Minimally invasive treatment of vertebral compression fractures at Ivy Hospital by per-cutaneous vertebroplasty by Dr Vineet Saggar (Neuro-Spinal Surgeon)

Minimally invasive treatment of vertebral compression fractures at Ivy Hospital by per-cutaneous vertebroplasty by Dr Vineet Saggar

A 54 years old female presented in our OPD with severe pain in back for past three months. Her X-Ray showed wedge collapse of L1 vertebrae without canal compromise. She had been on bed rest for three months but her pain had failed to subside even after full conservative therapy.  She was treated with percutaneous vertebroplasty and her pain was relieved and she was discharged in fully ambulatory state the next day.

 Fig Showing fluoroscopic placement of needle in fractured vertebrae

Fig showing vertebroplasty cement in fractured vertebrae

Post Operative Ct scan showing  vertebroplasty cement in L1 Vertebrae

 

Patient just before discharge  

Post op pic showing dressing and small incisions

WHAT IS VERTEBROPLASTY AND KYPHOPLASTY?

This is a technique of injecting  bone cement at the site of painful vertebral compression fractures under fluroscopyand. Painful vertebral osteoporotic compression fractures lead to significant morbidity and mortality.  A painful osteoporotic vertebral fracture can be a significant burden for patients (and their families), impairing physical function and quality of life.  Independent of pain, there is morbidity associated with the spinal deformity. In the thoracic spine this is due to decreased lung capacity (FVC and FEV1). In the lumbar spine compression fractures also affect lung capacity, probably due to restrictive airway disease caused by loss of height, and lead to a reduction in abdominal space associated with loss of appetite and secondary sequel related to poor nutrition. Additionally, vertebral body compression fractures (VCFs) cause chronic pain, sleep loss, decreased mobility, depression, and a loss of independence.

The medications taken for symptomatic relief can lead to further mood or mental alterations that compound the medical condition. A large prospective study noted a 23% increase in mortality in women older than 65 years with VCFs compared with age-matched controls. The mortality rate increases with the number of vertebrae fractured. Most painful VCFs are treated palliatively, with bed rest, narcotic analgesics, orthotics, and time. However, bed rest accelerates bone loss and leads to muscle de conditioning, resulting in increased pain from both of these mechanisms. The other treatments for osteoporosis (e.g., hormone replacement, bisphosphonates, calcitonin) are important for the long term treatment of this disease but often do not provide short-term pain relief.

INDICATIONS OF VETEBROPLASTY AND KYPHOPLASTY

PER CUTANEOUS VERTEBROPLASTY has been used in anterior and posterior stabilization of the spine for metastatic disease,  giant cell tumors of,  treatment of vertebral hemangiomas  and .  vertebral compression fractures via the transpedicular or paravertebral approach under CT and/or fluoroscopic guidance has been described.

TECHNIQUE OF VERTEBROPLASTY AND KYPHOPLASTY

Upon completing the informed consent process, the patient is placed in the prone position on the angiography table. Monitoring of blood pressure, heart rate, and pulse oximetry is done continuously throughout the procedure. Oxygen supplied via a nasal cannula is used when necessary. Neuroleptic analgesics in the form of fentanyl (Sublimaze, Abbott Labs, North Chicago, Ill) and midazolam (Versed, Roche Pharma, Manati, Puerto Rico) are administered by the angiography nurse under the direction of the operating physician. The procedure is performed under strict sterile conditions. All personnel wear surgical masks and caps in addition to gowns and gloves for the operators, to minimize the risk of infection. The vertebral body to be treated is localized under fluoroscopic control and the skin overlying this area is prepped and draped. Biplane fluoroscopy

is recommended, as it allows near simultaneous imaging of the stylet tip position in two planes, thus decreasing the overall procedure time. The anteroposterior tube is angled in such a way as to maximize the oval appearance of the pedicle (“looking down the barrel”) (Fig 1). The skin over the center of the pedicle oval is anesthetized with bupivacaine hydrochloride (0.25%)  followed by deep injection of bupivacaine to and including the periosteum. A small skin incision is made with a #11 scalpel blade. A disposable 11-gauge Jamshidi needle  is positioned with Fig 1. The pedicle to be punctured is isolated and marked with the tip of a surgical clamp. The skin, subcutaneous tissues, and periosteum are anesthetized with 0.25% bupivacaine. Fig 2. After a small skin incision is made, the Jamshidi needle is advanced nto the pedicle. Notice that the shaft of the needle (arrow) maintains a bulls-eye appearance in relation to the pedicular edges (arrowheads) in the anteroposterior plane. Fig 3. In the lateral plane, the shaft of  the needle runs parallel to the superior and inferior cortices of the pedicle (arrows). After the stylet has been withdrawn, the needle tip is positioned in the middle of the vertebral body.

                   Figure 1                                  Figure 2                            Figure 3

 

its tip in the center of the oval and advanced until the stylet tip abuts the bone. Lateral fluoroscopy shows the tip at the level of the upper to midpoint of the pedicle such that advancement of the needle is within the midportion of theof the pedicle oval to indicate that the needle is proceeding parallel to the X-ray beam (Fig 2). The lateral view shows the needle moving roughly parallel to the superior and inferior edges of the pedicle (Fig 3) or in a slightly descending course through the pedicle. Minor adjustments in either plane may be required during needle advancement. Once the needle tip has traversed the cortex and the pedicle. A slight twisting motion is used to advance the tip through the cortex, and frequent checking of needle placement in both planes is required. The anteroposterior view shows the needle shaft end-on as a circle within the center  pedicle and is located within soft bone marrow, less pressure may be required to advance the needle into the vertebral body. Care must be taken not to abrogate the anterior vertebral wall or the endplates. The stylet tip is placed at or near the junction of the anterior and middle third of the vertebral body line. Because the stylet tip projects beyond the end of the needle shaft, removal of the stylet will position the needle end in the middle or anterior half of the vertebral body (Fig 3). Before injecting the PMMA, venography is done to exclude needle placement directly within the basivertebral venous complex and to ensure continuity of the posterior vertebral wall as evidenced by containment of the contrast material within the bony trabeculae (Fig 4). We use a hand injection of 5 mL of iohexol (Omnipaque 300, Nycomed,Princeton, NJ) and film in both planes at a rate of two frames per second. Rapid flow of contrast material into the vena cava and/or perivertebral veins without visibility of intervening bone marrow indicates direct communication of the needle tip with a major venous outlet and requires needle advancement. Once correct placement of the needle is confirmed, treatment is begun. If a bone biopsy is warranted, a variety of standard, commercially available biopsy needles can be passed through the Jamshidi shaft to obtain tissue samples before vertebroplasty One operator injects the material as the second loads  the syringes. The stylet is removed and, unless blood fills the dead space in a retrograde manner, the dead space is injected with PMMA using a long 18-gauge spinal needle. The 1-mL syringe is attached tightly to the shaft port of the Jamshidi needle and injection begins. The injection pressure required to push the material will increase over time as the vertebral body fills and the PMMA polymerizes. Injection is performed under lateral or anteroposterior oblique fluoroscopy ( and particular attention must be paid to the region of the vena cava and the epidural space as seen on the venogram. If passage of material into the venous system is  when appropriate.noted, the injection is slowed or halted while the material attains a thicker consistency. Injection is continued until hemivertebral or holovertebral filling is achieved, no more material can be pushed into the body, or extravasation into veins or the disk space is noted. Repositioning of the needle is not recommended, as the location of the tip will be unknown, and unwanted vascular embolization may occur. Upon completing the injection, the needle is removed and hemostasis at the puncture site is achieved by gentle pressure. The contralateral hemivertebra is then treated in the same fashion. More than one vertebra can be treated at the same time, depending on the patient’s tolerance  After the procedure, the patient is placed supine and asked to remain flat for 3 hours to allow complete curing of the PMMA prior to axial loading. Although patients usually remain overnight, those from our local area are allowed to return home the same day.

Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990

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