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Michel Djindjian, Jean-Paul Nguyen, André Gaston, Jean-Marc Pavlovitch, Jacques Poirier and Issam A. Awad

V ertebral hemangiomas with neurological signs are not common. Involvement of multiple vertebrae is even less common and is rarely symptomatic. 4 A difficult therapeutic dilemma arises between total surgical excision, which is the treatment of choice for a benign pathology, and palliative interventions such as embolization, “vertebroplasty,” surgery, and radiation therapy. We present the rare case of a patient with four vertebral hemangiomas and progressive neurological signs attributable to two vertebral levels. Case Report This 42-year-old man

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Sam Bowen Charles L. Branch Jr. J. Wayne Meredith 7 1999 7 1 E3 10.3171/foc.1999.7.1.3 FOC.1999.7.1.3 Percutaneous vertebroplasty in vertebral osteonecrosis (Kümmell's spondylitis) Huy M. Do Mary E. Jensen William F. Marx David F. Kallmes 7 1999 7 1 E4 10.3171/foc.1999.7.1.4 FOC.1999.7.1.4 A new technique for the surgical management of unstable thoracolumbar burst fractures: a modification of the anterior approach and an outcome comparison to traditional methods Gregory C. Wiggins Michael J. Rauzzino Christopher I. Shaffrey Russ P. Nockels Richard Whitehill

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Huy M. Do, Mary E. Jensen, William F. Marx and David F. Kallmes

The authors report the clinical symptoms and response to therapy of a series of patients who presented with subacute or chronic back pain due to vertebral osteonecrosis (Kümmell's spondylitis) and who underwent percutaneous vertebroplasty.

The authors performed a retrospective chart review of a series of 95 patients in whom 149 painful, nonneoplastic compression fractures were demonstrated and who were treated with percutaneous transpediculate polymethylmethacrylate (PMMA) vertebroplasty. In six of these patients there was evidence of vertebral osteonecrosis, as evidenced by the presence of an intravertebral vacuum cleft on radiography or by intravertebral fluid on magnetic resonance (MR) imaging. Clinical and radiological findings on presentation were noted. Technical aspects of the vertebroplasty technique were compiled. Response to therapy, defined as qualitative change in pain severity and change in level of activity, was noted immediately following the procedure and at various periods on follow-up reviews.

One man and five women, who ranged in age from 72 to 90 years (mean 81 years), were treated. Each patient had one compression fracture. The fractures were at T-11 (one patient), L-1 (two patients), L-3 (two patients), and L-4 (one patient). The pain pattern was described as severe and localized to the affected vertebra, and sometimes radiated along either flank. Pain duration ranged from 2 to 12 weeks, and the pain was refractory to conservative therapy that consisted of bedrest, analgesics, and external bracing. At the time of treatment, all patients were bedridden because of severe back pain. In all patients either plain radiographic or computerized tomography evidence of intravertebral vacuum cleft or MR imaging evidence of vertebral fluid collection consistent with avascular necrosis of the vertebral body was demonstrated. Four patients underwent bilateral transpediculate vertebroplasty, and two patients underwent unilateral transpediculate vertebroplasty. The fracture cavities were specifically targeted for PMMA injection. Additional fortification of the osteoporotic vertebral body trabeculae was also performed when feasible. "Cavitygrams" or intraosseous venograms with gentle contrast injection were obtained prior to application of cement mixture. In all patients subjective improvement in pain and increased mobility were demonstrated posttreatment. The follow-up period ranged from 4 to 24 hours after treatment. Two patients made additional office visits at 1 and 3 months, respectively.

Patients presenting with vertebral osteonecrosis (Kümmell's spondylitis) often suffer from local paraspinous or referred pain. When performing vertebroplasty on these patients, confirmation of entry into the fracture cavities with contrast-enhanced "cavitygrams" should be performed prior to injection of PMMA cement. The response to vertebroplasty with regard to amelioration of pain and improved mobility is encouraging.

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Nelson B. Watts

Osteoporosis is a significant public health problem. Vertebral fractures are the most common fracture in patients with osteoporosis, occurring in approximately 750,000 cases each year. The fractures may cause acute or chronic pain, reduce the quality of life, and shorten life expectancy. Several medications are available that reduce the risk of fracture. Vertebroplasty and kyphoplasty (balloon-inflated expansion of collapsed vertebrae followed by injection of bone cement) may reduce or relieve pain in selected patients. Although surgery is rarely necessary for the management of osteoporotic vertebral fractures, it may be indicated for other reasons. No studies have been conducted to determine if the outcome of spinal fusion is different in patients with osteoporosis and, if it is, whether management of the patient's osteoporosis will improve the outcome.

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Patrick W. Hitchon, Vijay Goel, John Drake, Derek Taggard, Matthew Brenton, Thomas Rogge and James C. Torner

P olymethylmethacrylate has long been used to augment pedicle screws after stripping or failure in osteoporotic bone. 16, 35 Experimentally in the cadaveric spine, PMMA cement has been shown to augment the pullout strength of screws better than that of rib graft reinforcement. 15 In the treatment of traumatic and pathological fractures, PMMA has been used for stabilization and reconstruction through both anterior and posterior aspects of the spine. 1, 2, 8, 26 Polymethylmethacrylate has long been used to perform percutaneous vertebroplasty in cases of

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experience Henri-Dominique Fournier Philippe Mercier Philippe Menei October 2001 95 2 202 207 10.3171/spi.2001.95.2.0202 Effect of a prosthetic disc nucleus on the mobility and disc height of the L4–5 intervertebral disc postnucleotomy Hans-Joachim Wilke Sinead Kavanagh Sylvia Neller Christian Haid Lutz Eberhart Claes October 2001 95 2 208 214 10.3171/spi.2001.95.2.0208 Comparison of the biomechanics of hydroxyapatite and polymethylmethacrylate vertebroplasty in a cadaveric spinal compression fracture model

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Robert F. Heary and Christopher M. Bono

Metastatic spinal tumors are the most common type of malignant lesions of the spine. Prompt diagnosis and identification of the primary malignancy is crucial to overall treatment. Numerous factors affect outcome including the nature of the primary cancer, the number of lesions, the presence of distant nonskeletal metastases, and the presence and/or severity of spinal cord compression. Initial management consists of chemotherapy, external beam radiotherapy, and external orthoses. Surgical intervention must be carefully considered in each case. Patients expected to live longer than 12 weeks should be considered as candidates for surgery. Indications for surgery include intractable pain, spinal cord compression, and the need for stabilization of impending pathological fractures. Whereas various surgical approaches have been advocated, anterior-approach surgery is the most accepted procedure for spinal cord decompression. Posterior approaches have also been used with success, but they require longer-length fusion. To obtain a stable fixation, the placement of instrumentation, in conjunction with judicious use of polymethylmethacrylate augmentation, is crucial. Preoperative embolization should be considered in patients with extremely vascular tumors such as renal cell carcinoma. Vertebroplasty, a newly described procedure in which the metastatic spinal lesions are treated via a percutaneous approach, may be indicated in selected cases of intractable pain caused by non- or minimally fractured vertebrae.

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METASTATIC SPINAL TUMORS Ziya L. Gokaslan Topic Editor 12 2001 11 6 1 2 10.3171/foc.2001.11.6.1 FOC.2001.11.6.1 The role of vertebroplasty in metastatic spinal disease Julie G. Pilitsis Setti S. Rengachary 12 2001 11 6 1 4 10.3171/foc.2001.11.6.10 FOC.2001.11.6.10 Evaluation and treatment of spinal metastases: an overview W. Bradley Jacobs Richard G. Perrin 12 2001 11 6 1 11 10.3171/foc.2001.11.6.11 FOC.2001.11.6.11 Metastatic spinal tumors Robert F. Heary Christopher M. Bono 12 2001 11 6 1 9 10.3171/foc.2001.11.6.2 FOC.2001.11.6.2 Management of

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Julie G. Pilitsis and Setti S. Rengachary

Many advances have been made in the treatment of metastatic spinal disease over the last few decades. Radiotherapy offers benefit and pain relief to many patients; however, this modality provides minimal vertebral stabilization. Surgical management consists of decompression and complex fusions. Vertebroplasty offers an adjuvant therapy to both radiotherapy and surgery by providing additional stabilization and pain relief. The results of case studies suggest that including vertebroplasty in the management of these patients is beneficial. In this article the authors review the role of vertebroplasty in metastatic spinal disease.

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Kyung Sik Ryu, Chun Kun Park, Moon Chan Kim and Joon Ki Kang

option become available. Percutaneous PMMA vertebroplasty has provided good pain relief and improved function in patients treated for osteoporotic vertebral compression fractures. 1, 2, 4, 7–15, 17 Results have been mixed, as some patients experience no improvement after vertebroplasty. Those patients with persistent or aggravated pain were investigated to determine possible causes of treatment failure. One possible cause is the epidural leakage of PMMA after vertebroplasty, which may reduce the therapeutic effects by compressing the spinal cord and/or nerve roots