AJR 2004; 182:947-951
© American Roentgen Ray Society
Percutaneous Vertebroplasty in Patients with Spinal Canal Compromise
Noah B. Appel1,2 and
Louis A. Gilula3
1 Mallinckrodt Institute of Radiology, Section of Interventional Radiology,
Washington University Medical Center, St. Louis, MO 63110-1076.
2 Present address: Dallas Radiologists, P.A., 7515 Greenville Ave., Ste. 710,
Dallas, TX 75231-3848.
3 Mallinckrodt Institute of Radiology, Section of Musculoskeletal Radiology,
Washington University Medical Center, 510 S Kingshighway Blvd., St. Louis, MO
63110-1076.
Received July 30, 2003;
accepted after revision October 21, 2003.
Address correspondence to L. A. Gilula
(gilula{at}mir.wustl.edu).
Presented at the 2003 annual meeting of the American Roentgen Ray Society,
San Diego, CA.
Abstract
OBJECTIVE. The American College of Radiology Standard for
Performance of Percutaneous Vertebroplasty lists as relative contraindications
to the procedure conditions causing "significant spinal canal
compromise." We believe percutaneous vertebroplasty can be performed
safely and efficaciously in individuals without radicular symptoms who present
with canal compromise, with or without cord compression.
MATERIALS AND METHODS. We reviewed all vertebroplasties performed at
our institution over the past 4 years. Cases in which vertebroplasty was
performed at levels showing complete effacement of the epidural space,
particularly those with cord compression, were included in the review.
Follow-up data obtained from questionnaires routinely sent to our
vertebroplasty patients were used to evaluate symptomatic response in this
subset of patients as well as the occurrence of any complications.
RESULTS. Of 686 levels treated over the past 4 years, 26 levels in
23 patients qualified for our review. Follow-up ranged from 6 months to 2
years. Patients were asked to rate the degree of their original pain as
follows: gone, better than, the same as, or worse than before the procedure.
Of the 23 patients, five (22%) reported complete resolution of pain, 15 (65%)
reported their symptoms to be better, and three (13%) reported no appreciable
change. No complications with clinical sequelae were encountered.
CONCLUSION. Percutaneous vertebroplasty can be performed safely at
levels showing spinal cord compression in patients without radicular signs.
Most patients (87%) in our series showed some improvement or complete
eradication of their symptoms. No patient reported worsening symptoms.
Introduction
Vertebroplasty for the treatment of benign or malignant compression
fractures has gained widespread popularity in the 15 years since its initial
description [1]. In the many
articles and books written on the subject, including the American College
of Radiology (ACR) Standards
[2], spinal cord compression or
encroachment on the central spinal canal is mentioned as a relative
contraindication. We could find no articles or references to vertebroplasty
performed in patients with fractures impinging on the epidural space or spinal
cord. Subsequently, we reviewed all vertebroplasties performed at our
institution from June 9, 1998, to July 1, 2002, paying attention to levels
treated at which cord compression was thought to be present, with the goal of
showing that treating such levels can be safe and effective.
Materials and Methods
Over a period of approximately 4 years (June 9, 1998–July 1, 2002),
686 percutaneous vertebroplasties were performed in 288 patients during 350
treatment sessions. Imaging from all cases with MRI studies was reviewed for
evidence of effacement of the epidural space around the spinal cord and
compression of the cord. Cases in which MRI clearly showed complete effacement
of the epidural space or obvious deformity of the spinal cord as a result of a
compression fracture at the treated level were included in the subsequent
analysis.
Of the selected cases, broad classification of the degree of spinal canal
encroachment or spinal cord involvement was performed as follows: complete
effacement of the ventral epidural space but no spinal cord deformity,
deformity in spinal cord shape but no abnormal spinal cord signal on
T2-weighted MRI, and presence of abnormal signal within the spinal cord on
T2-weighted MRI (Fig. 1A,
1B,
1C,
1D). If the imaging studies
were performed at our institution, the dictated report of the study by the
neuroradiology department was reviewed to evaluate the level of agreement with
interpretation. In one case, there was disagreement with the dictated report.
The images in question were reviewed with a board-certified neuroradiologist
for resolution.
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Fig. 1B. —Graphics show classification of spinal canal (or spinal cord)
compromise (axial representation). Graphic shows category 1 classification:
loss of ventral epidural space with no spinal cord deformity.
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Fig. 1C. —Graphics show classification of spinal canal (or spinal cord)
compromise (axial representation). Graphic shows category 2 classification:
spinal cord deformity but no abnormal cord signal on T2-weighted images.
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Fig. 1D. —Graphics show classification of spinal canal (or spinal cord)
compromise (axial representation). Graphic shows category 3 classification:
cord deformity with increased signal within cord on T2-weighted images.
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Indications for the vertebroplasties were focal, severe, and intractable
pain at the level of a known compression fracture without definite radicular
signs or symptoms. The vertebroplasties were performed in patients who were
not candidates for surgery because of age, severe bone demineralization, or
debilitation. Contraindications included continued radicular symptoms and
unstable fractures involving posterior spinal elements. Percutaneous
vertebroplasty was performed under strict sterile conditions with patients in
the prone position using C-arm fluoroscopy for guidance. The patients' vital
signs were continuously monitored. Conscious sedation and analgesia were
accomplished with IV fentanyl (Sublimaze, Abbott Laboratories) and midazolam
(Versed, Roche Pharmaceuticals). The patients were kept alert enough so they
could state if any pain developed during the procedure. An 11- or 13-gauge
Jamshidi-type bone biopsy trochar (Medical Devices Technologies) was advanced
until its tip abutted the lamina posterior to the pedicle. With fluoroscopic
guidance, the trochar was passed through the pedicle selected and into the
vertebral body. Intraosseous venography was performed with 1–3 mL of
iohexol (Omnipaque 300, Nycomed) injected through the trochar. Adjustment of
needle positioning was made on the basis of contrast material passing directly
in a draining vein without first passing through osseous structures on the
venogram [3].
Methylmethacrylate powder (Osteobond copolymer bone cement, Zimmer) was mixed
with about 7 g of barium sulfate powder that had been previously sterilized
with dry heat [4] to increase
opacity. The barium was mixed and ground into fine particles and then combined
with the methylmethacrylate powder; 1.2 g of tobramycin (Nebcin, Eli Lilly)
was then added to the mixture in earlier cases. In later cases, an IV
antibiotic was given at the beginning of the procedure before injecting the
polymethylmethacrylate mixture. The liquid methylmethacrylate monomer was then
added to the powder and mixed into a toothpaste-like consistency. The
polymethylmethacrylate mixture was placed in a 20-mL syringe and back-filled
into a screw-type 10-mL syringe (LeVeen, Boston Scientific) or a modified type
of injector [5], while care was
taken to expel air from the polymethylmethacrylate mixture. The remainder of
the polymethylmethacrylate in the 20-mL syringe was placed in a cold water
bath for later use, if needed. The polymethylmethacrylate mixture was injected
through the trochar under fluoroscopy in the lateral projection. The stopping
point was determined when filling passed to the posterior quarter of the
vertebral body or leakage occurred in the paravertebral space or the
intervertebral disk space. If leakage outside the vertebral body was noted,
injection of the polymethylmethacrylate mixture was stopped for 1–2 min
to allow hardening of the mixture to plug the leak; alternatively the needle
was repositioned. If the polymethylmethacrylate mixture did not cross the
midline of the vertebral body from a single pedicle injection, the
contralateral pedicle was accessed for further filling of the vertebral
body.
Before vertebroplasty, the patient's level of pain was recorded using the
visual analog scale method. Approximately 1 hr after the procedure, patients
were asked again to rate their pain with the same visual analog scale. Pain
was evaluated at follow-up using telephone questionnaires as completely
resolved, better, unchanged, or worse. The intervals for follow-up were
immediately after the procedure and at 24 hr, 2 weeks, 1 month, 3 months, 6
months, 1 year, and 2 years. The initial data collection and subsequent review
were performed with the approval of our institutional review board, and
informed consent was obtained for the review of patient records.
Results
Twenty-six levels in 23 patients (six men and 17 women) were judged
suitable for this review. The average age of the patients was 72 years 4
months (range, 47 years–85 years 2 months); the median age was 76 years
6 months. Levels treated at which there was thought to be spinal canal
compromise were as follows: T4 (n = 2), T5 (n = 1), T6
(n = 2), T7 (n = 2), T8 (n = 3), T9 (n =
2), T11 (n = 3), T12 (n = 4), L1 (n = 6), and L2
(n = 1). Of these, six caused ventral epidural space effacement but
did not actually deform the spinal cord or conus medullaris (category 1); 19
caused cord compression with deformity in shape but no abnormal cord signal
(category 2) (Figs. 2A,
2B and
3A,
3B); and one showed cord
compression and abnormal spinal cord signal on T2-weighted MRI (category 3)
(Fig. 4A,
4B). Seven of the patients had
neoplasm-related compression fractures, and 16 were believed to have fractures
resulting from osteoporosis. The average volume of polymethylmethacrylate
mixture injected into the levels reviewed was 5.7 mL (range, 1–10.25
mL). Twenty-two of the levels were injected via a unilateral pedicle approach
only; the other four required bilateral pedicle injections.
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Fig. 2A. —83-year-old woman with metastatic carcinoma. Axial (TR/TE,
1,785/110) (A) and sagittal (4,400/110) (B) T2-weighted images
show category 2 lesion with deformation of spinal cord at T9 level.
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Fig. 2B. —83-year-old woman with metastatic carcinoma. Axial (TR/TE,
1,785/110) (A) and sagittal (4,400/110) (B) T2-weighted images
show category 2 lesion with deformation of spinal cord at T9 level.
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Fig. 3A. —84-year-old woman with osteoporotic compression fracture.
Axial (TR/TE, 6,610/112) (A) and sagittal (6,517/130) (B)
T2-weighted images of category 2 lesion show spinal cord deformity without
abnormal spinal cord signal at T12.
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Fig. 3B. —84-year-old woman with osteoporotic compression fracture.
Axial (TR/TE, 6,610/112) (A) and sagittal (6,517/130) (B)
T2-weighted images of category 2 lesion show spinal cord deformity without
abnormal spinal cord signal at T12.
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Fig. 4A. —51-year-old woman with multiple myeloma. Axial (TR/TE,
5,565/112) (A) and sagittal (5,664/112) (B) T2-weighted images
of category 3 lesion. At T11 level, spinal cord is deformed with increased
signal (arrow, A and arrowheads, B) within
cord itself.
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Fig. 4B. —51-year-old woman with multiple myeloma. Axial (TR/TE,
5,565/112) (A) and sagittal (5,664/112) (B) T2-weighted images
of category 3 lesion. At T11 level, spinal cord is deformed with increased
signal (arrow, A and arrowheads, B) within
cord itself.
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The mean pain score immediately before vertebroplasty was 7.6 (range,
2–10) the patient with a score of 2 was taking her usual dose of pain
medication. The mean pain score immediately (up to 24 hr) after vertebroplasty
was 1.7 (range, 0–5). Long-term follow-up ranged from 6 to 24 months
(mean, 12 months). At approximately 1 hr after the procedure, 12 patients
(52%) reported complete resolution of pain, 11 (48%) reported their pain to be
better, and none reported their pain to be the same or worse. At last
follow-up, five (22%) of these 23 patients reported complete resolution of
pain, 15 (65%) reported their pain to be better, three (13%) reported no
change, and none reported worsening of their pain. At last follow-up, 11
patients (48%) were no longer taking pain medication.
No complications with any clinical sequelae requiring surgical intervention
or making the condition worse than before treatment occurred at the levels
studied with canal compromise or cord compression. Extension of small amounts
of the polymethylmethacrylate mixture into the intervertebral disk,
paravertebral space or paravertebral veins was not considered a complication
in this study because such extension had no clinical significance (Fig.
5A,
5B,
5C,
5D). This position is
supported by previously published articles
[6–10].
In one case, only a small amount of the polymethylmethacrylate mixture could
be injected because of early extravasation into the disk inferior to the
vertebral body being treated. The patient continued to have pain at that
level, so repeated vertebroplasty at the same level was performed at a later
date with better filling of the vertebral body and improvement in symptoms.
Extension of a tiny amount of the mixture posteriorly into the epidural space
occurred in one patient (5%) and was not at the level with cord compression;
the patient experienced no symptoms related to the epidural
polymethylmethacrylate mixture. In another patient, postprocedural shortness
of breath developed with decreased oxygen saturation requiring up to 4 L of
oxygen by nasal cannula. The patient had undergone four-level vertebroplasty
and was admitted to the hospital after the procedure for further evaluation
and treatment. A chest radiograph showed subsegmental atelectasis. Pulmonary
embolus was excluded by clinical examination and ventilation–perfusion
scintigraphy; pulmonary function tests showed restrictive lung disease deemed
related to kyphosis. The patient was discharged home in good condition on the
fifth hospital day. A different patient had decreased pain at the treated
level but reported increased pain in both lower extremities. No radiographic
complication was noted, and neurologic examination findings were nonfocal and
unchanged. Her symptoms improved without further intervention.
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Fig. 5A. —Examples of polymethylmethacrylate leakage seen on
fluoroscopic spot radiographs. Patients experienced no complications related
to leakage of polymethylmethacrylate mixture. Frontal (A) and lateral
(B) radiographs of 84-year-old woman with osteoporatic compression
fracture (same patient as in Fig.
3A,
3B) with needles placed into
adjacent segments at T12 and L1 led to polymethylmethacrylate pasing through
intervening disk (A), anteriorly to form bridge (A and B)
between these two segments. This patient had preprocedure pain score
(lowest–highest, 0–10) of 8, postprocedural score of 0, and was
"better" at 6-month follow-up.
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Fig. 5B. —Examples of polymethylmethacrylate leakage seen on
fluoroscopic spot radiographs. Patients experienced no complications related
to leakage of polymethylmethacrylate mixture. Frontal (A) and lateral
(B) radiographs of 84-year-old woman with osteoporatic compression
fracture (same patient as in Fig.
3A,
3B) with needles placed into
adjacent segments at T12 and L1 led to polymethylmethacrylate pasing through
intervening disk (A), anteriorly to form bridge (A and B)
between these two segments. This patient had preprocedure pain score
(lowest–highest, 0–10) of 8, postprocedural score of 0, and was
"better" at 6-month follow-up.
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Fig. 5C. —Examples of polymethylmethacrylate leakage seen on
fluoroscopic spot radiographs. Patients experienced no complications related
to leakage of polymethylmethacrylate mixture. Frontal (C) and lateral
(D) spot radiographs of 51-year-old woman (same patient as in Fig.
4A,
4B) with small amount of
paravertebral leakage present bilaterally. This patient had preprocedural pain
score (lowest–highest, 0–10) of 7, immediate postprocedural score
of 3.5, and was "better" at 3-month follow-up and
"same" at 6-month follow-up.
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Fig. 5D. —Examples of polymethylmethacrylate leakage seen on
fluoroscopic spot radiographs. Patients experienced no complications related
to leakage of polymethylmethacrylate mixture. Frontal (C) and lateral
(D) spot radiographs of 51-year-old woman (same patient as in Fig.
4A,
4B) with small amount of
paravertebral leakage present bilaterally. This patient had preprocedural pain
score (lowest–highest, 0–10) of 7, immediate postprocedural score
of 3.5, and was "better" at 3-month follow-up and
"same" at 6-month follow-up.
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Discussion
Vertebroplasty for benign or malignant disease has been described
extensively [2,
6–14].
In these publications, the indications and contraindications are discussed.
Absolute contraindications as listed in the ACR Standards are
asymptomatic stable fracture, symptomatic improvement with medical therapy,
prophylaxis, osteomyelitis, acute traumatic fracture in nonosteoporotic
vertebrae, coagulopathy, and allergy to any of the various components used for
the procedure [2]. Other
contraindications listed elsewhere as absolute or relative include the lack of
ability to provide emergency decompressive surgery
[8,
9,
12], radicular signs due to
vertebral body collapse or tumor extension
[8,
9], and severe compression
deformities [2,
12]. The topic of severe
vertebral compression deformities in vertebroplasty has been addressed in a
previous article [8], showing
that though extra care must be taken, the severity of the compression fracture
itself is not necessarily a contraindication to vertebroplasty.
Spinal canal compromise and spinal cord compression have also been cited as
relative contraindications by the ACR Standards and other
publications [2,
12–14].
Limits listed in these various publications range from "significant
spinal canal compromise"
[2,
11] and "pressure of
bone fragments on the spinal cord"
[12] to "canal narrowing
of greater than 20%"
[13,
14]. On performing a search of
the literature, we could find no publications specifically addressing the
issue of percutaneous vertebroplasty in such cases.
In this retrospective study, we reviewed cases from our institution in
which percutaneous vertebroplasty was performed at levels with spinal canal
compromise. Cases were included if there was complete effacement of the
ventral epidural space or compression of the spinal cord. Twenty-six levels
were thought to meet the criteria stated. All patients underwent successful
percutaneous vertebroplasty. No complications with clinical or neurologic
sequelae occurred related to treatment of the compromised level. Almost all
the patients (20/23) experienced improvement or resolution of their
preprocedural pain.
On the basis of review of our data, we believe that severe spinal canal
compromise and even spinal cord compression should not preclude performance of
percutaneous vertebroplasty when approached by persons experienced in
performing vertebroplasty or when handled by a person who feels comfortable in
dealing with such potentially difficult cases. This procedure is especially
valuable in the older, markedly debilitated patient who has no other
alternative to treatment except bed confinement or doses of pain medication
that make the patient nonfunctional. With care, the procedure can be safely
performed in this group of patients. Because of low numbers in the group with
compression related to neoplastic disease, we cannot specifically address that
subset of patients. However, that issue is addressed in an article currently
pending publication [15].
Acknowledgments
We would like to thank Joshua Shimony and Jill Gibson for their assistance
with data used in the preparation of this manuscript.
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Abstract
Introduction
