Change in the cross-sectional area of the thecal sac following balloon kyphoplasty for pathological vertebral compression fractures prior to spine stereotactic radiosurgery

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OBJECTIVE

Percutaneous vertebral augmentation procedures such as vertebroplasty and kyphoplasty are often performed in cancer patients to relieve mechanical axial-load pain due to pathological collapse deformities. The collapsed vertebrae in these patients can be associated with varying degrees of spinal canal compromise that can be worsened by kyphoplasty. In this study the authors evaluated changes to the spinal canal, in particular the cross-sectional area of the thecal sac, following balloon kyphoplasty (BKP) prior to stereotactic radiosurgery (SRS).

METHODS

The authors retrospectively reviewed the records of all patients with symptomatic vertebral compression fractures caused by metastatic disease who underwent kyphoplasty prior to single-fraction SRS. The pre-BKP cross-sectional image, usually MRI, was compared to the post-BKP CT myelogram required for radiation treatment planning. The cross-sectional area of the thecal sac was calculated pre- and postkyphoplasty, and intraprocedural CT imaging was reviewed for epidural displacement of bone fragments, tumor, or polymethylmethacrylate (PMMA) extravasation. The postkyphoplasty imaging was also evaluated for evidence of fracture progression or fracture reduction.

RESULTS

Among 30 consecutive patients, 41 vertebral levels were treated with kyphoplasty, and 24% (10/41) of the augmented levels showed a decreased cross-sectional area of the thecal sac. All 10 of these vertebral levels had preexisting epidural disease and destruction of the posterior vertebral body cortex. No bone fragments were displaced posteriorly. Minor epidural PMMA extravasation occurred in 20% (8/41) of the augmented levels but was present in only 1 of the 10 vertebral segments that showed a decreased cross-sectional area of the thecal sac postkyphoplasty.

CONCLUSIONS

In patients with preexisting epidural disease and destruction of the posterior vertebral body cortex who are undergoing BKP for pathological fractures, there is an increased risk of further mass effect upon the thecal sac and the potential to alter the SRS treatment planning.

ABBREVIATIONS BKP = balloon kyphoplasty; ESCCS = epidural spinal cord compression scale; PMMA = polymethylmethacrylate; ROI = region of interest; SSRS = spine stereotactic radiosurgery; VAS = visual analog scale.

Article Information

Correspondence Eric Lis: Memorial Sloan Kettering Cancer Center, New York, NY. lise@mskcc.org.

INCLUDE WHEN CITING Published online October 19, 2018; DOI: 10.3171/2018.6.SPINE18206.

Disclosures Dr. Lis has received compensation from Medtronic for educational teaching. Dr. Laufer has been a consultant for Globus, Medtronic, DePuy/Synthes, Spinewave, and Brainlab. Dr. Yamada has received compensation from Varian Medical Systems, Brainlab, and Vision RT as part of their speakers bureau and has served on the medical advisory board for the Chordoma Foundation.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Images obtained in a 74-year-old man with stage IV esophageal cancer and an L3 metastasis with pathological collapse. A: Pre-BKP sagittal T2-weighted MR image obtained through the lumbar spine, showing a pathological collapse of L3 with the mid vertebral body having lost about 67% of its estimated height. B: Pre-KBP axial T2-weighted image obtained through L3, revealing ventral epidural disease resulting in moderate spinal compromise. The cross-sectional area of the thecal sac, as outlined by the ROI, was calculated to be 1.8 cm2. C: Post-BKP axial CT myelogram obtained through L3, showing destruction of the posterior vertebral cortex. The ROI outlining the thecal sac is also shown, with the cross-sectional area of the thecal sac calculated to be 1.5 cm2, a decrease of 17% compared to the pre-KBP cross-sectional area. D: Post-BKP sagittal CT myelogram showing fracture reduction, an increase of 57% in the midportion of the vertebral body compared to that in panel A. Increased epidural mass effect on the ventral thecal sac was confirmed. The time between the pre-BKP MR image and the CT myelogram was 10 days.

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    Images obtained in a 54-year-old man with colon cancer and a T9 metastasis with pathological collapse. A: Pre-BKP axial T1-weighted MR image obtained through T9, showing mild ventral epidural disease (ESCCS grade 1b) and the ROI outlining the thecal sac, whose cross-sectional area was calculated to be 1.6 cm2. B: Axial CT image obtained through T9 at the time of the kyphoplasty, showing the position of the inflated bilateral 15 mm bone tamps with permeative destruction of the posterior vertebral cortex. C: Post-BKP axial CT obtained through T9 with the ROI outlining the thecal sac and showing a 25% decrease in the cross-sectional area of the thecal sac, which now measures 1.2 cm2 (ESCCS grade 1c). D: Pre-BKP sagittal T2-weighted MR image showing a pathological collapse of T9 with an approximately 52% loss of vertebral body height at the mid vertebral body. E: Post-BKP sagittal CT myelogram showing fracture reduction, an increase of 27% in the midportion of the vertebral body compared to that in panel D. Increased epidural soft tissue can also be identified. The time between pre-BKP MRI and the CT myelogram was 20 days.

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