Technical Aspects of Percutaneous Vertebroplasty Dr. Cosme Argerich Neurosurgeon

History 1987: First description by Galibert and Deramond. 1995: First procedure in Geneva (Switzerland) First reported procedure in USA.

Schools European 38% methastases 31% Hemangiomas / Myelomas 31% Osteoporosis North American 70% Osteoporosis 17% Hemangiomas / Myelomas 13% Methastases

Demography USA 10 Million cases of Osteoporosis (45% white female > 50 years). 700 thousand vertebral fractures / year. 150 thousand hospital admissions / year. Total direct costs: U$ Millions. Estimated costs in 2030: Millions.

Diagnostic Sequence Clinic evaluation Anamnesis Physical exam Clinical Neurological Lab tests

Osteoporosis Plain x-RaysDensitometry Metabolic Lab

Tumors CTMRIMarkers Biopsy?

Indications for PV Pain / instability in: Osteoporotic collapse. Sub-acute traumatic collapse. Malignant vertebral tumors (Metastasis / Myeloma) Vertebral angiomas

Osteoporosis Intense and persistent post fractural pain: 1 to 12 weeks evolution. Pain focused on spinal mid-line, related to diagnosed vertebral collapse. Absence / poor response to medical therapy (Alendronate, Calcium, Opiates). Quality of Life impairment due to opiates side effects.

Osteoporosis T1: signal reduction in D 12. STIR: increased signal suggesting recent fracture.

Tumors High risk of vertebral collapse. Intractable pain. Marked side effects to opiates: blurred vision, bladder / bowel disorders, confinement to bed rest. Palliative treatment in terminal patients.

Malignant Tumors T1: signal reduction in vertebral body and posterior elements + C: increased signal

Note that: Most of skeletal metastasis occur in spine. Up to 10% of cancer patients present symptomatic spine metastasis. Course of local disease may be painful and invalidating.

General Exclusion Criteria Local / systemic infection. Recent fracture of posterior vertebral wall. Coagulation disorders. Poor general conditions. Vertebral collapse > 80 – 90%.

Particular Exclusion Criteria Osteoporosis. Adequate response to medical treatment. Lack of radiological progression of fracture. Cancer: Advanced systemic disease. Progression to spinal channel.

Vertebral Approaches (will vary according to surgeon’s specialty and experience) Cervical Spine: Anterior. Dorsal Spine: Transpedicular. Lumbar Spine: Transpedicular. Lateral. Lateral.

Alternative Approaches Latero-transpedicular.Latero-antepedicular.Laterovertebral.

Equipment

Fixed “C” Arm Advantages: Better image quality Easier operation Disadvantages: High operational costs Use subject to availability

Mobile “C” Arm Advantages: Low operational costs Availability Disadvantages: Lesser image quality More difficult operation

Immediate access to: CT Scan and / or RMI. ICU. Operating Room. Must be available for the treatment of potential complications

Local GeneralNeurolepto Anestesia Election will depend on surgeon’s experience and characteristics of patient.

Intraoperative Monitoring EKG. O 2 Saturation (early diagnosis of pleural lesion). Pressurometry (occasional vagal raction). During Local Anesthesia, Oxygen mask will provide sensation of comfort to patient.

Main advantages of Local Anesthesia Allows the surgeon to communicate with the patient. Benefits: Early diagnosis of lesions (radicular / pleural) which might not be diagnosed otherwise. Determine cement injection speed. Anticipate corrective measures. Abort the procedure.

Video (Actual Procedure under Local Anesthesia)

Conclusions PV is a Minimally Invasive Procedure. Surgical Technique may be acquired in a short time. PV may be performed on outpatients. Excellent tolerance to Local Anesthesia. May be combined with instrumental arthrodesis of the spine. Short and Long Term results are encouraging.