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Osteoporotic Compression Fracture and Percutaneous Vertrebroplasty dr.sandeep c agrawal agrasen hospital gondia maharashtra india
1. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Osteoporotic Compression Fracture
And Percutaneous Vertebroplasty
Loss of body Height
Kyphotic deformity
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
www.agrasenortho.com
drsandeep123@gmail.com
2. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Osteoporotic Compression Fracture
1.Most can be treated by
bed rest, brace, and analgesics
!
2.Rarely surgically treated –
High complications rate by implant
fixation
!
3.Alternative - Minimally Invasive
Method
4. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Vertebral Compression Fracture
Thoracic: wedge by kyphotic loading
!
Lumbar: central endplate cupping
!
!
MRI: high sensitivity
Bone scan
Sagittal reconstructed CT images
5. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Imaging guided percutaneous spine
intervention.
!
For painful benign or malignant, pathologic
vertebral fracture.
Vertebroplasty
6. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Confirmed by X-ray & MRI
!
Pain corresponding to level of the fracture
!
Unresponsive to conservative treatment
Patient Selection Criteria
7. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Contraindications
Uncorrected coagulopathy
!
Infection – local or systemic
!
Moderate or severe retropulsion of posterior
vertebral body cortex into spinal cord
!
Vertebra plana: Height loss > 80%
8. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Procedures
General or local anesthesia
!
Prone position (posture reduction)
!
Unilateral or bilateral transpedicular
approach under fluroscopic control
!
Cement - barium sulfate mixture
9. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Introduction
(Percutaneous vertebroplasty )
Galibert and Deramond in 1987
( vertebral angioma )!
Lapras in 1989 ( osteoporotic
compression fracture )!
Decreasing the pain and improving the
function !
Benefit from this procedure is uncertain
11. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Radiologic
Number of vertebral levels !
!
Percentage loss of vertebral height !
Distance (endplate to endplate) at center of vertebral body !
!
Height of vertebra above fractured vertebra =>!
!
Estimation of the prefracture height !
Height lost = (fractured height/estimated prefractured
height) × 100
12. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Radiologic
Location of the vertebral level !
T spine :T1 - T10!
TL junction : T11 - L2!
L spine : L3 - L5 !
Type of deformity (wedge, biconcave, or
compression) and osteonecrosis
13. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Height loss associated with
unfavorable result!
71.4% in vertebrae with a height loss
higher than 70%
14. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Leakage into disc associated with worse
result
15. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Imaging Guided Percutaneous Spine
Intervention.
!
New Treatment for Painful Benign or
Malignant Vertebral Compression
Fracture
Percutaneous Vertebroplasty
18. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
85 year male, low back pain
after trauma for one year
L1 compression
Fracture
19. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
T12 compression Fracture with nonunion
20. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
74 Year female, T11 T12 L1
Multiple Compression Fractures
21. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Percutaneous Vertebroplasty
Minimal invasive method
Stabilize the fracture vertebra
Dramatic Decreased back pain
=> Improved life quality
22. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Pain Relief in Vertebroplasty
Prevention of micromotion
!
Mechanical stabilization
!
Monomer cytotoxicity or exothermic
reaction
- Thomas A. Einhorn. Spine
vol 25. no. 9 -
23. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Complications of Vertebroplasty
Cement leakage
Adjacent new compression fracture
Pulmonary embolism
Infection
● Subcutaneous hematoma
● Neurological deficit
24. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Cement Leakage
34~75%
Not generally lead to complications
Possible paraplegia
! ! ! ! ! ! ! - OKU 7 -
26. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Increase Fracture Risk at
Adjacent Vertebrae
Additional new fractures
within one year - 15 %
(46/300 patients)!
Garfin et al, Eurospine 2001
27. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Risks for Adjacent Fracture
Adjacent fracture is not
associated with age, sex,
fracture level, bone mineral
density, cement volume and
kyphotic angle.
- Chen APOA 2004
29. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Adjacent Fracture
After Vertebroplasty
Natural course of disease
Provoked by an adjacent rigid
reinforcement.
Mechanism :
Combination of the underlying condition ,
osteoporosis , neoplastic disease , hard cement in the
disc , increased activities after vertebroplasty
30. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Vertebroplasty : Cement Leakage into the Disc
Increases the Risk of New Fracture of Adjacent
Vertebral Body
AJNR
Am
J
Neuroradiology
25
,
February
2004
Edward
P.Lin,
Sven
Ekholm,
Akio
Hiwatashi,
and
Per-Lennart
Westesson
Department
of
Radiology,
Division
of
Diagnostic
&
Interventional
Neuroradiology
,
University
of
Rochester
Medical
Center,
Rochester
,
New
York
Mechanism :
Combination of the underlying condition ,
osteoporosis , neoplastic disease , hard
cement in the disc , increased activities after
vertebroplasty
31. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Discussion
The amount of cement injected during vertebroplasty
The amount of cement that leaked into the disc
The incidence of new fractures
Require further studies
32. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Discussion
We should attempt to reduce the incidence and the
amount of cement leakage into the disc during
vertebropalsty :
!
The needle tip location – laterally , not centrally
The consistency of the cement – more viscous
The volume of cement injected – smaller volume
Stopping injection when detecting leakage into
disc , resumed after cement slightly hardened
33. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Discussion
Supplementary Vertebroplasty +
Posterior instrumentation and P-L fusion
Avoid anterior procedures
Provide sufficient axial loading of vertebral body
Prevent implants failure
34. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Percutaneous Vertebroplasty
Efficacious (but not a risk free) in
pain reduction (86%) for painful
osteoporotic spine fracture
Skillful techniques and careful
safeguards can minimize the
complications
35. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Discussion
Percentage of excellent results decrease in > 70% loss of
vertebral height!
!
Difficult technically!
!
High incidence of disc leakages!
!
Complete relief < 30% (29.6%) of the patients !
!
Progression of the fracture is evident => PV!
!
Fracture remains stable => keep conservative treatment
36. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Discussion
Involvement of > 2 segments was
associated with worse outcome!
!
Disseminated disease and multiple
level fractures are less likely to be free
of pain after a PV
37. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Conclusions
Appropriate patient selection
is essential for achieving
clinical success
Back pain is correlated to
image study esp. MRI
38. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
Conclusions
Better results can be expected
in patients with an ASA score
of I and the vertebral body
height loss is less than 70%.
39. Dr.Sandeep C Agrawal Agrasen Hospital Gondia India!
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Have Fun!
!
!
In our busy daily lives, most of us have!
forgotten one of the bare essentials of!
a happy life - having fun!!
!
!
Be silly. Crack jokes. Laugh. Be mischievous.!
Let your hair down. Leave your troubles!
behind. Play hard. Just play.!
Enjoy yourself.!
!
!
We are always so busy walking and running!
in our lives, we forget. We forget to stop!
and dance!!