DOI:10.2214/AJR.04.0675
AJR 2006; 186:909-910
© American Roentgen Ray Society
Percutaneous Vertebroplasty in Osteoporotic Compression Fracture with Epidural Hematoma
Anand Singh1,
Charles A. Wetherington2 and
Louis A. Gilula3
1 Barnes-Jewish Hospital Mallinckrodt Institute of Radiology St. Louis, MO
63110
2 Microsurgery and Brain Research Institute St. Louis, MO 63110
3 Washington University School of Medicine Mallinckrodt Institute of
Radiology St. Louis, MO 63110
An 81-year-old white man presented to an outside institution with back
pain. The patient was diagnosed with vertebral compression fractures at
multiple vertebral levels including T6, T8, L3, and L4, with focal pain
directly referable to those levels. A moderate subacute epidural hematoma was
evident at T6 in outside MR images (Figs.
5A and
5B). Conservative therapy
including analgesics showed no change in physical examination or functional
status for 3 months, and the patient remained bed-ridden because of severe
pain.
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Fig. 5A —81-year-old man with epidural hematoma at level of T6 vertebral
body. Sagittal spin-echo T1-weighted image (TR/TE, 450/14) shows increased
signal intensity (arrows) posteriorly within spinal canal consistent
with epidural hematoma at level of T6 vertebral body.
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Fig. 5B —81-year-old man with epidural hematoma at level of T6 vertebral
body. Axial spin-echo T1-weighted image (TR/TE, 450/15) shows severe
compression of spinal cord at level of T6 vertebral body secondary to epidural
hematoma.
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He presented for percutaneous vertebroplasty after neurosurgical
consultation concluded that no surgical procedure could be offered secondary
to his epidural hematoma and comorbidities. Because of clinical stability of
symptoms and findings at physical examination, the epidural hematoma itself
was thought to be unchanged.
Percutaneous vertebroplasty was then performed using our standard technique
[1] at T6, T8, L3, and L4
(Figs. 5C and
5D). Care was taken that
extravasation into the epidural space did not occur. After the procedure, the
patient stood for the first time in 3 months, had a subsequent cessation of
analgesic medications, and returned to baseline activity. The patient
continued to do well with full ambulation and resumption of activities of
daily living until his death 3 months later from an unrelated hip fracture and
fat embolism.
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Fig. 5C —81-year-old man with epidural hematoma at level of T6 vertebral
body. Lateral fluoroscopic radiograph obtained after polymethyl methacrylate
(PMMA) injection shows filling of T6 and T8 vertebral bodies from anterior
surface to posterior one third to one fourth of each vertebral body.
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Fig. 5D —81-year-old man with epidural hematoma at level of T6 vertebral
body. Frontal fluoroscopic radiograph confirms that PMMA fills T6 vertebral
body from side to side and fills T8 vertebral body up to right lateral cortex
(to reader's right). Inferior corners of each vertebral body are indicated
(arrows).
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Percutaneous vertebroplasty with polymethyl methacrylate (PMMA) is a
radiologic technique that may be used in patients in whom conservative therapy
fails [1]. Prior studies
[2] have excluded patients with
spinal compression secondary to various etiologies, including epidural
hematoma, from receiving percutaneous vertebroplasty for fear of further
spinal canal compromise. The main concern lies in potential epidural extension
of PMMA causing further cord compression
[2] superimposed on the
preexisting epidural disease. Such extension has been shown to occur
occasionally in tumoral lesions, but rarely in osteoporotic compression
fractures. Cotten et al. [3]
reported 15 of 40 cases of epidural extension in tumoral lesions after PMMA
vertebroplasty, while Jensen et al.
[2] showed only 1 of 47 cases
with such complications in osteoporotic fractures. Clinically significant
complications (including foraminal leakage, epidural leakage, cement emboli,
etc.) with vertebroplasty occur in patients with spinal metastatic disease at
a rate of 10% versus a rate of 3% in patients with osteoporotic fractures
[4]. Such results suggest that
osteoporotic compression fractures are less prone to suffer from canal
complications if attention is paid to certain details, such as careful partial
vertebral body filling [1].
Selection of appropriate candidates for percutaneous vertebroplasty has
often excluded patients with epidural disease
[2], including epidural
hematoma, because of fear that the complications from vertebroplasty may
exacerbate these symptoms [4].
Our patient had been denied intervention because of such beliefs, although his
epidural hematoma was clinically stable. Disabling pain from fracture was the
cause of his morbidity, not the epidural hematoma, and vertebroplasty restored
his previous function.
This is the first reported case of vertebroplasty used in a documented
spinal epidural hematoma from osteoporotic compression fracture. We believe
that percutaneous vertebroplasty by experienced personnel may represent a safe
technique that can be used in select patients with stable epidural disease who
were previously excluded from therapy.
References
- Peh WC, Gilula LA, Peck DD. Percutaneous vertebroplasty for severe
osteoporotic vertebral body compression fractures.
Radiology 2002;223
: 121-126[Abstract/Free Full Text]
- Jensen M. Evans A, Mathis J, Kallmes D, Cloft H, Dion J.
Percutaneous polymethyl methacrylate vertebroplasty in the treatment of
osteoporotic vertebral body compression fractures: technical aspects.
AJNR 1997; 18:1897
-1904[Abstract]
- Cotten A, Boutry N, Cortet B, et al. Percutaneous vertebroplasty:
state of the art. RadioGraphics 1998;18
: 311-320[Abstract]
- Murphy K, Deramond H. Percutaneous vertebroplasty in benign and
malignant disease. Neuro Clin of North Am2000; 10:535
-545
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