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1 Continuing Education Column Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures Jae Hyup Lee, MD Ji-Ho Lee, MD Department of Orthopaedic Surgery, Seoul National University College of Medicine E - mail : spinelee@snu.ac.kr jiholee@brm.co.kr J Korean Med Assoc 2009; 52(4): Abstract The consequences of osteoporotic vertebral compression fractures are pain, progressive vertebral collapse with resultant kyphosis, and systemic manifestations. Minimally invasive stabilization procedures such as vertebroplasty and balloon kyphoplasty have been introduced to treat for refractory pain due to these fractures. Vertebroplasty and kyphoplasty are new alternatives for the treatment of osteoporotic vertebral compression fractures. Both methods stabilize the fractured vertebra with polymethylmethacrylate cement to relieve pain and allow immediate mobilization. Kyphoplasty is an extension of vertebroplasty that uses an inflatable bone tamp to restore the vertebral body height while creating a cavity to be filled with bone cement. A large proportion of subjects had some pain relief both in vertebroplasty and kyphoplasty. Vertebral height restoration was possible using kyphoplasty and for a subset of patients using vertebroplasty. Cement leaks occurred in both groups but, the incidence of cement leakage in kyphoplasty is lower than that of the vertebroplasty. Vertebroplasty and kyphoplasty are safe and effective procedures. Good short-term results have been reported following both vertebroplasty and kyphoplasty for the painful osteoporotic vertebral fractures. Severe complications result from bone cement leakage into the spinal canal or the vascular system have been reported but the incidence was very rare. Both vertebroplasty and kyphoplasty offer therapeutic benefit significantly reducing pain and improving mobility in patients with vertebral fracture without significant differences between groups in term of quality. While early results are promising, more research is needed to better understand the log-term effects of both procedures on the human spine. Keywords: Osteoporotic vertebral fracture; Minimal invasive treatment; Vertebroplasty; Kyphoplasty 382

2 Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures 383

3 Lee JH Lee JH ü 384

4 Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures 385

The tips of the J-type biopsy needles are located on the lateral aspect of

5 Lee JH Lee JH Figure 1. Anteroposterior view of the C-arm during the vertebroplasty. The tips of the J-type biopsy needles are located on the lateral aspect of pedicles. Figure 2. Lateral view of the C-arm during the vertebroplasty. The tips of the J-type biopsy needles are located on the anterior aspect of the vertebral body. 386

6 Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures Figure 3. After placing the cannula over the blunt dissector and advance it just beyond the pedicle, place a drill bit down the cannula using manual control, twist the drill bit to enter the vertebral body. The final position is just posterior to the anterior cortex. Figure 4. Insert the inflatable bone tamps through the same cannula. 387

Lee JH Lee JH Figure 5. The inflatable bone tamps are prepared with contrast medium to facilitate imaging during inflation. The balloons are inflated using a manometer with digital pressure gauges.

7 Lee JH Lee JH Figure 5. The inflatable bone tamps are prepared with contrast medium to facilitate imaging during inflation. The balloons are inflated using a manometer with digital pressure gauges. Alternative slow filling of the balloons by raising the pressure to 150 psi. Figure 6. When ready to fill the PMMA, one or both inflatable bone tamps are deflated, and using lateral C-arm guidance, cement cannulas are inserted through the working cannulas to the anterior wall of the vertebral body. Confirm placement on anteroposterior and lateral images. The cement cannula sytlets are used to gently push the selected viscous bone filler from the cement cannula while the cement cannulas are withdrawn to the level of the middle of the cavity. 388

In thoracic vertebral bodies with small pedicles or in midthoracic vertebral bodies a transpedicular approach will result in lateral balloon placement.

8 Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures Figure 7. Transpedicular approach. The entry point is the bone at the junction of the pedicle and posterior vertebral body on the lateral X-ray film. Figure 8. Extrapedicular approach. In thoracic vertebral bodies with small pedicles or in midthoracic vertebral bodies a transpedicular approach will result in lateral balloon placement. The entry point is immediately superior and slightly lateral to the pedicle, just medial to the rib head. This may involve actually cannulating the rib head and entering the vertebral body through the rib facet on the posterosuperolateral corner of the vertebral body. 389

9 Lee JH Lee JH 11. Iqbal MM, Sobhan T. Osteoporosis: a review. Mo Med 2002; 99: Johnell O. Advances in osteoporosis: better identification of risk factors can reduce morbidity and mortality. J Intern Med 1996; 239: Gold DT. The clinical impact of vertebral fractures: quality of life in women with osteoporosis. Bone 1996; 18(3S): 185S - 189S. 14. Rao RD, Singrakhia MD. Painful osteoporotic vertebral fracture. Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003; 85-A: Ross PD, Davis JW, Epstein RS, Wasnich RD. Pain and disability associated with new vertebral fractures and other spinal conditions. J Clin Epidemiol 1994; 47: Keller TS, Harrison DE, Colloca CJ, Harrison DD, Janik TJ. Prediction of osteoporotic spinal deformity. Spine ; 28: Manson NA, Phillips FM. Minimally invasive techniques for the treatment of osteoporotic vertebral fractures. J Bone Joint Surg Am 2006; 88: Yamato M, Nishimura G, Kuramochi E, Saiki N, Fujioka M. MR appearance at different ages of osteoporotic compression fractures of the vertebrae. Radiat Med 1998; 16: Maynard AS, Jensen ME, Schweickert PA, Marx WF, Short JG, Kallmes DF. Value of bone scan imaging in predicting pain relief from percutaneous vertebroplasty in osteoporotic vertebral fractures. AJNR Am J Neuroradiol 2000; 21: Cook GJ, Hannaford E, See M, Clarke SE, Fogelman I. The value of bone scintigraphy in the evaluation of osteoporotic patients with back pain. Scand J Rheumatol 2002; 31: Eck JC, Hodges SD, Humphreys SC. Vertebroplasty: a new treatment strategy for osteoporotic compression fractures. Am J Orthop 2002; 31: ; discussion Galibert P, Deramond H, Rosat P, Le Gars D. [Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty]. Neurochirurgie 1987; 33: Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of kyphoplasty in the treatment of painful osteoporotic vertebral compression fractures. Spine 2001; 26: Spivak JM, Johnson MG. Percutaneous treatment of vertebral body pathology. J Am Acad Orthop Surg 2005; 13: Gaitanis IN, Hadjipavlou AG, Katonis PG, Tzermiadianos MN, Pasku DS, Patwardhan AG. Balloon kyphoplasty for the treatment of pathological vertebral compressive fractures. Eur Spine J 2005; 14: Phillips FM, Ho E, Campbell-Hupp M, McNally T, Todd Wetzel F, Gupta P. Early radiographic and clinical results of balloon 390

10 Minimally Invasive Treatment of Painful Osteoporotic Vertebral Fractures kyphoplasty for the treatment of osteoporotic vertebral compression fractures. Spine 2003; 28: ; discussion Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine 2003; 28(15S): S Gangi A, Kastler BA, Dietemann JL. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy. AJNR Am J Neuroradiol 1994; 15: Mathis JM, Petri M, Naff N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures. Arthritis Rheum 1998; 41: Teng MM, Wei CJ, Wei LC, Luo CB, Lirng, JF, Chang FC, Liu CL, Chang CY. Kyphosis correction and height restoration effects of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2003; 24: Cortet B, Cotten A, Boutry N, Flipo RM, Duquesnoy B, Chastanet P, Delcambre B. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J Rheumatol 1999; 26: Gaughen JR Jr, Jensen ME, Schweickert PA, Kaufmann TJ, Marx WF, Kallmes DF. Relevance of antecedent venography in percutaneous vertebroplasty for the treatment of osteoporotic compression fractures. AJNR Am J Neuroradiol 2002; 23: McGraw JK, Heatwole EV, Strnad BT, Silber JS, Patzilk SB, Boorstein JM. Predictive value of intraosseous venography before percutaneous vertebroplasty. J Vasc Interv Radiol 2002; 13(2 Pt 1): Phillips FM, Todd Wetzel F, Lieberman I, Campbell -Hupp M. An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002; 27: ; discussion Abdul-Jalil Y, Bartels J, Alberti O, Becker R. Delayed presentation of pulmonary polymethylmethacrylate emboli after percutaneous vertebroplasty. Spine 2007; 32: E Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol 2004; 183: Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate : a case report. J Bone Joint Surg Am 2001; 83-A: Rauschmann MA, von Stechow D, Thomann KD, Scale D. [Complications of vertebroplasty]. Orthopade 2004; 33: Cotten A, Dewatre F, Cortet B, Assaker R, Leblond D, Duquesnoy B, Chastanet P, Clarisse J. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996; 200: Heini PF, Orler R. [Vertebroplasty in severe osteoporosis. Technique and experience with multi-segment injection]. Orthopade 2004; 33: Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006; 31: Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001; 26: Grohs JG, Matzner M, Trieb K, Krepler P. Minimal invasive stabilization of osteoporotic vertebral fractures: a prospective nonrandomized comparison of vertebroplasty and balloon kyphoplasty. J Spinal Disord Tech 2005; 18: Kim MJ, Lindsey DP, Hannibal M, Alamin TF. Vertebroplasty versus kyphoplasty: biomechanical behavior under repetitive loading conditions. Spine 2006; 31: Luginbuhl M. Percutaneous vertebroplasty, kyphoplasty and lordoplasty: implications for the anesthesiologist. Curr Opin Anaesthesiol 2008; 21: Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine 2000; 25: Berlemann U, Ferguson SJ, Nolte LP, Heini PF. Adjacent vertebral failure after vertebroplasty. A biomechanical investigation. J Bone Joint Surg Br 2002; 84: Bouza C, Lopez T, Magro A, Navalpotro L, Amate JM. Efficacy and safety of balloon kyphoplasty in the treatment of vertebral compression fractures: a systematic review. Eur Spine J 2006; 15: Fourney DR, Schomer DF, Nader R, Chlan-Fourney J, Suki D, Ahrar K, Rhines LD, Gokaslan ZL. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg 2003; 98(1S): Grados F, Depriester C, Cayrolle G, Hardy N, Deramond H, Fardellone P. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford) 2000; 39: Kim SH, Kang HS, Choi JA, Ahn JM. Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty. Acta Radiol 2004; 45: Uppin AA, Hirsch JA, Centenera LV, Pfiefer BA, Pazianos AG, Choi IS. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology 2003; 226: Becker S, Garoscio M, Meissner J, Tuschel A, Ogon M. Is there an indication for prophylactic balloon kyphoplasty? A pilot study. Clin Orthop Relat Res 2007; 458:

11 Lee JH Lee JH 44. Lunt M, O'Neill TW, Felsenberg D, Reeve J, Kanis JA, Cooper C, Silman AJ. Characteristics of a prevalent vertebral deformity predict subsequent vertebral fracture: results from the European Prospective Osteoporosis Study (EPOS). Bone 2003; 33: Kaufmann TJ, Jensen ME, Schweickert PA, Marx WF, Kallmes DF. Age of fracture and clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2001; 22: Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of new vertebral fracture in the year following a fracture. Jama 2001; 285: Lim TH, Brebach GT, Renner SM, Kim WJ, Kim JG, Lee RE, Andersson GB, An HS. Biomechanical evaluation of an injectable calcium phosphate cement for vertebroplasty. Spine 2002; 27: Verlaan JJ, Oner FC, Verbout AJ, Dhert WJ. Temperature elevation after vertebroplasty with polymethyl-methacrylate in the goat spine. J Biomed Mater Res B Appl Biomater 2003; 67: Takemasa R, Yamamoto H. [Calcium phosphate paste injection for the treatment of vertebral fracture due to osteoporosis]. Clin Calcium 2001; 11: Seeherman HJ, Bouxsein M, Kim H, Li R, Li XJ, Aiolova M, Wozney JM. Recombinant human bone morphogenetic protein-2 delivered in an injectable calcium phosphate paste accelerates osteotomy-site healing in a nonhuman primate model. J Bone Joint Surg Am 2004; 86- A: Lieberman IH, Togawa D, Kayanja MM. Vertebroplasty and kyphoplasty: filler materials. Spine J 2005; 5(6S): 305S -316S. 52. Verlaan JJ, Oner FC, Slootweg PJ, Verbout AJ, Dhert WJ. Histologic changes after vertebroplasty. J Bone Joint Surg Am 2004; 86 - A: Peer Reviewers Commentary 392

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R