Study design Literature review Objectives To describe new treatments for painful osteoporotic compression fractures in light of available scientific literature and clinical experience Summary of background data Painful vertebral osteoporotic compression fractures lead to significant morbidity and mortality This relates to pulmonary dysfunction, eating disorders (nutritional deficits), pain, loss of independence, and mental status change (related to pain and medications) Medications to treat osteoporosis (primarily antiresorptive) do not effectively treat the pain or the fracture, and require over 1 year to reduce the degree of osteoporosis Kyphoplasty and vertebroplasty are new techniques that help decrease the pain and improve function in fractured vertebrae Methods This is a descriptive review of the background leading to vertebroplasty and kyphoplasty, a description of the techniques, a review of the literature, as well as current ongoing studies evaluating kyphoplasty Results Both techniques have had a very high acceptance and use rate There is 95% improvement in pain and significant improvement in function following treatment by either of these percutaneous techniques Kyphoplasty improves height of the fractured vertebra, and improves kyphosis by over 50%, if performed within 3 months from the onset of the fracture (onset of pain) There is some height improvement, though not as marked, along with 95% clinical improvement, if the procedure is performed after 3 months Complications occur with both and relate to cement leakage in both, and cement emboli with vertebroplasty Conclusion Kyphoplasty and vertebroplasty are safe and effective, and have a useful role in the treatment of painful osteoporotic vertebral compression fractures that do not respond to conventional treatments Kyphoplasty offers the additional advantage of realigning the spinal column and regaining height of the fractured vertebra, which may help decrease the pulmonary, GI, and early morbidity consequences related to these fractures Both procedures are technically demanding

New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures.

Study Design. An Institutional Review Board-approved Phase I efficacy study of inflatable bone tamp usage in the treatment of symptomatic osteoporotic compression fractures. Objectives. To evaluate the safety and efficacy of inflatable bone tamp reduction and cement augmentation, kyphoplasty, in the treatment of painful osteoporotic vertebral compression fractures. Summary of Background Data. Osteoporotic compression fractures can result in progressive kyphosis and chronic pain. Traditional treatment for these patients includes bed rest, analgesics, and bracing. Augmentation of vertebral compression fractures with polymethylmethacryiate, vertebroplasty, has been used to treat pain. This technique, however, makes no attempt to restore the height of the collapsed vertebral body. Kyphoplasty is a new technique that involves the introduction of inflatable bone tamps into the vertebral body. Once inflated, the bone tamps restore the vertebral body back toward its original height while creating a cavity that can be filled with bone cement. Patients and Methods. Seventy consecutive kyphoplasty procedures were performed in 30 patients. The indications included painful primary or secondary osteoporotic vertebral compression fractures. Mean duration of symptoms was 5.9 months. Symptomatic levels were identified by correlating the clinical data with MRI findings. Perioperative variables and bone tamp complications or issues were recorded and analyzed. Preoperative and postoperative radiographs were compared to calculate the percentage height restored. Outcome data were obtained by comparing preoperative and latest postoperative SF-36 data. Results. At the completion of the Phase I study there were no major complications related directly to use of this technique or use of the inflatable bone tamp. In 70% of the vertebral bodies kyphoplasty restored 47% of the lost height. Cement leakage occurred at six levels (8.6%). SF-36 scores for Bodily Pain 11.6-58.7, (P = 0.0001) and Physical Function 11.7-47.4, (P = 0.002) were among those that showed significant improvement. Conclusions. The inflatable bone tamp was efficacious in the treatment of osteoporotic vertebral compression fractures. Kyphoplasty is associated with early clinical improvement of pain and function as well as restoration of vertebral body height in the treatment of painful ostecporotic compression fractures.

Initial outcome and efficacy of kyphoplasty in the treatment of painful osteoporotic vertebral compression fractures

The uncinate fasciculus is a bidirectional, long-range white matter tract that connects lateral orbitofrontal cortex and Brodmann area 10 with the anterior temporal lobes. Although abnormalities in the uncinate fasciculus have been associated with several psychiatric disorders and previous studies suggest it plays a putative role in episodic memory, language and social emotional processing, its exact function is not well understood. In this review we summarize what is currently known about the anatomy of the uncinate, we review its role in psychiatric and neurological illnesses, and we evaluate evidence related to its putative functions. We propose that an overarching role of the uncinate fasciculus is to allow temporal lobe-based mnemonic associations (e.g. an individual’s name + face + voice) to modify behaviour through interactions with the lateral orbitofrontal cortex, which provides valence-based biasing of decisions. The bidirectionality of the uncinate fasciculus information flow allows orbital frontal cortex-based reward and punishment history to rapidly modulate temporal lobe-based mnemonic representations. According to this view, disruption of the uncinate may cause problems in the expression of memory to guide decisions and in the acquisition of certain types of learning and memory. Moreover, uncinate perturbation should cause problems that extend beyond memory to include social–emotional problems owing to people and objects being stripped of personal value and emotional history and lacking in higher-level motivational value.

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Dissecting the uncinate fasciculus: disorders, controversies and a hypothesis.

Object The current North American experience with minimally invasive vertebro- and kyphoplasty is largely limited to the treatment of benign osteoporotic compression fractures. The objective of this study was to assess the safety and efficacy of these procedures for painful vertebral body (VB) fractures in cancer patients. Methods The authors reviewed a consecutive group of cancer patients (21 with myeloma and 35 with other primary malignancies) undergoing vertebro- and kyphoplasty at their institution. Ninety-seven (65 vertebro- and 32 kyphoplasty) procedures were performed in 56 patients during 58 treatment sessions. The mean patient age was 62 years (+/- 13 years [standard deviation]) and the median duration of symptoms was 3.2 months. All patients suffered intractable spinal pain secondary to VB fractures. Patients noted marked or complete pain relief after 49 procedures (84%), and no change after five procedures (9%); early postoperative Visual Analog Scale (VAS) pain scores were unavailable in four patients (7%). No patient was worse after treatment. Reductions in VAS pain scores remained significant up to 1 year (p = 0.02, Wilcoxon signed-rank test). Analgesic consumption was reduced at 1 month (p = 0.03, Wilcoxon signed-rank test). Median follow-up length was 4.5 months (range 1 day-19.7 months). Asymptomatic cement leakage occurred during vertebroplasty at six (9.2%) of 65 levels; no cement extravasation was seen during kyphoplasty. There were no deaths or complications related to the procedures. The mean percentage of restored VB height by kyphoplasty was 42 +/- 21%. Conclusions Percutaneous vertebro- and kyphoplasty provided significant pain relief in a high percentage of patients, and this appeared durable over time. The absence of cement leakage-related complications may reflect the use of 1) high-viscosity cement; 2) kyphoplasty in selected cases; and 3) relatively small volume injection. Precise indications for these techniques are evolving; however, they are safe and feasible in well-selected patients with refractory spinal pain due to myeloma bone disease or metastases.

Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients

PURPOSE: To investigate the prevalence and findings of vertebral body compression fractures adjacent to those previously treated with percutaneous vertebroplasty. MATERIALS AND METHODS: The findings in 177 patients treated with percutaneous vertebroplasty for more than 2 years were reviewed retrospectively. The following parameters were reviewed: primary diagnosis, patient age and sex, date of treatment with vertebroplasty, vertebral level(s) treated, pedicular approach, and amount of polymethylmethacrylate injected per vertebral body. Patients with acute compression fractures secondary to osteoporosis were selected. RESULTS: Of 177 patients treated with percutaneous vertebroplasty, 22 (12.4%) developed a total of 36 new vertebral body fractures following treatment. Of the 36 newly documented fractures, 24 (67%) involved vertebrae adjacent to the previously treated vertebral level(s), whereas 12 (33%) involved the collapse of nonadjacent vertebrae. In addition, 24 (67%) of the 36 new vertebral fractures o...

Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis.

Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results.

Rationale and Objectives: Using magnetic resonance imaging (MRI), we investigated cerebral blood and cerebrospinal fluid (CSF) flows in patients with communicating hydrocephalus (CH) and in healthy volunteers to determine the contribution of CSF flow to brain pressure regulation in CH patients. Methods: Cine phase-contrast MRI data from 16 healthy volunteers and 12 patients with CH characterized by hyperdynamic aqueductal CSF flow were analyzed using in-house image-processing software that automatically measured flow curves. Amplitude and temporal CSF and blood flow parameters were compared in the 2 groups. Results: Jugular peak flow occurred significantly earlier (P 0.01) in the CH patients than in the healthy volunteers. Cervical CSF oscillations were not significantly different between the 2 groups. Conclusion: Venous vessel compression and/or changes in intracranial subarachnoid CSF flow produce an increase in ventricular CSF flush that compensates for vascular brain expansion in patients with CH.

Relationship between cerebrospinal fluid and blood dynamics in healthy volunteers and patients with communicating hydrocephalus.

OBJECT Stereotactic biopsy procedures are an everyday part of neurosurgery. The procedure provides an accurate histological diagnosis with the least possible morbidity. Robotic stereotactic biopsy needs to be an accurate, safe, frameless, and rapid technique. This article reports the clinical results of a series of 100 frameless robotic biopsies using a Medtech ROSA device. METHODS The authors retrospectively analyzed their first 100 frameless stereotactic biopsies performed with the robotic ROSA device: 84 biopsies were performed by frameless robotic surface registration, 7 were performed by robotic bone fiducial marker registration, and 9 were performed by scalp fiducial marker registration. Intraoperative flat-panel CT scanning was performed concomitantly in 25 cases. The operative details of the robotic biopsies, the diagnostic yield, and mortality and morbidity data observed in this series are reported. RESULTS A histological diagnosis was established in 97 patients. No deaths or permanent morbidity ...

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Frameless robotic stereotactic biopsies: a consecutive series of 100 cases.

Objective: To establish the impact of the imaging modality, registration method and use of intraoperative computed tomography (CT) scan on the accuracy of the ROSA® stereotactic robot. Methods: Using a dedicated phantom device, we measured the accuracy of the stereotactic robot for 20 targets as a function of the registration method (frameless, FL, or frame-based, FB) and the reference imaging modality (3T magnetic resonance imaging, MRI, CT scanner or flat-panel CT, fpCT). We performed a retrospective study of the accuracy of the first 26 FB and 31 FL robotized stereotactic surgeries performed in our department. Results: In a phantom study, the mean target accuracy was 1.59 mm for 3T MRI-guided FL surgery, 0.3 mm for fpCT-guided FL surgery and 0.3 mm for CT-guided FB surgery. In our retrospective series, the mean accuracy was 0.81 mm for FB stereotactic surgery, 1.22 mm for our 24 stereotactic surgery procedures with FL (surface recognition) registration and 0.7 mm for our 7 stereotactic surgery procedures with FL fiducial marker registration. Intraoperative fpCT fully corrected all the registration errors. Conclusions: The ROSA stereotactic robot is highly accurate. Robotized FB stereotactic surgery is more accurate than robotized FL stereotactic surgery.

The impact of the reference imaging modality, registration method and intraoperative flat-panel computed tomography on the accuracy of the ROSA® stereotactic robot.

In the course of our study, we have been able to confirm the feasibility, efficiency, and safety of percutaneous vertebroplasty in the treatment of vertebral fractures of tumorous origin with epidural involvement, with or without neurologic symptoms of medullary or cauda equina compression.

Daniel Le Gars

Papers

Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results.

Relationship between cerebrospinal fluid and blood dynamics in healthy volunteers and patients with communicating hydrocephalus.

Frameless robotic stereotactic biopsies: a consecutive series of 100 cases.

The impact of the reference imaging modality, registration method and intraoperative flat-panel computed tomography on the accuracy of the ROSA® stereotactic robot.

Percutaneous vertebroplasty for pain management in malignant fractures of the spine with epidural involvement.