Skeletal Radiology

, Volume 41, Issue 11, pp 1391–1400 | Cite as

CT fluoroscopy-guided percutaneous vertebroplasty in spinal malignancy: technical results, PMMA leakages, and complications in 202 patients

  • Christoph G. Trumm
  • Anne Pahl
  • Thomas K. Helmberger
  • Tobias F. Jakobs
  • Christoph J. Zech
  • Robert Stahl
  • Philipp M. Paprottka
  • Torleif A. Sandner
  • Maximilian F. Reiser
  • Ralf-Thorsten Hoffmann
Scientific Article

Abstract

Objective

To retrospectively evaluate the incidence and clinical impact of local polymethylmethacrylate (PMMA) leaks and pulmonary cement embolisms occurring under CT fluoroscopy-guided vertebroplasty of symptomatic malignant vertebral osteolyses.

Materials and methods

From December 2001 to June 2009, 202 cancer patients (116 women, 86 men; age 63.2 ± 8.6 years) with painful malignant vertebral osteolyses underwent vertebroplasty, with or without vertebral compression fracture. A total of 331 vertebrae were treated in 231 sessions under CT fluoroscopy guidance (120kV; 10–25mA; single slice, 4-, 16-, and 128-row CT). In the pre-vertebroplasty CT, the following items were assessed: osteolytic destruction (0, ≤25, ≤50, ≤75, or ≤100%) of vertebral cross-sectional area, posterior wall, and circumference; presence of perivertebral and degree of epidural (no, mild, moderate) soft tissue involvement. Local PMMA leaks were analyzed using the post-vertebroplasty CT. Pulmonary cement embolisms were evaluated in all patients having undergone radiography (CR; n = 53) or CT (n = 88) of the chest after vertebroplasty due to their underlying disease. Patient charts were reviewed regarding adverse events.

Results

Of 331 treated vertebrae, 32, 20.2, and 15.7% showed more than 50% osteolytic involvement of the vertebral cross-sectional area, posterior wall, and circumference, respectively. Mild or moderate epidural involvement was seen in 13.0 and 8.4%. Local PMMA leakage rate was 58.6% (194 of 331 vertebrae). Pulmonary cement embolisms (segmental, n = 10; central, n = 1) were seen after 7.8% of the procedures with follow-up imaging of the chest. No major complications occurred within a 30-day period after vertebroplasty.

Conclusion

Vertebroplasty of spinal malignancy can be safely performed under CT fluoroscopy guidance even in patients with substantial osteolytic involvement. In our patient collective, PMMA leaks and pulmonary cement embolisms visualized in post-procedural radiography and CT images had no clinical impact.

Keywords

Vertebroplasty Metastasis Multiple myeloma Complications Polymethylmethacrylate Pulmonary embolism 

Notes

Conflict of interest

R.T.H. is a speaker for OptiMed. The remaining authors declared no conflicts of interest.

References

  1. 1.
    Lieberman I, Reinhardt MK. Vertebroplasty and kyphoplasty for osteolytic vertebral collapse. Clin Orthop Relat Res. 2003(415 Suppl):S176–86.Google Scholar
  2. 2.
    Jensen ME, Kallmes DE. Percutaneous vertebroplasty in the treatment of malignant spine disease. Cancer J. 2002;8(2):194–206.PubMedCrossRefGoogle Scholar
  3. 3.
    Weill A, Chiras J, Simon JM, Rose M, Sola-Martinez T, Enkaoua E. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology. 1996;199(1):241–7.PubMedGoogle Scholar
  4. 4.
    Morrison WB, Parker L, Frangos AJ, Carrino JA. Vertebroplasty in the United States: guidance method and provider distribution, 2001-2003. Radiology. 2007;243(1):166–70.PubMedCrossRefGoogle Scholar
  5. 5.
    Vogl TJ, Proschek D, Schwarz W, Mack M, Hochmuth K. CT-guided percutaneous vertebroplasty in the therapy of vertebral compression fractures. Eur Radiol. 2006;16(4):797–803.PubMedCrossRefGoogle Scholar
  6. 6.
    Gangi A, Kastler BA, Dietemann JL. Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy. AJNR Am J Neuroradiol Am J Neuroradiol. 1994;15(1):83–6.Google Scholar
  7. 7.
    Pitton MB, Herber S, Koch U, Oberholzer K, Drees P, Duber C. CT-guided vertebroplasty: analysis of technical results, extraosseous cement leakages, and complications in 500 procedures. Eur Radiol. 2008;18(11):2568–78.PubMedCrossRefGoogle Scholar
  8. 8.
    Masala S, Konda D, Massari F, Simonetti G. Sacroplasty and iliac osteoplasty under combined CT and fluoroscopic guidance. Spine. 2006;31(18):E667–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Strub WM, Hoffmann M, Ernst RJ, Bulas RV. Sacroplasty by CT and fluoroscopic guidance: is the procedure right for your patient? AJNR Am J Neuroradiol. 2007;28(1):38–41.PubMedGoogle Scholar
  10. 10.
    Brook AL, Mirsky DM, Bello JA. Computerized tomography guided sacroplasty: a practical treatment for sacral insufficiency fracture: case report. Spine. 2005;30(15):E450–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Layton KF, Thielen KR, Wald JT. Percutaneous sacroplasty using CT fluoroscopy. AJNR Am J Neuroradiol. 2006;27(2):356–8.PubMedGoogle Scholar
  12. 12.
    Trumm CG, Jakobs TF, Zech CJ, Helmberger TK, Reiser MF, Hoffmann RT. CT fluoroscopy-guided percutaneous vertebroplasty for the treatment of osteolytic breast cancer metastases: results in 62 sessions with 86 vertebrae treated. J Vasc Interv Radiol. 2008;19(11):1596–606.PubMedCrossRefGoogle Scholar
  13. 13.
    Gangi A, Sabharwal T, Irani FG, Buy X, Morales JP, Adam A. Quality assurance guidelines for percutaneous vertebroplasty. Cardiovasc Interv Radiol. 2006;29(2):173–8.CrossRefGoogle Scholar
  14. 14.
    Baur A, Stabler A, Bruning R, Bartl R, Krodel A, Reiser M, et al. Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures. Radiology. 1998;207(2):349–56.PubMedGoogle Scholar
  15. 15.
    Shimony JS, Gilula LA, Zeller AJ, Brown DB. Percutaneous vertebroplasty for malignant compression fractures with epidural involvement. Radiology. 2004;232(3):846–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Kim YJ, Lee JW, Park KW, Yeom JS, Jeong HS, Park JM, et al. Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors. Radiology. 2009;251(1):250–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Paulson EK, Sheafor DH, Enterline DS, McAdams HP, Yoshizumi TT. CT fluoroscopy-guided interventional procedures: techniques and radiation dose to radiologists. Radiology. 2001;220(1):161–7.PubMedGoogle Scholar
  18. 18.
    Nussbaum DA, Gailloud P, Murphy K. A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site. J Vasc Interv Radiol. 2004;15(11):1185–92.PubMedCrossRefGoogle Scholar
  19. 19.
    Lee MJ, Dumonski M, Cahill P, Stanley T, Park D, Singh K. Percutaneous treatment of vertebral compression fractures: a meta-analysis of complications. Spine. 2009;34(11):1228–32.PubMedCrossRefGoogle Scholar
  20. 20.
    Barragan-Campos HM, Vallee JN, Lo D, Cormier E, Jean B, Rose M, et al. Percutaneous vertebroplasty for spinal metastases: complications. Radiology. 2006;238(1):354–62.PubMedCrossRefGoogle Scholar
  21. 21.
    Chew C, Craig L, Edwards R, Moss J, O’Dwyer PJ. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol. 66(1):63–72Google Scholar
  22. 22.
    Saliou G, el Kocheida M, Lehmann P, Depriester C, Paradot G, Le Gars D, et al. Percutaneous vertebroplasty for pain management in malignant fractures of the spine with epidural involvement. Radiology. 2010;254(3):882–90.PubMedCrossRefGoogle Scholar
  23. 23.
    Venmans A, Lohle PN, van Rooij WJ, Verhaar HJ, Mali WP. Frequency and outcome of pulmonary polymethylmethacrylate embolism during percutaneous vertebroplasty. AJNR Am J Neuroradiol. 2008;29(10):1983–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Caynak B, Onan B, Sagbas E, Duran C, Akpinar B. Cardiac tamponade and pulmonary embolism as a complication of percutaneous vertebroplasty. Ann Thorac Surg. 2009;87(1):299–301.PubMedCrossRefGoogle Scholar
  25. 25.
    Zaccheo MV, Rowane JE, Costello EM. Acute respiratory failure associated with polymethyl methacrylate pulmonary emboli after percutaneous vertebroplasty. Am J Emerg Med. 2008;26(5):636 e635–7.CrossRefGoogle Scholar
  26. 26.
    Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE. Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty. AJR Am J Roentgenol. 2004;183(4):1097–102.PubMedGoogle Scholar
  27. 27.
    Duran C, Sirvanci M, Aydogan M, Ozturk E, Ozturk C, Akman C. Pulmonary cement embolism: a complication of percutaneous vertebroplasty. Acta Radiol. 2007;48(8):854–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Venmans A, Klazen CA, Lohle PN, van Rooij WJ, Verhaar HJ, de Vries J, et al. Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II. AJNR Am J Neuroradiol. 2010;31(8):1451–3.PubMedCrossRefGoogle Scholar
  29. 29.
    Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF. Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty. AJNR Am J Neuroradiol. 2011;32(4):654–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Schmidt R, Cakir B, Mattes T, Wegener M, Puhl W, Richter M. Cement leakage during vertebroplasty: an underestimated problem? Eur Spine J. 2005;14(5):466–73.PubMedCrossRefGoogle Scholar

Copyright information

© ISS 2012

Authors and Affiliations

  • Christoph G. Trumm
    • 1
  • Anne Pahl
    • 1
  • Thomas K. Helmberger
    • 2
  • Tobias F. Jakobs
    • 3
  • Christoph J. Zech
    • 1
  • Robert Stahl
    • 1
  • Philipp M. Paprottka
    • 1
  • Torleif A. Sandner
    • 1
  • Maximilian F. Reiser
    • 1
  • Ralf-Thorsten Hoffmann
    • 4
  1. 1.Department of Clinical RadiologyKlinikum der Ludwig-Maximilians-Universität München-GroßhadernMunichGermany
  2. 2.Institute for Diagnostic and Interventional Radiology and Nuclear MedicineKlinikum BogenhausenMünchenGermany
  3. 3.Department of RadiologyKrankenhaus Barmherzige Brüder MünchenMünchenGermany
  4. 4.Department and Policlinics of Diagnostic RadiologyUniversitätsklinikum Carl Gustav Carus DresdenDresdenGermany

Personalised recommendations