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A Simple and Cost-effective Technique for Vertebroplasty

Bharti, Ajay MS*; Swaroop, Anand MS; Kumar, Pramod MS*; Rawat, Ashok MS*

doi: 10.1097/BTO.0000000000000056
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Multiple instrumentations are available by which fairly good transpedicular vertebroplasty can be performed. Usually needle/cannula are used for vertebroplasty and percutaneous injection of Acrylic cement is injected in the symptomatic vertebrae. Important attributes include the shape of the tip of the stylet and the cannula and the ease to use it, as well as the type of bone cement used. The authors present a simple technique for vertebroplasty that utilizes high viscosity bone cement at low temperature with a simplified cannula system consisting of Steinmann pin and a drill sleeve with 5-mL disposable syringe, which also incurs very low cost.

*G.S.V.M. Medical College, Kanpur

Medical College, Jalaun, Uttar Pradesh, India

The authors declare that they have nothing to disclose.

Address correspondence and reprint requests to Ajay Bharti, MS, L-16, G.S.V.M. Medical College, Kanpur, Uttar Pradesh 208002, India. E-mail: dr_ajay2001@rediffmail.com.

Vertebroplasty1 is a procedure used in the treatment of pathologic fractures (especially osteoporotic) of the vertebra and performed as the percutaneous injection of Acrylic cement (PMMA)1 into a symptomatic fractured vertebral body under fluoroscopic guidance. Technical differences are mostly minor and related to the availability of products and equipment used, as well as the operator’s training and skills. One can achieve remarkable results provided a good embolization technique is used and certain guidelines are respected. Multiple needles are available that are excellent for vertebroplasty. Usually 11-G needle is used for vertebroplasty. Important attributes include the shape of the tip of the stylet and the cannula, and the type of handle. Commonly vertebroplasty is performed through the transpedicular route. Some prefer to do it by the unipedicular or bipedicular route. Needle availability and its cost hamper its widespread use. We therefore describe a simple technique that achieves same goals at a very low cost for vertebroplasty in the dorsolumbar spine.

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AUTHOR’S TECHNIQUE

The patient is prepared as per the standard technique, a stab incision is given into the skin corresponding to pedicles of the dorsolumbar spine under C-arm image intensifier guidance, entry is made into the pedicle by 3.5-mm Steinmann pin (Fig. 1A) and advanced into the vertebral body under C-arm image intensifier guidance (Fig. 2-1). A drill sleeve 5 mm/3.5 mm, 110 mm long (Fig. 1B), similar to a drill sleeve of external fixator tube system of Mathys Medical Limited Switzerland (inner diameter 4 mm),2 is guided over the Steinmann pin till the junction of body and pedicle (under C-arm image intensifier guidance) in lateral view (Fig. 2-2). In our technique, we have used 5-mL disposable syringe (Fig. 1, B Braun inject) having an inner diameter of 12.3 mm (Fig. 1C). The outer diameter of the drill sleeve is 14 mm (at upper holding end) and inner diameter of the sleeve (cannula) is 4 mm/8-G. After removing, the plunger of a 5-mL syringe with cut anterior end (Fig. 1D) is fitted over the drill sleeve (Fig. 2-3). Prechilled cement is prepared and 4 mL is filled into the syringe (Fig. 2-4). Steinmann pin is removed, the plunger is inserted, and 2 to 2.5 mL is pushed through the vertebral body under C-arm image intensifier guidance with checking for leakage of cement (Fig. 2-5). This system remains there for 8 minutes and then the sleeve is twisted twice or three times and removed (Fig. 2-6). It can be performed through the unipedicular or bipedicular route also. The Steinmann pin and drill sleeve are cleaned and can be reused in the next patient after sterilization.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

The cost of different materials are given below:

  • Cost of Steinmann pin: Indian rupee
  • 50 ($0.90).
  • Cost of drill sleeve 5 mm/3.5 mm: Indian rupee
  • 255 ($4.46).
  • Cost of disposable syringe: Indian rupee
  • 5 ($0.09).
  • Simplex-P Bone cement: Indian rupee
  • 1500 ($26.80).
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DISCUSSION

This minimally invasive procedure is performed with a stab incision and usually performed in local anesthesia with sedation (general anesthesia may be preferred), giving comparable results to other techniques of vertebroplasty. Our technique is simpler, quicker, and cost-effective (Table 1). Total cost incurred is only 31.33 USD.

TABLE 1

TABLE 1

We have performed on 11 cases of osteoporotic vertebral fracture with this technique, and our results were comparable to other studies. In our study at 1-year follow-up, the mean modified Ronald-Morris disability questionnaire score decreased significantly from 16.72±1.62 to 1.273±0.47 (P<0.001) with mean improvement percentage raised from 62.02±4.87 to 92.36±3.93 (P<0.001). The Mean Visual analogue scale (VAS) score improved from 6.68±0.81 to 0.36±0.50 at 1-year follow-up. In the postoperative period at 72 hours, mean VAS score improvement from 6.68±0.81 to 2.54 ±0.78 was also statistically significant (P<0.01). Farrokhi et al3 in their study of percutaneous vertebroplasty in acute osteoporotic vertebral compression fractures. At 1-year follow-up showed mean VAS score of 8.4±1.69 decreased to 2.2±2.1 (P<0.011) and there was a significant improvement in QOL (Oswestry LBP Score) from 52.2±2.4 to 8±3.2. Pérez-Higueras et al4 showed results of 17 patients who underwent percutaneous vertebroplasty. The VAS showed significant improvement after treatment: the initial score was 9.07±0.6, falling to 2.07±1.14 on the third day, and 2.15±2.6 at 5 years. Pain reduction was statistically significant (P<0.001). The short McGill pain questionnaire showed a significant improvement after treatment (P<0.001), but had worsened by the last follow-up.

Baroud and Steffen5 in their study found pressure applied on the plunger of the syringe during vertebroplasty can often generate pressure exceeding 1.5 MPa (1 psi=6894.7 Pa, 1 MPa=106 Pa) that is approximately 170 N of force or 17 kg. In another study, Baroud et al6 stated in their system average injection pressure was 2.3 MPa, often approaching the human physical limit and resulting in insufficient filling, and therefore they redesigned the cannula and recorded average pressure 44% lower than that of the conventional cannula.

In our technique, the pressure generated in 5-mL syringe was 82 psi (0.565 MPa) with air, 180 psi (1.24 MPa) with brake fluid (polyethylene glycol).7 Moreover, at the time of injection of Simplex–P cement (Stryker) into fresh cadaver pressure was 210 psi (1.44 Mpa), temperature being 16° to 18°C.

We have used high-viscosity cement in our procedure that got easily injected into the vertebra owing to large diameter (8-G) cannula. Storage temperature8 of the cement was kept between 8 and 12°C. Use of high-viscosity cement is also supported by various studies9–11 that showed that high-viscosity cement is better than low viscosity cement, as it decreases the chances of leakage of cement. When a leak occurs while using a rapid-set cement, waiting only 1 to 2 minutes will usually allow sufficient polymerization of the injected cement to plug the leak and allow additional cement to be injected safely. This is less often the case with the slow-set material.12

Therefore, we advocate the use of this simple low-cost technique for vertebroplasty, which provides equally good results as other more expensive techniques.

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REFERENCES

1. Kallmes DF, Jensen ME. Percutaneous vertebroplasty. Radiology. 2003;229:27–36.
2. Synthes catalogue. Mathys Medical Limited Bettlach/Switzerland 1997 item No-393.790, page 240.
3. Farrokhi MR, Alibai E, Maghami Z. A randomized controlled trial of percutaneous vertebroplasty versus optimal medical management for the relief of pain and disability in acute osteoporotic vertebral compression fractures. J Neurosurg Spine. 2011;14:561–569.
4. Pérez-Higueras A, Alvarez L, Rossi R, et al.. Percutaneous vertebroplasty: long-term clinical and radiological outcome. Neuroradiology. 2002;44:950–954.
5. Baroud G, Steffen T. A new cannula to ease cement injection during vertebroplasty. Eur Spine J. 2005;14:474–479.
6. Baroud G, Martin PL, Cabana F. Ex vivo experiments of a new injection cannula for vertebroplasty. Spine. 2006;31:115–119.
7. Brake fluids. US Department of Transportation “Standard No. 116; Motor Vehicle Brake Fluids”. Available at: http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=571.116. Accessed November 4, 2013.
8. Stryker Corporation USA, Literature Number LSPBC-CB MS/GS 4C 07/08. Bone cement matters, Simplex P bone cements. Available at: http://www.stryker.com/en-us/GSDAMRetirement/index.htmstellent/groups/orthopaedics/documents/web_content/141313.pdf. Accessed November 4, 2013.
9. Rapan S, Jovanović S, Gulan G, et al.. Vertebroplasty—high viscosity cement versus low viscosity cement. Coll Antropol. 2010;34:1063–1067.
10. Baroud G, Crookshankn M, Bohner M. High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine (Phila Pa 1976). 2006;31:2562–2568.
11. Rüger M, Schmoelz W. Vertebroplasty with high-viscosity polymethylmethacrylate cement facilitates vertebral body restoration in vitro. Spine (Phila Pa 1976). 2009;34:2619–2625.
12. Mathisa JM. Percutaneous vertebroplasty: complication avoidance and technique optimization. AJNR. 2003;24:1697–1706.
Keywords:

dorsolumbar spine; transpedicular vertebroplasty technique

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