Vertebroplasty For Spinal Neoplasms

Vertebroplasty was first performed for painful spinal hemangiomas (1,61-69). European practitioners have continued to treat large numbers of patients with spinal neoplasms (2,9,61,70-72). In North America, however, treatment of neoplastic disease of the spine has failed to gain widespread acceptance (73).

Treatment of neoplasms may be requested in the case of malignant fractures with pain refractory to medical and radiation therapy (2,9,61,70-72) or in cases of impending fracture (18). The overall approach of vertebroplasty in treatment of neoplasms differs substantially from that for treatment of osteo-porotic fractures. First, preprocedure imaging should include CT and/or MRI to assess tumor extent and degree of bony involvement. Destruction of the posterior vertebral cortex renders vertebroplasty of higher risk, because of potential for cement extravasation into the spinal canal (Fig. 10) (9). However, osteolysis of the posterior wall is not an absolute contraindication. Only when frank epidural tumor is present should vertebro-plasty be avoided (9,24,70-72). Second, patients with multifocal spinal metastases may have great difficulty in lying in the prone position and general anesthesia should be strongly considered. Third, the routine transpedicular approach may be difficult or impossible in cases of pedicu-late involvement with tumor, and may require CT for needle placement (73). Fourth, venography may lead to large amounts of contrast leaking directly through areas of cortical destruction into the paravertebral and epidural spaces. This contrast cannot be readily removed from these spaces and thus may obscure cement deposition. Last, routine postprocedure CT scanning is considered prudent not only to assess location of cement but also to show changes in position of the tumor mass (A. Evans, personal communication).

The risk/benefit ratio of vertebroplasty for neoplastic disease is less favorable than that for osteoporotic fractures. Improvement in pain is seen in 50-80% of cases (1,2,9, 18,61,70-72); nerve irritation from cement extravasation is the most common complication (8,9).

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