Technical Aspects of Technical Aspects of Percutaneous Percutaneous VertebroplastyVertebroplasty

Dr. Cosme ArgerichNeurosurgeon

HistoryHistory

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

SchoolsSchoolsEuropeanEuropean

38% methastases38% methastases31% Hemangiomas / 31% Hemangiomas / MyelomasMyelomas31% Osteoporosis31% Osteoporosis

North AmericanNorth American70% Osteoporosis70% Osteoporosis17% Hemangiomas / 17% Hemangiomas / MyelomasMyelomas13% Methastases13% Methastases

DemographyDemographyUSAUSA

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

Diagnostic SequenceDiagnostic Sequence

Clinic evaluation

Anamnesis

Physical exam

Clinical

Neurological

Lab tests

Osteoporosis

Plain x-Rays Densitometry Metabolic Lab

Tumors

CT MRI Markers

Biopsy?

Indications for PVIndications for PV

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

OsteoporosisOsteoporosis

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

OsteoporosisOsteoporosis

T1: signal reduction in D 12.

STIR: increased signal suggesting recent fracture.

TumorsTumors

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

Malignant TumorsMalignant Tumors

T1: signal reduction in vertebral body and posterior elements

+ C: increased signal

Note that:Note that:

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

General Exclusion CriteriaGeneral Exclusion Criteria

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

Particular Exclusion CriteriaParticular Exclusion Criteria

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

CancerCancer::Advanced systemic Advanced systemic disease.disease.Progression to spinal Progression to spinal channel.channel.

Vertebral ApproachesVertebral Approaches(will vary according to surgeon’s specialty and experience)(will vary according to surgeon’s specialty and experience)

Cervical Spine: Cervical Spine: Anterior.Anterior.

Dorsal Spine: Dorsal Spine: Transpedicular.Transpedicular.

Lumbar Spine: Lumbar Spine: Transpedicular.Transpedicular. Lateral.Lateral.

Alternative ApproachesAlternative Approaches

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

EquipmentEquipment

Fixed “C” ArmFixed “C” ArmAdvantages: Better image qualityEasier operation

Disadvantages:High operational costsUse subject to availability

Mobile “C” ArmMobile “C” ArmAdvantages:Low operational costsAvailability

Disadvantages:Lesser image qualityMore difficult operation

Immediate access to:Immediate access to:

CT Scan and / or RMI.CT Scan and / or RMI.ICU.ICU.Operating Room.Operating Room.

Must be available for the treatment of Must be available for the treatment of potential complicationspotential complications

Local

GeneralNeurolepto

AnestesiaAnestesia

Election will depend on surgeon’s experience and characteristics of patient.

Intraoperative MonitoringIntraoperative Monitoring

EKG.EKG.OO22 Saturation Saturation (early diagnosis of pleural lesion).(early diagnosis of pleural lesion).

Pressurometry Pressurometry (occasional vagal raction).(occasional vagal raction).

During Local Anesthesia, Oxygen mask will During Local Anesthesia, Oxygen mask will provide sensation of comfort to patient.provide sensation of comfort to patient.

Main advantages of Local Main advantages of Local AnesthesiaAnesthesia

Allows the surgeon to communicate with the Allows the surgeon to communicate with the patient.patient.

Benefits:Benefits:Early diagnosis of lesions (radicular / pleural) Early diagnosis of lesions (radicular / pleural) which might not be diagnosed otherwise.which might not be diagnosed otherwise.Determine cement injection speed.Determine cement injection speed.Anticipate corrective measures.Anticipate corrective measures.Abort the procedure.Abort the procedure.

VideoVideo(Actual Procedure under Local Anesthesia)(Actual Procedure under Local Anesthesia)

ConclusionsConclusions

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