Republished: Parapedicular vertebral augmentation with polymethylmetacrylate for pedicle screw loosening.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

Parapedicular vertebral augmentation with polymethylmetacrylate for pedicle screw loosening.

A 71-year-old man who had a L1/S1 posterior fusion revision surgery complained of increasing back pain 5 weeks after the open surgical procedure. The pain was initially estimated at 9/10 on the visual analog scale (VAS) and thought to be related to a right-sided L2 screw loosening. A right parapedicular vertebroplasty was performed and polymethylmethacrylate cement was instilled around the right pedicle screw, filling the anterior two-thirds of the vertebral body. On postvertebroplasty day 1, the patient had significant improvement in his low back pain. The pain further decreased at 1 and 3 months after the intervention (2/10 on the VAS). Vertebroplasty is a minimally invasive, accessible, effective, and long lasting treatment for compression fractures. We believe that this technique could also be indicated to treat pain related to low grade screw loosening in properly selected patients.

The use of vertebral augmentation and external beam radiation therapy in the multimodal management of malignant vertebral compression fractures.

BACKGROUND: Vertebral augmentation (VA) techniques such as vertebroplasty and kyphoplasty are increasingly performed minimally invasive procedures for osteoporotic or malignant compression fractures (MCFs) and involve injection of polymethylmethacrylate (PMMA) cement directly into a compressed vertebral body. OBJECTIVE: This article will evaluate the efficacy of VA in relieving fracture-related pain. We also intend to identify procedural and clinical variables that could potentially influence outcomes in this population. In the subset of patients with cancer who received both external beam radiation therapy (EBRT) and VA, we will assess the impact of the treatment sequence on pain outcomes. STUDY DESIGN: We performed a retrospective analysis of 201 cases of patients with cancer and MCFs who underwent one or more vertebral augmentation procedures at our institution between 2003 and 2009. The majority of cancers represented were multiple myeloma, metastatic lung cancer, and metastatic breast cancer. The primary outcome measure was pain relief, as measured by the Visual Analog Scale and a 4-point pain scale. SETTING: We present an institutional experience at an academic medical center of 201 cases of MCFs. METHODS: We compiled an institutional database of vertebroplasty and kyphoplasty cases using paper and electronic medical records. Our data collection methodology has been previously reported and includes variables such as procedure dates, gender, age, type of malignancy, fracture etiology, history of cancer treatment, type of procedure performed, vertebral level treated, the number of levels treated per procedure, complications, and follow-up information on pain response. The updated dataset incorporates new variables including information on pain medications and standardized questionnaires such as the Visual Analog Scale (VAS) for pain and the Roland Morris Disability Questionnaire (RMDQ). RESULTS: In the 201 cases of MCFs, a total of 316 vertebral levels were treated with either vertebroplasty or kyphoplasty. Follow-up data on pain relief was available for 190 out of 201 cases (95%). Among this subgroup, 168 cases (88%) with MCFs responded. Thirty-nine percent (39%) of the time patients experienced complete pain resolution. In only 4% of cases did patients report worsening of their fracture-related pain post-procedure. There was no difference in pain outcomes with regard to sequencing of EBRT and VA. LIMITATIONS: One of the limitations of our analysis is that it did not evaluate the effect of pain improvement or resolution before and after EBRT alone and on activities of daily living in the majority of patients. However, one of the main goals of this analysis is to address previous limitations. We attempt to standardize outcome measures by using the Visual Analog Scale (VAS) for pain and the Roland Morris Disability Questionnaire (RMDQ). CONCLUSION: A multimodality approach for the management of MCFs includes VA procedures. The majority of patients with MCFs have excellent palliation with this approach. In patients who receive both EBRT and VA, the sequence in which they are given does not affect pain improvement outcomes.

The safety and effectiveness of a curved needle for vertebral augmentation: comparison with traditional techniques.

PURPOSE: To evaluate the safety and effectiveness of a curved needle compared with traditional (noncurved needle) techniques in a large single-center experience. MATERIALS AND METHODS: This study was a retrospective analysis of 243 consecutive vertebral augmentation procedures over a 17-month period. Curved needle procedures were compared with noncurved needle procedures for baseline clinical variables, complication rate, pain relief, and improvement in disability. Procedure duration and fluoroscopy time were compared between the two cohorts. RESULTS: Between curved needle and noncurved needle procedures, there were no statistically significant differences in the baseline clinical variables, fracture location, and fracture etiology. No complications were noted in either group. In both groups, there was a median improvement in the visual analog scale (VAS) score of 2.0 points (P = .62). More than 90% of procedures in both groups resulted in some pain improvement (P = .78). For both groups, the median improvement in disability on the Roland Morris Disability Questionnaire (RMDQ) was 4.0 points (P = .69). Approximately 70% of procedures in both groups resulted in improvement in disability (P = 1.00). In single-level cases, there were shorter procedure times (51.8 min ± 2.7 vs 62.8 min ± 2.2, P = .002) and shorter fluoroscopy times (P = .31) for curved needle procedures. CONCLUSIONS: The curved needle is as safe and effective as traditional vertebral augmentation techniques in treating the pain and disability related to vertebral compression fractures. Additionally, the curved needle is associated with shorter procedure duration and reduced fluoroscopy time.

Palliation of compression fractures in cancer patients by vertebral augmentation: a retrospective analysis.

AIM: To evaluate the efficacy of vertebral augmentation (VA) in cancer patients. MATERIALS AND METHODS: From a retrospectively compiled database, 147 cancer cases (236 levels) were treated with VA. Mean age was 71±12 years and 56.5% were female. Variables evaluated include age, sex, procedure type, vertebral level treated, number of levels treated per procedure and technical approach. Outcomes were assessed by a previously described method retrospectively applied from medical records: a binary system of 'responders' versus 'non-responders' and further subcategorization with a four level pain scale. Two patient groups were analyzed: (1) 147 cancer patients with either osteoporotic or malignant vertebral compression fractures (all compression fractures (ACFs)) and (2) 102 cases with documented metastatic compression fractures (MCFs). Univariate and multivariate analyses determined outcomes. RESULTS: 93% of MCFs and 88.5% of ACFs showed response to treatment (pain improvement or resolution): 30% of ACFs and 31% of MCFs experienced pain resolution. MCFs showed increasing age to be a predictor of response to treatment in univariate (OR=1.79, p=0.04) and multivariate (OR=2.05, p=0.03) analysis. In ACFs, bipedicular needle approach decreased the odds of pain resolution (OR=0.28, p=0.01). In MCFs, lung cancer (OR=0.06, p=0.03) and multiple myeloma (OR=0.10, p=0.01) decreased the odds of pain resolution. CONCLUSIONS: VA provides pain relief for a majority of ACFs and MCFs. Increasing age may be predictive of pain relief outcomes in MCFs. There are special planning, imaging and technical considerations (eg, needle placement) in using VA to treat cancer patients.

Predictors of successful palliation of compression fractures with vertebral augmentation: single-center experience of 525 cases.

PURPOSE: To determine the effectiveness of vertebral augmentation in relieving pain, differences in pain relief outcomes based on procedure type were investigated. Variables that potentially influence outcomes were identified. MATERIALS AND METHODS: A database of 525 cases (740 levels) treated for compression fractures with vertebroplasty, kyphoplasty, or S1-level sacroplasty was compiled. Average age was 75 years +/- 12, and 72.4% of patients were female. Variables evaluated included age, sex, fracture etiology, procedure type, vertebral level treated, number of levels treated per procedure, and technical approach. Outcomes were assessed by a binary system of "responders" (ie, patients with improvement/resolution of pain) versus "non-responders" (ie, those with no change/worsening of pain) and with a four-level pain scale (1, pain resolution; 2, pain improvement; 3, no change; 4, worse pain) retrospectively applied from medical records. Univariate and multivariate analyses determined outcomes. RESULTS: Four-hundred and sixty-seven patients (89%) showed a response to treatment: 40% had pain resolution and 49% had pain improvement. Multivariate analysis showed that women and older patients had greater odds of being responders (odds ratios [ORs], 0.56 and 0.98, respectively; P = .016 and P = .048, respectively). Patients without cancer (OR, 1.60; P = .012) and women (OR, 2.05; P = .0002) were more likely to experience pain resolution. Increasing numbers of levels treated per case were associated with decreased odds of pain resolution (OR, 0.69; P = .0081). Sex and number of levels treated were independently predictive of pain scale outcomes (ORs, 2.0 and 0.71, respectively; P = .0003 and P = .015). CONCLUSIONS: Vertebral augmentation procedures provide pain relief for a majority of patients regardless of underlying fracture etiology. There was no difference in pain outcomes among procedure types. Age and sex may be predictive of pain outcomes.

Treatment of metastatic carcinoma to the hip with CT-guided percutaneous acetabuloplasty: report of four cases.

Percutaneous acetabuloplasty (PA) is a promising treatment for painful metastatic lesions of the acetabulum. Four patients were treated with injection of the bone cement polymethylmethacrylate directly into the lesion. After the procedure, all four patients had improvement or relief of their pain and were able to resume weight-bearing activities. The procedure was well tolerated by each patient without morbidity. PA appears to be a reasonable palliative procedure for painful and fragile hips associated with metastatic bone disease.