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Sacroplasty in a cadaveric trial: comparison of CT and fluoroscopic guidance with and without balloon assistance

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Abstract

Sacral insufficiency fractures can cause severe, debilitating pain to patients concerned. The incidence of this fracture type correlates with the appearance of osteoporosis in the elderly population. A polymethylmethacrylate (PMMA) cement injection procedure called sacroplasty has been recently described as an optional method for the treatment of this fracture type. However, the correct cement placement in the complex anatomical structure of the sacrum is a surgical challenge. The aim of the study is to compare the precision, safety, and radiation exposure of standard multiplanar fluoroscopy and computed tomography (CT) guidance for PMMA application to the sacrum using both balloon-assisted sacroplasty and conventional sacroplasty. A controlled experimental investigation in a human cadaver trial has been performed. Two imaging and two application modalities to monitor percutaneous PMMA injection to the sacrum were examined. The application forms were randomized from side to side of the pelvis. We found less cement extravasation in the CT-guided groups, but also a significant higher radiation exposure (P < 0.05) by using CT guidance. The conventional fluoroscopy-guided sacroplasty revealed the shortest procedure time (incision to closure time) of all treatment groups (P < 0.01). These findings show no difference regarding cement extravasation between ballon-assisted and conventional sacroplasty. Further, in comparison to fluoroscopy-assisted technique, the CT-guided cement injection seems to decrease the risk of cement extravasation, irrespective of the use of an additional balloon assistance. However, we have to consider a greater radiation exposure using CT guidance. Further investigations will proof the suitability in the normal course of clinical life.

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References

  1. Anderson DE, Cotton JR (2007) Mechanical analysis of percutaneous sacroplasty using CT image based finite element models. Med Eng Phys 29:316–325. doi:10.1016/j.medengphy.2006.03.008

    Article  PubMed  Google Scholar 

  2. Babayev M, Lachmann E, Nagler W (2000) The controversy surrounding sacral insufficiency fractures: to ambulate or not to ambulate? Am J Phys Med Rehabil 79:404–409. doi:10.1097/00002060-200007000-00014

    Article  PubMed  CAS  Google Scholar 

  3. Backenkohler U, Strasmann TJ, Halata Z (1997) Topography of mechanoreceptors in the shoulder joint region—a computer-aided 3D reconstruction in the laboratory mouse. Anat Rec 248:433–441. doi:10.1002/(SICI)1097-0185(199707)248:3<433::AID-AR16>3.0.CO;2-Q

    Article  PubMed  CAS  Google Scholar 

  4. Barr JD, Barr MS, Lemley TJ, McCann RM (2000) Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine 25:923–928. doi:10.1097/00007632-200004150-00005

    Article  PubMed  CAS  Google Scholar 

  5. Betts A (2005) All-fluoroscopic technique for sacral vertebroplasty. Pain Physician 8:417–420

    PubMed  Google Scholar 

  6. Betts A (2008) Sacral vertebral augmentation: confirmation of fluoroscopic landmarks by open dissection. Pain Physician 11:57–65

    PubMed  Google Scholar 

  7. Bohner M, Gasser B, Baroud G, Heini P (2003) Theoretical and experimental model to describe the injection of a polymethylmethacrylate cement into a porous structure. Biomaterials 24:2721–2730. doi:10.1016/S0142-9612(03)00086-3

    Article  PubMed  CAS  Google Scholar 

  8. Boszczyk BM, Bierschneider M, Panzer S, Panzer W, Harstall R, Schmid K, Jaksche H (2006) Fluoroscopic radiation exposure of the kyphoplasty patient. Eur Spine J 15:347–355. doi:10.1007/s00586-005-0952-0

    Article  PubMed  Google Scholar 

  9. Buerger PM, Peoples JB, Lemmon GW, McCarthy MC (1993) Risk of pulmonary emboli in patients with pelvic fractures. Am Surg 59:505–508

    PubMed  CAS  Google Scholar 

  10. Bundesministerium für Umwelt Naturschutz und Reaktorsicherheit (1995) Umweltradioaktivität und Strahlenbelastung. Jahresbericht 1994, Bonn

  11. Butler CL, Given CA, Michel SJ, Tibbs PA (2005) Percutaneous sacroplasty for the treatment of sacral insufficiency fractures. AJR Am J Roentgenol 184:1956–1959

    PubMed  Google Scholar 

  12. Dasgupta B, Shah N, Brown H, Gordon TE, Tanqueray AB, Mellor JA (1998) Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 37:789–793. doi:10.1093/rheumatology/37.7.789

    Article  PubMed  CAS  Google Scholar 

  13. Deen HG, Nottmeier EW (2005) Balloon kyphoplasty for treatment of sacral insufficiency fractures. Report of three cases. Neurosurg Focus 18:e7

    PubMed  Google Scholar 

  14. Ehara S (2006) Percutaneous sacroplasty for osteoporotic insufficiency fractures. AJR Am J Roentgenol 186:580–581. doi:10.2214/AJR.06.5009

    Article  PubMed  Google Scholar 

  15. Einstein AJ, Henzlova MJ, Rajagopalan S (2007) Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 298:317–323. doi:10.1001/jama.298.3.317

    Article  PubMed  CAS  Google Scholar 

  16. Finiels H, Finiels PJ, Jacquot JM, Strubel D (1997) Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases. Presse Med 26:1568–1573

    PubMed  CAS  Google Scholar 

  17. Finiels PJ, Finiels H, Strubel D, Jacquot JM (2002) Spontaneous osteoporotic fractures of the sacrum causing neurological damage. Report of three cases. J Neurosurg 97:380–385

    PubMed  Google Scholar 

  18. Fishmann AJ, Greeno RA, Brooks LR, Matta JM (1994) Prevention of deep vein thrombosis and pulmonary embolism in acetabular and pelvic fracture surgery. Clin Orthop Relat Res 13:3–137

    Google Scholar 

  19. Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Daitch JS (2007) Efficacy and safety of percutaneous sacroplasty for painful osteoporotic sacral insufficiency fractures: a prospective, multicenter trial. Spine 32:1635–1640. doi:10.1097/BRS.0b013e318074d4e1

    Article  PubMed  Google Scholar 

  20. Garant M (2002) Sacroplasty: a new treatment for sacral insufficiency fracture. J Vasc Interv Radiol 13:1265–1267. doi:10.1016/S1051-0443(07)61976-9

    Article  PubMed  Google Scholar 

  21. Gheduzzi S, Webb JJ, Miles AW (2006) Mechanical characterisation of three percutaneous vertebroplasty biomaterials. J Mater Sci Mater Med 17:421–426. doi:10.1007/s10856-006-8469-6

    Article  PubMed  CAS  Google Scholar 

  22. Gosch D, Gosch K, Kahn T (2007) Conversion coefficients for estimation of effective dose to patients from dose area product during fluoroscopy X-ray examinations. Rofo 179:1035–1042

    PubMed  CAS  Google Scholar 

  23. Gotis-Graham I, McGuigan L, Diamond T, Portek I, Quinn R, Sturgess A, Tulloch R (1994) Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br 76:882–886

    PubMed  CAS  Google Scholar 

  24. Grangier C, Garcia J, Howarth NR, May M, Rossier P (1997) Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 26:517–524. doi:10.1007/s002560050278

    Article  PubMed  CAS  Google Scholar 

  25. Grasland A, Pouchot J, Mathieu A, Paycha F, Vinceneux P (1996) Sacral insufficiency fractures: an easily overlooked cause of back pain in elderly women. Arch Intern Med 156:668–674. doi:10.1001/archinte.156.6.668

    Article  PubMed  CAS  Google Scholar 

  26. Heron J, Connell DA, James SL (2007) CT-guided sacroplasty for the treatment of sacral insufficiency fractures. Clin Radiol 62:1094–1100. doi:10.1016/j.crad.2007.04.017

    Article  PubMed  CAS  Google Scholar 

  27. Hulme PA, Krebs J, Ferguson SJ, Berlemann U (2006) Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 31:1983–2001. doi:10.1097/01.brs.0000229254.89952.6b

    Article  PubMed  Google Scholar 

  28. Kelekis AD, Martin JB, Somon T, Wetzel SG, Dietrich PY, Ruefenacht DA (2003) Radicular pain after vertebroplasty: compression or irritation of the nerve root? Initial experience with the “cooling system”. Spine 28:E265–E269. doi:10.1097/00007632-200307150-00027

    Article  PubMed  Google Scholar 

  29. Lin JT, Lane JM (2003) Sacral stress fractures. J Womens Health (Larchmt) 12:879–888. doi:10.1089/154099903770948104

    Article  Google Scholar 

  30. Lourie H (1982) Spontaneous osteoporotic fracture of the sacrum. An unrecognized syndrome of the elderly. JAMA 248:715–717. doi:10.1001/jama.248.6.715

    Article  PubMed  CAS  Google Scholar 

  31. Mathis JM, Barr JD, Belkoff SM, Barr MS, Jensen ME, Deramond H (2001) Percutaneous vertebroplasty: a developing standard of care for vertebral compression fractures. AJNR Am J Neuroradiol 22:373–381

    PubMed  CAS  Google Scholar 

  32. Newhouse KE, el Khoury GY, Buckwalter JA (1992) Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am 74:1472–1477

    PubMed  CAS  Google Scholar 

  33. Palussiere J, Berge J, Gangi A, Cotten A, Pasco A, Bertagnoli R, Jaksche H, Carpeggiani P, Deramond H (2005) Clinical results of an open prospective study of a bis-GMA composite in percutaneous vertebral augmentation. Eur Spine J 14:982–991. doi:10.1007/s00586-003-0664-2

    Article  PubMed  Google Scholar 

  34. Phillips FM, Todd WF, Lieberman I, Campbell-Hupp M (2002) An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty. Spine 27:2173–2178. doi:10.1097/00007632-200210010-00018

    Article  PubMed  Google Scholar 

  35. Pommersheim W, Huang-Hellinger F, Baker M, Morris P (2003) Sacroplasty: a treatment for sacral insufficiency fractures. AJNR Am J Neuroradiol 24:1003–1007

    PubMed  Google Scholar 

  36. Smith DK, Dix JE (2006) Percutaneous sacroplasty: long-axis injection technique. AJR Am J Roentgenol 186:1252–1255. doi:10.2214/AJR.05.0823

    Article  PubMed  Google Scholar 

  37. Stamm G, Nagel HD (2002) CT-expo—a novel program for dose evaluation in CT. Rofo 174:1570–1576

    PubMed  CAS  Google Scholar 

  38. Strub WM, Hoffmann M, Ernst RJ, Bulas RV (2007) Sacroplasty by CT and fluoroscopic guidance: is the procedure right for your patient? AJNR Am J Neuroradiol 28:38–41. doi:10.3174/ajnr.A0653

    PubMed  CAS  Google Scholar 

  39. Trout AT, Kallmes DF (2006) Does vertebroplasty cause incident vertebral fractures? A review of available data. AJNR Am J Neuroradiol 27:1397–1403

    PubMed  CAS  Google Scholar 

  40. Tsiridis E, Upadhyay N, Giannoudis PV (2006) Sacral insufficiency fractures: current concepts of management. Osteoporos Int 17:1716–1725. doi:10.1007/s00198-006-0175-1

    Article  PubMed  CAS  Google Scholar 

  41. Uemura A, Matsusako M, Numaguchi Y, Oka M, Kobayashi N, Niinami C, Kawasaki T, Suzuki K (2005) Percutaneous sacroplasty for hemorrhagic metastases from hepatocellular carcinoma. AJNR Am J Neuroradiol 26:493–495

    PubMed  Google Scholar 

  42. Weber M, Hasler P, Gerber H (1993) Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 18:2507–2512

    Article  PubMed  CAS  Google Scholar 

  43. White JH, Hague C, Nicolaou S, Gee R, Marchinkow LO, Munk PL (2003) Imaging of sacral fractures. Clin Radiol 58:914–921. doi:10.1016/S0009-9260(03)00270-8

    Article  PubMed  CAS  Google Scholar 

  44. Whitlow CT, Yazdani SK, Reedy ML, Kaminsky SE, Berry JL, Morris PP (2007) Investigating sacroplasty: technical considerations and finite element analysis of polymethylmethacrylate infusion into cadaveric sacrum. AJNR Am J Neuroradiol 28:1036–1041. doi:10.3174/ajnr.A0500

    Article  PubMed  CAS  Google Scholar 

  45. Zaman FM, Frey M, Slipman CW (2006) Sacral stress fractures. Curr Sports Med Rep 5:37–43

    PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Kyphon® Europe for excellent technical support during the study.

Conflict of interest statement

The authors ensure that there were no conflicts of interest related to companies or products named in the manuscript.

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Authors and Affiliations

  1. Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    L. Grossterlinden, W. Lehmann, J. Nuechtern, J. M. Rueger & D. Briem

  2. Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    P. G. C. Begemann & G. Adam

  3. Institute of Anatomy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    U. Schumacher

  4. Philips Medizin Systeme GmbH, Röntgenstrasse 24, 22335, Hamburg, Germany

    H. D. Nagel

  5. Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany

    W. Linhart

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  1. L. Grossterlinden
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  2. P. G. C. Begemann
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  9. J. M. Rueger
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Correspondence to L. Grossterlinden.

Additional information

L. Grossterlinden and P. G. C. Begemann have contributed equally.

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Grossterlinden, L., Begemann, P.G.C., Lehmann, W. et al. Sacroplasty in a cadaveric trial: comparison of CT and fluoroscopic guidance with and without balloon assistance. Eur Spine J 18, 1226–1233 (2009). https://doi.org/10.1007/s00586-009-1001-1

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  • DOI: https://doi.org/10.1007/s00586-009-1001-1

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