Vertebroplasty

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Percutaneous vertebroplasty (PV) is a minimally invasive medical procedure for the treatment of vertebral body fractures , in which the broken vertebra is filled from the inside with bone cement and thereby stabilized. Percutaneous vertebroplasty is the pioneer of kyphoplasty .

History and areas of application

Vertebroplasties were initially performed as ordinary operations for decades. The not always satisfactory risk-benefit ratio gave the impetus to develop vertebroplasty as a percutaneous procedure. Percutaneous vertebroplasty was first performed in 1984 at Amiens University Hospital to fill a cavity at risk of fracture after removal of a benign hemangioma from the spine . The French authors published an article about this treatment and six other operations of this type in 1987.

Since then, the procedure has also become increasingly established for the treatment of osteoporotic vertebral fractures. The focus today is on the application of such sintering fractures . Percutaneous vertebroplasty is also used e.g. B. used for damage to vertebrae as a result of metastases in the spine. It can be used when the persistent pain from a collapsed vertebra cannot be adequately treated with medication.

Action

The patient is treated in the prone position on a fluoroscopy station (alternatively: CT table) and mostly under local anesthesia . A large hollow needle is inserted through the arch roots (also called feet or pediculi ) of the affected vertebra . Bone cement is then injected into the vertebral body, which hardens in a short time while generating heat.

Complications

Cement leakage

Very often, during the injection, bone cement escapes from the treated vertebral body in veins, in the paravertebral space, in the adjacent disc compartments or in the spinal canal. The frequency of such cement leaks was given in four studies with values ​​between 33% and 72%. Most of the time, the cement leakage remains asymptomatic. If cement penetrates the veins, however, the material can be carried over, in extreme cases into the pulmonary circulation with the appearance of an embolism . A leak of cement into the spinal canal can lead to a paraplegic syndrome due to compression of the spinal cord. Newer systems, such as the Confidence System, try to minimize these dangers through increased cement strength.

Secondary fractures

Further vertebral fractures after the operation - so-called follow-up or follow-up fractures - are the second most common complication, although it remains unclear in individual cases whether the follow-up fracture was provoked or favored by the operation, or whether it occurred independently of the ongoing or progressive osteoporosis would. The frequency of secondary fractures is given as around 10 to 20%, depending on the study. Overall, numerous factors have an influence on the balance of forces in the vertebral bodies, which can favor a further vertebral fracture, including primarily the shape of the treated vertebral fracture. But the mechanical properties ( modulus of elasticity ) of the hardened bone cement and the affected bone substance also play a role, as well as the amount of cement used during the operation and, last but not least, the movements with which the patient loads his spine, for example when walking or bending. Successful vertebroplasty gives the patient more freedom of movement, so that he may put more strain on his spine than an untreated patient who is more inhibited by pain. At the same time, vertebroplasty stiffens individual vertebral bodies at certain points, which can lead to greater stress on neighboring vertebral bodies. A cement leak into the intervertebral disc space also increases the risk of a subsequent fracture in the adjacent vertebral body.

A study from 2006 came to the conclusion that the frequency of vertebral body fractures (WK) is unlikely to increase as a result of the operation: “Overall, however, an increased risk of fractures compared to untreated patients after osteoporosis-related WK fractures cannot be credible "A study from 2012 looked specifically at sandwich vertebral bodies, i.e. untreated vertebral bodies that lie between two treated vertebral bodies. The authors concluded that sandwich vertebral bodies “do not fracture more frequently than the rest of the vertebral bodies”. Overall, however, the relevant studies reveal a mixed picture. The rate of follow-up fractures after vertebroplasty is sometimes higher or identical, but sometimes also lower than the spontaneous rate of further fractures without prior vertebroplasty. In the case of vertebral bodies that are directly adjacent to a vertebral body treated with vertebroplasty, the risk of a fracture appears to be partly increased, partly not increased in various studies.

Results

A very large proportion of the patients treated can be treated symptomatically or at least better with medication after a short time. The good success rates of PV are associated with a comparatively low rate of serious complications. Two studies from 2009 appeared to suggest that PV was not superior to placebo treatment; however, due to methodological deficiencies, these studies were heavily criticized. A 2015 study again questioned the clinical value of PV: It is probably no more effective than placebo treatment, but it does involve serious risks. However, due to the low number of cases, the authors themselves assessed the informative value of their study as only "moderate" and admitted the possibility that future studies might come to different conclusions.

Related procedures

Kyphoplasty

The kyphoplasty is an evolution of vertebroplasty by the American orthopedic surgeon Mark Railey. Here, a balloon is inserted into the vertebral body, which straightens it again and thus restores its original profile as much as possible, before cement is introduced into the cavity created in this way. A small, passive improvement in the position of the vertebral fracture can also be achieved with vertebroplasty. Since the balloon kyphoplasty works with low pressures, cement leaks into the neighboring tissue less often. The disadvantage of this method is that intact cancellous tissue is destroyed when the balloon is expanded and that there is no permanent interlocking between the artificial bone cement and the remaining cancellous bone.

Since 2009, in addition to balloon kyphoplasty, there has also been radiofrequency kyphoplasty, in which a more viscous cement is used, which is then cured using radio frequency energy. This is intended to prevent the cement from escaping. With this substance-preserving method, the cancellous tissue of the bone is spared, and a firm interlocking between the bone cement and the cancellous is guaranteed.

The trend today is towards kyphoplasty, as it enables height correction (repositioning) of the sintered vertebra. In addition, there is significantly less cement leakage than with vertebroplasty. Radiofrequency kyphoplasty combines the advantages of vertebroplasty and balloon kyphoplasty. According to Andreas Kurth, it is "gentle on the bones, pain-relieving, minimally invasive thanks to the unipedicular approach, and the ultra-high viscosity cement results in a massively lower extravasation rate".

Spongioplasty

Spongioplasty is located between vertebroplasty and kyphoplasty: two hollow needles (from the right and left) are inserted into the vertebral body from the side and, once a cylindrical cavity has been created, pulled back a little. Then liquid cancellous material is pressed in.

Vessel sculpture

Vesselplasty is a procedure that, similar to kyphoplasty, creates a cavity in the collapsed vertebra. Before the liquid bone cement is introduced, however, a balloon-like mesh is introduced, which remains in the vertebra as an additional foreign body and into which the bone cement is injected. This is also intended to reduce the undesirable leakage of bone cement from the vertebra into the surrounding tissue.

Sacroplasty

As with vertebroplasty, bone cement is injected percutaneously into the sacrum , which leads to good results, particularly with osteoporotic sacral fractures, so-called sacral insufficiency fractures.

Individual evidence

  1. ↑ P. Galibert, H. Deramond, P. Rosat, D. Le Gars: Note préliminaire sur le traitement des angiomes vertébraux par vertébroplastie acrylique percutanée. In: Neuro-Chirurgie , Volume 33, Number 2, 1987, pp. 166-168, PMID 3600949 .
  2. ↑ Vertebroplasty . DocCheck Flexikon
  3. ^ Anne Pahl: CT-guided vertebroplasty: Technical and clinical results in 365 treated patients . (PDF) Dissertation at LMU Munich, 2015, p. 3.
  4. ↑ Thomas Weiß: Comparison of vertebroplasty and kyphoplasty with regard to failure load, failure stress and localization of connecting fractures (PDF), dissertation at LMU Munich, 2013, p. 14.
  5. ↑ Thomas Weiß: Comparison of vertebroplasty and kyphoplasty with regard to failure load, failure stress and localization of connecting fractures (PDF), dissertation at LMU Munich, 2013, p. 4.
  6. ↑ CA Klazen et al .: Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomized trial. In: Lancet. Volume 376, number 9746, September 2010, pp. 1085-1092, doi: 10.1016 / S0140-6736 (10) 60954-3 , PMID 20701962 .
  7. ↑ A. Kurth; M. Rauschmann: Evidence for osteoplasty of the spine in osteoporotic vertebral body fractures . Osteologie 3/2012, pp. 163–167 (PDF), here p. 164.
  8. ^ Joel D. Siegal: Treatment of Vertebral Compression Fractures . In: US Musculoskeletal Review , 2009, 4, pp. 33-36; ( touchophthalmology.com (PDF)
  9. ↑ a b Thomas Weiß: Comparison of vertebroplasty and kyphoplasty with regard to failure load, failure stress and localization of connecting fractures (PDF), dissertation at LMU Munich, 2013, p. 15.
  10. ↑ A. Rohlmann, HN Boustani, G. Bergmann, T. Zander: A probabilistic finite element analysis of the stress in the augmented vertebral body after Vertebroplasty. In: European spine journal: official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Volume 19, number 9, September 2010, pp. 1585-1595, doi: 10.1007 / s00586-010-1386-x , PMID 20361339 , PMC 2989288 (free full text).
  11. ↑ Cf. Ulrich Nikolaus Lehmann: Clinical Findings on Balloon Kyphoplasty and Radiofrequency Kyphoplasty. Study on effectiveness, duration of action and safety (PDF) Dissertation at the University of Bonn, 2014, p. 43.
  12. ^ HH Fuchs et al .: Incidence of symptomatic secondary fractures after percutaneous vertebroplasty of osteoporotic vertebral body fractures . In: Advances in X-rays and Imaging 2006; 178: Lecture VO_403_5. doi: 10.1055 / s-2006-940925
  13. ↑ MA Joppke et al .: Frequency of sandwich vertebral body fractures after percutaneous vertebroplasty in patients with osteoporosis . In: Advances in X-rays and Imaging 2012; 184: Lecture VO_404_1. doi: 10.1055 / s-0032-1311293
  14. ↑ See overview and references to numerous studies by Thomas Weiß: Comparison of vertebroplasty and kyphoplasty with regard to failure load, failure stress and localization of connecting fractures (PDF) Dissertation at LMU Munich, 2013, p. 16.
  15. ^ R. Buchbinder et al .: A Randomized Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures . In: N Engl J Med , 2009, 361, pp. 557-568.
  16. ↑ DF Kallmes et al .: A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures . In: N Engl J Med , 2009, 361, pp. 569-579.
  17. ↑ Christof Birkenmaier; Stefan Huber-Wagner: Vertebroplasty: A critical analysis of “groundbreaking” studies ( memento of the original from December 24, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: Deutsches Ärzteblatt , 2010, 107 (12), pp. A-537 / B-469 / C-461. @1@ 2Template: Webachiv / IABot / www.aerzteblatt.de
  18. ↑ R Buchbinder et al .: Percutaneous vertebroplasty for osteoporotic vertebral compression fracture . Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No .: CD006349. doi: 10.1002 / 14651858.CD006349.pub2
  19. ^ Carsten Reichel: Operative procedures in osteoporosis .  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. In: Orthopedic News , February 2013@1@ 2Template: Toter Link / biermann-medizin.de  
  20. ^ Philipp Drees: Orthopedics meets osteology. Report from the 59th annual conference of the Association of South German Orthopedists and Trauma Surgeons, April 28th – May 1st, 2011, Baden-Baden. Orthopädische Praxis 6/2011 (PDF), p. 292 f.
  21. ↑ Lucía Flors et al .: Vesselplasty: A New Technical Approach to Treat Symptomatic Vertebral Compression Fractures . In: American Journal of Roentgenology , 2009, 193, pp. 218-226. doi: 10.2214 / AJR.08.1503
  22. ↑ LY Chao, YH Huang, WH Chih: Sacral insufficiency fracture diagnosed after vertebroplasty for L2 and L3 compression fractures: a case report. In: Acta orthopaedica Belgica , Volume 78, Number 1, February 2012, pp. 139-143, PMID 22523943 .