Vertebral body stenting and cement augmentation to restore structural stability in extreme spinal osteolysis

Transcription

1 Vertebral body stenting and cement augmentation to restore structural stability in extreme spinal osteolysis Poster No.: C-1719 Congress: ECR 2015 Type: Scientific Exhibit Authors: L. Danieli, E. Raz, M. Reinert, G. Pesce, G. Bonaldi, A. Cianfoni ; Rome/IT, New York, NY/US, Lugano/CH, 4 5 Bellinzona/IT, Bergamo/IT Keywords: Interventional non-vascular, Neuroradiology spine, Fluoroscopy, CT, Vertebroplasty, Neoplasia, Metastases DOI: /ecr2015/C-1719 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 11

2 Aims and objectives Extreme neoplastic osteolysis of the vertebral body (VB) determines risk of collapse and instability (Fig 1). Therefore, stabilization should be considered. Surgical treatment with anterior corpectomy, complex reconstruction and posterior stabilization (1) is often not possible or not desirable in these patients due to a poor risk-benefit profile. Percutaneous vertebral augmentation (VA) is a palliative treatment of painful or at-riskof-collapse neoplastic lytic VB lesions, aiming to arrest or prevent fracture (2-6). However, osteolysis widely involving cortical margins of the VB can be a contraindication to the cement augmentation (1), due to higher risk of cement leakage, possibly limiting the amount of cement injected, resulting in insufficient stabilization (7-8) (Fig. 2). Vertebral body stent (VBS) is a barrel-shaped semi-rigid implant with large support surface, allowing primary stabilization of anterior column and cement containment (Fig. 3). It has been recently introduced for the treatment of vertebral compression fractures (9-15), but the use of percutaneous VBS is off-label in extreme osteolysis. The aim of this study is to report the preliminary experience of two centers in palliative pain and stabilization treatment of extreme lytic neoplastic vertebral lesions with wide cortical erosion, by percutaneous VBS and cement augmentation. Images for this section: Page 2 of 11

3 Fig. 1: Sagittal CT image (A) shows an extensive lytic vertebral body metastasis. Sagittal fat-saturated T2-w image (B) demonstrates pathological collapse of the vertebral body with displacement of the posterior wall and spinal cord compression. Fig. 2: A) Axial maximal intensity projection (MIP) CT image after cement injection demonstrating leakage of polymethylmethacrylate (PMMA) into the spinal canal through an extensive lytic lesion of the vertebral body. B-D) Pre-procedure coronal CT image (B) and post-vertebroplasty axial (C) and coronal (D) CT images show extensive cortical erosion that limits the amount of injected PMMA and causes unsatisfactory stabilization. Page 3 of 11

4 Fig. 3: Lateral (A) and frontal (B) fluoroscopic images after transpedicular bilateral placement of two vertebral body stents in a symmetrical, paramedian position within the affected vertebral body. After insertion and balloon expansion, stent cavities will be then filled with cement. Page 4 of 11

5 Methods and materials We retrospectively analyzed technical and clinical results of 11 consecutive VA performed with VBS implants and cement in 10 patients (6 F, 4 M, age range years) with a neoplastic extensive lytic lesion of a thoracic or lumbar VB. Aim of the VA was pain-palliation and/or stabilization in painful and/or fractured and/or at-risk-of-collapse vertebral lesions. Decision to treat was reached in multidisciplinary spine-tumor board consisting of neuro-interventional radiologists, neuro-surgeons, neuro-oncologists and radiation oncologists. Seven of the 11 treated lesions were metastasis from solid tumors, 2 were multiple myeloma and 2 plasmocytoma. The procedures were variably performed before, during, or after radiation treatment and/or chemotherapy. The technique was not standardized, but tailored case by case. Intravenous sedation was used in 9/10 patients and general anaesthesia in 1/10. All procedures were performed under fluoroscopic-guidance, in 2 cases combined with CTguidance. We realized cavity creation before balloon inflation by coblation-plasma ionization in solid tumors with posterior wall erosion. There was variable use of coaxial drills, osteotomic curettes and curved cannulae for cement injection. Technical results were assessed through intra-operative images, immediate postprocedure CT, and one-month post-procedure spine radiographs. Clinical results were assessed by reviewing clinical charts of standard one-week and one-month follow-up. Results Seven lumbar and 4 thoracic levels were treated (Fig. 4-7). Procedures were uneventful in all cases. One epidural cement leak occurred, with no clinical consequence. The procedure was deemed technically successful in providing structural stability to the target VB by VBS implant and cement filling in all cases. Patients with pain (7/10) reported decrease in Visual Analogue Scale (VAS) from average 7.5 pre-procedure to 6.0 at one week and 3.5 at one month. No VBS implant mobilization nor further or newly developed VB collapse was noted at one-month spine radiograph. Page 5 of 11

6 Images for this section: Fig. 4: A 60-year-old woman with metastatic T11 vertebral body collapse. Pre-operative axial (A), coronal (B) and sagittal (C) CT images show extensive metastatic infiltration of the vertebral body including posterior wall and part of the right vertebral pedicle. Intraprocedural lateral (D, F) and frontal (E) fluoroscopic images demonstrating correct positioning of two vertebral body stents. Post-procedure axial (G), coronal (H) and sagittal (I) CT images: perfect filling of the cavities created through vertebral stents and consequent satisfactory stabilization of the vertebral body. Page 6 of 11

7 Fig. 5: A 66-year-old woman with metastatic renal cell cancer. Axial (A) and coronal (B) unenhanced CT demonstrate extensive lytic metastasis in the right aspect of the vertebral body, with wide cortical erosion. Intraprocedural fluoroscopic images show tumor coblation with cavity creation (C, D, E) before vertebral body stent positioning and expansion (F). Axial (G), sagittal MIP (H), and coronal (I) post-procedure CT images demonstrating restored structural stability with no cement leakage. Page 7 of 11

8 Fig. 6: Vertebral body stenting positioning under CT- guidance (A-C). Axial postprocedure CT image (D) shows good cement filling of the extensive lytic lesion of the right peduncle and vertebral body. Page 8 of 11

9 Fig. 7: A 77-year-old male with plasmocytoma broadly involving L4 and the left side of L5 vertebral body and their ipsilateral pedicle, as demonstrated in the pre-procedure axial (A-B) and coronal (C) CT images. Frontal (D) and lateral (E) fluoroscopic images show the positioning of 3 vertebral body stents (2 of which in L4 and 1 in L5 vertebral body). Post-procedure axial (F), coronal (G) and sagittal (H) MIP CT images demonstrate the result of the percutaneous vertebral bodies augmentation. Page 9 of 11

10 Conclusion Our results are preliminary, with short follow-up. VBS was effectively used as a primary structural implant that restored structural stability of the VB, and helped containing injected cement. In this way we obtained with increased safety and efficacy the percutaneous VA of extreme VB osteolysis. Personal information References Normal 0 14 false false false IT JA X-NONE 1. Laufer I, Sciubba DM, Madera M et al. Surgical management of metastatic spinal tumors. Cancer Control 2012 Apr;19(2): Shaibani A, Ali S, Bhatt H. Vertebroplasty and kyphoplasty for the palliation of pain. Semin Intervent Radiol Dec;24(4): Prince EA, Ahn SH. Interventional management of vertebral body metastases. Semin Intervent Radiol Sep;30(3): Eckel TS1, Olan W. Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol Mar;12(1): Anselmetti GC1, Tutton SM, Facchini FR et al. Percutaneous vertebral augmentation for painful osteolytic vertebral metastasis: a case report. Int Med Case Rep J Mar 20;5: Chew C, Craig L, Edwards R et al. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol Jan;66(1): Corcos G1, Dbjay J, Mastier C et al. Cement leakage in percutaneous vertebroplasty for spinal metastases: a retrospective evaluation of incidence and risk factors. Spine (Phila Pa 1976) Mar 1;39(5):E Mousavi P1, Roth S, Finkelstein J et al. Volumetric quantification of cement leakage following percutaneous vertebroplasty in metastatic and osteoporotic vertebrae. J Neurosurg Jul;99(1 Suppl): Klezl Z, Majeed H, Bommireddy R et al. Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine. Injury, 2011; 42(10): Thaler M, Lechner R, Nogler M et al. Surgical procedure and initial radiographic results of a new augmentation technique for vertebral compression fractures. Eur Spine J, 2013; 22(7): Page 10 of 11

11 11. Heini PF, Teuscher R. Vertebral body stenting/stentoplasty. Swiss Med Wkly, 2012; 142: w Rotter R, Martin H, Fuerderer S et al. Vertebral body stenting: a new method for vertebral augmentation versus kyphoplasty. Eur Spine J, 2010; 19(6): Hartmann F1, Griese M, Dietz SO et al. Two-year results of vertebral body stenting for the treatment of traumatic incomplete burst fractures. Minim Invasive Ther Allied Technol Sep 29: Diel P, Röder C, Perler G et al. Radiographic and safety details of vertebral body stenting: results from a multicenter chart review. BMC Musculoskelet Disord Aug 8;14: Werner CM1, Osterhoff G, Schlickeiser J et al. Vertebral body stenting versus kyphoplasty for the treatment of osteoporotic vertebral compression fractures: a randomized trial. J Bone Joint Surg Am Apr 3;95(7): Page 11 of 11