Elsevier

European Journal of Radiology

Volume 82, Issue 12, December 2013, Pages 2303-2308
European Journal of Radiology

Vertebra plana: Reappraisal of a contraindication to percutaneous vertebroplasty

https://doi.org/10.1016/j.ejrad.2013.08.042Get rights and content

Abstract

Purpose

We evaluated the efficacy of percutaneous vertebroplasty (PVP) in treating symptomatic vertebra plana, which is considered a relative contraindication to the procedure.

Methods

Out of 540 levels treated in 260 patients, we treated 40 patients (mean age: 74 years) with vertebra plana between T6 and L3 (37 osteoporotic and 3 metastatic levels). In most cases, the vertebra was accessed with fluoroscopic guidance from a single, transpedicular approach. All patients underwent a preliminary MRI examination, an immediate, post-procedure radiological examination, and a follow-up examination (mean duration, 6 months).

Results

Both immediate and follow-up examinations showed that the mean pain and physical disability scores were significantly reduced compared to the scores before treatment (p  0.001). No complications occurred during the procedures. In 23/40 cases, asymptomatic intradiscal cement leakage occurred. Posterior or perivertebral leakage never occurred. In most cases, an intravertebral cleft was present, and we filled it with polymethylmethacrylate, which healed the pseudarthrosis. Partial vertebral height was restored in 7 cases. In 6 cases, a new fracture occurred between 1 and 3 months at a different level from the treated level.

Conclusion

Our preliminary results showed that PVP was a safe, effective treatment for symptomatic vertebra plana; thus, it should not be discounted for this group of patients. In most cases, the procedure was favored by the presence of an intravertebral cleft that appeared to contribute to minimizing the risk of posterior cement leakage. Filling the cleft with polymethylmethacrylate allowed intravertebral stabilization.

Introduction

Percutaneous vertebroplasty (PVP) is a radioimaging-guided technique employed for treating vertebral fractures (osteoporotic or neoplastic) and symptomatic vertebral hemangiomas. PVP consists of an injection of biocompatible cement, polymethylmethacrylate (PMMA), into a vertebral body with specialized, metal needles. From the first time it was employed [1], its application has spread, and currently, it is considered an effective, safe, mini-invasive technique. PVP is considered a preferred alternative to the traditional, conservative therapy, which often incurs higher costs, requires prolonged immobilization, and involves drugs with serious side effects. Moreover, conservative therapy can lead to complications, often serious, in older or fragile patients. Currently, most authors agree on the indications and contraindications for the PVP procedure [2], [3], [4], [5], [6], [7], [8], [9], [15]. However, it is clear from the literature that many authors decline to use PVP for treating severe vertebral fractures, where the vertebral body height is reduced >70%; this condition has been considered an exclusion criteria [4], an unfavorable situation [10], or a relative contraindication [3] to PVP treatment.

“Vertebra plana” is a form of severe, compression-induced vertebral collapse. It is caused by osteoporosis or tumors in the adult population. On a radiograph, it appears as a uniform, somatic flattening of the complete vertebra, except the vertebral arch.

This retrospective study aimed to reappraise the vertebra plana condition as a candidate for PVP treatment. We report our experience over 5 years with a series of symptomatic vertebra plana cases treated with PVP, the results, and the complications observed.

Section snippets

Materials and methods

Institutional review board approval was obtained for this study. In this study, we retrospectively reviewed a series of 540 vertebral fractures treated with vertebroplasty in 260 consecutive patients in our Department of Radiology from April 2006 to April 2012. We identified 40 patients with symptomatic vertebra plana that were treated with the PVP technique. A small number of these patients were included in a previous report on vertebroplasty [5], but they were not analyzed separately. The 40

Results

From our single center records, we reviewed a total of 40 cases of symptomatic vertebra plana treated with PVP. All patients had provided written informed consent. In 22 cases, the vertebra plana was treated in the same session with other, non-adjacent metameres at different levels; in 5 cases, adjacent levels were also treated; and in 13 cases, the severe vertebral body collapse was isolated, without evidence of other spinal fractures.

Discussion

Most previous studies have considered severe vertebral collapse (>70%) to be a relative or absolute contraindication for PVP, due to the technical difficulties involved with the percutaneous approach in this condition [2], [3], [4], [6]. In contrast, the results of this study showed that the PVP approach could be facilitated by using specific fluoroscopic projections to control and guide the procedure. Our data were consistent with two other studies by Peh and Young [7], [8], which, to the best

Conclusion

Our results showed that PVP was a safe, effective procedure for treating vertebra plana; therefore, PVP should not be discounted or considered contraindicated for symptomatic patients. In fact, based on our results, we suggest that PVP should be considered a primary treatment option. We showed that, in most cases, this technique was favored by the presence of clefts inside the vertebral body. This facilitated cement introduction and seemed to reduce the risk of posterior cement leakage into the

Conflict of interest

We declare that we have no conflict of interest.

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