Table 12. Results of vertebroplasty Reference Patient number Levels treated Duration of FU Pain im- proved (%) Complications/remarks Prospective case series McKiernan [65] 46 66 6 months none Zoarski [105] 30 54 15–18 months 96 none, 2 local leaks, not symptomatic Perez-Higueras [77] 13 27 60 months 12/13 2 transitory neuritis, local leakage 48 %, 3 adjacent fractures McGraw [64] 100 156 21 months 93 1 sternal fracture, 1 transient neuritis Heini [37] 17 45 12 months 76% none/local leakage in 20 %, clinically insignificant Cortet [17] 16 20 6 months – no complications McKiernan [66] 41 65 2 weeks – dynamic fracture mobility present in 44%ofpatients Retrospective case series Barr [4] 39 70 18 months (2 –42) 95 1 transient neuritis Hodler [38] 152 363 8.8 months (1–24) 86 71% local leakage without clinical sequelae Jensen [41] 29 47 – 90 Brown [9] 41 77 15.8 months (6–28) 80 fractures older than 12 months Maynard [63] 27 35 – 93 patients with positive bone scan Cyteval [18] 20 nm – 75 one leakage into psoas, one adjacent level fracture Kaufmann [48] 75 122 7 days – preprocedural pain medication and activity level =predictive for outcome Peh [76] 37 48 11 months (3–24) 97 43 % leakage without clinical symptoms lapse[37].Eveninolderfractures,VPcanstillbeeffective[9].Inpatientswith severe osteoporosis and rapidly developing fractures, the reinforcement of multi- plelevelsisanefficientmeanstopreservepostureandpreventfurthercollapse ( Fig. 4) [36]. A non-union after a VBCF can occur in up to 40% of patients [66]. In these situations cementing of the defect provides stability ( Fig. 6). Vertebroplasty improves pain in about 80 –90% of patients The treatment of osteoporotic VBCF by percutaneous cement injection has become a well established treatment option. Several prospective case series have been published and confirm a rapid and lasting pain relief in 80–90% of patients ( Table 11) [4, 23, 36–38, 77]. In fresh fractures the pain improvement is seen in 93% of patients [63]. But also in older lesions the treatment can be effective in as many as 80% of patients ( Table 12) [9, 48]. The scientific evidence for the superiority of vertebroplasty compared to non-operative care is still lacking However, there are no randomized controlled trial (RCT) studies to compare this treatment with conservative measures. Besides the rapid pain reduction, an important aspect of vertebroplasty is the prevention of further collapse of the VB [36]. Restoration of lordosis after a VBFC can be attempted if the fracture is still mobile [100]. This is applicable in non-unions, which can occur in up to 40% [66] just by placing the patient in hyperextension. Furthermore, this can be achieved in fractures that are up to 2 months old. Pitfalls of Cement Reinforcement Complications (Table 13) related to percutaneous cement reinforcement may occur due to: Positioning of the patient (fragility fractures of the rib, prone position alone) Osteoporotic Spine Fractures Chapter 32 939 Table 13. Complications reported for vertebroplasty and kyphoplasty Rib and sternal fractures few case reports [41, 56, 64] Technical complications pedicle fractures [21, 44] fracture of transverse process [21] spinal cord injury during cannula placement [26] Infection 4 case reports [44, 88, 101, 104] Cement leakage severe complication after pulmonary cement embolism [11, 25, 69, 93, 94, 97] oligosymptomatic cement embolism [5, 7, 74, 79] neurological complication [12, 53, 91, 103] renal cement embolism [13] cerebral cement embolization [90] Fat embolism fatal outcome due to fat embolism [94] Adjacent fractures increased risk after VP [6, 30, 50, 57, 98] not significantly increased [54, 95] Anesthesia Placement of cannula Cement injection The inherent problems associated with any percutaneous cement injection tech- nique are: cement extravasation with compromise of neural structures cement embolization Although local cement leakage is well tolerated in most cases, if cement leaks into the spinal canal, it is potentially deleterious and the resulting neural damage often irreversible. Furthermore systemic reactions during cement injection can occur which might be related to the leaking of the toxic cement monomer in the blood circulation. In the literature many reports of complications can be found [7, 32, 75, 81, 86, 90, 97, 99, 103]. Cement leakage into the spinal canal is the most serious complication The frequency of local cement leakage in vertebroplasty is reported to be between 3% and 75% [80]. This wide variance depends on technique of assess- ment, i.e., radiographs are less reliable than CT [89]. In order to minimize the extravasation risk, it is strongly advocated to respect strictly the following recommendations: use of large diameter cannulas inject cement with enhanced radiopacity be aware of the key factor cement viscosity [8] The surgical guidelines must be strictly respected The use of small syringes allows direct control of the cement flow [3]. Any suspi- cious cement flow behavior must lead to immediate discontinuation of injection. The filling behavior is changing with increasing viscosity – if the cement flow does not behave as expected, one should pause for 45 s and reinject a small amount of cement. Pulmonary cement embolism is a potentially lethal complication Reinforcement of the osteoporotic VB means substitution of the bone marrow with cement. The fatty bone marrow is expelled into the circulation and is cleared in the lungs [94]. Therefore the maximal amount of cement that is injected per session is restricted to 25 cc ; in other words not more than six levels should be reinforced per session [36]. 940 Section Fractures Risk of Adjacent Vertebral Fractures The risk of adjacent level fractures appears to be increased after vertebroplasty The risk of a fracture in the adjacent levels seems to be increased after cement rein- forcement [6, 30, 50, 98]. However, the natural history of osteoporotic VBCF needs to be taken into consideration, as the risk of a new fracture rises exponentially with increasing number of fractures [58, 84]. Therefore patients and their post-treat- ment doctors should be informed about controlling the situation if new pain does appear. In such cases, reinforcement of the adjacent vertebrae should be performed. Of course, during the placement of the cannula itself there is the potential risk of an injury of the neural structures. Familiarity with the spinal anatomy and experience with open surgery is therefore mandatory. The occurrence of rib frac- tures during positioning might occur. Complications associated with local anes- thetic can occur in very rare instances. Kyphoplasty and Lordoplasty Kyphoplasty aims to correct kyphosis and height loss Vertebroplasty does not per se allow the restoration of the kyphotic deformity (unless the positioning itself provides some correction; Fig. 6). VP stabilizes the fractured vertebral body in situ. Kyphoplasty was therefore promoted to restore the VB height and correct the kyphotic deformity and realign the spine [26, 102]. Lordotic positioning is an important component of kyphoplasty Height restoration and decrease in cement leakage are the main points that dif- ferentiate this technique from vertebroplasty [70, 78]. However, the potential of kyphosis reduction appears to be moderate. The absolute correction of the kyphotic angle is reported with an average of 8.5 degrees [35, 56] without taking into consideration the spontaneous correction due to positioning [100] ( Table 14 ). Table 14. Comparison of kyphoplasty and lordoplasty Kyphoplasty Lordoplasty Number of patients 27 pts. 31 pts. Min. FU >1 year >1 year Average kyphosis correction 8.5° (47 %) 14° (68 %) Cost (euros) 3000 300 Based on a prospective case series [73] Its excessive cost and more complex procedure on one hand and the improved surgical technique in vertebroplasty by injecting high viscosity cement, with a rate of leakage no different from that of kyphoplasty on the other hand, place a questionmark over its usefulness. Its indications are restricted to selected cases where height loss is associated with a spinal stenosis and its restoration can relieve the symptoms or in cases of traumatic fractures where the repositioning of the endplate is attempted ( Case Introduction). Furthermore the cavity forma- tion might be of help in difficult indications for tumorous lesions [31, 35, 62, 70]. Lordoplasty is an effective alternative to kyphoplasty Alternatively, a lordoplasty procedure can be performed. Analogous to the established principle of the “fixateur interne,” an indirect reduction maneuver is performed [22]. The vertebral bodies above and below the fracture are instru- mented with cannulas and reinforced in a classical technique. After curing of the cement, the cannulas are used as a lever and the collapsed VB is reduced and maintained in this position until the cement is injected and cured in the fractured vertebra [35]. This principle might be combined with a kyphoplasty procedure and help to overcome a shortcoming of kyphoplasty, i.e., the partial loss of initial reduction after deflation of the balloons [100]. The resulting segmental kyphosis correction was 14° on average measured one year postoperatively in a prospec- tive series of 31 patients for the lordoplasty procedure and 8.5° for kyphoplasty Osteoporotic Spine Fractures Chapter 32 941 (Table 14) [73]. The indication for this procedure is given if a relevant kyphotic deformity is present that still has a potential for reduction. Combined Procedures Cases of VBCF with subsequent neural compromise due to a deformity (thoracic kyphosis) or instability (lumbar spinal stenosis, Fig. 4d) are seen with increasing frequency [33, 34, 49, 52, 72]. Displaced fragments may narrow the spinal canal with subsequent compression of the myelon or nerves. Due to the height loss, a foraminal narrowing may lead to nerve root compression. The fact of increasing incidence of spinal stenosis per se and the high risk of osteoporotic fractures seems to boost the frequency of acute exacerbation of these groups of patients where only open surgery with decompression and stabilization can help to solve the problem [14, 40, 42, 71]. Pedicle screw fixation with cement reinforcement allows even fragile vertebrae to be stabilized A surgical decompression procedure only, without stabilization, provides unsatisfactory results for this kind of problem – the decompressive measure will further compromise the mechanical stability [49, 71]. Any closed measures with cement reinforcement will not relieve symptoms derived from a spinal stenosis aslongasthecollapsedsegmentcannotberestored(seebelow).Anopenproce- dure with decompression of the spinal canal and internal fixation and fusion is usually required. However, the problem of anchoring the implants in the osteo- porotic bone on one hand and the risk of new fractures adjacent to the stabilized part of the spine needs to be addressed. Combined internal fixation with cemen- ted screws and the reinforcement of adjacent levels can help to overcome the troubles associated with these osteoporotic spines and allow the same technical principles to be applied as in healthy bone. The combination of internal fixation and cement reinforcement appears extremely helpful. Prophylactic vertebroplasty of an adjacent vertebra must be considered However, in our series of 21 patients who were treated in this manner, five out of eight who received only a cement fixation of screws showed a fracture of the adjacent vertebrae within 2–6 weeks after the stabilization, and needed an exten- sion of the fixation. Therefore it appears mandatory to reinforce the adjacent ver - tebrae in order to prevent this complication. Recapitulation Epidemiology. Osteoporotic vertebral body com- pression fractures (VBCFs) are the hallmark of oste- oporosis and are frequent. Approximately 30–50% of women and 20–30 % of men will develop verte- bral fractures during their life, and half of them will develop multiple fractures. The socioeconomic costs of this problem are enormous. Pathogenesis and classification. Osteoporosisisthe result of an imbalance between bone formation and bone loss. Osteoporosis can be either primary or sec- ondary. Primary osteoporosis is either postmeno- pausal (type 1) or senile osteoporosis (type 2). Sec- ondary osteoporosis can be due to diseases, medical treatments, or lifestyle (diet, smoking). Osteoporosis is defined as a bone mineral density below 2.5 SD of the mean for a young adult reference population. Clinical presentation. Patients who acquire a frac- ture can be asymptomatic. The cardinal symptoms of acute osteoporotic vertebral fractures are acute, sharp girdle like pain that can be breathtaking ini- tially. The pain is often misconceived as back strain and is not further diagnosed unless more severe problems occur. The physical findings are almost al- ways non-specific. However, neurologic assessment is mandatory to rule out neural compromise. Diagnostic work-up. The assessment of patients with VBCFs should include a formal evaluation of the underlying osteoporosis as a systemic disease (laboratory testing, DEXA scan). A tumorous lesion or secondary osteoporosis must be excluded. Stan- dard radiographs remain the method of choice in the diagnostic work-up. An MRI scan is necessary to 942 Section Fractures determine whether a fracture is acute or has already healed by using a fluid-sensitive sequence (e.g. STIR). A CT scan is helpful to better assess the fracture type and anatomy. Non-operative treatment. Medical treatment of the osteoporosis is mandatory after a thorough osteologic assessment. The majority of patients with osteoporotic vertebral fractures become pain free within a few days or weeks. Bed rest for a few days may be necessary. Painkillers should be pre- scribed. Non-operative treatment means careful follow-up of the patients. Severe pain that is persist- ing means a progression of vertebral collapse and patients should obtain a follow-up X-ray examina- tion. Operative treatment. Vertebroplasty is the treat- ment of choice for severely painful fractures. This leads to immediate pain relief in up to 90% of cases and prevents further collapse of the vertebrae while helping to preserve spinal alignment and bal- ance. If a complex fracture is present, which means a concomitant neurological compression and/or a severe spinal deformity, open surgical treatment is advocated. In these cases a combination of cement reinforcement and internal fixation might be neces- sary in order to achieve sufficient stability. Key Articles Delmas PD (2002) Treatment of postmenopausal osteoporosis. Lancet 359:2018 – 26 Excellent review on the medical treatment of osteoporosis. Hodler J, Peck D, Gilula LA (2003) Midterm outcome after vertebroplasty: predictive value of technical and patient-related factors. Radiology 227:662 – 668 This study evaluated different types of polymethylmethacrylate (PMMA) leakage and patient-related factors in relation to clinical midterm (1 –24 month) outcome after verte- broplasty. Standardized four-view radiographs obtained during 363 vertebroplasties in 181 treatment sessions in 152 patients were reviewed (121 patients with osteoporotic frac- tures, 30 with malignant disease, and one with hemangioma). Four types of PMMA leak- age and other potential predictors were related to postprocedural pain response and mid- term outcome after vertebroplasty. The mean follow-up period was 8.8 months (range 1–24 months). At the time of discharge after the procedure, pain was absent after 106 of the 181 sessions (58.5%), better after 50 (27.6%), and the same after 25 (13.8%). In 258 of the 363 treated vertebral levels, at least one type of leakage was found. None of the evalu- ated factors was related significantly to postprocedural pain response, including PMMA leakage. The authors concluded that small to moderate amounts of PMMA may escape from the vertebral body with no significant effect on therapeutic success. Immediate postprocedural pain relief was regarded as the best predictor of midterm clinical outcome after vertebroplasty. Alvarez L, Alcaraz M, Perez-Higueras A, Granizo JJ, de Miguel I, Rossi RE, Quinones D (2006) Percutaneous vertebroplasty: functional improvement in patients with osteopo- rotic compression fractures. Spine 31:1113 – 8 In this prospective, double-cohort study on the outcome of vertebral compression frac- tures, 101 consecutive patients who underwent percutaneous vertebroplasty (PV) were compared to 27 patients who refused PV treatment and were managed conservatively. Patients elected for PV as a treatment had significantly more pain and functional impair- ment before the procedure than the patients of the conservative group (P<0.001). The pain, functional, and general health scores of the PV group were improved from the pre- operative mean values (P<0.001) in all postoperative periods. 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J Vasc Interv Radiol 13:139–148 Osteoporotic Spine Fractures Chapter 32 947 33 Primary Tumors of the Spine Bruno Fuchs, Norbert Boos Core Messages ✔ Primary spine tumors are relatively rare ✔ Cancer is a genetic disease ✔ The acquired capabilities of cancer are: self-suf- ficiency to growth signals, insensitivity to anti- growth signals, tissue invasion and metastasis, limitless replicative potential, sustained angio- genesis, evading apoptosis ✔ Spine tumors are classified based on the histol- ogy ✔ Pain, spinal deformity, and neurologic deficits frequently are presenting symptoms ✔ Age and location are important parameters for establishing a differential diagnosis ✔ CT and MRI are essential for systemic and surgi- cal staging ✔ Biopsy is required to establish the tissue diagnosis ✔ The biopsy has to be placed so that it does not compromise subsequent surgical resection ✔ Do not rely completely on the result of the biopsy – the final histology may be different ✔ The “wait and see” approach is very rarely indi- cated ✔ Conservative treatment is only indicated for benign tumors and in asymptomatic patients ✔ Malignant tumors in general are treated surgi- cally ✔ In sensitive tumors, chemo- and radiotherapy are considered as an adjuvant treatment ✔ The goal of surgery is to remove the primary tumor in its entirety followed by stable recon- struction of the spine Epidemiology Primary spinal tumors are rare Approximately 2000 new cases of bone cancer and 6000 new cases of soft tissue tumorarediagnosedintheUnitedStateseachyear[30].Ofthese,onlyabout5% involve the spine. The incidence of primary spinal tumors has been estimated at 2.5–8.5 per 100000 people per year [15]. Tumors of the lymphoid system, e.g., Plasmocytomas are tumors of the lymphoreticular system plasmocytoma, are generally considered in the discussion of spine tumors although they are tumors of the lymphoreticular system. Some bone tumors have a special predilection for the vertebral column (e.g., osteoblastoma), while others occur exclusively in the spine (e.g., chordoma). There are two important clinical features to be considered when evaluating the potential of malignancy of a spine lesion, i.e.: age location In children younger than 6 years of age, most spinal tumors are malignant, e.g.: neuroblastoma astrocytoma sarcoma (less commonly) However, benign spinal tumors outnumber malignant tumors by a ratio of 2:1 among children of all ages. Tumors and Inflammation Section 951 . decompression of the spinal canal and internal fixation and fusion is usually required. However, the problem of anchoring the implants in the osteo- porotic bone on one hand and the risk of new fractures. (VBCFs) are the hallmark of oste- oporosis and are frequent. Approximately 30–50% of women and 20–30 % of men will develop verte- bral fractures during their life, and half of them will develop multiple. the evaluation of bone density, loss of bone density and struc- tures. Consequences for prophylaxis and treatment. Drugs Aging 12 Suppl 1:15–24 20. Delmas PD (2002) Treatment of postmenopausal