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Percutaneous Vertebroplasty for Compression Fracture in a Patient with HIV
Letter to the Editor
Percutaneous Vertebroplasty for Compression Fracture in a Patient with HIV From: Kieran J. Murphy, MD, FRCPC, Amit D. Malhotra, BS, Marcus W. Parker, MD, Raymond S. Fryrear, MD, Niranjan Khandelwal, MD, Philippe Gailloud, MD Russell H. Morgan Department of Radiology The Johns Hopkins Hospital B-100, 600 North Wolfe Street Baltimore, MD 21287 Editor: Osteoporotic vertebral compression fractures represent a major public health issue, with nearly 400,000 fractures occurring each year in the United States (1). Several risk factors, including age, race, early menopause, cigarette smoking, and lack of exercise, are associated with osteoporotic fracture in elderly patients. Type I diabetes, hypogonadism, and long-term steroid treatment place patients in all age groups at risk for osteoporosis. Accelerated bone mineral loss has been reported in patients with HIV treated with antiretroviral therapy, particularly protease inhibitors (2– 4). The authors report herein the case of an HIV-positive man treated with protease inhibitors, who presented with severe back pain secondary to a vertebral compression fracture, which was relieved by percutaneous vertebroplasty. A 55-year-old man with a serologically proven HIV infection complained of severe, rapidly progressive back pain that significantly impaired his daily activities. His medical history was significant for antiretroviral therapy and lymphoma treated by chemotherapy years earlier. Magnetic resonance imaging documented a T12 compression fracture. Dual-energy radiographic absorptiometric measurements revealed a bone density value of 5.34 standard deviations less than the mean value at the lumbar spine, indicating severe osteoporosis. He had no evidence of an acute infection that could be responsible for his symptoms. The patient was referred to us after an unsuccessful trial of conventional pain management that included narcotic analgesics and bracing. A transpedicular vertebral biopsy was performed that showed no evidence of abnormal cellularity, and the cultures remained negative. The patient agreed to undergo percutaneous vertebroplasty after a detailed review of the potential risks and benefits of the procedure. Approval from our institutional review board was obtained. The patient was placed prone on the angiography table and the skin of the back was prepared in a sterile fashion. The procedure was performed under local anesthesia and conscious sedation with use of a combination of fentanyl and midazolam. Prophylactic antibiotic therapy was administered intravenously (cefazolin 1 g). Bilateral transpedicular vertebroplasty was performed with use of approximately 5 mL of a mixture of polymethylmethacrylate (Osteobond; Zimmer, Warsaw, IN) and sterile barium powder injected within the vertebral body, with
DOI: 10.1097/01.RVI.0000141444.69357.86
no venous or soft tissue leak. The patient was observed in the recovery area for 3 hours before being discharged home. He reported an immediate improvement of his pain, which he judged as 60% decreased compared with his initial pain level. He described sustained improvement at the 1-day and 1-week follow-up phone evaluations. He also noted significant improvement in the performance of his daily activities without the help of narcotic analgesics or bracing. Back pain secondary to osteoporotic compression fractures represents a significant therapeutic challenge and causes a severe decrease in quality of life. Compression fractures place patients at risk for deep venous thrombosis and pneumonia and cause increased isolation, depression, and institutionalization. Deramond invented vertebroplasty in Amien, France, and it was first reported in 1987 (5), and we have performed this procedure since 1996. We perform vertebroplasty with use of a biplane angiography suite; alternatively, it can be safely performed with use of a single plane. The literature supports its use in malignant and benign disease (6). It is possible to achieve complete pain resolution within 1 hour of the procedure. The pain relief associated with vertebroplasty is probably related to the following: (i) increase in structural strength of the vertebral body and a decrease in microscopic motion of the fracture plane; and (ii) the heating effect of the bone cement potentially causing local neurolysis. The bone cement achieves a temperature of as high as 60°C during polymerization, which is comparable to the target temperature for radiofrequency ablation. The transpedicular approach into the vertebral body is very safe. Vertebroplasty has much to offer as a simple mechanical solution to a structural problem. Although it is typically used in older patient populations with osteoporosis or patients with malignant disease, it may now be applicable to patients with HIV, as advances in HIV treatment have lengthened these patients’ life expectancy. It is key to rule out infections with use of rapid molecular biologic tests so that early effective treatment can be offered. Although osteoporosis in HIV has not been clearly documented in the literature, it has been documented in patients with HIV after treatment with protease inhibitors (2– 4). The possible mechanism for osteoporosis may be related to lipodystrophy and redistribution syndromes (2,3). It may also be related to hepatic dysfunction secondary to underlying disease, infections, or medications. References 1. Wu SS, Lachmann E, Nagler W. Current medical, rehabilitation, and surgical management of vertebral compression fractures. J Womens Health (Larchmt) 2003; 12:17–26. 2. Laurence J. Accelerated bone mineral loss in HIV-positive patients. AIDS Reader 2000; 10:192–200. 3. Bonfani P, Gabbuti A, Carradori S, et al. Osteonecrosis in protease inhibitor-treated patients. Orthopedics 2001; 24:271–272. 4. Weiel JE, Lenhard JM. Bone mineral loss in HIV-positive patients receiving antiretroviral therapy. AIDS 2000; 14:2218 –2219. 5. Galibert P, Deramond H, Rosat P, Le Gars D. [Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty] Neurochirurgie 1987; 33:166 –168. 6. Murphy KJ, Deramond H. Percutaneous vertebroplasty in benign and malignant disease. Neuroimaging Clin N Am 2000; 10:535–545.
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Percutaneous Vertebroplasty for Compression Fracture in a Patient with HIV From: Kieran J. Murphy, MD, FRCPC, Amit D. Malhotra, BS, Marcus W. Parker, MD, Raymond S. Fryrear, MD, Niranjan Khandelwal, MD, Philippe Gailloud, MD Russell H. Morgan Department of Radiology The Johns Hopkins Hospital B-100, 600 North Wolfe Street Baltimore, MD 21287 Editor: Osteoporotic vertebral compression fractures represent a major public health issue, with nearly 400,000 fractures occurring each year in the United States (1). Several risk factors, including age, race, early menopause, cigarette smoking, and lack of exercise, are associated with osteoporotic fracture in elderly patients. Type I diabetes, hypogonadism, and long-term steroid treatment place patients in all age groups at risk for osteoporosis. Accelerated bone mineral loss has been reported in patients with HIV treated with antiretroviral therapy, particularly protease inhibitors (2– 4). The authors report herein the case of an HIV-positive man treated with protease inhibitors, who presented with severe back pain secondary to a vertebral compression fracture, which was relieved by percutaneous vertebroplasty. A 55-year-old man with a serologically proven HIV infection complained of severe, rapidly progressive back pain that significantly impaired his daily activities. His medical history was significant for antiretroviral therapy and lymphoma treated by chemotherapy years earlier. Magnetic resonance imaging documented a T12 compression fracture. Dual-energy radiographic absorptiometric measurements revealed a bone density value of 5.34 standard deviations less than the mean value at the lumbar spine, indicating severe osteoporosis. He had no evidence of an acute infection that could be responsible for his symptoms. The patient was referred to us after an unsuccessful trial of conventional pain management that included narcotic analgesics and bracing. A transpedicular vertebral biopsy was performed that showed no evidence of abnormal cellularity, and the cultures remained negative. The patient agreed to undergo percutaneous vertebroplasty after a detailed review of the potential risks and benefits of the procedure. Approval from our institutional review board was obtained. The patient was placed prone on the angiography table and the skin of the back was prepared in a sterile fashion. The procedure was performed under local anesthesia and conscious sedation with use of a combination of fentanyl and midazolam. Prophylactic antibiotic therapy was administered intravenously (cefazolin 1 g). Bilateral transpedicular vertebroplasty was performed with use of approximately 5 mL of a mixture of polymethylmethacrylate (Osteobond; Zimmer, Warsaw, IN) and sterile barium powder injected within the vertebral body, with
DOI: 10.1097/01.RVI.0000141444.69357.86
no venous or soft tissue leak. The patient was observed in the recovery area for 3 hours before being discharged home. He reported an immediate improvement of his pain, which he judged as 60% decreased compared with his initial pain level. He described sustained improvement at the 1-day and 1-week follow-up phone evaluations. He also noted significant improvement in the performance of his daily activities without the help of narcotic analgesics or bracing. Back pain secondary to osteoporotic compression fractures represents a significant therapeutic challenge and causes a severe decrease in quality of life. Compression fractures place patients at risk for deep venous thrombosis and pneumonia and cause increased isolation, depression, and institutionalization. Deramond invented vertebroplasty in Amien, France, and it was first reported in 1987 (5), and we have performed this procedure since 1996. We perform vertebroplasty with use of a biplane angiography suite; alternatively, it can be safely performed with use of a single plane. The literature supports its use in malignant and benign disease (6). It is possible to achieve complete pain resolution within 1 hour of the procedure. The pain relief associated with vertebroplasty is probably related to the following: (i) increase in structural strength of the vertebral body and a decrease in microscopic motion of the fracture plane; and (ii) the heating effect of the bone cement potentially causing local neurolysis. The bone cement achieves a temperature of as high as 60°C during polymerization, which is comparable to the target temperature for radiofrequency ablation. The transpedicular approach into the vertebral body is very safe. Vertebroplasty has much to offer as a simple mechanical solution to a structural problem. Although it is typically used in older patient populations with osteoporosis or patients with malignant disease, it may now be applicable to patients with HIV, as advances in HIV treatment have lengthened these patients’ life expectancy. It is key to rule out infections with use of rapid molecular biologic tests so that early effective treatment can be offered. Although osteoporosis in HIV has not been clearly documented in the literature, it has been documented in patients with HIV after treatment with protease inhibitors (2– 4). The possible mechanism for osteoporosis may be related to lipodystrophy and redistribution syndromes (2,3). It may also be related to hepatic dysfunction secondary to underlying disease, infections, or medications. References 1. Wu SS, Lachmann E, Nagler W. Current medical, rehabilitation, and surgical management of vertebral compression fractures. J Womens Health (Larchmt) 2003; 12:17–26. 2. Laurence J. Accelerated bone mineral loss in HIV-positive patients. AIDS Reader 2000; 10:192–200. 3. Bonfani P, Gabbuti A, Carradori S, et al. Osteonecrosis in protease inhibitor-treated patients. Orthopedics 2001; 24:271–272. 4. Weiel JE, Lenhard JM. Bone mineral loss in HIV-positive patients receiving antiretroviral therapy. AIDS 2000; 14:2218 –2219. 5. Galibert P, Deramond H, Rosat P, Le Gars D. [Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty] Neurochirurgie 1987; 33:166 –168. 6. Murphy KJ, Deramond H. Percutaneous vertebroplasty in benign and malignant disease. Neuroimaging Clin N Am 2000; 10:535–545.
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