E.G. Pedachenko, S.V. Kushchaev, A.R. Garmish
(Ukrainian Institute of Neurosurgery, Kiev)
Introduction. Puncture vertebroplasty (PV) (percutaneous cementoplasty) is a little-invasive method, ensuring stabilization and consolidation of injured vertebrae with the help of bone cements. It is used in patients with osteoporosis, trauma, tumors (metastases) for prevention of a compression fracture and neurological complications. Its clinical effect manifests itself in regression of pain syndrome and improvement of life quality.
Materials and Methods. There were 106 cases, operated in 2000-2004. Interventions were performed at Th3-L5 levels. An algorithm of a preoperative examination included spondylography, MRI with MR-spectroscopy, CT of an involved vertebral segment, radionuclide scintigraphy (in tumors).
In case of hemangiomas (3% of patients) PV was made after determining a tumor aggressiveness with MR-spectroscopy. Aggressive hemangiomas were characterized by local pain syndrome in all the cases; they were accompanied by compression fractures in 3 patients. A soft-tissue component, located epidurally, was present in 2 cases with aggressive hemangiomas; it demanded combined treatment (microsurgical removal of a tumor and PV).
As for cases with osteoporosis (31), PV was performed in acute compression fractures. Surgical treatment was carried out against a background of conservative therapy of osteoporosis under densitometric control. Indications for an operation were ascertained with taking into account biomechanical peculiarities. One-, two-, three- and four-level vertebroplasty was made in 5, 7, 17 and 3 cases respectively.
There were 19 cases with metastatic lesions of the spine. Single osteolytic metastases (3-5) into vertebral bodies without spread beyond the limits of an involved vertebra and absent neurological symptoms were indications for an operation.
Cases with multiple myeloma (7) were subject to PV in focal (plasmacytoma) and diffuse-focal types of the disease, accompanied by marked pain syndrome.
There were 11 cases with traumatic fractures of vertebral bodies. PV was used in compression fractures of the first degree without radicular and conductive neurological symptoms.
PV was performed under local anesthesia with a patient in a face-down position. A transpedicular approach was used in interventions on the thoracic and lumbar spine most frequently; a posterolateral (intercostovertebral) approach was rather rare. A puncture was made with a special needle under the control of an image converter. Intraoperative venospondylography was applied, when a process was localized in a posterior third of a vertebral body. Special X-ray additives were used in injection of bone cement.
The cases were out of bed on a day of operation. A CT-examination was carried out for control of a composite position in a vertebral body.
Results. Estimation of results was based on three main criteria: subjective perception of pain syndrome severity, motor activity of a patient, dependence on analgesics. The results were estimated pre- and postoperatively (immediately after intervention and in 1, 3, 6, and 12 months) with using special scales. Postoperative CT allowed to assess PV efficacy.
It was as follows: aggressive hemangiomas – 97.3%, osteoporosis – 100%, metastatic lesions – 100%, multiple myeloma – 86%, traumatic compression fractures – 100%.
Complications. There were 12 patients with transitory pain in muscles, which was caused by their trauma, inflicted during an approach (cases with multi-level vertebroplasty).
Asymptomatic extravertebral discharge of cement (up to 0.2 ml) without compression of neurovascular structures was watched in 3 cases. Radicular irritative pain was present in 4 cases postoperatively. It regressed in applying conservative therapy. Transitory hyperemia, being an individual response to implantation of bone cement, was watched in 2 cases.