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Vascular and Interventional Radiology |
1 From the Lahey Clinic Medical Center, Burlington, Mass. From the 2001 RSNA scientific assembly. Received November 27, 2001; revision requested January 7, 2002; revision received April 15; accepted May 24. Address correspondence to J.A.H., Department of Neurointerventional Radiology, Beth Israel Deaconess Medical Center, One Deaconess Rd, West Campus, Boston, MA 02215 (e-mail: jhirsch@caregroup.harvard.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: The findings in 177 patients treated with percutaneous vertebroplasty for more than 2 years were reviewed retrospectively. The following parameters were reviewed: primary diagnosis, patient age and sex, date of treatment with vertebroplasty, vertebral level(s) treated, pedicular approach, and amount of polymethylmethacrylate injected per vertebral body. Patients with acute compression fractures secondary to osteoporosis were selected.
RESULTS: Of 177 patients treated with percutaneous vertebroplasty, 22 (12.4%) developed a total of 36 new vertebral body fractures following treatment. Of the 36 newly documented fractures, 24 (67%) involved vertebrae adjacent to the previously treated vertebral level(s), whereas 12 (33%) involved the collapse of nonadjacent vertebrae. In addition, 24 (67%) of the 36 new vertebral fractures occurred within 30 days after treatment of the initial fracture(s).
CONCLUSION: A substantial number of patients with osteoporosis develop new fractures after undergoing percutaneous vertebroplasty; two-thirds of these new fractures occur in vertebrae adjacent to those previously treated.
© RSNA, 2003
Index terms: Osteoporosis, 321.56, 331.56 • Spine, fractures, 321.41, 331.41 • Spine, MR, 321.121411, 321.121413, 321.121416, 331.121411, 331.121413, 331.121416 • Spine, vertebroplasty
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The technique of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) for the treatment of aggressive spinal angiomas was described by Deramond et al (1) in France in 1984. The indications for this procedure have increased to include the treatment of osteoporotic compression fractures and malignant vertebral neoplasms (1). In preliminary studies (1–4), percutaneous vertebroplasty has been shown to facilitate substantial pain relief and improve mobility in up to 90% of patients, with such results occurring as early as 24–48 hours following intervention.
The overall complication rate associated with percutaneous vertebroplasty for the treatment of osteoporotic compression fractures is reported to be 1%–3% (1,5). The findings of some authors (1,6–8) have indicated that there is a risk of collapse of a vertebral body adjacent to the one injected with PMMA in a subset of patients. To our knowledge, there have been no reports to date of a large series of compression fractures that developed within adjacent vertebral bodies. The purpose of our study was to investigate the development of compression fractures in vertebral bodies adjacent to those previously treated with percutaneous vertebroplasty. Herein we report our experiences.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The vertebroplasty technique currently used at our institution is equivalent to the procedure (with the associated materials) that has been thoroughly described by Centenera et al (4). A multidisciplinary team that consists of an endocrinologist (A.G.P.), orthopedic surgeon (B.A.P.), and interventional neuroradiologist (J.A.H., I.S.C.) examines the patients referred to our vertebroplasty clinic. Complete medical history data and physical examination findings are supplemented with the results of diagnostic imaging, which may include anteroposterior and lateral radiography and magnetic resonance (MR) imaging of the spine or technetium 99m (99mTc)–labeled planar and single photon emission computed tomographic (CT) bone scintigraphy. Typical MR examinations include transverse and sagittal T1- and T2-weighted imaging, in addition to sagittal short inversion time inversion-recovery (STIR) imaging of the spine (Fig 1).
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The risks and complications of vertebroplasty, including bleeding; infection; pain; cement extravasation to the perivertebral venous plexus, epidural veins, or intervertebral disk space; nerve root compression; paralysis; and pulmonary embolization, are discussed with the patient. Informed consent is obtained. The procedure is performed with neuroleptic analgesia, which is induced by an anesthesiologist who is present during the procedure. The patient is placed in a prone position. With an aseptic technique, the skin and paravertebral soft tissues are anesthetized with lidocaine (1%) and sodium bicarbonate. With use of biplanar fluoroscopy—that is, in anteroposterior and lateral projections—the pedicle of interest is localized and an 11-gauge needle (Jamshedi Needle; Cook Medical, West Lafayette, Ind) is positioned at the anterior and middle one-third regions of the vertebral body. Transosseous venography with manual contrast agent injection is performed to identify the perivertebral venous plexus.
Next, PMMA is prepared by combining 6 g of sterile barium, 1.2 g of injectable tobramycin (Nebcin; Eli Lilly, Indianapolis, Ind), and one packet of cranioplastic cement (Codman Cranioplastic; Johnson & Johnson Medical, Bershire, United Kingdom) and then storing the mixture on ice to delay rapid polymerization. The PMMA mixture is then administered to the patient, with fluoroscopic visualization, in 0.2–0.3-mL increments. The vertebral body is filled as much as possible, and the process is stopped when there is filling in the posterior one-fourth of the vertebra, the epidural vein, the anterior or lateral disk space, or the intervertebral disk space. If PMMA does not extravasate to the opposite pedicle, the contralateral pedicle is localized and the procedure is repeated.
Multiple vertebral levels can be treated during a single session as long as the patient can tolerate the prone positioning and is not at risk of developing complications secondary to an underlying coexistent morbidity. In our initial experience, we obtained a nonenhanced CT scan of the area of interest to more clearly delineate the PMMA extravasation or associated complications. We no longer follow this practice, however. After the vertebroplasty procedure, the patient is observed in the recovery area for 3–4 hours and instructed at discharge to perform normal activities slowly within the next 48 hours. Three to 4 weeks after the procedure, patients either are contacted by telephone by a clinical nurse coordinator or undergo a follow-up examination at the vertebroplasty clinic, after which they are instructed to contact us on an as-needed basis.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The mean age of the 22 patients was 77.5 years (age range, 54–88 years). Seventeen patients were women, and five were men. Although all of the patients had received a diagnosis of osteoporosis, seven of them had steroid-induced osteoporosis. Thirteen (59%) of the 22 patients had signs and symptoms of multiple vertebral level involvement—that is, acute or chronic fracture involving two or more segments—at presentation. The average number of treated vertebral segments was 3.2, and the new fractures involved segments of the thoracolumbar spine from the T6 through L4 vertebrae. A bipedicular approach was used in 60 (86%) of the 70 vertebroplasties performed, whereas a unipedicular approach was used in 10 (14%) vertebroplasties. The average amount of PMMA injected per vertebral body was 9.14 mL (range 5.0–14.5 mL).
The results of analysis with these 22 patients are summarized in Table 1. In this series of 22 patients, a total of 70 vertebral fractures were treated. Thirty-six (51%) of these fractures represented new compression fractures that developed after treatment of another vertebral level. Twenty-four (67%) of these 36 newly documented fractures involved vertebrae adjacent to the previously treated vertebral level(s), whereas 12 (33%) of the new fractures involved a collapse of a nonadjacent vertebral body. All patients who returned to our institution with new fractures underwent subsequent vertebroplasty for the treatment of newly involved vertebra(e).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Some of the earliest and most comprehensive results with percutaneous vertebroplasty have been reported by Deramond et al (1). Along with the frequently discussed complications of percutaneous vertebroplasty, including cement extravasation, infection, nerve root compression, and cement embolization, a risk of collapse of a vertebral body adjacent to one injected with PMMA also was proposed by these authors. They believed that this risk is low and probably an inherent risk for any patient with osteoporosis of the spine.
Other authors (2,3,6–8,12–14) have observed and briefly discussed similar findings in small subsets of patients with osteoporosis; a summary of these observations in the English-language literature is provided in Table 2. Grados et al (7) evaluated 25 patients with osteoporosis (with 34 treated vertebrae) who were followed up for an average of 48 months (range 12–84 months). Although there was no progression of collapse within the vertebrae injected with PMMA, the authors reported an increased risk of adjacent vertebral body fractures as follows: 13 (52%) patients developed at least one new vertebral fracture, and the relative risk of fracture of a vertebral segment adjacent to a treated vertebral body was 2.27 (7).
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In a clinical study of osteoporosis in women performed by Lindsay et al (15), the patients had a propensity to develop a second—even third—vertebral fracture within 1 year after an incident fracture; this phenomenon occurred in as many as 20% of the patients. The baseline bone mineral density and architecture inherent of osteoporosis of the spine are unfavorable; this assertion is supported by in vitro study results (8,9). Tohmeh et al (9) evaluated the strength and stiffness of the spine in cadavers with osteoporosis (bone mineral density t score, -3.7 to -8.8). Following compression, these vertebrae were observed to be structurally weaker and less stiff than they had been before the fracture (9). In addition, the fractured vertebrae that were not treated were weaker and less stiff than those that were treated with vertebroplasty (9).
The biomechanical forces that act on the spine are complex and beyond the focus of this article. Following a vertebral fracture, deformity and kyphosis alter the vectors of the forces that are in action throughout the spine (16). Load-bearing kinetics redistribute the forces to other vertebrae, particularly those vertebrae adjacent to the original fracture (8,16). An individual with a normal spine may be able to tolerate these altered biomechanics; however, a person with a diseased spine may tolerate these alterations poorly.
The goal of vertebroplasty is to strengthen and stabilize a collapsed vertebral body and, consequently, restore the integrity of the collapsed vertebral body so that it can support weight-bearing kinetics (9). Percutaneous vertebroplasty strengthens a vertebra, but it also increases the stiffness of the segment (9,11). This altered stiffness of the vertebral body may again alter the distribution of forces to nearby vertebrae and thus increase the risk of fracture of these bodies (7,8). Other investigators (1,6) suggest that the collapse of adjacent vertebrae may, to some extent, reflect the natural evolution of osteoporosis in the spine (1,6). In the present study, 67% (24 of 36) of the new vertebral fractures represented a collapse of a vertebra adjacent to a level initially treated with percutaneous vertebroplasty. Three of the 22 patients had multiple new fractures after vertebroplasty (Table 1).
It is also important to note that 24 (67%) of the 36 new fractures occurred within 30 days after treatment with vertebroplasty and two other fractures occurred within 31 days (Table 1). It appears that a majority of the patients developed this complication within a relatively short period. It has been postulated that bone loss may occur in vertebral bodies adjacent to an original fracture (16). Following treatment with vertebroplasty, patients may demonstrate rapid clinical improvement. As a result, they may become more active and engage in activities that they were unable to perform previously. This new axial load on the vertebra may be stressful and result in new compression on adjacent vertebrae. Other patients may resume full activity and fall, fracturing another vertebra, an extremity, or even a hip (17).
The current uses of percutaneous vertebroplasty include treatment of both benign and malignant disease. In this retrospective analysis, we limited our study population to patients with osteoporosis. We observed a recurrent phenomenon in our experience, the development of a new fracture after vertebroplasty, and then attempted to analyze it. This observation bias represents another limitation that was inherent to the design of this retrospective study: We performed all vertebroplasties as clinical cases. There was no random selection of patients or a control population of patients who did not receive treatment with vertebroplasty.
In terms of follow-up, the patients were contacted by telephone or seen in the vertebroplasty clinic in the 3–4-week interim after treatment. Most of these patients were instructed to contact us on an as-needed basis. Therefore, we were able to report on only those patients who returned to our institution for reevaluation if vertebral body compression recurred or new symptoms occurred. In addition, we were not able to obtain substantial long-term follow-up data to determine if more patients experience this phenomenon.
In conclusion, percutaneous vertebroplasty has become an option for the treatment of painful osteoporotic compression fractures in patients in whom conservative medical management has failed. The risks of complications with this procedure are low, and patients demonstrate marked improvement with a rapid return to normal activities (1). We recognize that a substantial number of patients with osteoporosis, 12.4% of the study population, experienced new fractures following treatment with vertebroplasty. It is our hope that further study and recognition of this phenomenon will facilitate pretreatment screening of individuals who are at higher risk of having this complication.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, J.A.H.; study concepts and design, A.A.U., J.A.H., L.V.C.; literature research, A.A.U.; clinical studies, J.A.H., L.V.C., I.S.C., B.A.P., A.G.P.,; data acquisition, A.A.U., J.A.H.; data analysis/interpretation, A.A.U.; manuscript preparation, A.A.U.; manuscript definition of intellectual content, A.A.U., J.A.H.; manuscript editing, A.A.U., J.A.H., L.V.C.; manuscript revision/review, J.A.H., L.V.C., B.A.P., A.G.P., I.S.C.; manuscript final version approval, A.A.U., J.A.H., L.V.C., B.A.P., I.S.C.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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