J Korean Neurosurg Soc.  2018 Nov;61(6):700-706. 10.3340/jkns.2017.0253.

Multilevel Percutaneous Vertebroplasty (More than Three Levels) in the Management of Osteoporotic Fractures

• Zidan I
• Fayed AA
• Elwany A

• KMID: 2428111
• DOI: http://doi.org/10.3340/jkns.2017.0253

Abstract

OBJECTIVE
Percutaneous vertebroplasty (PV) is a minimally invasive procedure designed to treat various spinal pathologies. The maximum number of levels to be injected at one setting is still debatable. This study was done to evaluate the usefulness and safety of multilevel PV (more than three vertebrae) in management of osteoporotic fractures.
METHODS
This prospective study was carried out on consecutive 40 patients with osteoporotic fractures who had been operated for multilevel PV (more than three levels). There were 28 females and 12 males and their ages ranged from 60 to 85 years with mean age of 72.5 years. We had injected 194 vertebrae in those 40 patients (four levels in 16 patients, five levels in 14 patients, and six levels in 10 patients). Visual analogue scale (VAS) was used for pain intensity measurement and plain X-ray films and computed tomography scan were used for radiological assessment. The mean follow-up period was 21.7 months (range, 12-40).
RESULTS
Asymptomatic bone cement leakage has occurred in 12 patients (30%) in the present study. Symptomatic pulmonary embolism was observed in one patient. Significant improvement of pain was recorded immediate postoperative in 36 patients (90%).
CONCLUSION
Multilevel PV for the treatment of osteoporotic fractures is a safe and successful procedure that can significantly reduce pain and improve patient's condition without a significant morbidity. It is considered a cost effective procedure allowing a rapid restoration of patient mobility.

Keyword

Percutaneous vertebroplasty; Bone cement; Osteoporotic fractures; Polymethyl methacrylate

MeSH Terms

Female
Follow-Up Studies
Humans
Male
Osteoporotic Fractures*
Pathology
Polymethyl Methacrylate
Prospective Studies
Pulmonary Embolism
Spine
Vertebroplasty*
X-Ray Film
Polymethyl Methacrylate

Figure

• 

  Fig. 1. CT scan (sagittal view) showing a D10 and L1 osteoporotic fractures in a 73 years old female patient (A). Postoperative CT scan follow-up after one year (sagittal and coronal cuts) showing multilevel percutaneous vertebroplasty from D9 to L1 with good restoration of the vertebral heights after vertebroplasty (B and C). CT : computed tomography.

• 

  Fig. 2. CT scan (sagittal view) showing multiple dorsolumbar osteoporotic fractures in a 77 years old female patient (A). Postoperative plain x-ray followup (axial and lateral views) showing multiple level vertebroplasty from D12 to L5 (B and C). CT : computed tomography.

• 

  Fig. 3. Examples of cement leakage after vertebroplasty. A : Leakage in the disc space. B : Paravertebral leakage.

• 

  Fig. 4. A diagram showing the difference between the preoperative and postoperative VAS. VAS : visual analogue scale.

Reference

References

1. Aebli N, Krebs J, Davis G, Walton M, Williams MJ, Theis JC. Fat embolism and acute hypotension during vertebroplasty: an experimental study in sheep. Spine (Phila Pa 1976). 27:460–466. 2002.

2. Anselmetti GC, Corrao G, Monica PD, Tartaglia V, Manca A, Eminefendic H, et al. Pain relief following percutaneous vertebroplasty: results of a series of 283 consecutive patients treated in a single institution. Cardiovasc Intervent Radiol. 30:441–447. 2007.

3. Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976). 25:923–928. 2000.

4. Benneker LM, Heini PF, Suhm N, Gisep A. The effect of pulsed jet lavage in vertebroplasty on injection forces of polymethylmethacrylate bone cement, material distribution, and potential fat embolism: a cadaver study. Spine (Phila Pa 1976). 33:E906–E910. 2008.

5. Braunstein V, Sprecher CM, Gisep A, Benneker L, Yen K, Schneider E, et al. Long-term reaction to bone cement in osteoporotic bone: new bone formation in vertebral bodies after vertebroplasty. J Anat. 212:697–701. 2008.

6. Chen HL, Wong CS, Ho ST, Chang FL, Hsu CH, Wu CT. A lethal pulmonary embolism during percutaneous vertebroplasty. Anesth Analg. 95:1060–1062. 2002.

7. Chiras J, Depriester C, Weill A, Sola-Martinez MT, Deramond H. Percutaneous vertebral surgery. Technics and indication. J Neuroradiol. 24:45–59. 1997.

8. Cyteval C, Thomas E, Solignac D, Blin D, Decoux E, Lopez F, et al. Prospective evaluation of fracture risk in osteoporotic patients after low cement volume vertebroplasty. J Radiol. 89:797–801. 2008.

9. Evans AJ, Jensen ME, Kip KE, DeNardo AJ, Lawler GJ, Negin GA, et al. Vertebral compression fractures: pain reduction and improvement in functional mobility after percutaneous polymethylmethacrylate vertebroplasty retrospective report of 245 cases. Radiology. 226:366–372. 2003.

10. Grados F, Depriester C, Cayrolle G, Hardy N, Deramond H, Fardellone P. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford). 39:1410–1414. 2000.

11. Jang JS, Lee SH, Jung SK. Pulmonary embolism of polymethylmethacrylate after percutaneous vertebroplasty: a report of three cases. Spine (Phila Pa 1976). 27:E416–E418. 2002.

12. Kallmes DF, Jensen ME. Percutaneous vertebroplasty. Radiology. 229:27–36. 2003.

13. Kim AK, Jensen ME, Dion JE, Schweickert PA, Kaufmann TJ, Kallmes DF. Unilateral transpedicular percutaneous vertebroplasty: initial experience. Radiology. 222:737–741. 2002.

14. Kim SH, Kang HS, Choi JA, Ahn JM. Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty. Acta Radiol. 45:440–445. 2004.

15. Kobayashi N, Numaguchi Y, Fuwa S, Uemura A, Matsusako M, Okajima Y, et al. Prophylactic vertebroplasty: cement injection into non-fractured vertebral bodies during percutaneous vertebroplasty. Acad Radiol. 16:136–143. 2009.

16. Lavanga A, Guarnieri G, Muto M. Medical therapy and multilevel vertebroplasty in osteoporosis: when and why. Neuroradiol J. 23:244–248. 2010.

17. Layton KF, Thielen KR, Koch CA, Luetmer PH, Lane JI, Wald JT, et al. Vertebroplasty, first 1000 levels of a single center: evaluation of the outcomes and complications. AJNR Am J Neuroradiol. 28:683–689. 2007.

18. Lee DG, Park CK, Park CJ, Lee DC, Hwang JH. Analysis of risk factors causing new symptomatic vertebral compression fractures after percutaneous vertebroplasty for painful osteoporotic vertebral compression fractures: a 4-year follow-up. J Spinal Disord Tech. 28:E578–E583. 2015.

19. Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol. 25:175–180. 2004.

20. Mailli L, Filippiadis DK, Brountzos EN, Alexopoulou E, Kelekis N, Kelekis A. Clinical outcome and safety of multilevel vertebroplasty: clinical experience and results. Cardiovasc Intervent Radiol. 36:183–191. 2013.

21. McGraw JK, Lippert JA, Minkus KD, Rami PM, Davis TM, Budzik RF. Prospective evaluation of pain relief in 100 patients undergoing percutaneous vertebroplasty: results and follow-up. J Vasc Interv Radiol. 13(9 Pt 1):883–886. 2002.

22. Murphy KJ, Deramond H. Percutaneous vertebroplasty in benign and malignant disease. Neuroimaging Clin N Am. 10:535–545. 2000.

23. Peh WC, Gilula LA, Peck DD. Percutaneous vertebroplasty for severe osteoporotic vertebral body compression fractures. Radiology. 223:121–126. 2002.

24. Ryu KS, Park CK, Kim MC, Kang JK. Dose-dependent epidural leakage of polymethylmethacrylate after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures. J Neurosurg. 96(1 Suppl):56–61. 2002.

25. Singh AK, Pilgram TK, Gilula LA. Osteoporotic compression fractures: outcomes after single-versus multiple-level percutaneous vertebroplasty. Radiology. 238:211–220. 2006.

26. Syed MI, Jan S, Patel NA, Shaikh A, Marsh RA, Stewart RV. Fatal fat embolism after vertebroplasty: identification of the high-risk patient. AJNR Am J Neuroradiol. 27:343–345. 2006.

27. Syed MI, Patel NA, Jan S, Harron MS, Morar K, Shaikh A. New symptomatic vertebral compression fractures within a year following vertebroplasty in osteoporotic women. AJNR Am J Neuroradiol. 26:1601–1604. 2005.

28. Spiegl UJ, Beisse R, Hauck S, Grillhösl A, Bühren V. Value of MRI imaging prior to a kyphoplasty for osteoporotic insufficiency fractures. Eur Spine J. 18:1287–1292. 2009.

29. Tanigawa N, Komemushi A, Kariya S, Kojima H, Shomura Y, Sawada S. Radiological follow-up of new compression fractures following percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 29:92–96. 2006.

30. Tsou IY, Goh PY, Peh WC, Goh LA, Chee TS. Percutaneous vertebroplasty in the management of osteoporotic vertebral compression fractures: initial experience. Ann Acad Med Singapore. 31:15–20. 2002.

31. Uppin AA, Hirsch JA, Centenera LV, Pfiefer BA, Pazianos AG, Choi IS. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology. 226:119–124. 2003.

32. Voormolen MH, Lohle PN, Juttmann JR, van der Graaf Y, Fransen H, Lampmann LE. The risk of new osteoporotic vertebral compression fractures in the year after percutaneous vertebroplasty. J Vasc Interv Radiol. 17:71–76. 2006.

33. Voormolen MH, Lohle PN, Lampmann LE, van den Wildenberg W, Juttmann JR, Diekerhof CH, et al. Prospective clinical follow-up after percutaneous vertebroplasty in patients with painful osteoporotic vertebral compression fractures. J Vasc Interv Radiol. 17:1313–1320. 2006.

34. Yu SW, Chen WJ, Lin WC, Chen YJ, Tu YK. Serious pyogenic spondylitis following vertebroplasty--a case report. Spine (Phila Pa 1976). 29:E209–E211. 2004.

35. Zoarski GH, Snow P, Olan WJ, Stallmeyer MJ, Dick BW, Hebel JR, et al. Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes. J Vasc Interv Radiol. 13(2 Pt 1):139–148. 2002.