Literature References Supporting the Technique Vertebroplasty Results from the ScientificLiterature Clin Rheumatol. 2004 Aug;23(4):310-7. Epub 2004 May 18. Long-term follow-up of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Legroux-Gerot I, Lormeau C, Boutry N, Cotten A, Duquesnoy B, Cortet B. Department of Rheumatology, Hopital R. Salengro, University-Hospital of Lille, France. The aim of this study was: to assess the long-term efficacy and safety of percutaneous vertebroplasty (PVP) for treating painful vertebral osteoporotic fractures, and to estimate the risk of vertebral fracture in the vicinity of a cemented vertebra. A prospective open study was conducted. PVP were carried out between July 1995 and September 2000 for 16 patients with symptomatic osteoporotic vertebral fracture that had not responded to extensive conservative medical therapy. All the patients were followed-up for more than 1 year. The efficacy of the PVP was assessed by the changes over time in pain on Huskisson's visual analog scale (VAS) and on the McGill-Melzack scoring system (MGM). The efficacy of the procedure was also assessed by measuring the changes over time in quality of life assessed by the Nottingham Health Profile (NHP instrument): twenty-one vertebrae treated by PVP in 16 patients were evaluated. The mean duration of follow-up was 35 months. Pain assessed by the VAS significantly decreased from a mean of 71.4 mm+/-13 before PVP to 36 mm+/-30 after 6 months, and to 39 mm+/-33 at the time of maximal follow-up ( p<0.05 for both comparisons). The results were also significant for the MGM: 3.00+/-0.57 before PVP to 1.6+/-1.4 at the long-term follow-up ( p<0.05). The solely statistically significant decrease for quality of life was noted for pain. A slight but not significant improvement was noted for 3/6 dimensions of the NHP scores. A slight but significant increase in social isolation was also found. No severe complication occurred immediately after PVP. At the long term follow-up (35 months) there was a slight but not significantly increased risk of vertebral fracture in the vicinity of a cemented vertebra: odds ratio 3.18 (95% confidence interval (CI) 0.51-19.64). The odds ratio of a vertebral fracture in the vicinity of an uncemented fractured vertebra was 2.14 (95% CI: 0.17-26.31). In conclusion, PVP appears to be safe and effective for treating persistent painful osteoporotic fractures. Controlled studies with long-term follow-up are needed to evaluate the risk of vertebral fractures in the vicinity of a cemented vertebra. Rofo. 2004 Jul;176(7):1005-12. [Evaluation of percutaneous vertebroplasty in osteoporotic vertebral fractures using a combination of CT fluoroscopy and conventional lateral fluoroscopy] [Article in German] Pitton MB, Drees P, Schneider J, Brecher B, Herber S, Mohr W, Eckardt A, Heine J, Thelen M. Klinik fur Radiologie, Universitatskliniken Mainz. PURPOSE: Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures. MATERIALS AND METHODS: Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions. RESULTS: A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case. CONCLUSION: Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure. J Anesth. 2004;18(4):292-5. Long-term pain relief effects in four patients undergoing percutaneous vertebroplasty for metastatic vertebral tumor. Yamada K, Matsumoto Y, Kita M, Yamamoto K, Kobayashi T, Takanaka T. Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8641, Japan. We reviewed long-term pain relief in four patients undergoing percutaneous vertebroplasty (PVP) for lumbar or back pain due to metastatic vertebral tumors. The patients received anesthesiological palliative care with analgesics until their death after PVP. Pain intensity, the presence or absence of recurrence of pain, changes in dosage of analgesics given before and after PVP, and complications associated with PVP were evaluated. A numerical rating scale (NRS) from 0 (no pain) to 10 (worst pain imaginable) was used to measure pain. The patients were three men and one woman (mean age, 58 years). PVP was performed in five vertebrae (one thoracic and four lumbar). The NRS scores on moving before PVP were 10, 8, 10, and 10. After PVP, NRS decreased to 0, 3, 5, and 0, respectively, within 72 h. No recurrence of pain in the treated area occurred until death in any of these patients. The dosages of analgesics given were decreased in two cases, but no changes were made in the other two cases. There were no complications associated with PVP. Percutaneous vertebro-plasty is a safe and effective treatment for long-time pain relief in patients with metastatic vertebral tumors. Acta Neurochir (Wien). 2004 May;146(5):469-76. Epub 2004 Apr 08. Treatment of pain from osteoporotic vertebral collapse by percutaneous PMMA vertebroplasty. Winking M, Stahl JP, Oertel M, Schnettler R, Boker DK. Neurosurgical Clinic, Justus-Liebig University Giessen, Giessen, Germany. michael.winking@neuro.med.uni-giessen.de BACKGROUND: Vertebral compression fractures are common complications in advanced osteoporosis. In general, this disease of the elderly patient is characterized by severe local back pain. Pathophysiologically, bony instability triggers local pain during body movement. Serious pain immobilizes the patients and forces them to bed rest. As a result, complications like thrombosis or pneumonia occur. Invasive treatment with surgical instrumentation for vertebral stabilization is not indicated in elderly patients especially with additional diseases.The purpose of this study was to test the hypothesis that percutaneous polymethylmethacrylate (PMMA) vertebroplasty significantly reduces pain due to vertebral collapse in osteoporotic patients and improves quality of life. METHODS: A total of 38 patients with osteoporotic vertebral compression fractures of the thoracic and lumbar spine were treated by PMMA vertebroplasty. After admission, before discharge from the hospital, six weeks, half a year and one year later patients answered the Oswestry Low Back Pain Disability (OLBPD) Questionnaire for assessment of treatment related change in disability. In all patients percutaneous vertebroplasty was performed under local anesthesia. FINDINGS: A total of 92% of patients reported a significant pain reduction immediately after treatment. Also one year after vertebroplasty pain remained significantly reduced. Vertebroplasty was highly beneficial for patients with pain related to local instability of the spine. Extravasation of PMMA beyond the vertebral margins was observed in 26% of the cases. No treatment related clinical or neurological complications were noticed. INTERPRETATION: PMMA vertebroplasty is a useful and safe method of pain relief which rapidly regains quality of life for patients with osteoporotic vertebral compression. Copyright 2004 Springer-Verlag Chang Gung Med J. 2004 Apr;27(4):261-7. Minimally invasive treatment of osteoporotic vertebral compression fracture. Chen LH, Niu CC, Yu SW, Fu TS, Lai PL, Chen WJ. Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taipei. lhchen2132@cgmh.org.tw BACKGROUND: The use of percutaneous vertebroplasty (PV) to treat osteoporotic vertebral fractures is increasing. This investigation assesses the efficacy and safety of PV for refractory pain owing to osteoporotic vertebral compression fractures. METHODS: A retrospective investigation of PV was conducted with a minimal of 1 year follow up. PV with polymethylmethacrylate (PMMA) was performed on 75 patients with osteoporotic vertebral compression fractures that responded poorly to the conservative therapy. Patients were asked to quantify their degree of pain using Huskisson's visual analogue scale to assess the clinical results. RESULTS: Eighty-seven vertebrae treated using PV in 70 patients were evaluated with a minimal of 1 year follow up. Pain, as assessed on the VAS, decreased from 80+/-16 mm before PV to 36+/-28 mm at 1 month after PV and 30+/-19 mm at the most recent follow up. The reduction in pain from the baseline to 1 month (p=0.031) and to final follow up (p=0.023) were both statistically significant. Sixty-two patients (85.5%) quickly returned to their pre-injury activity level and achieved better quality of life. CONCLUSIONS: PV is effective in pain reduction for painful vertebral compression fractures. It provided significant pain relief. Skillful techniques and careful safeguards can minimize the risks of PMMA migration. Neurol Res. 2004 Jan;26(1):41-9. Percutaneous vertebroplasty: technique and results in 192 procedures. Cohen JE, Lylyk P, Ceratto R, Kaplan L, Umanskyt F, Gomori JM. Department of Neurosurgery and Interventional Neuroradiology, Eneri, Clinica Medica Belgrano, Buenos Aires, Argentina. jcohenns@yahoo.com Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success. Dtsch Med Wochenschr. 2003 Nov 28;128(48):2525-30. [Polymethylmethacrylate-vertebroplasty. A new and effective method of pain treatment in vertebral compression] [Article in German] Winking M, Stahl JP, Oertel M, Schnettler R, Boker DK. Neurochirurgische Klinik, Justus-Liebig Universitat Giessen. michael.winking@neuro.med.uni-giessen.de BACKGROUND AND OBJECTIVE: Percutaneous polymethylmethacrylate (PMMA) vertebroplasty is increasingly used in the treatment of back pain related to compression of the vertebral bodies. After the procedure immediate mobilization of the patient is possible. The purpose of the study was to examine the change in quality of life of patients with vertebral collapse achieved by vertebroplasty during a six-month period. PATIENTS AND METHODS: 28 patients with osteolytic metastases (mean age 59,7 +/- 7,8 years, 2,1:1male/female ratio) and 38 patients with osteoporotic vertebral collapse (mean age 73 +/- 6 years, 1:3,5male/female ratio ) of the thoracal and lumbar spine were treated with PMMA vertebroplasty and analysed prospectively. After admission, before, six weeks and 6 months after discharge from the hospital patients answered the Oswestry Low Back Pain Disability (OLBPD) questionnaire for assessment of treatment-related changes in disability. RESULTS: Immediately and 6 months after treatment 83 % of tumor patients and 92 % of ostoporotic patients had significant pain reduction. Extravasation of PMMA beyond the vertebral margins were observed in 26 % of the patients. No treatment-related clinical or neurological complications were observed. CONCLUSION: PMMA vertebroplasty is an efficacious and safe method of pain relief for patients with osteolytic metastases or osteoporotic compression with good long-term results. Arq Neuropsiquiatr. 2003 Sep;61(3A):625-30. Epub 2003 Sep 16. [Percutaneous vertebroplasty: option of treatment for osteoporotic vertebral fracture] [Article in Portuguese] Figueiredo N, Amaral Filho JC, Serra Ada R, Nogueira AM, Garcia VC, Weissheimer FL. Universidade de Cuiaba, Cuiaba, MT, Brasil. nicandro2@yahoo.com Percutaneous vertebroplasty (PV) is a minimally invasive procedure used to treat focal pain from compressive vertebral fracture. The PV is indicated for the treatment of debilitating vertebral pain from osteoporotic vertebral fractures, metastatic disease (osteolytic), myeloma and hemagioma. We analyzed the results of PV at 18 vertebrae of 11 patients. In 90.9% there war significant pain relief. The return to their usual activities at the first month occurred at 77.8% of the patients. According to the literature review and our study, PV is a promising therapy for selected cases. Neurocirugia (Astur). 2003 Sep;14(4):323-32. [Percutaneous vertebroplasty: technique and early results in 25 procedures] [Article in Spanish] Martinez-Quinones JV, Hernandez-Sanchez G. Servicio de Neurocirugia, Hospital Central de la Defensa (Antiguo HMC "Gomez Ulla"). Madrid. Spain. Vertebroplasty procedure which involves percutaneous injection of bone cement into a collapsed vertebra using fluoroscopic guidance, has been introduced not only for treatment of osteoporotic patients, who have prolonged long lasting pain following vertebral fracture, but also for osteolytic vertebral compression fractures, to restore its loadbearing capacity and stiffness. Our result suggest that vertebroplasty is associated with pain relief in almost 100% of cases. Proper patient selection and a good technique should minimize complications. Ned Tijdschr Geneeskd. 2003 Aug 9;147(32):1549-53. Comment on: Ned Tijdschr Geneeskd. 2003 Aug 9;147(32):1553-9. [Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: first short term results] [Article in Dutch] Voormolen MH, Lohle PN, Fransen H, Juttmann JR, de Waal Malefijt J, Lampmann LE. Sint Elisabeth Ziekenhuis, Postbus 90.151, 5000 LC Tilburg. mhjvoorm@tiscali.nl OBJECTIVE: To describe the technique of percutaneous vertebroplasty and the short-term results in patients with symptomatic, osteoporotic vertebral compression fractures. DESIGN: Prospective follow-up study. METHOD: In a pilot-study to evaluate the short-term safety and effectiveness of percutaneous vertebroplasty, 18 consecutive patients with a total of 33 osteoporotic thoracic or lumbar vertebral compression fractures were treated from October 2001 to June 2002 with a follow-up of 3-6 months. The indication for treatment was a symptomatic, therapy-resistant osteoporotic vertebral compression fracture. Percutaneous vertebroplasty was performed under radiographic control, after previous intraossal venography, using bone cement mixed with barium sulphate. Post-procedural follow-up consisted of radiological evaluation with conventional thoracolumbar X-rays and MRI scans, and interviews of the patients. RESULTS: Percutaneous vertebroplasty was technically successful in 31 of 33 vertebral fractures (94%), and in 16 of 18 patients (89%). One patient with extreme venous contrast leakage could not be treated. Sixteen patients had less or no pain after treatment. One patient retained thoracolumbar back pain after inadequate cementations and refused further treatment. None of the patients reported aggravation of symptoms following the procedure. Contrast leakage was absent in 18 vertebrae. In 8 vertebrae there was contrast leakage to paravertebral veins. In three of these cases the leakage was so severe that embolisation was performed, with success in one case. In 13 vertebrae, cement leakage to intervertebral and paravertebral spaces and pedicular cement spurs were seen, without clinical consequences. Immediately after the procedure and during follow-up there were no clinically relevant complications. CONCLUSION: Percutaneous vertebroplasty was a technically feasible treatment in these patients with symptomatic, therapy-resistant, osteoporotic vertebral fractures. The first short-term results were comparable with results in the literature. A prospective randomised intervention study will be needed to compare percutaneous vertebroplasty with optimal conservative treatment. Pain Med. 2001 Sep;2(3):248. (221) percutaneous vertebroplasty: minimally invasive procedure for vertebral fracture. Patel JG, Singh SK, Singh MK, Gallagher RM. MCP Hahnemann University. Objective: Vertebral fracture is a common health problem. Percutaneous Vertebroplasty (PVP) is a minimally invasive procedure done to provide pain relief and stabilization. This study examined the results of a case series of persons with vertebral fractures. Method: Eighteen cases (16 women, 2 men; 53-89 year old: mean age 74.68 years) with mid and low back pain were evaluated and vertebral fractures were confirmed with MR Imaging. Seventeen patients had osteoporotic and one patient had metastatic fracture. PVPs using polymethylmethacrylate were performed under fluoroscopic guidance by transpedicular approach between April 1999 to October 2000 at an outpatient surgery center. A semi-structured evaluation of response to PVP was conducted immediately, at 3 days and after 3 weeks. Results: PVP were done for 27 vertebral levels (17 Thoracic and 10 Lumber). Prior to procedure pain levels on numeric scale (0-10) ranged from 5 to 10 with a mean of 9.15. On short term follow up at 3rd post-procedure day, four patients has less then 50% pain relief while 14 patients reported 50% to 100% relief with mean of 78%. On long term follow up 15 patients reported 50% to 100% pain relief with mean of 72.66%. No complications were reported during intra as well as post-operative period. Conclusion: PVP is a minimally invasive procedure for the treatment of vertebral fracture with promising results. It provides significant pain relief with the potential for improving functional outcome.