Percutaneous Vertebroplasty and Kyphoplasty


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Table of contents

The patients enrolled in the studies may have had facet joint-related pain and not the severe pain that one would usually associate with an acute VCF.

Treatments

This may explain why the patients did not show improvement following VP. It is recognised clinically that the severe pain due to an acute VCF subsides if the fracture starts to heal but patients can experience residual pain related to a resultant deformity. The deformity alters the facet joint mechanics and facet-related pain can ensue. Wilson et al. In this study, the percentage of the enrolled patients may had facet-related pain rather pain from the original fracture 41 , Significant reduction in mortality and morbidity using cement augmentation with BKP or VP versus nonsurgical management was reported in retrospective analyses 25 , However, these studies reported outcomes on osteoporotic and not on cancer patients.

BKP was found to be significantly more favourable than NSM offering rapid and sustained pain relief at 1 year, as well as improved back function, QoL, activity, reduced use of analgesics and bed rest days. Additional kyphoplasty was more effective than additional radiation or systemic therapy in terms of pain relief, reduction of pain associated disability and of fracture incidence of the entire thoracolumbar spine It is very important that we do not deny treatment in MM patients that may be very effective in relieving the pain from their acute VCF. The pain relief from cement augmentation has been sustained over long post-operative periods in patients with MM 21 , 30 , 50 , 53 , Many patients with myeloma who get over the acute fracture pain may benefit from facet joint injections for facet-related pain due to the kyphotic deformity.

The evidence on bracing in the management of osteoporotic VCFs is conflicting and the role of the use of external supportive devices including rigid thoracolumbar spinal orthosis TLSO or hyperextension braces is yet to be defined Splinting of fractures and thermoplastic bracing of spinal deformities has been used for many years to treat disability and pain.

This may be all that is needed to give the patients pain relief from their acute fracture pain. The thermoplastic brace may also give temporary stability to a fractured spine and to patients with sternal fracture 56 while chemotherapy is initiated. The most important treatment modality is the systemic anti-myeloma therapy to get the myeloma under control. After one or two cycles of systemic anti-myeloma therapy, cement augmentation PV and BKP can be performed if in fact the acute fracture pain is still present.

This means that the patients may not need cement augmentation. Instead if they have chronic pain of a lower intensity over their kyphotic deformity they may benefit from some facet joint injections. A small group of myeloma patients present with a soft tissue myelomatous mass within the spinal canal that can result in spinal cord or cauda equine compression. These patients often present with neurological deficits and each case needs to be assessed individually.

MRI scanning is clearly imperative but a CT scan with soft tissue windows will help to delineate whether the neural compression is due to bone or soft tissue.

Percutaneous vertebroplasty and kyphoplasty: current status, new developments and old controversies

Patients with cord compression and no neurological deficit may not need radiotherapy because chemotherapy and steroids have been shown to result in excellent resolution of the soft tissue myelomatous mass. All decisions regarding patients with spinal cord compression need to be taken into conjunction with an experienced spinal surgeon.

Clearly, if a patient has spinal cord or cauda equina compression and has significant neurological sequelae then they may require urgent surgical decompression and associated fixation. The metalwork has a higher than normal risk of failure because the bone is very weak due to MM causing secondary osteoporosis. In addition, there is a higher risk of metalwork infection because the patients are immunosuppressed during their conventional chemotherapy, immunotherapy and stem cell transplantation.

After resolution of the intraspinal mass with chemotherapy, radiotherapy and steroids the fractured vertebra may need to be augmented with cement to treat the acute fracture pain but also to give mechanical support to the anterior and middle columns of the spine 57 thereby preventing further collapse of the vertebral body.

Further collapse, particularly into kyphosis, may lead to spinal cord compromise because of the deformity. Patients that present with no intraspinal soft tissue mass, but overt bony destruction and dubious spinal stability are another important group of patients. Often all that is needed is a spinal brace to keep them out of pain while the spine confers itself stability by producing bridging bony osteophytes 58 , This appearance is similar to diffuse idiopathic skeletal hyperostosis It is a phenomenon that may be accelerated by or the result of treatment with bisphosphonates. This is a very interesting finding and warrants further research to see whether patients with myeloma present a completely different clinical problem than patients with osteolytic metastases due to solid tumours.

The following is the consensus statement for recommendations for spinal support and cement augmentation from the International Myeloma Working Group. MM patients with significant pain at a fracture site should be offered a BKP or PV procedure and the procedure should be performed within 4—8 weeks unless there are medical contraindications Tables 1 and 2 , Fig. Careful assessment to determine the severity and site of the pain Patients with acute fracture pain should be considered and not the patient with facet joint-related pain. The clinical picture should be confirmed with MRI scanning.

In addition, T1 images may also show the fracture line. CT scan with sagittal and coronal reconstructions may be needed to assess if there is spinal instability. A SINS classification can be helpful when determining the stability of the spine. If patients get a recurrence of pain after a successful cement augmentation, then sagittal T1 and STIR images of the spine should be repeated to see if there is a new fracture that could develop following myeloma treatment.

Assessment of myeloma disease status and therefore risk related to anaesthetic and any cement augmentation procedure. This includes potential anti-myeloma treatment requirements and risk for infection and bleeding. The functional outcome RDQ was superior for the patients having BKP in the 1st month compared to the patients who received non-surgical treatment. The patients in the BKP group showed a marked reduction in back pain and required less pain relief.

This is important for myeloma patients since most of them have a degree of renal impairment. In addition, improvement of function and mobility can reduce thrombotic and infection risk. There is no upper limit for total number of vertebrae that should be treated in one intervention. The reason for this is that cement embolus to the lungs may occur compromising respiratory function. Cement augmentation without cement leakage into the disc above or below should not increase the risk of adjacent vertebral body fracture. This is also the consensus of the panel.

Cement augmentation of the spine is possible at all spinal levels. The C2 vertebral body can be augmented via a trans-oral or submandibular route. The C3—C7 vertebral bodies can be accessed and augmented through a standard open anterior cervical approach 64 , 65 , 66 or percutaneously if the experience is available.

The thoracic and lumbar vertebral bodies can be augmented with cement in the standard transpedicular or extrapedicular approach. Pain due to fractures from T1 to T4 rarely needs to be treated with cement augmentation because the pain usually settles with conservative management. Sarcroplasty can be performed if there is evidence of sacral insufficiency fractures.

Published studies report contradicting results for cement augmentation 38 , 39 , 40 , 48 , 67 , 68 , 69 , 70 , Although there has been a change in emphasis from VP to BKP, the evidence for one procedure over the other is debatable. BKP was better in restoring mid-vertebral height and in changing kyphotic angle than VP and was also associated with less incidence of refracture. BKP, which involves inflation of a balloon tamp to create a void in the vertebral body, controls the delivery of cement better than PV.

A hyperkyphosis results in a positive sagittal alignment also termed sagittal imbalance. Patients with a positive sagittal balance find it more difficult to stand in the upright posture and in attempting to do so expend more energy. Poor sagittal alignment has been shown to be a strong predictor of disability More research is needed to answer this question definitively. MRI and CT scans are crucial to differentiate between a soft tissue myelomatous mass in the spinal canal from bony encroachment.

The reason for this is that radiation therapy is very effective in reducing the size of a soft tissue myelomatous mass but not effective if there is bony neural compression and does not stabilise the VCF. Current systemic combination therapies of steroids with novel agents work rapidly and should decrease the need for palliative radiotherapy. Radiation therapy may be appropriate for:. Receiving radiotherapy and the dose of previous radiotherapy are not contraindications for cement augmentation PV or BKP if it is needed. The cement augmentation procedures are performed through small stab incisions and therefore the usual concerns over wound healing do not exist.

Planned vertebral augmentation 4—8 weeks later or after the second cycle of chemotherapy is appropriate for patients with relative vertebral instability. The aim of the cement augmentation is to halt further collapse of the fractured vertebral body that could result in progressive kyphosis and secondary neural compromise. The patient was treated with dexamethasone and radiotherapy for cord compression, had TLSO brace fitted for relative stability and received 2 cycles of chemotherapy for kappa light chain myeloma.

The MRI confirmed soft tissue mass response and spinal stability. Overall, the proposed algorithm for spinal support in myeloma presenting with VCFs or spinal cord compression is summarised in a flow diagram in Fig. Obviously, if there is, this is an urgent matter and recommendations proceed accordingly. Once the situation has been assessed, stabilised and treated, then cement augmentation can be an option if there is persistent pain.


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For patients without neurologic compromise, imaging and multi-disciplinary assessment are recommended as the basis for consideration of cement augmentation. Integration within the total treatment schema is the primary plan. The prognosis of patients with myeloma has improved considerably over the last 15 years because of the advances in Haematological Oncology. Patients may present with significant spinal fracture pain or neurological compromise.

These signs and symptoms may present at the time of the index procedure or when there is a relapse of the disease. Those that present with neurological compromise may have spinal cord, cauda equina or nerve root compression. It is imperative, in patients with neurological compromise, to get not only an MRI scan with STIR and T1 weighted images but also a CT scan with soft tissue windowing to delineate whether it is bone or soft tissue compromising the neurological structures.

Surgery may be needed in this cohort of patients. Patients who present with spinal pain, but no neurological compromise should have an MRI scan performed with STIR and T1 weighted images to detect any spinal fractures.

Introduction

The T1 weighted images may be better than the STIR images in highlighting the fracture line in vertebrae infiltrated with a myelomatous deposit. Patients can have quite significant bony defects but still be structurally stable in an orthotic brace A brace may be all that is needed in patients with a spinal fracture if they can mobilise without significant pain. The external orthosis will also keep the patients in the upright posture and potentially prevent the development of a kyphotic deformity while their fractures heal. Patients who present with spinal pain and have a new diagnosis of myeloma may need, depending on systemic symptoms, to have their disease controlled with chemotherapy prior to any consideration for cement augmentation.

The chemotherapy immune-compromises the patients and therefore the correct timing of cement augmentation should be a multi-disciplinary decision. Antibiotic prophylaxis in the peri-operative period is strongly advised to avoid infection. The orthotic brace can be a very useful tool to control the pain to an acceptable level while the disease is being treated with the first couple of cycles of chemotherapy.

Another important aspect of the treatment in myeloma patients involves bisphosphonate therapy. This drug treatment clearly helps to stabilise the bone density in patients with myeloma but, in addition may have a positive effect in producing an external scaffold of bone around the vertebral bodies to confer them extra stability. This external scaffold, which has been described as DISH in prior publications 81 in patients with myeloma, may decrease the need for spinal fixation in patients otherwise thought to be at risk of spinal instability because of involvement of all three bony spinal columns The prognosis of MM is continually improving due to medical advances.

The treatment of myeloma with chemo- immunotherapeutic agents and autologous stem cell transplantation renders the patient immunocompromised for periods of time, exposing them to infection. Spinal fixation has been employed traditionally to treat myeloma patients when decompression and stabilisation were deemed to be essential. However, it is well established that in situ instrumentation is at risk of getting infected when the patients are in an immunocompromised state.

If the metalwork gets infected, then the consequences can be catastrophic. Cement augmentation is a very effective way of stabilising the anterior and middle spinal columns without the need for metalwork fixation. It is an excellent way to relieve the pain from a VCF. The myeloma spine treated with bisphosphonates appears to produce an external scaffold of bone that stabilises even the most moth-eaten spinal elements once the disease process is under control.

An external orthosis can be very effective when trying to achieve pain relief from a fracture. It also helps to maintain the correct sagittal balance in patients with multiple fractures while they heal or before they are treated with cement augmentation. The development of radiofrequency ablation in combination with cement augmentation procedures is currently under investigation with encouraging results.

Terpos, E. Biology and treatment of myeloma related bone disease. Metabolism 80 , 80—90 Pathogenesis of bone disease in multiple myeloma: from bench to bedside. Blood Cancer J. Mechanisms of bone destruction in multiple myeloma. Cancer Care 26 , e— Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding. Compared with placebo , high- to moderate-quality evidence from five trials indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month.

Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo - controlled trial remains unreported. Mean pain on a scale zero to 10, higher scores indicate more pain was five points with placebo and 0. Mean disability measured by the Roland-Morris Disability Questionnaire scale range zero to 23, higher scores indicate worse disability was Low-quality evidence downgraded due to imprecision and potential for bias from the usual-care controlled trials indicates uncertainty around the risk estimates of harms with vertebroplasty.

Notably, serious adverse events reported with vertebroplasty included osteomyelitis , cord compression, thecal sac injury and respiratory failure.

Background

Our subgroup analyses indicate that the effects did not differ according to duration of pain acute versus subacute. Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity. Vertebroplasty for treating spinal fractures due to osteoporosis Background Osteoporosis is characterised by thin, fragile bones and may result in minimal trauma fractures of the spine bones vertebrae.

Study characteristics This Cochrane review is current to November Quality of the evidence High-quality evidence shows that vertebroplasty does not provide more clinically important benefits than placebo. Authors' conclusions:. Search strategy:. Selection criteria:.

Data collection and analysis:. Thank you for updating your details.


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