Vertebroplasty in the treatment of spine disease

Abstract

We report our experience in the treatment of thoracic and lumbosacral spinal pain due to vertebral bone fractures. This pathology can be related to osteoporosis but also to metastatic disease and less frequently vertebral haemangioma. From April 2001 through December 2004 we treated 238 patients for a total of 455 vertebral bodies. 175 patients had osteoporosis, 70 had metastasis and 13 had vertebral haemangioma. Sacroplasty was performed in six patients to obtain a cement filling of sacral metastasis. The procedures were mostly performed under fluoroscopy and only in cases of metastasis or sacroplasty was CT/fluoroscopy guidance preferred for optimal filling of the area of osteolysis. We evaluated the results at six and 18 months follow-up and analysed the incidence of new vertebral fractures, vascular and disk leakage and the incidence of major and minor complications. Biopsy was performed only in doubtful cases. We obtained different results considering the etiology of the disease. We obtained a 92% success rate at six months follow-up and 89% success at 18 months follow-up in osteoporosis, a 77% and 72% success rate at six and 18 months follow-up in metastastic patients, and no change at six and 18 months follow-up in patients with vertebral haemangioma in which the success rate was of 95%. We noted extravertebral leakage in 41% of vertebral bodies of which 31% were treated at the level of the vascular space and only 10% at the level of the disk space, and symptomatic in only two cases (acute compressive radiculitis, medically treated and resolved within a month). Six patients presented new fractures in the adjacent vertebral body and 30% had a partial recovery in the height of the vertebral body with kyphosis curve reduction. Vertebroplasty is a good technique to obtain spine pain relief and has a low incidence of side effects. Good quality equipment is important to obtain these results.

Figure 1

Vertebroplasty in a patient with porotic bone fracture of T12. Sagittal T1 wi (A) and T2 wi (B) ahow evidence of an abnormal morphology of T12 that appears hypointense in T1 and moderately hyperintense in T2 wi. CT axial scan (C) disclosed microfractures and mild sclerotic reaction. The patient had pain for three months before treatment. Vertebroplasty was performed with a good clinical outcome with a small amount of cement injected seen in AP (D) and LL (E) views.

Figure 2

Aggressive vertebral haemangioma. Sagittal T1 wi (A) and T2 wi (B) show partial L3 collapse with isointensity in T1 wi and hyperintensity in T2 wi. CT axial scan (C) confirms the typical findings. VP was performed obtaining a good filling with extravertebral leakage visible in AP (D) and LL (E) views.

Figure 3

Diagnostic approach in patients with spine pain. After AP and LL x-ray views, MR represent the first approach in T1 (A),T2 (B) and STIR sequences (C) that can clarify the presence of an acute bone marrow oedema that is more evident with STIR sequences. CT scan (D) focuses on evaluation of the posterior wall of the vertebral body to identify microfractures.

Figure 4

Vertebroplasty in a patient with osteolytic metastasis. CT scan shows two lytic lesions at T12 (A) and L1 (B) levels. Under CT guidance a 13 G needle is positioned within the lytic area (C). Post VP axial scan (D) shows a good filling of the lytic lesion, better visible in MPR (E).

Figure 5

Sacroplasty in a patient with lytic lesion of the left sacrum wing. Axial T1 wi (A) shows a hypointense area of the left sacral wing that is very well filled with cement injection (B) as also confirmed by MPR (C).

Figure 6

Sacroplasty in a patient with pathologic fractures. CT scan (A) shows pathologic fractures of both sacral wings, more evident on the left side. Under CT guidance (B) two 13 G needles are positioned and the post-operative CT axial scan (C) shows a good filling of the fracture lines, visible also in MPR (D).

Figure 7

VP of a patient with metastasis and left paravertebral leakage. AP (A) and LL (B) views show evidence of a good filling of the R half vertebral body while the filling in the left half is inhomogeneous with visible left paravertebral leakage.

Figure 8

VP of T12 in a patient with a previous fracture of L1 already treated with vertebroplasty. The sagittal T1 wi (A) and T2 (B) show an area hypointense in T1 and T2 wi of L1 due to the presence of the cement and an area hypointense in T1 wi and hyperintense in T2 wi of T12 due to bone marrow oedema (new fracture a week after the previous one). The patient was treated with a new VP at T12 level with good recovery.

Figure 9

Recovery of the height of the vertebral body after VP. The patient presents a vertebral porotic bone fracture treated with a monopedicular approach (A). The filling of the vertebral body is homogeneous as seen in AP (B) and LL (C) views. Comparing the vertebral height before (D) and after (E) treatment, a recovery of more than 30% is seen.