British Journal of Radiology (2005) 78, 261-264
© 2005 British Institute of Radiology
doi: 10.1259/bjr/55389916
Successful treatment of a chronic post-traumatic 5-year-old osteoporotic vertebral compression fracture by percutaneous vertebroplasty
F G Irani, MBBS, MD
1
J P Morales, MD
1
T Sabharwal, MBBCH, FRCSI, FRCR
1
R Dourado, DCR
1
A Gangi, MD, PhD
1,2 and
A Adam, FRCP, FRCS, FRCR
1
1 Department of Radiology, Guy's and St Thomas' Hospital, London, UK and 2 University Louis Pasteur, Strasbourg, France
Correspondence: Dr Tarun Sabharwal, Consultant Radiologist, Department of Radiology, 1st Floor Lambeth Wing, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK
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Abstract
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Osteoporotic vertebral compression fracture (VCF) is a frequently encountered clinical problem associated with chronic pain and disability. Conservative treatment in the form of bed rest, pain control and bracing may create a vicious circle, in which reduced activity leads to further reduction in bone density and fracture risk. Percutaneous vertebroplasty (PVP) is an accepted treatment modality for osteoporotic vertebral body collapse present for less than 1 year, vertebral myeloma, haemangioma, metastasis and recent traumatic fractures (between 3 and 12 months). We describe an osteoporotic patient in whom successful PVP was performed, under general anaesthesia using CT and fluoroscopic guidance, in a post-traumatic 5-year-old VCF with complete alleviation of debilitating pain. In the light of our experience, we suggest that PVP should be carried out in a series of similar patients to asses its value as a treatment option in patients with chronic osteoporotic vertebral fractures for pain relief and improvement in mobility, independent of fracture age.
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Introduction
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Osteoporosis is a chronic debilitating disease, which has reached epidemic proportions in Western societies and which has substantial social and economic consequences. Each year more than 700 000 vertebral compression fractures (VCFs) secondary to osteoporosis are diagnosed in the USA, resulting in 115 000 hospital admissions, 161 000 physician office visits and 5 million restricted activity days annually [1]. In the European Union there are said to be almost 435 000 VCF per year. Osteoporotic VCFs are a leading cause of disability and morbidity in the elderly, adversely affecting quality of life, physical function, psychosocial performance, mental health and survival [2, 3]. Treatment of VCFs is largely conservative, in the form of bed rest, pain control, and occasionally bracing. Hormone replacement therapy (HRT), calcitonin and biphosphonates are effective in maintaining or increasing bone mass and reducing the risk of compression fractures, but are often not prescribed until the disease is diagnosed by the presence of a fracture [4, 5]. Percutaneous vertebroplasty (PVP) with acrylic cement (polymethylmethacrylate, PMMA) is a minimally invasive procedure aimed at preventing further vertebral collapse and producing pain relief in patients with pathological vertebral bodies. It was first described by Galibert et al in 1984 for treatment of an aggressive vertebral haemangioma [6].
The procedure alleviates pain in 75–90% of patients with osteoporotic VCFs [3] and is now an established modality of treatment. Several studies have documented the effectiveness of PVP for pain relief in VCFs that are 1–4 months old [7]. This report describes a patient in whom PVP was performed in a chronic 5-year-old VCF with complete alleviation of debilitating pain.
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Case report
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We were asked to consider a 58-year-old female patient with a chronic anterior wedge compression fracture of T12 vetebral body for PVP. The patient was a known asthmatic with reduced lung function and shortness of breath on exertion. She had been on long-term beclometasone therapy. In June 1997, following a horse-riding accident, she developed severe pain in the back. The plain thoracic radiographs revealed an anterior wedge compression fracture of the body of T12. She was treated conservatively with analgesics and bed rest. However her pain persisted.
In 2000–2001 she was referred to her local pain specialist and treated with several epidural injections of morphine but these did not relieve her pain. Therefore, an epidural catheter was introduced for patient controlled analgesia, which proved very effective. However, on three subsequent occasions, the procedure failed owing to entry site infection. The patient was then referred to our pain clinic. As further treatment with intrathecal opiates was considered inappropriate, we were asked to assess the feasibility of PVP.
Plain radiographs of the thoracolumbar spine showed an anterior wedge compression fracture of the T12 vertebral body with 25–40% reduction in height. A limited CT study with sagittal reconstruction showed no obvious disruption of the anterior and posterior vertebral walls and intact superior and inferior endplates. The bones showed evidence of reduced mineral content suggestive of osteoporosis, which was confirmed by a dual energy X-ray absorptiometry (DXA) scan.
We explained to the patient that published studies have shown vertebroplasty to be successful in the treatment of recent traumatic vertebral fractures (3–12 months) and that the likelihood of pain relief was uncertain in relation to chronic fractures. On examination, there was severe localized tenderness at the T12 vertebral spinous process without kyphotic deformity.
A pre-procedure MRI scan revealed anterior wedging of the T12 vertebral body, with minimal posterior retropulsion causing indentation on the thecal sac. However the involved vertebral body was isointense on T1 weighted scan and showed minimal signal increase on T2 weighting (Figure 1a
) and short tau inversion recovery (STIR) sequences (Figure 1b). The scan showed no evidence of facet arthropathy, spinal canal stenosis or disc herniation. Full informed written consent was obtained. The procedure was performed in the CT suite under general anaesthesia, as the patient was not able to tolerate sedo-analgesia. Blood pressure, ECG and oxygen saturation were monitored continuously. She was placed prone on the CT table and the procedure performed under combined CT and fluoroscopic guidance.
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Figure 1. (a) T2 weighted and (b) short tau inversion recovery (STIR) images showing anterior wedge compression of T12 vertebra with minimal increase in signal intensity of the vertebral body.
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Using a posterior lateral approach, the overlying skin, subcutaneous tissue and periosteum of T12 vertebra were infiltrated with local anaesthetic. An 11 G bone biopsy needle (OptiMed Cemento set, High Wycombe, UK), was introduced into the centre of the T12 vertebral body via a unilateral left intercostovertebral route. Once satisfactory placement of the needle was confirmed on fluoroscopy and CT (Figure 2), 4 ml of cement (PMMA) (Osteopal® V Vertebroplasty; Biomet Merck, Altdorf, Switzerland) was injected into the vertebral body, under continuous lateral fluoroscopic control. Fluoroscopy and CT images showed adequate filling of the cement in the anterior two-thirds of the vertebral body (Figure 3). No epidural, paravertebral, discal or venous leakage of cement was noted.
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Figure 2. Lateral radiograph showing final placement of needle in the anterior portion of the T12 vertebral body.
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Figure 3. Lateral radiograph demonstrating adequate filling of the anterior two-thirds vertebral body with cement (PMMA).
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At 24 h follow up, the patient reported significant pain relief and decreased need for analgesics. On 3, 6 and 12 monthly follow up the patient has had complete pain relief from the T12 compression fracture site, with no use for narcotic analgesics.
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Discussion
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Osteoporosis, as a result of bone mineral loss may be primary (age related) or secondary (commonly due to steroid use) [3, 8]. Chronic steroid use for asthma, chronic obstructive airways disease, rheumatoid arthritis, lymphoma, multiple myeloma and transplantation predispose to the development of secondary osteoporosis and insufficiency fractures due to accelerated bone resorption by osteoclasts [3]. Cumulative prednisolone doses are strongly associated with the risk of development of vertebral fractures [9]. Our patient was a post-menopausal woman on long term steroid therapy for asthma, both of which are high risk factors for the development of osteoporosis and VCF. PVP is the injection of radio-opaque bone cement (e.g. PMMA) into the painful osteoporotic compression fracture or painful pathological vertebral body (e.g. multiple myeloma, metastatic disease and haemangioma), with use of imaging guidance [10]. It is an established therapeutic alternative for treatment of painful VCFs in patients refractory to medical and conservative treatment, where surgery is poorly tolerated and frequently unsuccessful due to the poor quality of osteoporotic bone. Surgery is usually employed in patients with neurogenic complications [11]. PVP has been shown to be effective in acute and subacute fractures, 1 to 4 months old [7]. A recent study suggests treatment within a few weeks of a painful VCF, as a lengthy period of non-operative treatment may lead to continued collapse of the fractured vertebra [8]. Indications for intervention within days of a painful VCF include post-fracture complications such as pneumonia and thrombophebitis, and intolerance to narcotic analgesics [8]. However, it is safest to perform the procedure 3–4 weeks after the fracture, to allow time for consolidation of the fractured posterior elements and clotting of the venous plexus, both of which help to decrease the risk of leakage of cement [11].
According to Gangi et al [12] the ideal candidate for PVP is one who presents within 4 months of the fracture, has midline non-radiating back pain that increases with weight bearing and which is exacerbated by manual palpation of the spinous process of the involved vertebra.
Treatment after 6 months was thought to be less successful in relieving pain [3]. However, there is increasing evidence of the usefulness of PVP in the treatment of chronic osteoporotic VCFs. Kaufmann et al [7] found PVP to provide very effective pain relief and improvement in mobility in chronic VCFs (duration of pain before PVP ranging from 1 week to 104 weeks, mean 19 weeks) with a reduction in the requirement of analgesia. They concluded that patient selection for PVP should not be based on the age of the VCF but on evidence of non-healing of the fracture on the isotope bone scans or MRI images. Brown et al [13] in a retrospective review of 41 patients with symptomatic VCF with mean and median fracture ages of 40.4 months and 28 months, respectively, reported pain relief in 80% patients and improved mobility in 49% patients following PVP. Our case suggests that PVP may be beneficial in the treatment of 5-year-old chronic fractures. Bone scans are helpful in differentiating acute from chronic fractures. Acute fractures show increased uptake of tracer and are highly predictive of positive clinical response after PVP [3]. However, increased tracer uptake may be seen as long as 12 months after fracture [3, 7]. MRI is very useful in patient selection as it provides both functional and anatomical information. Marrow signal changes help determine the age of the fracture. Acute and subacute fractures are hypointense on T1 weighted images and hyperintense on T2 weighted and STIR sequences suggestive of marrow oedema [3, 8]. Fully healed compression fractures become isointense to normal bone marrow on T1 and T2 weighted sequences. Hypointense signal on both T1 and T2 weighted images is suggestive of healing with sclerosis. If suspected a confirmatory CT scan should be performed, as needle placement and injection of PMMA in such cases will be difficult and yield suboptimal radiological and clinical results [3].
In our patient, the MR was equivocal and showed the involved vertebra to be isointense to bone marrow on T1 weighting, with only minimal increased signal on T2 weighted and STIR images. There is anecdotal evidence that equivocal non-contrast MRI scans in patients with severe pain would benefit from gadolinium enhancement as the involved vertebrae show contrast enhancement and they do well with PVP.
Pain in VCFs is thought to be caused by compressive forces acting on the nociceptor endings within the bone matrix. Increasing the rigidity and strength of the bone through the injection and subsequent hardening of PMMA cement reduces bone deformation and painful micro-motion at the fracture site. This is the consolidation effect. In addition, pain relief is thought to be affected by the destruction of sensitive nerve endings in the matrix by the PMMA cement, which is directly toxic because of enhanced production of free oxygen radicals and heating during cement polymerization [8, 12, 14].
Immediate and long-term outcomes of PVP are very encouraging. Immediate pain relief within 24–48 h after PVP has been seen in 75–90% of patients [10, 12, 13, 15, 16]. In our patient both immediate and long term (14 months) pain relief was noted with significant improvement in her mobility. In view of our experience in this case, we suggest that a study of the effectiveness of PVP in VCFs over 1 year old is indicated.
Received for publication March 26, 2004.
Revision received October 13, 2004.
Accepted for publication November 25, 2004.
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Abstract
Introduction
