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Percutaneous Vertebroplasty in Metastatic Disease: Transpedicular Access and Treatment of Lysed Pedicles—Initial Experience¹

¹ From the Department of Radiology (J.B.M., S.G.W., T.S., A.K., D.A.R.), Division of Oncology (Y.S, P.Y.D.), and Division of Neurosurgery (M.P.), Geneva University Hospital, Rue Micheli-du-Crest 24, CH-1211 Geneva 14, Switzerland; and the Interventional Neuroradiology Section, Johns Hopkins Medical Institutions, Baltimore, Md (P.G.). From the 2000 RSNA scientific assembly. Received August 2, 2002; revision requested October 7; revision received January 8, 2003; accepted February 28. Address correspondence to J.B.M. (e-mail: jean-baptiste.martin@dim.hcuge.ch).

View larger version (145K): [in a new window]   Figure 1. Images obtained in 55-year-old man with myeloma and osteolysis of L4 including the left pedicle. A, Anteroposterior fluoroscopic image obtained with patient in prone position prior to treatment. The destroyed left pedicle of L4 is not visible. The position of the pedicle (*) can be deduced from the spinous process (black arrow), the intact right contralateral pedicle (white arrow), and the superior and inferior ipsilateral pedicles of L3 and L5. For correct localization, it is important that the spinous process is aligned in midline and that the visible pedicle projects exactly between the superior and inferior endplate. B, Lateral fluoroscopic image obtained after vertebroplasty. Bone cement extends from the vertebral body into the treated pedicle (*). Note the minimal cement leakage anterior to the vertebral body. C, Sagittal CT reconstruction through the pedicle and vertebral body confirms the location of the cement.

View larger version (61K): [in a new window]   Figure 2. Schematic drawings (transverse view) of needle direction during pedicle access and pediculoplasty. Left: While passing through the pedicle, the bevel of the needle points medially to avoid penetration of the spinal canal. Right: After treatment of the vertebral body, pediculoplasty is performed with the bevel pointing laterally to avoid cement delivery into the spinal canal.

View larger version (14K): [in a new window]   Figure 3. Schematic drawing (lateral view) of cement delivery during pediculoplasty. Introduction of the stylet pushes cement from the needle into the pedicle. Barium particles (depicted as black boxes) should move parallel to the needle direction (position 1 on drawing). Movement of particles perpendicular to the needle and pedicle (position 2 on drawing) indicates potential PMMA leakage, and the injection should be immediately stopped.

View larger version (121K): [in a new window]   Figure 4. Images obtained in 43-year-old man with lung cancer and metastatic osteolysis of L4 including the left pedicle. A, During venography (lateral view), a severe venous leakage into epidural veins is noted (arrows). B, During a second venography procedure (lateral view), needle is positioned more anteriorly in the vertebral body and no opacification of epidural veins is present. C, D, Fluoroscopic images obtained after treatment in anteroposterior view (C) and lateral view (D) show cement filling of the pedicle and the adjacent vertebral body. Note the small deposit of contrast agent in the epidural space (arrows) remaining from the prior venography. This collection can be distinguished from bone cement (arrowheads) because no barium particles are visible. E, F, CT reconstructions in sagittal plane (E) and transverse plane (F) show pediculoplasty and the osteolytic area (arrowheads) in the adjacent vertebral body. A small bulk of cement (arrow) is shown in the spinal canal adjacent to the treated pedicle. This leakage occurred despite the immediate cessation of the filling procedure at the moment when cement leakage was observed.