AJR 2003; 180:87-91
© American Roentgen Ray Society
Additional Value of a Modified Method of Intraosseous Venography During Percutaneous Vertebroplasty
Wilfred C. G. Peh1 and
Louis A. Gilula2
1 Department of Diagnostic Radiology, Singapore General Hospital, Outram Rd.,
169608 Singapore.
2 Mallinckrodt Institute of Radiology, Washington University Medical Center, 510
S. Kingshighway Blvd., St. Louis, MO 63110.
Received February 28, 2002;
accepted after revision June 18, 2002.
Address correspondence to L. A. Gilula.
Introduction
Percutaneous vertebroplasty is a relatively new radiologic procedure that
relieves pain and strengthens collapsed vertebrae with the injection of
polymethyl methacrylate (PMMA), a rapidly setting bone cement, into the
vertebral body. This procedure is being increasingly adopted as an option in
the management of severe midline back pain caused by vertebral compression
fractures. The risks of the procedure are generally low when performed
carefully, but complications may be severe
[1,2,3,4,5,6,7].
PMMA extension into the epidural venous plexus and into the spinal canal can
contribute to spinal stenosis with cord or nerve root compression
[1,2,3,4,5,6,7].
PMMA extending from the paraspinous veins into the vena cava may result in
pulmonary embolus [1,
4,5,6,7].
The risk of venous embolus increases if the radiologist cannot see PMMA
passing into the venous system. On the basis of our experience in performing
574 percutaneous vertebroplasties in 291 consecutive patients over a 43-month
period (June 9, 1998—January 24, 2002), we describe a modification of
the routine intraosseous venography technique that we use and highlight the
value of this modified procedure during percutaneous vertebroplasty.
Technique
After positioning an 11- or 13-gauge disposable bone biopsy trochar needle
tip in the anterior one third to one fourth of the compressed or diseased
vertebral body, the operator removes the stylet from the trochar needle. The
hub of a 7-inch (18 cm) 22-gauge needle is attached to a connecting tube,
which is attached to a syringe containing contrast material suitable for
myelography (Omnipaque 180 [iohexol]; Nycomed, Princeton, NJ). The 22-gauge
needle is pushed into the trochar needle until its tip reaches the vertebral
body. If the operator does not feel the 22-gauge needle tip touching the bone,
then lateral fluoroscopy can be used to determine whether the needle has
passed through the vertebral body (Fig.
1A,1B,1C).
The needle tip may not be felt to touch the bone in some patients,
particularly in those with soft or diseased vertebral bodies. This 22-gauge
needle is used to fill the trochar needle from the vertebral body outward to
eliminate air in the needle before injecting the contrast material.
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —88-year-old woman with severe osteoporosis who underwent
vertebroplasty of L1 and L3 vertebrae performed elsewhere without subsequent
relief of pain. New fracture occurred at T12 vertebra. Fluoroscopic image
shows needle tip (arrow) at anterior aspect of vertebral body;
22-gauge needle was passed through 11-gauge trochar with little
resistance.
|
|
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —88-year-old woman with severe osteoporosis who underwent
vertebroplasty of L1 and L3 vertebrae performed elsewhere without subsequent
relief of pain. New fracture occurred at T12 vertebra. Fluoroscopic image
shows that less than 0.5 mL of contrast material (arrows) is pooling
at anterior edge of vertebral body.
|
|
View larger version (142K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —88-year-old woman with severe osteoporosis who underwent
vertebroplasty of L1 and L3 vertebrae performed elsewhere without subsequent
relief of pain. New fracture occurred at T12 vertebra. Fluoroscopic image
shows that saline flush of trochar needle causes contrast material
(arrows) to pool anteriorly without filling draining veins.
|
|
Contrast material is then injected to fill the trochar needle, the needle
is removed from the connecting tube, and the connecting tube is attached
directly to the trochar needle. A lateral fluoroscopic image is obtained and
displayed as the last image hold on one fluoroscopic screen. Intraosseous
venography using 0.5-2 mL of iohexol is then performed under direct lateral
fluoroscopic visualization. Approximately 0.5 mL of the contrast material is
injected into the vertebral body. The operator should watch for the following
three features: passage of the contrast material into bone trabeculae before
leaving the bone through draining veins, the amount of bone vascularity, and
the site of the draining veins (Fig.
2A,2B,2C).
View larger version (132K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —84-year-old woman with painful osteoporotic fracture of L1
vertebra. Fluoroscopic image shows that approximately 0.5 mL of contrast
material that was injected through 11-gauge trochar needle is pooling
anteriorly. Contrast material moved posteriorly through intraosseous central
vein (arrows) into posterior vein (arrowheads).
|
|
View larger version (135K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —84-year-old woman with painful osteoporotic fracture of L1
vertebra. Fluoroscopic image obtained after saline flush shows dispersion of
contrast material with small residual amount in anteroinferior aspect of
vertebral body.
|
|
View larger version (139K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —84-year-old woman with painful osteoporotic fracture of L1
vertebra. Fluoroscopic image obtained after injection of polymethyl
methacrylate with sterilized barium shows this injected material is passing
into area where contrast material was previously injected. Larger particles of
barium (arrows) are visible within needle.
|
|
A second look at these features is provided by a washout injection. A
washout venogram can be obtained by injecting saline from a 20-mL syringe that
is attached directly to the trochar needle. The saline clears residual
contrast material from the vertebral body and the adjacent structures. If all
the desired features still cannot be seen, a second or third injection of 0.5
mL of contrast material can be performed. No subtraction series is performed
except in rare cases when anatomy cannot be determined. The saline syringe
remains attached to the trochar needle so that the trochar needle is filled
with fluid until the PMMA is ready for injection. After final adjustment of
the needle position and intraosseous venography, vertebroplasty may
proceed.
Discussion
Among the increasing number of articles about the various aspects of
percutaneous vertebroplasty, some authors have discussed using intraosseous
venography [6,
8], whereas others do not favor
its use
[2,3,4,5].
In a recent review article, Mathis et al.
[1] remarked that venography is
not commonly used in Europe. Some of the leading proponents of vertebroplasty
from Europe do not appear to advocate its routine use
[2,3,4].
In fact, Cotten et al. [5], in
a response to an invited commentary by Barr and Barr, stated that they do not
perform intraosseous venography. These authors mentioned that they did the
procedure earlier in their experience, particularly in patients with
aggressive vertebral hemangiomas. Deramond et al.
[4] reported that they perform
venography only for managing angioma.
The major goals of intraosseous venography are to determine whether the
needle is positioned in a direct venous anastomosis to the central or epidural
veins, observe the venous structures that are filled first, and gain
information to anticipate the preferential pathway of cement passage during
subsequent injection [6].
However, the technical details and additional potential usefulness of routine
intraosseous venography during this procedure have not been, to our knowledge,
previously emphasized. In our search of the literature, we found that Jensen
and Dion [6] wrote what is
probably the most detailed description of the intraosseous venography
technique in their review article. They use 3-5 mL of iohexol for venography
during vertebroplasty. These authors stated that in addition to showing needle
placement directly in the basivertebral venous plexus and outlining the
trabecular venous drainage, vertebrography allowed easy identification of the
junction between the basivertebral venous plexus and the anterior epidural
venous plexus, giving the operator a reference point to watch during PMMA
injection. Maynard et al. [8]
recommended using 3-5 mL of contrast medium and performed intraosseous
venography using a biplane digital subtraction angiography unit at a framing
rate of 2 frames per second.
In one of our early cases, a needle communicated directly with the lung.
Recognizing this fact before injecting PMMA prevented a potentially serious
complication. If any suspicion that a trochar tip is close to or through the
side of a vertebral body exists, fluoroscopy can be used as the X-ray tube and
image intensifier are rotated around the vertebral body. If the trochar tip is
within 1-2 mm of the side of the vertebral body, venography can help ensure
that the PMMA stays inside the vertebral body after injection (Fig.
3A,3B).
If the trochar tip has penetrated the side of the vertebral body, the first
trochar needle can be left in place to block that hole and a second trochar
needle can be placed through the opposite pedicle to perform vertebroplasty.
We used this method in one of our patients and were able to successfully
perform vertebroplasty through the second needle without leakage through the
first needle hole.
View larger version (133K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —47-year-old man with metastatic lung cancer to L3 vertebra.
Fluoroscopic image shows needle passing obliquely through right pedicle,
across midline, to left lateral side of vertebral body. Venography revealed
density of contrast material overlying left pedicle (arrows) with
draining vein overlying left side of vertebral body.
|
|
View larger version (144K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —47-year-old man with metastatic lung cancer to L3 vertebra.
Fluoroscopic image shows that needle tip is close to side of vertebral body.
Intraosseous venography shows contrast material passing through vertebral body
(arrows) before passing to draining vein. Subsequent vertebroplasty
was successful and without complication.
|
|
In a few other cases, the injection of contrast material reveals direct
communication of the central vein in the vertebral body without prior passage
through some bone trabeculae, leading to direct passage of contrast material
to the epidural veins. Even a tiny amount of osseous filling may be sufficient
to safely inject PMMA (Fig.
3A,3B).
Recognizing direct filling of a venous structure allows the needle position to
be readjusted, typically by advancing the needle more anterior in the
vertebral body, to ensure that the bone trabeculae opacify before venous
filling. Another value of watching the flow of contrast material in the
vertebral body is that extreme vascularity of the vertebral body or even no
appreciable vascularity—as seen in areas of solid fibrous, osseous, or
tumor tissue—can be detected.
In the presence of a vascular bone, allowing 30-60 sec or more for a small
amount of PMMA from the first injection to set up in the vertebral body before
injecting all the PMMA is helpful (Lawler GJ, personal communication). Since
we started using this variation of the injecting technique, we rarely see the
vascular structures immediately filling with PMMA. Recognizing the location of
draining venous structures allows one to predict where venous filling may
first occur.
If a fracture cleft is present in the vertebral body, the injection of
contrast material can also show fluid communication to the cleft (Fig.
4A,4B,4C,4D).
If the fracture cleft begins to fill with contrast material, the injection
should be stopped immediately to avoid fully opacifying the cleft. When a
fracture cleft is present and contrast material does not pass into the
fracture cleft, the needle may need to be read-justed at that time, or later,
to fill the fracture cleft. We believe that when a fracture cleft is present,
the cleft may need to be filled to eliminate the patient's presenting
pain.
View larger version (154K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —80-year-old woman with painful osteoporotic fracture of T12
vertebra containing area affected by vacuum phenomenon. Fluoroscopic image,
obtained with patient lying prone after less than 0.5 mL of contrast material
had passed through needle inside of trochar needle, shows layering (black
arrows) of contrast material inside area affected by vacuum phenomenon.
Layering of contrast material reveals that subsequent injection of methyl
methacrylate will pass into fracture cleft (vacuum phenomenon). Small amount
of contrast material passes (white arrows) anteriorly and
superiorly.
|
|
View larger version (165K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —80-year-old woman with painful osteoporotic fracture of T12
vertebra containing area affected by vacuum phenomenon. Fluoroscopic image
obtained after saline flush of trochar needle shows contrast material
dispersing through remainder of vertebral body, but not so much that
subsequent methyl methacrylate injection will be disrupted. Area affected by
vacuum phenomenon (arrows) is outlined with contrast material.
|
|
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C. —80-year-old woman with painful osteoporotic fracture of T12
vertebra containing area affected by vacuum phenomenon. Fluoroscopic image
shows area affected by vacuum phenomenon (arrows) is filled partially
with methyl methacrylate.
|
|
View larger version (151K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4D. —80-year-old woman with painful osteoporotic fracture of T12
vertebra containing area affected by vacuum phenomenon. Fluoroscopic image
reveals that area affected by vacuum phenomenon and fracture cleft are filled
with methyl methacrylate.
|
|
Care should be taken not to introduce too much contrast material into the
vertebral body because differentiating the contrast material leaving the
vertebral body from PMMA may be difficult during the subsequent PMMA
injection. If residual contrast material is excessive, repeated flushing of
the needle with sterile saline can be performed, as mentioned. Early in our
experience with a few patients, we performed routine intraosseous venography
by injecting a few milliliters of contrast material and then examining the
images, often with image subtraction (Fig.
5). We soon recognized that this approach took more time and was
not needed to gather the needed information. Murphy and Deramond
[7] stated that valuable time
during intraosseous venography may be lost in assessing whether PMMA or
contrast material is observed to move after contrast retention
[7]. The approach we describe
takes only a few seconds to 1 min and requires no filming or capturing only
one or more fluoroscopic images.
View larger version (132K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5. —78-year-old woman with painful osteoporotic fracture of L1
vertebra. Fluoroscopic image obtained during digital subtraction intraosseous
venography shows contrast material (arrowheads) is pooling within
vertebral body. Major draining veins (arrows) are visible.
|
|
Mathis et al. [1] emphasized
some limitations of intraosseous venography—namely, different flow
characteristics between contrast medium and PMMA—and questioned whether
the depiction of extracorporeal venous filling actually led to modification of
the injection technique. In addition, they stated that contrast filling of
fracture clefts may preclude early detection of PMMA leakage at the same site
[1]. Deramond et al.
[4] mentioned that when
performing vertebroplasty for malignant spinal tumors, contrast material that
has been injected into the tumor may diffusely stain the tumor tissue and may
not be washed out. This staining may interfere with the fluoroscopic
evaluation during PMMA injection. Although intraosseous venography has been
reported to obscure bone detail so much that vertebroplasty cannot be
performed [1], we have never
encountered this problem.
We believe that the difficulties highlighted by some of the other authors
can be overcome by our technique of using a small amount (0.5-2 mL) of
low-concentration contrast medium. The key is to carefully scrutinize the
fluoroscopic images to identify opacification of bone trabeculae and filling
of any venous structures with the initial 0.5-mL contrast injection. Using
small amounts of contrast material (
0.5 mL) should overcome the problems
of excessive staining of tumor or tissue and filling of the fracture cleft
(Fig.
6A,6B).
This method can also show whether the placement of the needle tip allows
injected material to pass directly into a disk or some other undesirable
structure. Unwanted residual contrast material can be reduced or eliminated by
flushing the needle with a small amount of saline
(Fig. 6B); however, access to
a high-quality fluoroscopy machine with the capability to hold the last
fluoroscopic image is essential, and the radiologist must have a thorough
knowledge of regional venous anatomy.
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A. —47-year-old man with metastatic lung cancer to T10 vertebra.
Fluoroscopic image obtained during intraosseous venography shows patchy
distribution of contrast material throughout vertebral body (arrows)
with contrast material pooling posteroinferiorly (small arrowheads).
Anterosuperior and inferior corners of vertebral body (large
arrowheads) are faintly visible. Thoracolumbar vertebrae at lung-liver
interface may be challenging to see and to produce good images of at
fluoroscopy.
|
|
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6B. —47-year-old man with metastatic lung cancer to T10 vertebra.
Fluoroscopic image obtained after saline flush of trochar needle shows
contrast material (arrows) has dispersed so much that it is barely
visible.
|
|
We believe that the additional minimal time and effort spent in performing
intraosseous venography are justified in view of the potentially severe
complications. Solutions for overcoming persistent venous communication
include repositioning the needle tip more anteriorly, injecting gelatin sponge
pledgets (which we have not performed in a vertebral body to date), and
introducing PMMA into the needle to block the vein and puncturing the
contralateral pedicle with a second needle
[6]. Cotten et al.
[5] stated that the best way to
minimize the risk of venous leakage is to inject PMMA that has the consistency
of a paste rather than a liquid. When performing the procedure on a highly
vascular bone, allowing the first injected PMMA to set up in the vertebral
body for a short time may also help eliminate rapid passage of PMMA into
vascular structures.
References
- Mathis JM, Barr JD, Belkoff SM, Barr MS, Jensen ME, Deramond H.
Percutaneous vertebroplasty: a developing standard of care for vertebral
compression fractures. AJNR
2001;22:373
-381[Free Full Text]
- Weill A, Chiras J, Simon JM, Rose M, Sola-Martinez T, Enkaoua E.
Spinal metastases: indications for and results of percutaneous injection of
acrylic surgical cement. Radiology
1996;199:241
-247[Abstract/Free Full Text]
- Cyteval C, Sarrabere MP, Roux JO, et al. Acute osteoporotic
vertebral collapse: open study on percutaneous injection of acrylic surgical
cement in 20 patients. AJR
1999;173:1685
-1690[Abstract]
- Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous
vertebroplasty with polymethyl-methacrylate: technique, indications, and
results. Radiol Clin North Am
1998;36:533
-546[Medline]
- Cotten A, Boutry N, Cortet B, et al. Percutaneous vertebroplasty:
state of the art. RadioGraphics
1998;18:311
-323[Abstract]
- Jensen ME, Dion JE. Percutaneous vertebroplasty in the treatment of
osteoporotic compression fractures. Neuroimag Clin North
Am 2000;10:547
-568
- Murphy KJ, Deramond H. Percutaneous vertebroplasty in benign and
malignant disease. Neuroimag Clin North Am
2000;10:535
-545
- 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
2000;21:1807
-1812[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. K. Singh, T. K. Pilgram, and L. A. Gilula
Osteoporotic Compression Fractures: Outcomes after Single- versus Multiple-Level Percutaneous Vertebroplasty
Radiology,
January 1, 2006;
238(1):
211 - 220.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. S. Shimony, L. A. Gilula, A. J. Zeller, and D. B. Brown
Percutaneous Vertebroplasty for Malignant Compression Fractures with Epidural Involvement
Radiology,
September 1, 2004;
232(3):
846 - 853.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. B. Appel and L. A. Gilula
Percutaneous Vertebroplasty in Patients with Spinal Canal Compromise
Am. J. Roentgenol.,
April 1, 2004;
182(4):
947 - 951.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. D. Souftas, L. A. Gilula, W. C. G. Peh, and M. S. Gelbart
Gas in the Epidural Space After Percutaneous Vertebroplasty: Where Does the Gas Come From?
Am. J. Roentgenol.,
March 1, 2004;
182(3):
818 - 819.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Gilula, D. F. Kallmes, M. E. Jensen, and W. F. Marx
Is Insufficient Use of Polymethylmethacrylate a Cause for Vertebroplasty Failure Necessitating Repeat Vertebroplasty?
AJNR Am. J. Neuroradiol.,
November 1, 2003;
24(10):
2120 - 2122.
[Full Text]
[PDF]
|
|
|
Top
Introduction
Technique
