Percutaneous vertebroplasty of a myelomatous compression fracture in the presence of previous posterior instrumentation

Report of two cases

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✓ The authors report the use of percutaneous transpedicular vertebroplasty performed using polymethylmethacrylate (PMMA) in two patients. These men (53 and 57 years old) had previously undergone open surgery and posterior instrumentation to treat myelomatous compression fractures. Both patients presented with acute back pain that manifested after minor activities. Kyphotic wedge fractures were diagnosed at T-11 in one case and at L-1 in the other. Both patients were treated at other hospitals with laminectomy and instrumented fusion; multiple myeloma was diagnosed after surgery. The patients experienced severe, recalcitrant, and progressive pain; on referral, they were found to have persistent kyphosis. Multiple myelomatous lesions of the spine were seen in one case and in the other the L-1 fracture represented the only site of disease. Percutaneous vertebroplasty was performed by injecting PMMA into the anterior third of the compressed vertebral body. Both patients experienced a 50% reduction in pain immediately after treatment; 3 months later both were walking and reported minimal back pain while undergoing treatment for multiple myeloma. Three years after surgery one patient reported no back pain and no progressive instability of the spine. Four years after surgery the other patient remains pain free, ambulatory, and with overall disease remission.

Percutaneous vertebroplasty provided effective analgesia in these two patients with progressive back pain despite posterior stabilization. In both cases, the anterior column was effectively stabilized. A much larger operative intervention with its attendant risks of morbidity was avoided. In addition, subsequent aggressive medical treatment was well tolerated.

Abbreviations used in this paper:AP = anteroposterior; MDACC = M. D. Anderson Cancer Center; PMMA = polymethyl-methacrylate; VAS = visual analog scale; VB = vertebral body.

Article Information

Address reprint requests to: Ehud Mendel, M.D., The University of Texas M. D. Anderson Cancer Center, Department of Neuro-surgery, Box 442, 1400 Holcombe Boulevard, Suite FC7.2000, Houston, Texas 77230-1402. email: espine911@gmail.com.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Intraoperative AP (A) and lateral (B) x-ray studies obtained during percutaneous vertebroplasty to treat the T-11 anterior wedge compression fracture. Note the more lateral trajectory of the needle around the preexisting rods on the AP images. On the lateral image the cement is seen spreading into the anterior third of the collapsed VB.

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    Case 2. Lateral x-ray study obtained after vertebroplasty for the patient with L-1 kyphotic compression fracture. The cement and sagittal alignment are unchanged at 4 years. The initial refractory mechanical pain at that segment is now minimal.

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    Case 1. Lateral x-ray film obtained 3 years after the T-11 percutaneous vertebroplasty procedure. The patient’s multiple myeloma remains in remission, the sagittal alignment is unchanged, and his pain is well controlled.

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