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Percutaneous Vertebroplasty: Evaluating the short and long term results for 1000 treated fractures 2006

Interventional Spine

Kennith F Layton, MD, Non ASSR Member
Patrick H Luetmer, MD, Non ASSR Member
John T Wald, MD, Non ASSR Member
John I Lane, MD, Non ASSR Member
Kent R Thielen, MD, Non ASSR Member
David F Kallmes, MD, Non ASSR Member

Scientific Paper

Purpose

To evaluate the experience and outcomes of the first 1000 compression fractures treated with percutaneous polymethylmethacrylate (PMMA) vertebroplasty at our institution.

Methods & Materials

This is a retrospective study from a single academic center in the United States, and Institutional Review Board approval was granted for the study. The study includes all patients who underwent percutaneous vertebroplasty between February 1999 and October 2005. All patients underwent a preprocedure evaluation and were assessed two hours after the procedure, prior to discharge. Followup telephone interviews were conducted at 1 week, 1 month, 6 months, 1 year and 2 years by a trained vertebroplasty nurse. The inability to contact a patient at one time point did not preclude an interview at the next followup time point. Followup assessment included a 10-point pain scale at rest and with activity, subjective assessment of pain relief at rest and with activity, changes in mobility, and changes in pain medication usage. Over the last few years, we have also incorporated the modified Roland-Morris Disability Questionnaire (RDQ) into our evaluation and followup of vertebroplasty patients. The RQD score is a comprehensive assessment of patients' overall disability due to back pain. This assessment tool, which is considered a more comprehensive evaluation of patients with compression fractures, was also used in the followup of patients treated in the last half of our study (1).
Vertebroplasty was offered to patients with imaging evidence of an acute or subacute compression fracture of the thoracic or lumbar vertebrae and exclusion criteria included noncorrelating pain, improvement with conservative medical management or technical barriers. All etiologies of compression fracture were included in the study, including osteoporosis, neoplasm, hemangioma and trauma.
The vertebroplasty technique was performed according to previously described methods (2). The procedures were performed with intravenous conscious sedation, deep sedation or general anesthesia utilizing a biplane fluoroscopy unit. Transpedicular or parapedicular approaches were performed after application of local anesthesia to the subcutaneous tissue and periosteum. Various brands of PMMA were used during the study but always included a mixture with barium sulfate and gentamicin powder. Injection of cement was performed with an injector device or by hand with 1cc syringes. Patients were placed on bedrest for two hours after the procedure and then allowed to ambulate as tolerated.

Results

Over the course of our study, 1000 compression fractures were treated in 552 patients (69% female) during 673 treatment sessions. The average age of the patients was 74 years (range 28-96 years). The number of levels treated per procedure varied from one to five with 425 (63%) at a single level, 180 (27%) at two levels and 68 (10%) at three or more levels. Osteoporosis accounted for 562 cases (84%) while neoplasm was the next most common etiology with 74 cases (11%). Trauma (35 cases) and hemangioma (2 cases) accounted for the remaining 5% of cases. The average duration of pain was 3.6 months. Treatment was performed at every thoracic and lumbar level with T12, L1 and L2 encompassing 41% of treated levels (Figure 1).
Compared to the preprocedure evaluation, there was a dramatic improvement in the visual analog pain score (0-10) at rest and with activity as well as the Roland score (Figure 2). The subjective pain response at rest and with activity was also noted to improve (Figure 3). The trend toward improvement was noticeable at the two hour time point and was sustained over the two year followup period. Furthermore, a reduction in pain medication usage and an improvement in mobility were also observed over the two year followup period (Figure 4).

Conclusion

Percutaneous PMMA vertebroplasty appears to be an effective tool for the treatment of spinal compression fractures. A significant improvement in pain, disability, pain medication usage and mobility was observed in our large patient population over both short and long term followup time points. This study is limited by its retrospective nature. Randomized prospective clinical trials, such as the ongoing INVEST study, will be important to thoroughly evaluate the effectiveness of percutaneous vertebroplasty.

References

References:

1. Trout AT, Kallmes DF, Gray LA, et al. Evaluation of vertebroplasty with a validated outcome measure: the Roland-Morris Disability Questionnaire. AJNR Am J Neuroradiol 2005;26:2652-2657.
2. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997;18:1897-1904.

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