Indian Journal of Pain

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 36  |  Issue : 4  |  Page : 40--45

Percutaneous vertebroplasty in metastatic vertebral fracture: A retrospective cross-sectional study


Shivani Rastogi1, Anurag Agarwal1, Yasum Litin1, Neha Singh1, Hitesh Patel2,  
1 Department of Anesthesiology, CCM and Pain Medicine, Dr. RMLIMS, Lucknow, Uttar Pradesh, India
2 Department of Anesthesiology, LiveWell Hospital, Ahmedabad, Gujarat, India

Correspondence Address:
Dr. Anurag Agarwal
Department of Anesthesiology, CCM and Pain Medicine, Dr. RMLIMS, Lucknow, Uttar Pradesh
India

Abstract

Introduction: Metastatic vertebral fractures (VF) commonly cause severe disabling pain in cancer patients. VFs are common among elderly patients and account for approximately 1.5 million per year in the general population. Objective: Bone metastasis, which is a second major cause of pathologic fracture, may lead to severe intolerable pain, life-threatening hypercalcemia, spinal cord compression, and immobility. The purpose of this study was to evaluate pain relief and improvement in quality of life (QOL) in patients with metastatic VF undergoing percutaneous vertebroplasty (PVP). Methods: Ten cancer patients having metastatic VF underwent PVP from July 2018 to August 2020. All demographic data, procedures, improvement in pain, and analgesic requirements of patients were taken from a computer data system and telephonic follow-up. Results: Majority of patients were suffering from carcinoma lung followed by carcinoma pancreas. The mean ± standard deviation of Visual Analog Scale preoperatively was 8.8 ± 1.35, reduced to 2.14 ± 2.11 at 6 months postoperatively, suggesting significant pain reduction. Eight patients had reduction in analgesic requirements and two did not require any analgesics postoperatively. During the entire follow-up, there was no delayed complication. Conclusion: PVP is an effective, safe, and minimally invasive procedure for treating painful metastatic vertebral compression fracture refractory to conservative treatments. It provides a marked reduction of pain, maintains mechanical stability of the vertebrae, and improves QOL.



How to cite this article:
Rastogi S, Agarwal A, Litin Y, Singh N, Patel H. Percutaneous vertebroplasty in metastatic vertebral fracture: A retrospective cross-sectional study.Indian J Pain 2022;36:40-45


How to cite this URL:
Rastogi S, Agarwal A, Litin Y, Singh N, Patel H. Percutaneous vertebroplasty in metastatic vertebral fracture: A retrospective cross-sectional study. Indian J Pain [serial online] 2022 [cited 2023 Feb 1 ];36:40-45
Available from: https://www.indianjpain.org/text.asp?2022/36/4/40/366473


Full Text



 Introduction



Vertebral fractures (VF) are common among elderly patients and account for approximately 1.5 million per year in the general population. The prevalence of VF increases with age with approximately 40% population affected by 80 years of age.[1],[2] The various causes of VF are osteoporosis, metastatic spinal tumors, primary malignant bone tumors such as hemangioma and traumatic fractures. Vertebral metastasis occurs in 40% of patient of all cancer patients of which 30% are symptomatic and require treatment.[3],[4] Thoracic spine is the most affected site being involved in 60%–80% cases followed by lumbar spine (15%–30%) and cervical spine (<10%).[5],[6],[7]

Percutaneous vertebroplasty (PVP) is a minimally invasive procedure that consists of the injection of polymethylmethacrylate (PMMA) into the vertebral body under fluoroscopy guidance. It overcomes the problems that are associated with surgery and radiotherapy in the treatment of VF. In addition, it is an effective procedure for prompt pain control and preventing further vertebral collapse and spinal cord compression.[8],[9],[10] The common indications for PVP are mentioned in [Table 1].[11]{Table 1}

Objective

Over the years, the incidence of spinal metastases has increased due to improved diagnostics and life expectancy of cancer patients.[12],[13]

In this regard, the preservation of quality of life (QOL) is a mandatory event in the later stage of cancer. This study is aimed to assess the effectiveness of PVP in providing immediate pain relief and improve activity by the measurement of “Activity Score” depicting the improved QOL in patients with painful vertebral metastasis.[13],[14]

 Methods



Study design

This was a retrospective cross-sectional study.

Study time and institution

After taking ethical review board approval, a retrospective study from July 2018 to August 2020 was conducted at our institute comprising of patients treated with PVP for VF due to metastatic spinal tumors and primary tumors.

A total of 20 patients visited the pain medicine outpatient department with severe back pain due to metastatic VF. Diagnosis of VF was confirmed by a review of the history and computerized tomography or magnetic resonance imaging findings [Figure 1]. Of these, eight patients with epidural extension of the tumor and two with multiple levels of VF due to multiple myelomas were treated conservatively and excluded from the study. Ten patients underwent PVP and were included in this study.{Figure 1}

The inclusion criteria were as follows: (1) Patient suffering from any cancer with vertebral metastasis (2) Age between 18 and 65 years (3) excruciating pain despite pharmacological treatment, or adverse effects related to opioids (constipation, urinary retention, or confusion (4) patients treated with spine radiotherapy or waiting to receive radiotherapy, and (5) expected survival time for more than 5 months. The exclusion criteria were as follows: (1) Patients with spinal canal extension of tumor, (2) patients with signs and symptoms of neurological deficit, and (3) patients with deranged coagulation profile.

Observational indexes and evaluation criteria

All demographic data, procedures, improvement in pain, analgesic drugs before and after PVP and incidence of complications, for example, bone cement leakage, were taken from computer data system and telephonic conversation.

Technique

Before undergoing PVP, all the patients were informed about the benefits and known associated risks. Heart rate, blood pressure, oxygen saturation, and electrocardiogram were monitored during the procedures. All the patients were placed in the prone position, and the procedure was conducted under monitored anesthesia care with intravenous sedation and local anesthesia.

Under fluoroscopic guidance, the vertebral body and the pedicles were identified. The entry point chosen for the transpedicular technique was the superior lateral quadrant of the pedicle, which allowed the needle tip to be angled more toward the centre of the vertebra and facilitated easy filling of the vertebra with a single needle. 11G Jamshidi needle was inserted transpedicular and advanced under AP fluoroscopic control in antero-medio-caudal direction with rotatory hand pressure or using a mallet. In the lateral view, care was taken to keep the needle parallel to the superior and inferior edges of the pedicle and advanced into the anterior third portion of the vertebra. This area is devoid of venous plexuses and avoids the risks of excessive bleeding and cement embolization. In a bilateral technique, both cannulae were inserted before the injection of cement from both sides simultaneously. PMMA polymer was mixed with PMMA monomer to obtain toothpaste-like consistency [Figure 2] and [Figure 3]. Under lateral real-time fluoroscopic control, PMMA cement was injected to ensure the early detection of cement leakage into the epidural space, vena cava, or disc space till it reached the posterior vertebral wall in the lateral view. The procedure was considered satisfactory when cement filled the superior and inferior vertebral endplates. After cement had been injected, the cannulae were removed. Patients were advised bed rest for 2 h thereafter.{Figure 2}{Figure 3}

Observational indexes and evaluation criteria

SPSS version 21.0 (statical package for social science-21: Chicago, Illinos, USA) was used for the data analysis. P ≤ 0.05 was considered clinically significant with a 95% confidence interval. The difference in mean values and Chi-square test was utilized for categorical and independent Student's t-tests to compare the preoperative and postoperative Visual Analog Scale (VAS) scores. A significant difference was accepted at P ≤ 0.05.

Males were more affected than females. The mean age of the study population was 59.81 ± 7.61 years. Comparison of age and sex revealed Chi-square test χ2 = 2.81; P = 0.901 suggestive of a homogeneous study population. A total of 18 vertebrae were treated of which 7 vertebrae were treated with bi-pedicular approach and rest with the uni-pedicular approach. The demographic data and management summary are summarized below [Table 2].{Table 2}

Majority of patients were suffering from lung metastasis followed by carcinoma pancreas [Graph 1].[INLINE:1]

In 10 cases included, the mean (±standard deviation) VAS score was 8.8 (±1.35) preoperatively, which reduced to 2.14 (±2.11) at 6 months postoperatively, showing a statistically significant difference in the VAS scores thus suggesting remarkable improvement.

There is a statistically significant difference in the preoperative and postoperative analgesic required. All 10 patients required strong opioids analgesics preoperatively. In postoperative period, 20% patients did not require any narcotic drug while in 80%, analgesic requirement reduced from strong opioids to nonnarcotic opioids.

The preoperative activity score of all patients was 4 (bed-ridden). Postoperatively, majority (60%) of patients had a score of 0, (independent activity without assistance), and 40% of patients could walk without assistance (score 1). There is a statistically significant difference between the preoperative and postoperative activity scores, which suggests definite improvement among patients.

 Discussion



Significant progress has been made in interventional pain medicine for vertebral metastasis resulting in considerably improved QOL. The spine is a common metastatic location, and this constitutes an essential element not just for the tumor evolution but also for the patient's prognosis.[15] However, this also risks further neurological complications in the setting of an already limited life expectancy and psychological deterioration.[16]

Conservative management in patients with VF results in complications related to prolonged bed rest (such as deep-vein thrombosis, bed sores, and pneumonia). Analgesics abuse in these patients can lead to gastric ulcerations and analgesic nephropathy. In addition, limited and often unsatisfactory relief has been observed in patients with conservative treatment.

The role of surgical options is often limited due to age, morbidity, poor bone quality, and poor cancer survival.[17],[18] Therefore, PVP has been accepted as an early and effective minimally invasive treatment option for pathological VF allowing for rapid improvement of pain relief and QOL.[19],[20]

In our study, vertebral metastasis was more in males, with the mean age of the study population 59.81 ± 7.61 years. The primary sites of the cancer were as follows: lung metastasis (5), carcinoma pancreas (2), carcinoma breast (1), carcinoma prostate (1), and carcinoma buccal mucosa (1) [Graph 1]. Eighteen vertebrae in ten patients were treated in our study; 7 with a bi-pedicular approach and 11 with a unipedicular approach. The bi-pedicular approach was used more at the mid-thoracic level due to the vertical orientation of the thoracic pedicles. The uni-pedicular approach was sufficient in rest to achieve bilateral cement fill due to the midline placement of the cannula [Table 2].

In our study, preoperative and postoperative VAS score was compared by cancer pain intensity, usually referencing currently experienced back pain, and were rated on a VAS. Our findings closely corroborate to those of Anselmetti et al.[21] who reported a median drop in posttreatment to VAS 0 (range 0–10) from pretreatment median VAS of 8 (range 5–10). This decrease in VAS score was considered significant (P < 0.0001). In a study comprising 25 patients, Botton et al.[22] observed that there was significant reduction in pain1month postprocedure as against a day prior to the procedure (P = 0.04). In a study of PVP involving 74 vertebrae, Saliou et al.[23] reported satisfactory analgesia for 94% (48 of 51) of patients after one day, 86% (31 of 36) patients after 1 month, and 92% (11 of 12) patients after one year. In our patients, reduction in site-specific pain started in the immediate postoperative period. Analgesic requirement was reduced from strong opioids to nonnarcotic opioids from preoperative to postoperative period in 80% patients and rest 20% didn't require any narcotic postoperatively [Table 3]. Some patients were initially not appreciative of their relief primarily because of the postoperative pain of instrumentation. Their VAS score was reassessed at 1 month and 6 months when procedural pain had got resolved. In all 10 cases, the mean of VAS scores reduced from that in the preoperative period. The mean preoperative VAS was 8.8 ± 1.35, which reduced to 4.9 ± 1.23 (P = 0.012) at 1 month, 4.22 ± 1.64 (P = 0.026) at 3 months and 2.14 ± 2.11 (P = 0.002) at 6 months postoperatively [Table 4].{Table 3}{Table 4}

Frankel et al.[24] reported comparable postoperative pain relief with PVP as with kyphoplasty while mitigating the risk of adjacent level fracture associated with the latter. They also reported use of lesser bone cement with uni-pedicular approach. Eck et al.[25] also confirmed that both vertebroplasty and kyphoplasty offer significantly improved VAS without demonstrating superiority of one procedure above the other. As PVP involves less instrumentation, is quicker and is easier to perform, our institutional protocol mandates considering PVP over kyphoplasty whenever feasible.

Barr et al.[1] in their study on 38 patients, reported marked pain relief in 63% and moderate pain relief in 32% patients following PVP. Only 5% of patients did not have any improvement after the PVP. Spinal stabilization was successful in abolishing pain in these unresponsive patients. None of the patients in our study required spinal stabilization.

Improvement in functional status as evident by activity score, (mean of 1 at 1 months postoperatively compared to 4 preoperatively) reflects the improved QOL in patients after PVP [Table 5].{Table 5}

All our cases were performed on a day-care basis. No major complications were encountered in our patients in the immediate postoperative period. Two patients had cement leakage into the adjacent disc without any sequelae. There was no cement leakage into the epidural space. Further follow-ups at 1 month, 3 months, and 6 months were uneventful. Our study had certain limitations, like absence of control group, relatively small sample size and lack of long follow-up because of short lifespan. As ours is an retrospective study, quantitative reduction in analgesic drug requirement could not be measured.

 Conclusion



PVP is an effective, safe, and minimally invasive procedure for the treatment of painful vertebral compression fracture refractory to conservative treatments. It demonstrated a marked reduction of pain, reduced the analgesics dose and improved the QOL. PVP should be considered as the first option for definitive treatment for painful metastatic vertebral compression fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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