Spinal Cement Q&A

Do spinal fractures happen as a result of osteoporosis frequently?
Dr. Zoarski: Osteoporotic compression fractures are a common problem particularly in elderly patients and particularly in women.

Why do heart transplants or transplant patients have more risk?
Dr. Zoarski: There are metabolic complications that come with a lot of large transplant surgeries. Suppression, immunosuppression related to the surgery and preservation of transplanted organs that also affect the calcification of bones.

What are the effects of spinal fracture?
Dr. Zoarski: The most common complaint in patients who have a spinal fracture is fairly localized pain at the level of the fracture. There can be more serious complications such as compression of the spinal cord, it could lead to weakness in the legs or paralysis.

How were these people treated before?
Dr. Zoarski: Probably the most common treatment for a compression fracture would be to place the patient on bed rest and to treat them symptomatically with analgesics. Basically treating the pain not the fracture itself.

Why is that not acceptable anymore today?
Dr. Zoarski: The technique that we’re utilizing to treat fractures can be performed on an outpatient basis. It’s relatively easy to perform, it’s a safe procedure and it can get patients up and mobilized much quicker, avoid a prolonged period of bed rest and help stabilize a fracture. Prevent the fracture from progressing and worsening.

Could you describe this new treatment?
Dr. Zoarski: The procedure that we perform is done in an angiography suite where we do various types of procedures. The patient is positioned lying on their abdomen and using fluoroscopy in order to have a real time x-ray of the patient. We’re able to place a needle through the skin into the pedicle of the vertebral body, a portion of the ring that surrounds the spinal canal, and advance that needle into the collapsed vertebral body. When we have the needle in the satisfactory position we inject some contrast material that can be seen with the x-rays, into the vertebral body to be as certain as we can that we’re in the proper position. At that point we mix up an epoxy called methacrylate which comes as a two part kit of liquid and powder. Mix the solution and before it hardens which is only a matter of several minutes we inject that through the needle into the vertebral body to increase its strength, solidify the vertebral body and prevent further fractures from occurring.

It’s the consistency of toothpaste?
Dr. Zoarski: Yes, when we initially mix it it’s the consistency of toothpaste, it very rapidly hardens over a period of four or five minutes and becomes rock hard. We mix the methacrylate and very quickly deliver that with a syringe by injecting it through the needle that has already been positioned into the vertebral body.

You squeeze it in and it flows out?
Dr. Zoarski: It is very hard to inject, in fact you have red spots on your hand after injecting it. It takes quite a bit of force to inject the methacrylate paste into the vertebral body.

Where you put it is where it stays?
Dr. Zoarski: More or less, you do have quite a bit of control as it’s being injected because of the thick consistency of the methacrylate.

How long does it take to harden?
Dr. Zoarski: The hardening of the methacrylate occurs very quickly, in a period of only several minutes, about four or five minutes. At that point the needle is removed. Typically the procedure is performed on both sides of the vertebral body in order to fortify the entire vertebral body.

How does this procedure differ from the kind of procedure that would have been done before?
Dr. Zoarski: In the past, major surgery has been performed for stabilization of spinal fractures. This involves a large surgical procedure performed in the operating room and surgical removal of the fractured portions of the vertebral body. The surgical procedure like that requires a lengthy recovery period and also carries the risks of anesthesia and time in the operating room that our approach avoids. We’re meticulously careful about how we mix methacrylate mixture, about all the material that’s used, the equipment that’s used in the room in order to reduce the possibility of introducing an infection with the methacrylate injection.

It is the texture of bone or harder than bone or is it a plastic?
Dr. Zoarski: It’s an acrylic epoxy. Methacrylate is extremely hard material but it is brittle. It is somewhat brittle when it is not stabilized. However, when it is injected into a vertebral body and conforms to the vertebral body it seems to have enough compressive resilience that it does not fracture. We have not seen a patient develop a fracture of the methacrylate injection.

How long does it take before people are up and moving around after this procedure?
Dr. Zoarski: We typically observe patients for one day keeping them overnight in the hospital after performing this procedure. If their pain is significantly diminished on the following day as it usually is, they are discharged from the hospital, told to moderate their activity for several days but are allowed to return to the base line activities as they feel comfortable.

It’s a local anesthetic as opposed to general?
Dr. Zoarski: The procedure is performed under local anesthesia so there’s no need to undergo general anesthesia.

Can it be done on several occasions, if the bone collapses some more?
Dr. Zoarski: Certainly we can treat more than one vertebral body. It can be done at one session or if a patient experiences a fracture months or even years after we’ve treated one vertebral body we can certainly return and treat another effective level.

You can’t rebuild the bone, you can just fill the cavity that’s there?
Dr. Zoarski: That’s right, we can’t restore the height of a fractured vertebral body, however we can stabilize it and prevent further fractures from occurring. Frequently we’ll see one particular patient how they will have multiple episodes of pain associated with recurrent fractures of a single vertebral level and a solitary vertebral body over time can become what we call a vertebral plana, or simply a flat disc of bone from multiple compression fractures. We try to prevent that from occurring by stabilizing it when the fracture first occurs.

Would your first line of treatment be some kind of fixation device?
Dr. Zoarski: Not for osteoporosis certainly. Most patients still who have osteoporotic compression fractures are treated with pain medication and bed rest.

So this would be the next line of treatment?
Dr. Zoarski: Yes it would be.

Is this an expensive treatment?
Dr. Zoarski: No, compared to a surgical procedure the cost of a percutaneous treatment of a fractured vertebral body is significantly less. Even compared to the cost of bed rest and analgesics there’s a cost to the patient in terms of days lost from work. Compared to a patient who has surgery it’s probably a twentieth of the cost but certainly doing an overnight procedure as opposed to going to the operating room involving anesthesia and a prolonged hospital stay this procedure is much, much less costly.

Can this technique be used on other types of cases?
Dr. Zoarski: This is also a technique in some patients who have malignancies of the spine. That can be either a primary bone malignancy or metastatic disease from a primary tumor elsewhere in the body.

Source: Ivanhoe

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