Abstract No. 5: Percutaneous Vertebroplasty (PV)in the Cervical Spine from C1 to C7: Results and Complications in Benign and Malignant Lesions

bral body augmentation, such as CONFIDENCE, are therefore providing high-viscosity cements with precision delivery systems. In this study, the incidence and pattern of cement leakage with Confidence was compared to that of standard kyphoplasty. MATERIALS & METHODS: Post-operative radiographs of patients treated with either kyphoplasty or Confidence were analyzed for cement leakage, using a stringent and thorough 4-point scale (none; mild; moderate; severe). When leakage was observed, location of cement leakage was also recorded as: discal, venous (paravertebral), or epidural. RESULTS: 65 patients with 105 treated levels were included in this retrospective review. There were 47 kyphoplasty vs. 58 Confidence levels, which ranged from T5 to L5. The average vertebral collapse reached 26% in the Confidence group vs. 25% in the kyphoplasty group. There was no or minimal/mild leakage in 91% Confidence and 85% Kyphon cases. Severe leakage was only reported in 1 (2%) Confidence and 1 (2%) Kyphon cases. In both cases, the severe leakage was found in the disc space. No significant leakage was noticed that required any surgical intervention. CONCLUSION: The high-viscosity Confidence cement results in comparable leakage rate to Kyphoplasty. Highly viscous cement may increase the safety of standard vertebroplasty techniques. Reference Baroud G. Crookshank M. Bohner M. High-viscosity cement significantly enhances uniformity of cement filling in vertebroplasty: an experimental model and study on cement leakage. Spine. 31(22):2562-8, 2006. 10:36 AM

Abstract No. 4

Percutaneous Vertebroplasty for Osteoporotic Compression Fracture, First 500 Levels of a Single Center: Long Term Evaluation of the Technical and Clinical Outcomes. N. Tanigawa1, S. Kariya1, A. Komemushi2, Y. Shomura1, T. Tokuda1, S. Sawada1; 1Kansai Medical University Hirakata Hospital, Hirakata, Japan; 2Kansai Medical University Takii Hospital, Moriguchi, Japan. PURPOSE: To evaluate the technical and clinical outcomes of our first 500 consecutively treated osteoporotic compression fractures to demonstrate long-term efficacy and frequency of new compression fracture after percutaneous vertebroplasty (PVP). MATERIALS & METHODS: The first 500 osteoporotic compression fractures (T6-L5) treated by PVP at our institution were enrolled in this study. The site of the cement leakage were evaluated by volumetric CT obtained immediately after PVP. Evaluation at each follow-up time point (one day, 1 month, 4 months, 1 year, 2 years, 3 years, 4 years, 5 years after PVP) included pain response by using visual analog score (VAS) and frontal and lateral plain radiographs of the thoracic and lumbar vertebrae regardless of the symptoms. RESULTS: There were 203 patients (mean:72.9 years, range:44-89 years, 167 women, 36 men) treated between December 2002 and March 2008. These 203 patients underwent 272 sessions to treat 500 compression fractures. The average cement volume injected was 3.3 ml per level. Cement leakage was found in intradiscal leakages in 105 levels (21%), in epidural vein or paravertebral vein in 100 levels (20%), in soft tissue in 22 levels (4.4%), in spinal S4

canal or neural foramen in 6 levels (1.2%), and in lung in 2 cases (0.4%).Clinically significant complications were encountered in only one patient who had a clinically significant cement leakage into the adjacent disk and underwent surgical decompression. Average VAS score was 7.5 before PVP, 3.0at 1 day after PVP, 2.4 at 1 month, 1.8 at 4 months, 1.3 at 1 year, 1.5 at 2 years, 1.5 at 3 years, 2.3 at 4 years, and 1.7 at 5 years after PVP. New compression fracture was confirmed in 78 vertebral bodies in 52 patients (25.6%), affecting 52 adjacent vertebral bodies (66.7%), 25 nonadjacent vertebral bodies (32%) and 1 treated vertebral body (1.3%). CONCLUSION: PVP was effective in relieving the pain associated with osteoporosis-induced vertebral compression fractures and this analgesic effect was long lasting. Radiological follow-up observation showed that new compression fractures occurred in about one fourth of the patients, and more than half of the new compression fractures occurred at the adjacent vertebral bodies. 10:48 AM

Abstract No. 5

Percutaneous Vertebroplasty (PV)in the Cervical Spine from C1 to C7: Results and Complications in Benign and Malignant Lesions. G. Anselmetti1, A. Manca1, G. Chiara1, M. Liotti2, F. Russo2, D. Regge2; 1Institute for Cancer Research and Treatment - Interventional Radiology, Candiolo, Italy; 2Institute for Cancer Research and Treatment - Radiology, Candiolo, Italy. PURPOSE: To assess feasibility, safety and effectiveness of PV in the cervical spine in different pathology MATERIALS & METHODS: Since June 2003 27 patients (pts) (11 males, mean age 65⫾18 years) underwent PV on 31 cervical vertebrae for painful lesions not responding to conservative treatment (metastases and symptomatic angioma) or because surgery was contraindicated (trauma). All traumatic fractures (6 cases) and the symptomatic angioma (1 case) were located on C2 odontoid process. The remnant 20 pts suffered from lityc painful metastases from breast cancer (C1; C2-4 lesions; C4; C5), renal cancer (C2; C5; C6), thyroid cancer (C2; C4), oropharingeal cancer (C2; C3; C5), hepatocellular carcinoma (C2), gastric cancer (C2; C3; C5; C6), lung cancer (C7), sarcoma (C2) and myeloma (C2; C4). PV with transoral approach was performed in general anesthesia in all case of C2 whereas the other cervical vertebrae were treated in antero- (11), postero- (1) or laterolateral (1) approach in local anesthesia. All procedures were executed under combined digital fluoroscopy and computed tomography (CT) guidance. Monitoring of heart rate and pulse oximetry was carried out continuously throughout all the procedure. Prophylactic antibiotic therapy with a thirdgeneration cephalosporine before the procedure and for 5 days after the procedure was applied. RESULTS: All procedures were successfully performed without any major complications. Pts with symptomatic angioma and trauma reported complete pain relief; this clinical result was stable during long-term follow-up (3 years) although CT demonstrated a pseudoarthrosis in 1 pt. Pts with malignancy reported significant pain relief (mean VAS of 7,6⫾2,1 dropped to 1,8⫾2,2 p⬍ .0001 paired t-Test) during average follow-up of 6 months. 1 pt with thyroid cancer metastases required posterior surgical fixation 3 months after PV. All pts dismissed external neck brace support and decreased analgesic assumption after PV.

Abstract No. 6

The Biomechanical and Clinical Efficacy of CERAMENT, A Bi-Phasic Bone Substitute for the Treatment of Vertebral Compression Fractures. H. Hatten; Indian River Radiology, Vero Beach, FL. PURPOSE: The fruit of research in Sweden, CERAMENT is a bio-compatible, injectable ceramic bone substitute which has been introduced for the treatment of vertebral compression fractures (VCFs) to reduce pain and the incidence of secondary fractures. The bi-phasic powder comprises a synthetic calcium sulfate (60% by weight) and a balance of sintered hydroxyapatite, mixed with a radioopacity enhancing component which contains iohexol to produce a flowable and injectable paste. The resultant product is designed to increase cancellous bone mass in vertebral bodies and avoid the negative aspects of implanting inert (e.g. barium) material. The calcium sulfate resorbs with time producing porosity which allows for new bone ingrowth through occupation of osteoprogenitor cells and osteoblasts, while the hydroxyapatite acts as a long term osteoconductive matrix. MATERIALS & METHODS: CERAMENT is designed to provide the appropriate mechanical environment for stability of the VCF and pain prevention. The material construction delivers a compressive strength similar to that of cancellous bone when implanted and this restores initial strength to aid pain prevention. The stiffness is also similar to that of cancellous bone to help prevent additional fractures in adjacent vertebrae. These biomechanical properties shall be discussed. RESULTS: A pilot clinical study for VCFs was performed on 7 patients in Sweden in 2004. This was followed by a multi-center study in Germany, 2005-2007. A CE mark is pending in the EU. In the U.S. the F.D.A. cleared CERAMENT via the 510(k) process in 2006 as a bone void filler and the material has subsequently been used in over 250 patients with no known clinical complications. CONCLUSION: Presented is the early data on the use of this novel bone substitute in VCFs in the United States. 11:12 AM

Abstract No. 7

Follow-Up of Percutaneous Treatment of Early and Late Ureteral Strictures After Kidney Transplantation. S. Rao, A. Bhatt; The Ohio State University Medical Center, Columbus, OH. PURPOSE: To evaluate the relationship between early and late presentation of renal transplant strictures for percutaneous nephrostomy (PCN) on eventual clinical success of the transplant. MATERIALS & METHODS: A retrospective analysis was conducted of all kidney transplant patients referred for PCN evaluation and treatment over a 7 year period. All patients had minimum of 1 year follow-up. Patients were excluded for: 1) current ongoing treatment, 2) referrals following surgical revision of the ureteral anastamosis, and 3) underlying lymphoproliferative disorders. Strictures identified on nephrostogram were treated with multi-purpose biliary

RESULTS: From April 2000 to June 2007, 1916 patients underwent renal transplantation. Forty-four were referred post-operatively for PCN for ureteral stricture (n⫽35) and leak (n⫽9). Twenty-seven cases of ureteral stricture met inclusion and exclusion criteria. Of these cases, 29.6% (n⫽8) had clinically successful outcomes. Clinically successful outcomes were seen in cases presenting after a mean 92.8 days post transplantation; clinically unsuccessful cases presented with stricture after a mean of 428.7 days (Zscore ⫽ 2.50). Fifteen of 19 clinically unsuccessful transplants required subsequent surgery, including stricture resection with ureteral reimplantation(n⫽11). CONCLUSION: Patients undergoing post-renal transplant percutaneous nephrostomy relatively early in the post-transplant period (⬍3 months) are more likely to experience a clinically successful outcome than patients undergoing PCN later in the post-operative period. 11:24 AM

Abstract No. 8

Clinical Significance of Post Renal Transplant Ureteritis Following Treatment with Multi-Purpose Biliary Drainage Catheters. S. Rao, A. Bhatt, H. Khabiri; The Ohio State University Medical Center, Columbus, OH. PURPOSE: A mainstay of percutaneous treatment of urological complications following kidney transplantation is drainage via multi-purpose biliary catheters. The effect of the large side-bores on these catheters on the adjacent ureter is not well understood or described. This study retrospectively evaluates the hypothesis that the presence of internal biliary drains correlates with the secondary radiographic appearance of ureteritis. Further, the study attempts to assess the clinical significance of this finding. MATERIALS & METHODS: Ureterograms performed on post renal transplant referrals for percutaneous nephrostomy (PCN) were retrospectively analyzed for 1) ureteral appearance, 2) position/type of prior PCN drainage, and 3) corresponding plasma creatinine (Cr). Patients were excluded for: 1) incomplete follow-up, 2) referrals after surgical revision of the ureteral anastamosis, and 3) underlying lymphoproliferative disorders. Patients were categorized: Group 1 (internal-external drain only), Group 2 (external only), Group 3 (internal-external drain followed by subsequent external drainage), and Group 4 (external drain followed by subsequent internal-external drain). Assessment of ureterograms for changes in ureteral appearance was correlated with Cr to quantify the clinical significance. RESULTS: From April 2000 to June 2007, 1619 renal transplants were performed. Thirty-four of 44 referrals for PCN met inclusion and exclusion criteria. Ureteral irregularity (n⫽15) occurred either after internal-external drain placement or after conversion from external to internalexternal drain in 14 patients (93%). Eight of 15 (53%) patients had persistent ureteritis until conclusion of treatS5

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drainage catheters and, as deemed necessary, balloon dilation (conventional and cutting). Patients percutaneously treated for ureteral strictures were categorized based on outcomes of radiographic and clinical success. Radiographic success was defined by resolution of stricture on final nephroureterogram. Clinical success was defined by patients not requiring hemodialysis, transplant nephrectomy, or surgical revision of the transplant ureter during follow-up. Statistical significance in outcomes of early and late stricture presentation was calculated with a Z-test.

Scientific Sessions

CONCLUSION: PV in the cervical spine is feasible, safe and effective either in benign or in malignant painful lesions. This therapeutic option should be proposed if conservative treatments fail or if surgery is contraindicated.