Vertebroplasty presentaion

Ramsin Benyamin, MD, DABIPP, FIPP

The most rewarding intervention:

Vertebroplasty

DisclaimerPresident/Medical Director, Millennium Pain Center, Bloomington, IllinoisMedical Director, Millennium Pain Center, Chicago, IllinoisMedical Director, OSF Millennium Pain Center, Normal, IllinoisCo-founder, Millennium Pain Management-Teknon Medical Center, Barcelona, Spain

Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana/ChampaignAdjunct Professor, Department of Biological Sciences, Illinois State University

President-Elect, ASIPPBoard of Directors, SIPMS

Board of Examiners, ABIPP Board of Examiners, FIPP

Member, Guidelines committee, ASIPPMember, Research committee, ASIPP

Associate Editor, “ Pain Physician”Editorial Board, “ Pain Practice”Editorial Board, “Journal of Opioid Management”

Scope of the problemOsteoporosis epidemic: - 200 million worldwide

- 40 million in USA

Women over 80: - 80% osteoporosis

- 40% VCF

9x increased mortality Cauley et al, Osteo Intern, 2000

Self-care assistance: >50% of 1-2 VCF (8% in OA/LBP )

One VCF: 19.2% Two VCF: 24% more chance of another VCF in next year

Midwest Pain Society Presentation 2C - Ramsin Benyamin, MD September 19, 2008 3:45 pm

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Most common risk factors

Oral glucocorticoid use

Early menopause

Unintentional weight loss and malnutritionOther factors

20%10%

36%34%

Tannenbaum C et al. J Clin Endocrin Metab. 2002

Risk of fracture from steroid use

Van Staa TP et al. J Bone Miner Res. 2000

Ris

k of

ve

rteb

ral f

ract

ure

Oral glucocorticoidusers

(n=244,235)

Age- and gender-matched controls

(n=244,235)

• 2.6-fold increase

1 2 3 4 5 6 7 8

Fracture prevalence (%)

T4T5T6T7T8T9T10T11T12L1L2L3L4

Incidence of vertebral fractures in spine

Nevitt MC et al. Bone. 1999


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Consequences of VCF

Pain

ImmobilityKyphosis

More Compression

Opioid dependence

Impact of ImmobilityOsteoporosis(loss of BMD): 2% per weekMuscle wasting: 1-3% per dayLoss of Strength : 50% in 3-5 weeksConstipation, loss of appetite, fecal impactionDepression/ anxietyDecubitus ulcers: 70% in 2 weeks (70& older): 50% more nursing cost

UTI/ calculiLow FVC: 9% with each VCFAtelectasis, less effective coughing, reduced cilliaryclearance: 25-50% reduced inspiration: PneumoniaDVT: 61% in bed rest: PE in 2-12%: 0.5-10% fatal

Benefits of Vertebroplasty

Pain Relief Quick & Complete• Osteoporotic

75-90% complete relief of pain (immediately or within 72 hours)

• Neoplastic59-86% complete relief of pain ormarked reduction in opioids

Improved Mobility• within 24 hours, reduced AE (cost) in elderly Brown et al, JAmGerSoc,2004


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Position Statement· American Society of Interventional and Therapeutic Neuroradiology

· Society of Interventional Radiology· American Association of Neurological Surgeons/Congress of Neurological Surgeons

· American Society of Spine Radiology

Percutaneous vertebral augmentation is a safe, efficacious, and durable procedure

in appropriate patients with symptomatic osteoporotic & neoplastic fractures

“Benefits far outweigh its risk and the risk of conservative therapy”

Jensen et al, Position Statement, JVIR, 2007

Vertebroplasty, First 1000 Levels of a Single Center: Evaluation of the Outcomes and Complications

Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, Kallmes DF, AJNR 2007

Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, Kallmes DF, AJNR 2007


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Percutaneous Vertebroplasty for Painful Compression Fractures in a Small Cohort of Patients with a Decreased

Expectation-Related Placebo Effect due to Dementia

METHODS: 10 patients with dementia who had vertebroplasty

RESULTS: Pain with activity decreased or resolved in 80%-100% of patients at each time point, whereas pain at rest decreased or resolved in 78%-100% of all patients at each time point. Improved mobility was reported in 80%-100% of patients at all time points. Pain medication was decreased or stopped in 67% of patients at 1 week and in 100% of patients at 6 months and 1 year.

CONCLUSION: Treatment of painful compression fractures in patients with dementia demonstrates a high rate of success regarding pain relief and mobility. This study offers additional evidence that vertebroplasty has true benefit.

Lehman VT, Gray LA, Kallmes DF , AJNR Am J Neuroradiol. 2008 Jun 12

Vertebroplasty in multiple myeloma: outcomes in a large patient series

Significant improvement in:rest pain (82%) and activity pain (89%) 65% of patients requiring fewer narcotics 70% having improved mobility

Vertebroplasty provides significant & durable pain relief

McDonald RJ, Trout AT, Gray LA, Dispenzieri A, Thielen KR, Kallmes DF, AJNR 2008

Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels with

osteoporotic vertebral compression fractures

Out of 334 procedures, 15 patients with unrelieved pain in 4 to 32 days after an initial PV

Complete pain relief in 11 (73%) and partial pain relief in 4 patients (27%), in a mean follow-up of 15 months

Absent or inadequate filling of cement may be responsible for the unrelieved pain after the initial PV

He SC, Teng GJ, Deng G, Fang W, Guo JH, Zhu GY, Li GZ, Spine, 2008


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Indication“Painful Compression Fracture”

Osteoporosis, Trauma, CancerAcute, Sub-acuteNot totally collapsedNo (significant) retropulsionPain consistent with imaging

Exam under FluoroscopyEstablish diagnosisEvaluate the view, fractureDecide feasibility: fluoro / CTPlan the approach (? fractured peddicle)Do NOT be a maverick!

Preparation

Antibiotics: systemic

Positioning: padding, self-positioning

Anesthesia: MAC + local

Strict sterile technique


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Image Guidance

High-quality fluoroscopy• Biplane• Single plane• C-arm

CT and fluoroscopy

Love the Dog!

Discography and Intradiscals Facet Joint

Medial Branch

Epidural or Intrathecal

Transforaminal

Vertebroplasty

Final needle position


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Vertebral Venous Plexus


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Posterior leakage

Rarely symptomatic

May require SxIntradural leakage

Too medial??

Massive Pulmonary Edema

•Insufficient polymerisation of the injected cement, probably due to an unbalanced monomer-to-powder ratio?•3 levels (T12, L1 & L2)•15 ml retrieved

Monticelli, Forensic Sci Int, 2005

More cases

Aortic embolism!: Breast Ca. 6ccRight Laterovertebral artery

Asymptomatic Amoretti, Skeletal Radiol 2007


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L4 radiculopathy Pedicle fracture

No cement in the vertebrae!!!

Baumann C. Cardiovasc Intervent Radiol, 2007


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Safe Deposit Area!

Trans-Pedicular approach

Vertebroplasty


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Hammer!

Too far medial Too far lateral

Blind Spots !


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Bi-pedicular technique

Cement injection

Radio-opaque: 30% BariumAdequate curing time: “tooth-paste”Real-time fluoro in lateralVolume of cement: 2-4ml- not correlated with pain relief- not correlated with strengthening


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Final X-Ray

Finally……..

Vertebroplasty vs. Kyphoplasty

Clinical response rate is similarNo proven advantage of Kyphoplasty in:- Pain relief

- Height restoration - Complication rate

Position Statement, J Vas Interv Radiol, 2007:American Society of Interventional and Therapeutic NeuroradiologySociety of Interventional RadiologyAmerican Association of Neurological Surgeons/Congress of Neurological SurgeonsAmerican Society of Spine Radiology


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EvidenceASIPP Guidelines, 2007

Level of evidence is Moderate

Final Comments

Best suited: Interventional Pain Physician (Anesthesia, PM&R, IR, Surgeon)

Not : Part-timers (Anesthesiologist, Radiologist, Spine surgeon)- Comprehensive clinic & follow-up

- Fluoroscopy/percutaneous

- Resuscitation skills

Physicians (not marketplace): determine patient selection criteria

It’s not the procedure that changes the outcome, it’s the operator

Thanks!

[email protected]


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Vertebroplasty presentaion

Education

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