary Embolism


Increase Fracture Risk at Adjacent Vertebrae

Additional new fractures within one year - 15 %

(46/300 patients)!Garfin et al, Eurospine 2001


Risks for Adjacent Fracture

Adjacent fracture is not associated with age, sex,

fracture level, bone mineral density, cement volume and

kyphotic angle.

- Chen APOA 2004


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Adjacent level fracture


Adjacent Fracture After Vertebroplasty

Natural course of disease Provoked by an adjacent rigid

reinforcement.

Mechanism : Combination of the underlying condition , osteoporosis , neoplastic disease , hard cement in the disc , increased activities after vertebroplasty


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Vertebroplasty : Cement Leakage into the Disc Increases the Risk of New Fracture of Adjacent

Vertebral Body

AJNR Am J Neuroradiology 25 , February 2004

Edward P.Lin, Sven Ekholm, Akio Hiwatashi, and Per-Lennart Westesson Department of Radiology, Division of Diagnostic & Interventional

Neuroradiology , University of Rochester Medical Center, Rochester , New York

Mechanism : Combination of the underlying condition ,

osteoporosis , neoplastic disease , hard cement in the disc , increased activities after

vertebroplasty


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Discussion

The amount of cement injected during vertebroplasty The amount of cement that leaked into the disc

The incidence of new fractures

Require further studies


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DiscussionWe should attempt to reduce the incidence and the

amount of cement leakage into the disc during vertebropalsty :

! The needle tip location – laterally , not centrally

The consistency of the cement – more viscous

The volume of cement injected – smaller volume

Stopping injection when detecting leakage into disc , resumed after cement slightly hardened


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DiscussionSupplementary Vertebroplasty +

Posterior instrumentation and P-L fusionAvoid anterior procedures Provide sufficient axial loading of vertebral bodyPrevent implants failure



Efficacious (but not a risk free) in pain reduction (86%) for painful

osteoporotic spine fracture Skillful techniques and careful safeguards can minimize the

complications


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DiscussionPercentage of excellent results decrease in > 70% loss of

vertebral height!!

Difficult technically!!

High incidence of disc leakages!!

Complete relief ＜ 30% (29.6%) of the patients !!

Progression of the fracture is evident => PV!!

Fracture remains stable => keep conservative treatment


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Discussion

Involvement of > 2 segments was associated with worse outcome!

!

Disseminated disease and multiple level fractures are less likely to be free

of pain after a PV


Conclusions

Appropriate patient selection is essential for achieving

clinical success Back pain is correlated to

image study esp. MRI


Conclusions

Better results can be expected in patients with an ASA score of I and the vertebral body height loss is less than 70%.


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Have Fun!!!

In our busy daily lives, most of us have! forgotten one of the bare essentials of!

a happy life - having fun!!!!

Be silly. Crack jokes. Laugh. Be mischievous.! Let your hair down. Leave your troubles!

behind. Play hard. Just play.! Enjoy yourself.!

!!

We are always so busy walking and running! in our lives, we forget. We forget to stop!

and dance!!

osteoporotic compression fracture and percutaneous vertrebroplasty dr.sandeep c agrawal agrasen...

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