Repeat vertebroplasty for the subsequent refracture of procedured vertebra

Abstract

Vertebroplasty (VP) can effectively treat pain and immobility caused by vertebral compression fracture. Because of complications such as extravasation of bone cement (polymethylmethacrylate, PMMA) and adjacent vertebral fractures, some practitioners prefer to inject a small volume of PMMA. In that case, however, insufficient augmentation or a subsequent refracture of the treated vertebrae can occur. A 65-year-old woman visited our clinic complaining of unrelieved severe low back and bilateral flank pain even after she had undergone VP on the 1(st) and 4(th) (L1 and L4) lumbar vertebrae a month earlier. Radiologic findings showed the refracture of L1. We successfully performed the repeat VP by filling the vertebra with a sufficient volume of PMMA, and no complications occurred. The patient's pain and immobility resolved completely three days after the procedure and she remained symptom-free a month later. In conclusion, VP with small volume cement impaction may fail to relieve fracture-induced symptoms, and the refracture of an augmented vertebral body may occur. In this case, repeat VP can effectively resolve both the persistent symptoms and problems of new onset resulting from refracture of the augmented vertebral body due to insufficient volume of bone cement.

Keywords: refracture; repeat; vertebral compression fractures; vertebroplasty.

Fig. 1

AP (A) and lateral (B) radiographs showing augmented 1^st and 4^th lumbar vertebral bodies filled with 2 ml and 2.5 ml of PMMA, respectively. The small volume injectates were unevenly distributed into the small portion of fractured vertebrae.

Fig. 2

In the pre-VP image (A), the collapse of vertebral body and the low-signal intensity in the anterior part of L1 represented the acute vertebral compression fractures. Comparing to the pre-VP image, the T1 and T2 weighted images a month after the first VP (B and C, respectively) showed slightly increased vertebral collapse and kyphotic angle, and an increase in low-signaled area to the posterior part of the L1 vertebral body, which are viewed as the refracture of L1.

Fig. 3

AP (A) and lateral (B) radiographs after repeat VP in the L1 vertebral body. Bone cement was evenly distributed into the fractured vertebra without cement leakage or migration of previous injectate.