Radiologic Finding of Failed Percutaneous Vertebroplasty Liu, Wei Chiang 1, M.D., Sang-Ho Lee 2, M.D., Won Gyu Choi 2, M.D., Dong-Yeob Lee 2, M.D., Sung Suk Paeng 3, M.D., Amy Kwon 4, Ph.D. Department of Radiology, Wooridul Spine Hospital Department of Neurosurgery, Wooridul Spine Hospital Department of Pathology, Wooridul Spine Hospital Department of Biomedical Research Institutes, Seoul National University Hospital
Disclosure of Commercial Interest! Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content.
Introduction! Vertebroplasty for treating of painful osteoporotic compression fractures widely discussed in the literature & approved in medical circles 1,2.! Nonetheless, acute complications are reported, such as bleeding at the puncture site, local infections, pulmonary embolism, and leakage of cement into the spinal canal, adjacent discs, paravertebral soft tissues, or perivertebral venous 3,4. Jensen et al. Am J Neuroradiol 1997;18:1894-904! Garfin et al. Spine 2001;26:1511-5! Abdul-Jalil et al. Spine 2007 32:E589-93! Baumann et al. Cardiovasc Intervent Radiol 2007;30:161-8!
Introduction! Delayed sequelae are also reported, such as adjacent vertebral fracture, cement dislodgement or fragmentation, and pyogenic spondylodiscitis 5,6.! Most of theses complications can be resolved with conservative treatment, but in some circumstances, surgical intervention is indicated 7. Patel et al. Spine 2007;16:1728-34! Vats et al. Spine 2001;31:E859-62! Yang el al. Eur Spine J 2008;17:982-8!
Purpose! The purpose of this study was to evaluate the etiology of failed percutaneous vertebroplasty.
Materials & Methods! From March 2007 to August 2012.! This retrospective study consited of 23 consecutive patients (4 male, 19 female) who were treated with corpectomy after percutaenous vertebroplasty for compression fractures proven by clinical & radiologic findings.! Age range, 61-86 years (mean, 71.8) years.
Materials & Methods! Diagnostic studies included clinical data, plain radiography, CT 1,2 and MR 3,4 imaging in all patients.! Two spine radiologists evaluated the affect segment, distribution patterns, and configuration of failed vertebroplasty.! Evaluated preoperative MR imaging finding can decreased fail vertebroplasty using finding of fracture type, avascular necrosis, fluid collection in the fracture segments, kyphotic change, compression fracture with infection, interspinous ligament injury, adjacent interbody fusions, poor-qualified MRI. Brilliance 16, Sensation 64 (Philips Medical Systems, Siemens Medical Solutions)! Achieva CV, Avanto (Philips Medical Systems, Siemens Medical Solutions)!
Results Fracture Type! Compression Fracture! 11 (47.8%)! Bursting Fracture! 12 (52.2%)! Total! 23 (100%)!
Results Level (n = 23)! T11! 1 (4.3%)! L1! 8 (34.8%)!! L2! 4 (17.4%)! L3! 6 (26.1%)! L4! 4 (17.4%)!
Fig 1-A to C. 77-year old female with acute lower back pain. Acute compression fractures are visualized on the sagittal image views of L2, L3. (Fig 1-A to C) 1-A. T2WI! 1-B. T1WI! 1-C. T2-Fat Sat!
Fig 1-D to F. Two weeks after percutaneous vertebroplasty (PVP), spondylodiscitis is visualized on the previous PVP site (Fig 1-D, 1-E). Axial contrast T1WI (Fig 1-F) reveals psoas abscess on the previous PVP level. 1-D. T2WI! 1-E. Contrast T1WI! 1-F. Contrast T1WI!
Fig 1-G to I. Preoperative MR images were retrospectively reviewed, A previously missed diagnosis of epidural abscess on L2-3 and bone marrow edema due to spondylitis mistakenly diagnosed as acute compression fracture were seen. 1-G. T2WI! 1-H. T1WI! 1-I. T2-Fat Sat!
Fig 3-J, K. A retrospective review of an preoperative MR image, revealing paraspinal muscle inflammatory change on the psoas muscle. 1-J. T2WI! 1-K. T1WI!
Fig 2-A to C. A 64-year old female with acute low back pain. An acute compression fracture is visualized on L4 (Fig 1-A, 1-B). A ligamentum flavum injury is highly suspected on the T1W-sagittal image (arrow), but the patient was unwilling to undergo T2 fat-saturated image that can-not be confirm ligamentum flavum injury. 2-A. Fig 3-D! T2WI! Fig 2-B.3-E! T1WI!
Fig 3-A to C. A 64-year old female with acute lower back pain. An acute compression fracture of L4 is seen on the sagittal-images (Fig 3-A, 3-B). Ligamentum flavum injury can-not be detect on the image due to poorly qualified fatsaturated T2WI (Fig 3-C). 3-A. T1WI! 3-B. T2WI! 3-C. T2-Fat Sat!
Conclusion! Our study showed that 16 of 23 (69.6%) patients had abnormal preoperative MRI findings that were not detected initially. Such findings included interspinous ligament injury in failed percutaneous vertebroplasty due to poor qualified MRI (lack of T2 fat saturated, low tesla MRI).! Evaluation of the interspinous ligament by using high-quality MR images is therefore important prior to performing percutaneous vertebroplasty for the treatment of osteoporotic compression fractures.