PERCUTANEOUS VERTEBROPLASTY PVP IN THE TREATMENT OF VERTEBRAL

PERCUTANEOUS VERTEBROPLASTY (PVP) IN THE TREATMENT OF VERTEBRAL FRACTURES CAUSED BY AGGRESSIVE HEMANGIOMAS: A SHORT AND MEDIUM TERM CLINICAL FOLLOW-UP N. ACHOUR, I. NACCACHE, H. RAJHI, F. BEN AMARA, N. MNIF Radiology service , Charles Nicolle Hospital INTV 2

INTRODUCTION Vertebral hemangiomas are benign tumors and most frequent in thoracic spine. � The majority of them are asymptomatic and require no treatment , and less than 1℅ of vertebral hemangiomas are agressive and produce symptoms. �

INTRODUCTION � Percutaneous vertebroplasty (PV) is a minimally invasive interventional radiology technique where pathological vertebral bodies are filled with acrylic cement to strengthen the bone and relieve pain.

INTRODUCTION � The purpose of the study is to evaluate the efficacy and safety of percutaneous vertebroplasty using polymethylmethacrylate in the treatment of vertebral fractures caused by aggressive hemangiomas. � We report on our preliminary results a short and medium term clinical follow-up.

Materials and methods � A retrospective study of 10 cases was performed between 2006 and 2011 in the interventional radiology unit of Charles Nicolle hospital.

Materials and methods � Sociodemographic characteristics : age , sex; �Clinical parameters; � Comorbidity; � Caracteristics of spinal pain : course duration and schedule ; � The repercussion on the physical activity; � Anterior treatment to VPP.

Materials and methods • Clinical examination: � Analgesic attitude ; � Spinal deformation; � Spinal stiffness ; � Pain in the pressure of thorny apophysis ; � Neurologic symptoms.

Materials and methods � Before �X VPP: ray radiographics: ›The importance of the spinal compression ›Posterior arch extension ›Spinal deformation �M RI: ›Achievement of the vertebral body ›Posterior wall recession ›Posterior arch extension �CT-scan : ›Cortical rupture.

Materials and methods �Technical procedure of VPP : Most procedures have been carried out in the interventionnal radiological unit of Charles Nicolle hospital equipped with a Philips apparatus (V 3000) with a rotative bow around the examining table in order to secure a better control of the cement injection.

Materials and methods Two patients have benefited from VPP under CT guidance in the CT room of the medical imagery service of Charles Nicolle hospital equipped with a multi detector CT Général Electrique (GE) 16 Bits.

Materials and methods The VPP procedure carried out under general anaesthesia or neuroleptanalgesia in rigorous aseptic conditions. � Transpedicular access way. � Three to ten ml of PMMA cement were injected under scopic or CT control after having placed an 11 G trocart. �

Materials and methods � The outcome was measured using a subjective evaluation of the pain before vertebroplasty and the improvement of the pain after the short term (3 -15 days) and the medium term (1 -3 months).

RESULTS Age: 18 -68 � Sex: 4 females 6 Males � Kind of pain: mixed ( 4 cases), inflammatory( 6 cases) � Pain average duration: 13, 9± 14 months �

RESULTS � The initial pain was classified according to: ØThe analgesic treatment consumption ØThe repercussion on the physical activity determining this way the stage of the pain that varies from 0 to 3 (0 absent-3 invalidating).

RESULTS Clinical examination: � Analgesic attitude: 3 cases � Spinal stiffness : 3 cases � Pain in the pressure of thorny apophysis: 5 cases � Neurologic symptoms : cord compression : 3 cases ü Bilateral sciatalgy L 5 ü Paraplegia flask ü Spastic paraparesis

RESULTS X ray radiographics: �The angiomatous locations : dorsal spine (9 cases) , lumbar spine (1 case) �Vertebral fractures: (7 cases) �Morphological type of the spinal compression: cuneiform ( 5 cases) pancake shaped( 5 cases) �The semiquantitative classification of GRENANT : rank 1: (8 cases) rank 2: ( 1 case) rank 3: (1 case)

X ray radiographics centered on the dorsal and lumbar hinge Showing a cuneiform compression of L 1 rank 2 of GRENANT.

RESULTS � CT scan: Rupture of cortical bone: (4 cases) � Posterior wall recession: (2 cases) � Typical striated bony appearance: (2 cases) � Posterior arch extension : (5 cases) �

RESULTS � MRI: Posterior arch extension : 2 cases � Posterior wall recession : 2 cases � Pedicle extension: 1 case � Epidural extension : 3 cases � Endocanal extension : 1 case � Cord compression without marrow suffering: 1 case. �

Spinal MRI sagittal T 2 ( A ) and sagittal T 1 ( B ) of an aggressive hemangiomas of D 2 with epidural extension

RESULTS � VPP procedure: NEUROLEPTANALGESIA: 8 cases � Under scopic control: 8 cases : The great majority of the authors (3, 4, 11) realize vertebroplasties under scopic control � CT control: 2 cases � Transpedicular access way: 9 cases � Three to ten ml of PMMA cement were injected under scopic or CT control after having placed a 11 G trocart. �

� VPP of an aggressive hemangioma of D 11 by bi pedicular access under scopic control.

RESULTS Technical incidents: � Leak of cement : vascular system , intra-canalar (1 case), foraminal , intervertebral discs and soft tisssus.

Discussion CT in coronal reconstruction ( A ) and sagittal ( B ) in the immediate fall of a VPP of D 3 for an aggressive hemangioma realized under scopic showing an intracanalar leak of acrylic cement. Let us note the presence of intracanalar air bubbles which is possible during this procedure.

RESULTS Improvement of the pain : � the short term: 3 -15 days • Total regression : 1 case • Partial regression: 10% 1 st - 30% 3 rd day � Medium term 1 -3 months • Occasional pains in the prolonged effort • Analgesic treatment on demand : 20℅ • Partial regression

DISCUSSION � The vertebral hemangiomas is a frequent benign vascular dysplasia generally asymptomatic. Only 0, 9 % to 1, 2 % of the cases become symptomatic by the appearance of invalidating pains or neurological signs or present signs of aggressiveness in imagery(4) that were described by Laredo (12): the achievement of the vertebral body, the extension in the posterior arc of the vertebra, in neighboring soft tissues and epidural extension.

DISCUSSION � The VPP is an effective therapeutic means in the symptomatic forms of spinal hemangiomas or in the aggressive forms which present a high potential risk of fracture (2, 5 ). The objective of the injection of PMMA in the vertebral body is to obtain a definitive hardening of the hemangiomas by a complete filling by the cement ( 1 ). The analgesic effect is immediate and complete in most cases according to the various studies carried out.

DISCUSSION For example, an immediate complete improvement was obtained in 9 cases out of ten in the series of Galibert and Deramond ( 5 -6) and in 11 cases out of 12 in the experience of Chiras and al ( 11 ). � A long-term clinical evaluation of patients handled by VPP for VH realized by Brunot ( 4) demonstrated a long-term symptomatic relief in 90 % of the patients, without premature or late complication bound to the method. �

DISCUSSION VPP combines 2 effects: � Vertebral stabilization (5): using PMMA which is a hard and resistant material � Analgesic effect: consolidation of micro fractures(7, 8) destruction of the nerve endings of the normal bone (10).

DISCUSSION � The results of our series consolidate those of the literature with 100 % of short and medium-term improvement (at least partial improvement) among which 57 % of medium-term total relief.

CONCLUSION � The percutaneous vertebroplasty appears to be an effective and simple technique in the treatment of symptomatic vertebral hemangiomas providing a significant improvement of the pain with biomechanical stability and a low complications rate.

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