1. Ankit M. Patel, MD

2. I have NO RELEVANT financial disclosures.

3. Comprehensive evaluation of pain in a patient with history of cancer Systematic & multidisciplinary treatment approach Interventional pain management options

4. 82 y.o. male, history of prostate cancer, on androgen deprivation therapy, left kidney tumor s/p resection C/o diffuse mid-back and low back pain, which began 4 weeks ago after working in his garden

5. Thorough H&P! Global assessment: impact of pain on function, mood & quality of life Always consider recurrence or progression of cancer Etiology of pain: -Primary tumor -Metastatic disease - Cancer treatment - Non-malignant

6. Axial symptoms only, moderate to severe daily pain Worse with standing, walking, sitting, bending, and twisting Better with lying down No fever, weight loss, or nocturnal pain Symptoms refractory to relative rest, acetaminophen, NSAIDs, tramadol, and elastic back brace Adverse impact of function, mood, and QOL Difficulty getting out of bed and transferring in/out of a car Spouse reported dysphoria and poor appetite

7. Physical exam findings: Loss of lumbar lordosis Pain with percussion along the thoracolumbar junction and lumbosacral junction No neurologic deficits, neural tension signs, or myelopathy Imaging: Thoracic and Lumbar spine x-rays demonstrate vertebral compression fractures at T12, L3, and L4

8. A) MRI B) CT Scan C) Bone scan D) All of the above can help

10. MRI T/L spine: wedge fracture at T12 vertebral body superior endplate deformity at L3 and L4 bodies heterogeneous marrow signal concerning for metastatic disease

11. MRI STIR sequence images reveal: Edema in T12 Edema in L4

12. Communication with patient, family, and oncologist regarding goals of pain management Integration of plan with other cancer treatments i.e. chemotherapy, radiation, surgery Incorporation of patient’s prognosis & life expectancy

13. Bracing: TLSO Physical therapy Opioids Calcitonin

14. Interventions: the fourth step? http://www.nationalpainfoundation.org/

15. T12 & L4 kyphoplasty with bone biopsies

16. 90% reduction in pain within the first 24hrs & at 2 week Improved ability to sit, stand, & ambulate with less pain Able to get in/out of a vehicle with less pain Decreased pain medication requirement Biopsies negative for cancer Evaluation with bone mineral & metabolism service for workup of osteoporosis

17. An estimated 75K-100K cancer-induced VCF occur annually Stage IV Breast and Lung Multiple Myeloma Stage III and IV of Prostate Including secondary osteoporotic fractures due to ADT treatment Metastatic thyroid and renal carcinoma

18. A) Multiple Myeloma B) Prostate cancer C) Thyroid cancer D) Lung cancer

20. Vertebroplasty & Kyphoplasty minimally invasive procedures to stabilize fracture and reduce pain V: PMMA is injected into a compressed vertebral body K: Tamp inflation/deflation followed by PMMA injection

21. Vertebroplasty: >Less expensive >Faster for the operator and patient Kyphoplasty: >More anatomic correction of spinal deformity than vertebroplasty >Greater height restoration in recent fractures, less than 3 months old ***Taylor RS, Fritzell P, Taylor RJ. Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J. 2007 Aug. 16(8):1085-100. >Less PMMA extravasation, with better “controlled’ spread

22. 134 pts, randomized to kyphoplasty vs. non-surgical management; multicenter trial Primary endpoint: back-specific functional status measured by the Roland-Morris disability questionnaire (RDQ) score at 1 month Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomized controlled trial Dr James Berenson MD, Robert Pflugmacher MD, et al. The Lancet Oncology - 1 March 2011 ( Vol. 12, Issue 3, Pages 225-235 )

23. At 1 month, the mean RDQ score reduction of 8.3 points in the kyphoplasty group; p<0·0001 (compared to 0.1 point reduction in control group) Common adverse events: Symptomatic new vertebral fracture two in the kyphoplasty group vs. three in the control group

24. 1–3% complication rate for benign disease and up to 10% with metastatic disease 1-3 Cement leakage: up to 41% of the cases, mostly asymptomatic 4 Foraminal/epidural cement leakage 4 Venous uptake of cement…. Pulmonary embolism 5 Leakage into the disc space 6 Others: rib fractures, TP fracture, pneumothorax, hematoma, infection, foreign body reactions to the cement 1. Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996;200:525–30. 2. Mathis JM, Ortix O, Zoarski GH. Vertebroplasty versus kyphoplasty: a comparison and contrast. AJNR Am J Neuroradiol 2004;25:840–45. 3. Weill A, Chiras J, Simon JM, et al. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996;199:241–7. 4. Phillips FM, Wetzel FT, Lieberman T, Campbell-Mupp M. An in vivo comparison of the potential for extra vertebral cement leak after vertebroplasty and kyphoplasty. Spine 2002;19:2173-8 5. Jang J, Lee S, et al. Pulmonary Embolism of Polymethylmethacrylate After Percutaneous Vertebroplasty: A Report of Three Cases. Spine. October 2002, Vol 27 (19), E416-8 6. Mirovsky Y, Anekstein Y, Shalmon E, et al. Intradiscal cement leak following percutaneous vertebroplasty. Spine 2006;31:1120–4.

27. Lindsay – Osteoporos Int 2005 Lindsay 2001 Lindsay 2001 analyzed VCF risk within one year in patients with 0, 1 or 2 or more prior VCFs. (JAMA 2001) Lindsay 2005 used the same patient cohort to analyze VCF risk within one year in patients with 0, 1, 2, 3, 4, 5, 6, 7, or 8 prior VCFs. (Osteoporos Int 2005)

29. 5/2004 9/2005

30. Klazen C, Venmans A, et al. Percutaneous Vertebroplasty Is Not a Risk Factor for New Osteoporotic Compression Fractures: Results from VERTOS II. American Journal of Neuroradiology, Sept 2010 (31), pp 1447-1450 Mean follow up 11.4 months Incidence of new VCFs not significantly different between groups Risk factor: number of VCFs at baseline 202 ptsVertebroplasty 18 new fx’s in 15pts Conservative tx 30 new fx’s in 21pts

31. Exclusion criteria were evidence or suspicion of neoplasm in the target vertebral body

32. VCFs are increasingly prevalent, with significant biopsychosocial impact Importance of multidisciplinary pain management, optimization of patient function, and prevention of new fractures Vertebral augmentation is commonly performed for painful compression fractures in cancer patients, with fairly good safety track

33. Recent RCT’s challenge the role of vertebral augmentation for pain & raise more ?’s Limited data on outcomes from vertebral height restoration & anatomic correction of VCFs Role of posterior element in pain from VCFs? Individualized treatment with informed consent