Diapositiva 1

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VERTEBROPLASTY / KYPHOPLASTY State of the
art Advances in biomechanical research Current
and new indications for vertobroplasty and
kyphoplasty Dr. Joan Serra Unitat
dintervencionisme Percutani (CRC UDIP) Long term
experience with vertebroplasty Treatment of
Complications of vertebroplasty and kyphoplasty
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FREQUENCY OF VERTEBRAL FRACTURE

• The risk of osteoporotic fracture is high.
• The most frequently fractured bones in
  osteoporotic patients are firstly vertebrae,
  then proximal femur, distal radius and
  finally proximal humerous.
• The incidence of vertebral osteoporotic
  fractures (VCF) increases wth age, being more
  frequent in women. 25 of women aged upper 50 are
  affected by the fractures and 40 of them aged
  80-85.
• 60 are silent.
• The most important consideration in VCF is its
  effect on the quality of life.

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MORTALITY RATE ASSOCIATED TO VCF

• Mortality rate increases 15-30 in patients
  with osteoporotic vertebral compression
  fractures.
• Mortality rate increases with number of
  fractured vertebral levels, either symptomatic
  or not.

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MANAGEMENT OF PAIN IN VCF

• The management of pain in VCF can be difficult.
• The management of pain starts with conservative
  therapy including bedrest and pharmacologic
  therapy, physical rehabilitation and nerve
  blocks.
• When these therapies fail we can proceed to more
  agressive treatments such as VP, KP or even
  surgery.

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VERTEBRAL TUMORAL INFILTRATION

• Metastasis account for 70 of all spinal tumors
  (mostly in lumbar zone).
• Paliative treatment has known complications.
• Radiotherapy provides significant pain relief but
  limited spinal stabilization.
• The pain in collapsed vertebra due to a tumoral
  infiltration and in cases of agressive
  hemangyoma, can also be very difficult to
  treate, even more than in VCF.
• VP and KP are very effective treatments in such
  patients and safe indeed when practiced by
  experienced hands.

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AIMS OF THEVERTEBROPLASTY (VP) ANDKYPHOPLASTY
(KP)

• Pain relief.
• Spine stabilization.
• Restore lost volume (KP).

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Courtesy of James Hamada, M.D., Torrance, CA
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INDICATIONS FOR VP AND KP.

• Osteoporotic vertebral compression fractures.
• Kümmell disease.
• Tumor infiltration (metastasis, myeloma).
• Painful or agressive vertebral hemangyoma.
• Symptomatic sacral insufficiency or pathologic
  fractures can be candidates for a
  sacroplasty.
• Traumatic vertebral fracture (in usa
  currently not indicated in young non-
  osteoporotic patients).
• () A. Orlando Ortiz. Abstract published
  01/27/2009

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REQUISITES OF OSTEOPOROTIC VERTEBRAL FRACTURE

• Pain.
• Fracture visualized by XR film.
• The best imaging modality is MRI.
• Changes include hiposignal in T1 and
  hypersignal in T2 and STIR.
• Bone scan if MRI is not possible.
• CT if there is suspicion of rupture of posterior
  wall.

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VP KP IN OSTEOPOROTIC VERTEBRAL FRACTURES.WHEN
TO PRACTICE?

• After failure of conservative treatment during a
  period of 4-6 weeks.
• If the management of pain is difficult and
  includes i.v. opioids during in-patient care
  it can be practiced before.

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OSTEONECROSIS RELATED TO A OSTEOPOROTIC VERTEBRAL
FRACTURE

• The practice of VP or KP in osteonecrotic
  vertebra is indicated.
• MRI changes include fluid and/or air into he
  vertebra.
• Currently there is a discussion about whether
  to treat the osteonecrotic cavity alone or
  combined with cementation of the rest of
  vertebral body.

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VP KP IN METASTATIC VERTEBRAE

• Metastases account for 70 of all spinal
  tumors (mostly in lumbar zone).
• Paliative treatment has known complications.
• Radiotherapy provides significant pain relief
  but limited spinal stabilization.
• VP KP may be conducted to prevent further
  vertebral collapse when surgery is
  contraindicated.
• Radiotherapy diminishes the volume of the
  vertebral infiltration reducing the compression
  and also the pain.
• Radiotherapy takes several weecks to reinforce
  the vertebral stability and in this period the
  collapse can increase.
• The role of vp in metastatic spinal desease.
• Julie g. pilitsis m.d. et al.
• neurosurgical focus 02-08-2002

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METASTATIC VERTEBRAE

• VP and KP are effective at reducing the pain and
  reinforcing the vertebral structure, with
  immediate results.
• VP and KP can be combined with radiotherapy or
  chemotherapy.
• VP and KP must be practiced before radiotherapy
  (cement not affected by radiation)
• VP and KP can be adjuvant to surgical fusion.
• Murray et al. J Bone Joint Surg. Am 56311-312,
  1974

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METASTATIC VERTEBRAE

• Lytic.
• Mixed.

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METASTATIC VERTEBRAE

• Breast cancer (45.3).
• Lung cancer (14.5).
• Myeloma (7.7).
• Other cancer (32.5).
• VP for spinal metastases complications.
• Radiology 2006238354-362.

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HEMANGYOMA

• First vertebroplasty was practiced in
  cervical hemangyoma by
• Dr. Deramond.
• There must be no other cause of pain present.
• Pain must exist in the exact place where the
  hemangyoma is located.
• Hemangyoma with aggressive behaviour ,
  growing and/or compressing nerval structures
  must be treated.
• Association between VP/KP and other
  modalities of treatment may exist.

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CONTRAINDICATIONS

• Pregnancy.
• Non -painful fractures.
• Bleeding disorders.
• Osteoblastic metastasis.
• Active infection.
• Acute burst fracture or high energy
  fracture.
• Any medical condition that precludes
  anesthesia and or intervention.

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LIMITATIONS TO THE TECHNIQUE IN VCF

• Vertebra plana.
• Osseous fragment retropulsed into the channel.
• Radiculopaty or nerval compression.
• Tumor epidural extension.

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CONTROVERSIAL SITUATIONS

• 1 To treat non-painful vertebrae with
  abnormal signal marrow in MRI in
• chronic vertebral fractures.
• Pain over the fractured vertebrae is always
  necessary?
• Neurosurgical focus VP and KP a Comprehensive
  review Posted 03/24/2005
• 2 To treat painful vertebrae without changes
  in bone marrow in MRI.
• Correlation between preprocedural MRI findings
  and outcomes in the
• treatment of chronic symptomatic VCF with
  percutaneous vertebroplasty.
• Daniel B. Brown et al.
• From American Journal of Roentgenology
  06/10/2005

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• We dont treat non-painful vertebrae even with
  abnormal signal in MRI.
• But in some cases we treat painful vertebrae
  without abnormal signal in MRI.
• The indication of VP or KP must be done by a
  multidisciplinary team. In cases with a chronic
  vertebral compression fracture without changes in
  MRI signal, but clearly painful at that level,
  excluding other causes of pain, we probable will
  decide to practice VP or KP.

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Three Months Earlier
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CONSIDERATIONS ABOUT VERTEBROPLASTY AND
KYPHOPLASTY

• Vertebroplasty is less expensive and easier to
  practice.
• Kyphoplasty seems to be safer than vertebroplasty
  (but in experienced hands vertebroplasty is
  safe).
• There is no general rule to treat a collapsed
  vertebra.
• We usually practice VP in VCF in older people and
  in collapsed vertebrae by tumor.
• Vertebral traumatic fracture in young people can
  be treated with kyphoplasty using biological
  cement (not possible to use with vertebroplasty).
• Kyphoplasty is more indicated when correction of
  kyphosis is demanded overall in the toraco-lumbar
  junction.

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Courtesy Dr. Joe BreytenbachVereeniging,
South-Africa
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CONSIDERATIONS ABOUT VERTEBROPLASTY AND
KYPHOPLASTY

• VP in all levels of spine.
• KP only in thoracic or lumbar levels.
• KP only in acute or subacute vertebral
  compression fractures.
• KP allows to use biological material with a
  bigger needle .
• KP with biological material not suitable in upper
  thoracic levels.
• KP with material cement needs more time to be
  effective for pain relief
• (2-3 weeks).
• VP and KP can be combined with radiofrequency
  ablation in metastatic vertebrae.

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Dr. Joan Serra Unitat dintervencionisme
Percutani (CRC UDIP) Barcelona