- Clinical Professor of Neurosurgery, The Albert Einstein College of Medicine, Bronx, NY, USA and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, NY 11501, USA
DOI:10.4103/2152-7806.63904© 2010 Epstein NE This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite this article: Epstein NE. Computed tomography-guided vertebroplasty using a stereotactic guidance system (stereo-guide). Surg Neurol Int 31-May-2010;1:10
How to cite this URL: Epstein NE. Computed tomography-guided vertebroplasty using a stereotactic guidance system (stereo-guide). Surg Neurol Int 31-May-2010;1:10. Available from: http://sni.wpengine.com/surgicalint_articles/computed-tomography-guided-vertebroplasty-using-a-stereotactic-guidance-system-stereo-guide/
This technical note entitled “Computed tomography (CT)-guided vertebroplasty using a stereotactic guidance system [stereo-guide]” focuses on the utilization of this protractor with CT guidance in the radiology suite to perform percutaneous vertebroplasty with greater safety and accuracy. Their protractor consisted of a flat plastic block with “deeply grooved protractor markings at 5° intervals” (range from 0° to 30°). While in the CT scanner, the device was placed on the patient's back, and the needle was optimally directed through the center of the pedicle through the appropriate groove. It was successfully employed in nine patients undergoing 10 procedures involving either the thoracic or lumbar spine; there were no complications. Furthermore, the CT scanner additionally facilitated monitoring the injection of vertebroplasty material into the vertebral body; cement consolidation and the presence/absence of extravasation could be immediately assessed. The authors should be commended for devising this protractor that appears to be a useful adjunct when performing percutaneous vertebroplasty in the radiology suite utilizing CT guidance.
Previously, when vertebroplasties were performed under fluoroscopic guidance either in the radiology suite by neuroradiologists/radiologists or in the operating room by spine surgeons, localizing the correct level, particularly in the thoracic spine, was often difficult. Another limitation was the inability to “accurately” document extravasation of material into the spinal canal, disc space, etc. (as compared with the use of the CT scan in the radiology suite). This, therefore, increased the risk of inadvertently injecting more material, causing further neural and/or other injuires.
Although other studies have routinely employed CT-guidance in radiology suites to perform vertebroplasty/kyphoplasty (VK), one unique report focused on the safety and efficacy of utilizing the Isocentric C-arm fluoroscopic cone beam CT (Iso-C) in the operating room.[
One of the major concerns regarding the performance of vertebroplasty is the advanced age of the patients involved, and their increased number of attendant comorbidities making them poor candidates for “open” operations. Osteoporotic compression fractures of vertebral bodies occur in 5-20% of patients between the ages of 50 and 80, and are four times more frequent in females.[
Neurological deficits attributed to cement leakage
Vertebroplasty and kyphoplasty can also cause severe neurological injury in an estimated of 1-19% of cases utilizing polymethylmethacrylate (PMMA) or Cortoss (OrthoVita, Malvern, PA, USA).[
Nevertheless, with malignant disease, the risks of neurological injury from VK are mitigated by the patients' limited long-term prognoses. In a series involving 74 vertebrae in 51 patients with terminal metastatic disease or multiple myeloma, 15 (29%) had incomplete/complete cord compression before vertebroplasty and sustained no further deficits; only one patient developed a new cauda equina syndrome within 48 h.[
Adjacent-level fractures following VK
An added concern is the increased risk for adjacent-level fractures following VK. In one study, 2 of 25 patients treated with VK compared with none managed conservatively developed delayed adjacent-level fractures.[
Careful patient selection and long-term outcomes of VK procedures
Given the risks/complications associated with VK procedures utilizing any modality, we should reexamine patient selection based upon short- and long-term outcomes. In a randomized prospective study, 50 patients with acute/subacute osteoporotic compression fractures (<8 weeks old) were treated either with percutaneous vertebroplasty or conservative management.[
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