50 22. Ciras J, Depriester C, Weill A. Vertebroplasties per- cutanees. Technique et indications. J Neuroradiol 1997; 24,45-59. 23. Cotten A, Deramond H, Cortet B. Preoprative percu- taneous injection of methylmethacrylate and N-bu ryl cyanoacrylate in vertebral hemangiomas. Am J Neu- roradiol 1996; 17:137-142. 24. Co Hen A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasry for osteolytic metastases and my- l eoma. Radiology 1996; 200:525--530. 25. Weill A, ChirasJ, SimonJM, Rose M, Sola-Martinez T, Enkaolla E. Spinal merastases: indications fo r and results of percuraneous injection of acrylic surgi cal cement. Radiology 1996; 199:241-247. 26. Debussche-Depriester C, Deramond H, Farde ll one P. Percutaneous vertebroplasry with acrylic cement in the lrerment of osteoporo tic vertebral cru sh frac- ture syndrome. Neuroradiology 1991; 33:149- 152. 27 . Coren A, Boutry N, Cortet B, et al. Percutaneous vertebroplasry: sca te of the art. Radiographies 1998; 18:311-320. 28. Deramond H, Depriester C, GaBbert P, Le Ga rs D. Perrutaneous venebroplasry with polymethylmethac- rylate: techniques, indications and results. Radiol Clin N Am 1998; 36:53;}-546 29. Bostrom MP, Lane JM. Future directions: augmenta- tions of osteoporotic vertebral bodies. Spine 1997; 22:385-425. 30. Wi l son D, Mathis )M, Scribner R, Talmadge K, Hayes W. Effect of augmentation on the mechanics of ver- tebral wedge fractures. Spine (in press) 31. Mathis J M, Fenton 0, Scribner R, Riley MA, Talmedge K, Belkoff SM. Biomechanical comparison of new treatments for vertebral body compression fractures. Presented at 13th Annual North American Spine Society; November 1998; San Francisco, CA. 3,20 pm Percutaneous Vertebroplasty: The Tricks of the Trade Jacques E. Diort, MD Emory University Hospital Atlanta, Georgia Learning obj ectives: Upon completion of this presenta- tion, the attendee will be able to: 1) List the indications and selection process for vertebroplasty, 2) Describe the transpedicular puncture approach, 3) List the materials usedfor vertebroplasty, and describe how to u.se them, 4) List the complications of vertebroplasty. History and Bac kground Many clinical entities can cause painful vertebral col- lapse, including osteoporosis, vertebral hemangioma s, multiple myeloma and metastatic disease; of these, the most common in North America is osteoporosis. In the United States, 700,000 osteoporotic vertebral co mpres- sion fractures occur every year, causing 115,000 hospital admissions each year; additional patients suffer fractures from chronic steroid use (particularly organ transplant pati en ts). The average length of hospital stay for each of these admissions is 8 days; in addition, the average number of disabiliry days per fracture is 14 days. Finally, the care of these patients at home is Significant because they are of ten incapacitated in their activities of da ily living (ADL), requiring home nurSing care and some- times moving from home to a nurs in g faciliry . Therefore, the annual cost to the American health ca re system is very Sign ificant. The lifetime risk of a vertebral compression fracture is 16% for white women, and 5% for white men. The risk is comparatively higher for the Asian population and lower for the black p opu lation. Once an osteoporotic fracture has occurred, there is a five-fold increase in the risk for a second fracture; when two fractures have occurred, the risk of another fra cture increases to twelve-fold. The pain syndrome that follows a vertebral compression frac- ture often causes patient s to be bed- or wheelchair- ridden and dependen t on anal geSiCS . Conservative medical treatment with medication, bracing, and ilruno- bil iza ti on leads to accelerated bone loss, compounding the problem. On average, the pain syndrome lasts ap- proximately 4-10 weeks, but may persist for months and never fully subS id e; this may be caused by constant micro-motion at the fracture s ite and nonunion. As a result of the fracture(s), there is progressive kyphosis, which ca uses ftmher pain and di sabiliry (early satiery, pseudo bowel obstruction), worsening the problems of loss of in dependence, low self-esteem, and depression. Patients with fractures are more dependent in ADLs and suffer from weight loss, decreased exercise lOlerance, and depression. To date, treatment has been mostly conservative, consisting of bed rest, analgesi cs, or cumbersome, ex - pens iv e back braces. Medical pain therapy with analge- sics (often narcotics), because of s ide effects, has a sig- nificant negative impa ct on patients' quality of life. Current med ical therapy of osteoporosis itself is ex- tremely important and should include hormonal replace- ment therapy, biphosphonates and caicilOnin (which has a central analgeSiC effect); they are unfortunately pre- scribed only after osteoporosis has heen uncovered hya fr acture. In the mid-1980s, a procedure ca ll ed "percuta- neous vertebroplasry" was described by the French. It was a minimally invasive procedure where the fractured vertebral body was accessed percutaneously with a nee - dle positioned with a transpedicular or paravertebral approach; then, PM..r..tA was injected to provide bone augmentation and stabilization, thereby preventing fur· [her co ll apse and movement. This "internal casting" alleviated pain and allowed increased mobiliry in a sig- nificant percentage of patients; this resulted in improve- ment in ADts and de crease in the amount of analgesiC medication reqUired. The initial European experience 50 22. Ciras J, Depriester C, Weill A. Vertebroplasties per- cutanees. Technique et indications. J Neuroradiol 1997; 24,45-59. 23. Cotten A, Deramond H, Cortet B. Preoprative percu- taneous injection of methylmethacrylate and N-butyl cyanoacrylate in vertebral hemangiomas. Am J Neu- roradiol 1996; 17,137-142. 24. Cotten A, Dewatre F, Corret B, et al. Percutaneous vertebroplasty for osteolytic metastases and my- leoma. Radiology 1996; 200525-530. 25. Weill A, ChirasJ, SimonJM, Rose M, Sola-Martinez T, Enkaoua E. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996; 199,241-247. 26. Debussche-Depriester C, Deramond H, Fardellone P. Percutaneous vertebroplasry with acrylic cement in the tretment of osteoporotic vertebral crush frac- ture syndrome. Neuroradiology 1991; 33,149-152. 27. Caten A, Boutry N, Cortet B, et al. Percutaneous vertebroplasry: state of the art. Radiographies 1998; 18,311-320. 28. Deramond H, Depriester C, Galibelt P, Le Gars D. PerQJtaneous venebroplasty with polymethylmethac- rylate: techniques, indications and results. Radiol Clin N Am 1998; 3653;}-546 29. Bostrom MP, Lane JM. Future directions: augmenta- tions of osteoporotic vertebral bodies. Spine 1997; 22385-425. 30. Wilson D, MathisJM, Scrihner R, Talmadge K, Hayes W. Effect of augmentation on the mechanics of ver- tebral wedge fractures. Spine (in press) 31. Mathis JM, Fenton D, Scribner R, Riley MA, Talmedge K, Belkoff SM. Biomechanical comparison of new treatments for vertebral body compression fractures. Presented at 13th Annual North American Spine Society; November 1998; San Francisco, CA. 3,20 pm Percutaneous Vertebroplasty: The Tricks of the Trade Jacques E. Dian, MD Emory University Hospital Atlanta, Georgia Learning objectives: Upon completion of this presenta- tion, the attendee will be able to: 1) List the indications and selection process for vertebroplasty, 2) Describe tbe transpedicular puncture approach, 3) List the materials usedfor vertebroplasty, and describe how to use them, 4) List the complications of vertebroplasty. History and Background Many clinical entities can cause painful veltebral col* lapse, including osteoporoSiS, vertebral hemangiomas, multiple myeloma and metastatic disease; of these, the most common in North .Ameriea is osteoporosis. In the United States, 700,000 osteoporotic vertebral compres- sion fractures occur every year, causing 115,000 hospital admissiOns each year; additional patients suffer fractures from chronic steroid use (particularly organ transplant patients). The average length of hospital stay for each of these admissions is 8 days; in addition, the average number of disability days per fracture is 14 days. Finally. the care of these patients at home is significant because they are often incapacitated in their activities of d.aily living (ADL), requiring home nursing care and some- times moving from home to a nursing facility. Therefore, the annual cost to the American health care syslem is very significant. The lifetime risk of a vertebral compression fracture is 16% for white women, and 5% for white men. The risk is comparatively higher for the Asian population and lower for the black population. Once an osteoporotic fracture has occurred, there is a five-fold increase in the risk for a second fracture; when two fractures have occurred, the risk of another fracture increases to twelve-fold. The pain syndrome that follows a vertebral compression frac- ture often causes patients to be bed- or wheelchair- ridden and dependent on analgeSiCS. Conservative medical treatment with medication, bracing, and i.lruno- bilization leads to accelerated bone loss, compounding the problem. On average, the pain syndrome lasts ap- proXimately 4-10 weeks, but may persist for months and never fully subside; this may be caused by constant micro-motion at the fracrure site and nonunion. As a result of the fracture(s), there is progressive kyphosis, which causes ftmher pain and disability (early satiety, pseudo bowel obstruction), worsening the problems of loss of independence, low self*esteem, and depression. Patients with fracrures are more dependent in ADLs and suffer from weight loss, decreased exercise wlerance, and depression. To date, Crearment has been mostly conservative, consisting of bed rest, analgesics, or cumbersome, ex- pensive back braces. Medical pain therapy with analge- sics (often narcotics), because of side effecls, has a sig- nificanr negarive impact on patients' quality of life. Current medical therapy of osteoporosis itself is ex- tremely important and should include hormonal replace- ment therapy, biphosphonates and calcitonin (which has a central analgeSiC effect); they are unfortunately pre- scribed only afler osteoporosis has been uncovered by a fractllre. In the mid-1980s, a procedure called "percuta- neous vertebroplasty" was described by the French. It was a minimally invasive procedure where the fractured vertebral body was accessed percutaneously with a nee- dle positioned with a transpedicular or paravertebral approach; then, PMMA was injected to prOVide bone augmentalion and stabilization, [hereby preventing fur* ther collapse and movement. This "internal casting" alleviated pain and allowed increased mobiliry in a sig- nific<im percentage of patients; this resulted in improve- ment in ADts and decrease in the amount of analgesic medication required. The initial European experience