Utility of routine biopsy at vertebroplasty in the management of vertebral compression fractures: a tertiary center experience

Clinical article

Soumya Mukherjee M.A., M.B.B.S. 1 , Bhaskar Thakur M.A., M.B.B.S., M.R.C.S. 1 , Dolin Bhagawati M.A., M.B.B.S., M.R.C.S. 1 , Dimpu Bhagawati M.A., M.B.B.S., F.R.C.S.(Orth) 2 , Samira Akmal M.B.B.S., M.R.C.S. 1 , Vasileios Arzoglou M.B.B.S., F.R.C.S.(SN) 1 , John Yeh B.A., M.B.B.Chir., F.R.C.S.Ed.(NeuroSurg) 1 , and Habib Ellamushi M.B.Ch.B., F.R.C.S.(SN) 1
View More View Less
  • 1 Department of Neurosurgery, Royal London Hospital, London ; and
  • 2 Department of Trauma & Orthopaedic Surgery, John Radcliffe Hospital, Oxford, United Kingdom
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

The authors assess the utility of routine biopsy at vertebroplasty for vertebral compression fracture (VCF) as a tool in the early detection of malignancy in presumed benign VCF.

Methods

A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty over a 5-year period between April 2006 and March 2011 at the Royal London Hospital. Polymethylmethacrylate cement injection was used in every procedure. Intraoperative vertebral body biopsy was performed routinely at every level of VCF. Pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage, and complications were recorded preoperatively and at 1 day, 1 week, 1 month, 6 months, and 1 year postoperatively.

Results

A total of 202 levels were augmented in 147 patients. The most common levels augmented were T-12 (17%), L-1 (18%), and L-4 (10%). Analysis of 184 routine vertebral biopsies in 135 patients revealed that in 86 patients with presumed osteoporosis and no prior cancer diagnosis, 4 (4.7%) had a malignant VCF. In 20 known cancer patients presumed to be in remission, 2 (10%) had a malignant VCF. Routine vertebral biopsy returned an overall cancer diagnosis rate of 5.5% (6 of 109) when combining the 2 groups (patients with no prior history of cancer or cancer thought to be in remission). In these 6 patients, history, examination, laboratory tests, and preprocedure imaging all failed to suggest malignancy diagnosed at routine biopsy. Significant reductions in pain VAS and ODI scores were evident at Day 1 and were sustained at up to 1 year postoperatively (p < 0.001). They were not dependent on the level of fracture (T3–10, T11–L2, or L3–S1) (p > 0.05), number of levels treated (single level, 2 levels, or > 2 levels) (p > 0.05), or etiology of VCF (p > 0.05). The complication rate was 6% (9 of 147). There were 5 deaths, none of which were directly related to surgery.

Conclusions

Routine vertebral biopsy performed at vertebroplasty may demonstrate cancer-related VCFs in unsuspected patients with no previous cancer diagnosis or active malignancy in patients previously thought to be in remission. This early diagnosis of cancer or relapsed disease will play an important role in expediting patients' subsequent cancer management. In cases of multiple-level VCF, the authors advocate biopsy at each level to maximize the diagnostic yield from the specimens and to avoid missing a malignancy at a single level.

Abbreviations used in this paper:EPR = electronic patient records; LDH = lactate dehydrogenase; ODI = Oswestry Disability Index; VAS = visual analog scale; VCF = vertebral compression fracture.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Soumya Mukherjee, M.A., M.B.B.S., 2nd Floor Flat, 15 Galveston Rd., London SW15 2RZ, United Kingdom. email: soumya1701@gmail.com.

Please include this information when citing this paper: published online August 15, 2014; DOI: 10.3171/2014.7.SPINE121015.

  • 1

    Akerman M, , Berg NO, & Persson BM: Fine needle aspiration biopsy in the evaluation of tumor-like lesions of bone. Acta Orthop Scand 47:129136, 1976

    • Search Google Scholar
    • Export Citation
  • 2

    An HS, , Andreshak TG, , Nguyen C, , Williams A, & Daniels D: Can we distinguish between benign versus malignant compression fractures of the spine by magnetic resonance imaging?. Spine (Phila Pa 1976) 20:17761782, 1995

    • Search Google Scholar
    • Export Citation
  • 3

    Bostrom MP, & Lane JM: Future directions. Augmentation of osteoporotic vertebral bodies. Spine (Phila Pa 1976) 22:24 Suppl 38S42S, 1997

  • 4

    Buchbinder R, , Osborne RH, , Ebeling PR, , Wark JD, , Mitchell P, & Wriedt C, : A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 361:557568, 2009

    • Search Google Scholar
    • Export Citation
  • 5

    Dahl OE, , Garvik LJ, & Lyberg T: Toxic effects of methylmethacrylate monomer on leukocytes and endothelial cells in vitro. Acta Orthop Scand 65:147153, 1994

    • Search Google Scholar
    • Export Citation
  • 6

    Danilewicz-Stysiak Z: Experimental investigations on the cytotoxic nature of methyl methacrylate. J Prosthet Dent 44:1316, 1980

  • 7

    Evans AJ, , Kip KE, & Boutin SM: Prospective assessment of pain and functional status after vertebroplasty for treatment of vertebral compression fractures. J Neurointerv Surg 1:6670, 2009

    • Search Google Scholar
    • Export Citation
  • 8

    Fourney DR, , Schomer DF, , Nader R, , Chlan-Fourney J, , Suki D, & Ahrar K, : Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg 98:1 Suppl 2130, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Hentschel SJ, , Burton AW, , Fourney DR, , Rhines LD, & Mendel E: Percutaneous vertebroplasty and kyphoplasty performed at a cancer center: refuting proposed contraindications. J Neurosurg Spine 2:436440, 2005

    • Search Google Scholar
    • Export Citation
  • 10

    Ho CS, , Choi WM, , Chen CY, , Chen WY, & Chan WP: Metastasis in vertebra mimicking acute compression fractures in a patient with osteoporosis: MRI findings. Clin Imaging 29:6467, 2005

    • Search Google Scholar
    • Export Citation
  • 11

    Jefferiss CD, , Lee AJ, & Ling RS: Thermal aspects of self-curing polymethylmethacrylate. J Bone Joint Surg Br 57:511518, 1975

  • 12

    Kallmes DF, , Comstock BA, , Heagerty PJ, , Turner JA, , Wilson DJ, & Diamond TH, : A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 361:569579, 2009

    • Search Google Scholar
    • Export Citation
  • 13

    Karaman H, , Kaya S, , Tüfek A, , Ölmez Kavak G, , Baysal Yildirim Z, & Celik F, : [Our percutaneous vertebroplasty applications in vertebral compression fractures]. Agri 24:104110, 2012. (Turkish)

    • Search Google Scholar
    • Export Citation
  • 14

    Kaufmann TJ, , Jensen ME, , Schweickert PA, , Marx WF, & Kallmes DF: Age of fracture and clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 22:1860 1863, 2001

    • Search Google Scholar
    • Export Citation
  • 15

    Klazen CAH, , Lohle PNM, , de Vries J, , Jansen FH, , Tielbeek AV, & Blonk MC, : Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet 376:10851092, 2010

    • Search Google Scholar
    • Export Citation
  • 16

    Klezl Z, , Clamp JA, , Becker J, , Jones M, , Calthorpe D, & Bommireddy R: Impact of kyphoplasty treatment for vertebral compression fractures on pain and function in 105 patients. Acta Chir Orthop Traumatol Cech 78:551555, 2011

    • Search Google Scholar
    • Export Citation
  • 17

    Knavel EM, , Thielen KR, & Kallmes DF: Vertebroplasty for the treatment of traumatic nonosteoporotic compression fractures. AJNR Am J Neuroradiol 30:323327, 2009

    • Search Google Scholar
    • Export Citation
  • 18

    Köse KC, , Cebesoy O, , Akan B, , Altinel L, , Dinçer D, & Yazar T: Functional results of vertebral augmentation techniques in pathological vertebral fractures of myelomatous patients. J Natl Med Assoc 98:16541658, 2006

    • Search Google Scholar
    • Export Citation
  • 19

    Lis E, , Bilsky MH, , Pisinski L, , Boland P, , Healey JH, & O'Malley B, : Percutaneous CT-guided biopsy of osseous lesion of the spine in patients with known or suspected malignancy. AJNR Am J Neuroradiol 25:15831588, 2004

    • Search Google Scholar
    • Export Citation
  • 20

    Masala S, , Anselmetti GC, , Marcia S, , Massari F, , Manca A, & Simonetti G: Percutaneous vertebroplasty in multiple myeloma vertebral involvement. J Spinal Disord Tech 21:344348, 2008

    • Search Google Scholar
    • Export Citation
  • 21

    Masala S, , Lunardi P, , Fiori R, , Liccardo G, , Massari F, & Ursone A, : Vertebroplasty and kyphoplasty in the treatment of malignant vertebral fractures. J Chemother 16:Suppl 5 30 33, 2004

    • Search Google Scholar
    • Export Citation
  • 22

    Moulopoulos LA, , Yoshimitsu K, , Johnston DA, , Leeds NE, & Libshitz HI: MR prediction of benign and malignant vertebral compression fractures. J Magn Reson Imaging 6:667674, 1996

    • Search Google Scholar
    • Export Citation
  • 23

    Mpotsaris A, , Abdolvahabi R, , Hoffleith B, , Nickel J, , Harati A, & Loehr C, : Percutaneous vertebroplasty in vertebral compression fractures of benign or malignant origin: a prospective study of 1188 patients with follow-up of 12 months. Dtsch Arztebl Int 108:331338, 2011

    • Search Google Scholar
    • Export Citation
  • 24

    Muijs SP, , Akkermans PA, , van Erkel AR, & Dijkstra SD: The value of routinely performing a bone biopsy during percutaneous vertebroplasty in treatment of osteoporotic vertebral compression fractures. Spine (Phila Pa 1976) 34:23952399, 2009

    • Search Google Scholar
    • Export Citation
  • 25

    National Institute for Health and Care Excellence: Percutaneous vertebroplasty (http://guidance.nice.org.uk/IPG12) [Accessed July 8, 2014]

    • Search Google Scholar
    • Export Citation
  • 26

    Nourbakhsh A, , Grady JJ, & Garges KJ: Percutaneous spine biopsy: a meta-analysis. J Bone Joint Surg Am 90:17221725, 2008

  • 27

    Ogura A, , Hayakawa K, , Maeda F, , Saeki F, , Syukutani A, & Shibutani S, : Differential diagnosis of vertebral compression fracture using in-phase/opposed-phase and short TI inversion recovery imaging. Acta Radiol 53:450455, 2012

    • Search Google Scholar
    • Export Citation
  • 28

    Rupp RE, , Ebraheim NA, & Coombs RJ: Magnetic resonance imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor. Spine (Phila Pa 1976) 20:24992504, 1995

    • Search Google Scholar
    • Export Citation
  • 29

    San Millán Ruíz D, , Burkhardt K, , Jean B, , Muster M, , Martin JB, & Bouvier J, : Pathology findings with acrylic implants. Bone 25:2 Suppl 85S90S, 1999

    • Search Google Scholar
    • Export Citation
  • 30

    Schoenfeld AJ, , Dinicola NJ, , Ehrler DM, , Koerber A, , Paxos M, & Shorten SD, : Retrospective review of biopsy results following percutaneous fixation of vertebral compression fractures. Injury 39:327333, 2008

    • Search Google Scholar
    • Export Citation
  • 31

    Seppäläinen AM, & Rajaniemi R: Local neurotoxicity of methyl methacrylate among dental technicians. Am J Ind Med 5:471477, 1984

  • 32

    Shindle MK, , Tyler W, , Edobor-Osula F, , Gardner MJ, , Shindle L, & Toro J, : Unsuspected lymphoma diagnosed with use of biopsy during kyphoplasty. J Bone Joint Surg Am 88:2721 2724, 2006

    • Search Google Scholar
    • Export Citation
  • 33

    Siemionow K, & Lieberman IH: Vertebral augmentation in osteoporosis and bone metastasis. Curr Opin Support Palliat Care 1:323327, 2007

  • 34

    Thawait SK, , Marcus MA, , Morrison WB, , Klufas RA, , Eng J, & Carrino JA: Research synthesis: what is the diagnostic performance of magnetic resonance imaging to discriminate benign from malignant vertebral compression fractures? Systematic review and meta-analysis. Spine (Phila Pa 1976) 37:E736 E744, 2012

    • Search Google Scholar
    • Export Citation
  • 35

    Thillainadesan J, , Schlaphoff G, , Gibson KA, , Hassett GM, & Mc-Neil HP: Long-term outcomes of vertebroplasty for osteoporotic compression fractures. J Med Imaging Radiat Oncol 54:307314, 2010

    • Search Google Scholar
    • Export Citation
  • 36

    Togawa D, , Lieberman IH, , Bauer TW, , Reinhardt MK, & Kayanja MM: Histological evaluation of biopsies obtained from vertebral compression fractures: unsuspected myeloma and osteomalacia. Spine (Phila Pa 1976) 30:781786, 2005

    • Search Google Scholar
    • Export Citation
  • 37

    Truumees E, , Hilibrand A, & Vaccaro AR: Percutaneous vertebral augmentation. Spine J 4:218229, 2004

  • 38

    Ward JC, , Jeanneret B, , Oehlschlegel C, & Magerl F: The value of percutaneous transpedicular vertebral bone biopsies for histologic examination. Results of an experimental histopathologic study comparing two biopsy needles. Spine (Phila Pa 1976) 21:24842490, 1996

    • Search Google Scholar
    • Export Citation
  • 39

    Watts NB: Osteoporotic vertebral fractures. Neurosurg Focus 10:4 E12, 2001

  • 40

    Zhang L, , Li J, , Yang H, , Luo Z, & Zou J: Histological evaluation of bone biopsy results during PVP or PKP of vertebral compression fractures. Oncol Lett 5:135138, 2013

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 278 209 26
Full Text Views 353 18 0
PDF Downloads 243 17 1
EPUB Downloads 0 0 0