Relief of radicular pain in metastatic disease by vertebroplasty.

Two patients with compression fractures from metastases who had pain with radicular symptoms mainly in upright position that resolved when not upright and were treated with vertebroplasty were retrospectively analyzed. Both patients had symptom relief at treated levels until death. These cases show that patients with radicular signs and symptoms from compression fractures secondary to metastases or myeloma, worse in upright position and relieved when recumbent, may benefit from vertebroplasty.

Importance of intravertebral fracture clefts in vertebroplasty outcome.

OBJECTIVE: The importance of filling intravertebral fracture clefts with polymethylmethacrylate during percutaneous vertebroplasty to maximize stabilization of fracture fragments has been emphasized in the literature. The purpose of this study was to determine whether patients with a single compression fracture with an intravertebral cleft have better outcome after percutaneous vertebroplasty than do patients with a compression fracture but no cleft. MATERIALS AND METHODS: A retrospective study was conducted to review 354 consecutive percutaneous vertebroplasty procedures on 694 compression fractures. Patients were excluded from consideration if they were treated for metastatic compression fracture or if they were treated at more than a single vertebral body level. Sixty-five patients met the inclusion criteria. Preprocedure radiographs and MR images were reviewed with specific attention to the presence or absence of intravertebral gas or fluid. Images obtained at the procedure also were reviewed for the presence or absence of an intravertebral cleft. Imaging findings were correlated with subjective pain scores immediately, 2 weeks, 1 month, 3 months, 6 months, 1 year, and 2 years after the procedure. RESULTS: Thirty-one (48%) of the 65 patients had evidence of a fracture cleft. Twenty-seven patients had opacification of an intravertebral fracture cleft at percutaneous vertebroplasty, and four patients had an intravertebral cleft on preprocedure imaging but did not have cleft opacification. Thirty-four (52%) of the patients had no evidence of a fracture cleft and had only a trabecular pattern of opacification. Although there was a trend toward a greater failure rate in patients with a filled cleft, there was no statistically significant difference in subjective pain scores between the groups. CONCLUSION: Pain relief with vertebroplasty is similar in patients with and those without intravertebral fracture clefts. Because of the small number of unfilled fracture clefts in our population, the true incidence of post-percutaneous vertebroplasty pain in patients with an un-filled cleft remains uncertain.

Response of nonmidline pain to percutaneous vertebroplasty.

OBJECTIVE: The purpose of this study was to determine the prevalence of nonmidline symptoms in patients undergoing percutaneous vertebroplasty and the response of these symptoms to vertebroplasty. MATERIALS AND METHODS: This is a retrospective study performed through examination of patient records, baseline questionnaires, demographic sheets, follow-up questionnaires, reports from telephone follow-up, and pain location diagrams completed before and after percutaneous vertebroplasty. Data were gathered from 350 patient encounters, 686 vertebroplasty procedures, and 288 patients. After determining the prevalence of nonmidline pain, analysis of acquired data was performed to determine the efficacy of vertebroplasty in relieving nonmidline pain. RESULTS: Nonmidline pain was present in 240 of 350 patient encounters. Major symptom areas were the ribs; hip, groin, and buttocks; and legs and thighs. Lesser areas of nonmidline symptoms were the abdomen, shoulders, and waistline. Overall there was improvement in nonmidline pain in 83% of the procedures. CONCLUSION: Most patients presenting for percutaneous vertebroplasty have nonmidline pain. Vertebroplasty reduced or eliminated nonmidline pain in 76-92% of the patients in whom it was reported. Procedures involving lumbar vertebrae tended to be successful less often than others, but even in these patients the procedure was successful in approximately 75%.

Management of recalcitrant osteoarthritis of the atlanto-axial joint.

The medical records and radiographs of 17 patients with recalcitrant pain secondary to C1-C2 osteoarthritis were independently reviewed. All patients were treated by the senior author (K.D.R.). Initial treatment included physical therapy, nonsteroidal anti-inflammatory drugs, and soft collar immobilization. If non-responsive, patients were referred to a single radiologist for injection of the involved C1-C2 joint(s). If symptoms persisted, then transarticular screw fixation and Magerl wire fixation with structural iliac crest bone graft was performed. Postoperatively, all patients were placed in a soft collar. Postoperative anteroposterior (AP), lateral, flexion/extension, and open-mouthed odontoid radiographs were taken at 6 weeks, 3 months, and 1 year. Three independent observers assessed all radiographs for fusion. Fusion was noted by radiographic evidence of bridging bony trabeculae across the C1-C2 joint and/or bridging bone from the posterior arch of C1 to the C2 spinous process. Patient satisfaction improved significantly whether they were treated by corticosteroid injection or surgically.

Percutaneous vertebroplasty: an update.

Percutaneous vertebroplasty is an imaging-guided interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a painful compressed vertebral body. This technique is safe and effective, and provides increased strength and pain relief in vertebrae weakened by bone diseases. Among the current indications for vertebroplasty are intractable nonradicular pain caused by compression fractures due to osteoporosis, myeloma, metastasis, and aggressive vertebral hemangioma. Contraindications include bleeding disorder, unstable fracture, and lack of definable vertebral collapse. The preprocedural evaluation, technique, complications, and expected results of performing this procedure are also reviewed.

Osteoporotic compression fractures: outcomes after single- versus multiple-level percutaneous vertebroplasty.

PURPOSE: To compare single- and multiple-level percutaneous vertebroplasty (PV) in terms of pain relief, activity level, and analgesic use in patients with osteoporotic vertebral compression fractures (VCFs). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained, and the study was HIPAA compliant. One hundred seventy-three patients (mean age at treatment, 73.8 years +/- 11.9 [standard deviation]) with 422 symptomatic osteoporotic VCFs underwent 204 treatment sessions for over 4 years. Pain immediately before and after PV was measured by using a visual analogue scale (VAS). Pain degree, activity level, and analgesic use were assessed at 2 weeks and 1, 3, 6, 12, and 24 months after PV by using telephone interview questionnaires. Data were analyzed by using a combination of paired t tests, analysis of variance, contingency tables, and chi2 tests. RESULTS: Findings of 172 PV treatment sessions for 149 patients (mean age at treatment, 73.4 years +/- 12), 110 (74%) of whom were women, were assessed; 32 treatment cases were lost to follow-up or lost owing to death. A single fracture level was treated at 65 sessions; two fracture levels, at 52 sessions; and three or more fracture levels, at 55 sessions. The mean VAS pain score decreased significantly (P < .001), from 76 +/- 21 before to 19 +/- 27 immediately after PV. Of the outcomes reported at 24 months, 82% (64 of 78 treatment sessions) were marked to complete resolution of the initial pain, 51% were complete cessation of analgesic use, and 51% were increased activity levels. These results did not differ greatly over time or when stratified into groups according to the number of fracture levels treated. CONCLUSION: PV performed at a single fracture level and that performed at multiple fracture levels were equally effective in facilitating long-term pain relief, increased activity level, and decreased analgesic use in patients with osteoporotic VCFs.

Correlation between preprocedural MRI findings and clinical outcomes in the treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty.

OBJECTIVE: The purpose of our study was to correlate findings of prevertebroplasty MRI with outcomes in the treatment of chronic osteoporotic compression fractures. MATERIALS AND METHODS: Forty-five patients with osteoporotic spinal compression fractures of more than 1 year's duration were treated with vertebroplasty. Changes in pain and mobility were assessed by follow-up of 1-28 months. Preprocedural MR images were reviewed using the Modic criteria and were correlated with outcomes. RESULTS: Fifteen patients (33%) had marrow edema on MRI and 30 (67%) of the 45 patients did not. All 15 of the patients with edema had clinical benefit: six patients (40%) achieved complete relief and nine (60%) experienced symptom improvement. Ten patients (67%) had improvement in mobility, and the remaining five patients (33%) had no change. Of patients with no marrow edema (n = 30), five (17%) had complete resolution of pain, 19 (63%) were improved, and six (20%) were unchanged. None had worsening of their symptoms. Mobility was improved in 17 (57%) and unchanged in 10 (33%). Mobility was diminished in three patients (10%). In two cases, impaired mobility was due to causes other than spine disorders. CONCLUSION: Most (87%) of the 45 patients with compression fractures older than 1 year derived clinical benefit from vertebroplasty irrespective of MRI findings. Although 100% of patients with bone marrow edema had clinical benefit, no direct correlation was seen between symptom resolution and the presence of edema on preprocedural MRI. In our experience, absence of abnormal marrow signal does not definitively predict the outcome of vertebroplasty in chronic fractures.

Vertebroplasty: reusable flange converter with hub lock for injection of polymethylmethacrylate with screw-plunger syringe.

During percutaneous vertebroplasty, a screw-plunger syringe provides a powerful controlled injection, but coupling of the screw plunger with interchangeable disposable standard syringe barrels results in syringe flange bending failure during the middle of the injection. A flange converter produced from stainless steel and a hub lock produced from plastic or aluminum were used during vertebroplasty at 172 levels in 86 patient-treatment sessions. The flange converter and hub lock increase the achievable volume that can be injected, can be fabricated with hand machining, and cost much less than other commercially available devices.

Midterm outcome after vertebroplasty: predictive value of technical and patient-related factors.

PURPOSE: To evaluate different types of polymethylmethacrylate (PMMA) leakage and patient-related factors in relation to clinical midterm (1-24-month) outcome after vertebroplasty. MATERIALS AND METHODS: Standardized four-view radiographs obtained during 363 vertebroplasties in 181 treatment sessions in 152 patients were reviewed (121 patients with osteoporotic fractures, 30 with malignant disease, and one with hemangioma). Four types of PMMA leakage and other potential predictors (patient age and sex, treated region, number of vertebral levels injected, preprocedural pain, PMMA volume per vertebra) were related to postprocedural pain response and midterm outcome after vertebroplasty. chi2 and Kruskal-Wallis tests were used for statistical analysis. The mean follow-up period was 8.8 months (range, 1-24 months). RESULTS: At the time of discharge after the procedure, pain was absent after 106 of the 181 sessions (58.5%), better after 50 (27.6%), and the same after 25 (13.8%). In 258 of the 363 treated vertebral levels, at least one type of leakage was found. None of the evaluated factors were related significantly to postprocedural pain response, including PMMA leakage. Pain response at midterm outcome was strongly related to postprocedural treatment success, however (P <.001). CONCLUSION: Small to moderate amounts of PMMA may escape from the vertebral body with no significant effect on therapeutic success. Immediate postprocedural pain relief is the best predictor of midterm clinical outcome after vertebroplasty.

Treatment of chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty.

OBJECTIVE: Most fractures treated with percutaneous vertebroplasty are subacute and less than 1 year old. We report our experience treating chronic vertebral fractures with vertebroplasty. MATERIALS AND METHODS: Our database identified 41 patients with symptomatic fractures more than 1 year old. These patients were categorized into subgroups determined by fracture age: 12 months 1 day-24 months (n = 16) or more than 24 months 1 day (n = 25). Changes in pain and mobility for the study group were compared with those in 49 patients with fractures less than 1 year old. RESULTS: Thirty-three (80%) of the 41 patients in the study group had improvement in pain-seven (17%) had complete and 26 (63%) had partial relief. Forty-five (92%) of the 49 control group patients had improvement in pain-24 (49%) had complete and 21 (43%) had partial relief. The number of patients achieving partial or complete relief of pain was not statistically different between groups (p > 0.05), although complete relief was significantly more frequent in the control group (p = 0.002). Twenty patients (49%) in the study group versus 34 patients (69%) in the control group had improved mobility after vertebroplasty (p = 0.047). Patients with fractures 12 months 1 day-24 months old had improvement in mobility similar to that in patients in the control group (p = 0.962). Fractures more than 24 months 1 day old were associated with significantly less improvement in mobility (p = 0.006). CONCLUSION: Most patients with fractures more than 1 year old will experience clinical benefit from vertebroplasty. Complete relief of pain is more likely when less mature fractures are treated.