Technical Aspects of Percutaneous Vertebroplasty

1
Technical Aspects of Percutaneous Vertebroplasty
Dr. Cosme Argerich Neurosurgeon
2
History

• 1987 First description by Galibert and Deramond.
• 1995 First procedure in Geneva (Switzerland).
• 1997 First reported procedure in USA.

3
Schools

• European
• 38 methastases
• 31 Hemangiomas / Myelomas
• 31 Osteoporosis

• North American
• 70 Osteoporosis
• 17 Hemangiomas / Myelomas
• 13 Methastases

4
DemographyUSA

• 10 Million cases of Osteoporosis (45 white
  female gt 50 years).
• 700 thousand vertebral fractures / year.
• 150 thousand hospital admissions / year.
• Total direct costs U 13.800 Millions.
• Estimated costs in 2030 60.000 Millions.

5
Diagnostic Sequence
6
(No Transcript)
7
(No Transcript)
8
Indications for PV

• Pain / instability in
• Osteoporotic collapse.
• Sub-acute traumatic collapse.
• Malignant vertebral tumors (Metastasis / Myeloma)
• Vertebral angiomas

9
Osteoporosis

• Intense and persistent post fractural pain 1 to
  12 weeks evolution.
• Pain focused on spinal mid-line, related to
  diagnosed vertebral collapse.
• Absence / poor response to medical therapy
  (Alendronate, Calcium, Opiates).
• Quality of Life impairment due to opiates side
  effects.

10
Osteoporosis
STIR increased signal suggesting recent fracture.
T1 signal reduction in D 12.
11
Tumors

• High risk of vertebral collapse.
• Intractable pain.
• Marked side effects to opiates blurred vision,
  bladder / bowel disorders, confinement to bed
  rest.
• Palliative treatment in terminal patients.

12
Malignant Tumors
C increased signal
T1 signal reduction in vertebral body and
posterior elements
13
Note that

• Most of skeletal metastasis occur in spine.
• Up to 10 of cancer patients present symptomatic
  spine metastasis.
• Course of local disease may be painful and
  invalidating.

14
General Exclusion Criteria

• Local / systemic infection.
• Recent fracture of posterior vertebral wall.
• Coagulation disorders.
• Poor general conditions.
• Vertebral collapse gt 80 90.

15
Particular Exclusion Criteria

• Osteoporosis.
• Adequate response to medical treatment.
• Lack of radiological progression of fracture.

• Cancer
• Advanced systemic disease.
• Progression to spinal channel.

16
Vertebral Approaches(will vary according to
surgeons specialty and experience)

• Cervical Spine Anterior.
• Dorsal Spine Transpedicular.
• Lumbar Spine Transpedicular.
• Lateral.

17
Alternative Approaches

• Latero-transpedicular.
• Latero-antepedicular.
• Laterovertebral.

18
Equipment
19
Fixed C Arm
Advantages Better image quality Easier operation
Disadvantages High operational costs Use subject
to availability
20
Mobile C Arm
Advantages Low operational costs Availability
Disadvantages Lesser image quality More
difficult operation
21

• Immediate access to
• CT Scan and / or RMI.
• ICU.
• Operating Room.
• Must be available for the treatment of potential
  complications

22
Anestesia
Election will depend on surgeons experience and
characteristics of patient.
23
Intraoperative Monitoring

• EKG.
• O2 Saturation (early diagnosis of pleural
  lesion).
• Pressurometry (occasional vagal raction).
• During Local Anesthesia, Oxygen mask will provide
  sensation of comfort to patient.

24
Main advantages of Local Anesthesia

• Allows the surgeon to communicate with the
  patient.
• Benefits
• Early diagnosis of lesions (radicular / pleural)
  which might not be diagnosed otherwise.
• Determine cement injection speed.
• Anticipate corrective measures.
• Abort the procedure.

25
Video(Actual Procedure under Local Anesthesia)
26
Conclusions

• PV is a Minimally Invasive Procedure.
• Surgical Technique may be acquired in a short
  time.
• PV may be performed on outpatients.
• Excellent tolerance to Local Anesthesia.
• May be combined with instrumental arthrodesis of
  the spine.
• Short and Long Term results are encouraging.