vertebral compression fx question

[painrelief]

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just want to get some of your opinions on what is a relative versus absolute contraindication to vertebral cement augmentation?

I have a patient with about 8mm retropulsion of a T12 fracture (50% height loss with edema on STIR) without contact of cord or myelopathy. back pain has been refractory to bracing, PT, meds, etc. would you consider balloon vertebroplasty?

 

[clubdeac]

just want to get some of your opinions on what is a relative versus absolute contraindication to vertebral cement augmentation?

I have a patient with about 8mm retropulsion of a T12 fracture (50% height loss with edema on STIR) without contact of cord or myelopathy. back pain has been refractory to bracing, PT, meds, etc. would you consider balloon vertebroplasty?

How can there be 8mm retropulsion w/o contact of the cord? How big is this guys canal???

 

[lobelsteve]

8mm is not small, but if the canal is huge, then it might not be moderately stenosed. Without any more data, I'd punt to surgery. If that chip moves back and pins the conus, they can open and decompress.
It might be an unlikely outcome, but not one which I'd like to deal with.

 

[Tenesma]

i don't care about % of height loss... i care about % of canal compromise... typically when >50% of canal is compromised, then kypho is definitely bad, and v-plasty is very risky.... i say that because i have heard others say it... so far, i haven't actually see any body locally get in trouble for doing a v-plasty on >50% canal compromise... but i bet it will happen sooner than later

 

[painrelief]

fortunately, he has a fairly capacious canal. I am more concerned about pushing the already retropulsed bone further if I perform kypho under fluoro guidance.

With mild retropulsion (1 or 2 mm) and no significant canal stenosis, I have used a balloon to create a cavity and fill the cement without issues.... not sure if there is much evidence behind that pratice but it has worked for me.

i was considering a referral to intervention radiology since they can do it under CT guidance. I am curious if having CT during the procedure can improve safety in high risk cases such as this patient. any thoughts??

 

[Jcm800]

4 years ago i would said go do it. Now i would say, hold off. I have done many a retropulsed fragement, but that ones pretty big (not seeing the pictures) but more importantly its high up enough to be an issue...

i ahve gone the other direction in the last year... i have gotten more cautious, and dont do some of the fractures i previously would have and have done. if it was L4, maybe...

 

[lobelsteve]

fortunately, he has a fairly capacious canal. I am more concerned about pushing the already retropulsed bone further if I perform kypho under fluoro guidance.

With mild retropulsion (1 or 2 mm) and no significant canal stenosis, I have used a balloon to create a cavity and fill the cement without issues.... not sure if there is much evidence behind that pratice but it has worked for me.

i was considering a referral to intervention radiology since they can do it under CT guidance. I am curious if having CT during the procedure can improve safety in high risk cases such as this patient. any thoughts??

The chip will or will not move. Based on training, the chip is very unlikely to move. But if it does, you or the Rad guy are hosed. Pass it of to the surgeon- if the chip moves, he takes it out during the kyphoplasty. Yes, that means cutting open and laminoplasty or laminectomy.

 

[hyperalgesia]

The chip will or will not move. Based on training, the chip is very unlikely to move. But if it does, you or the Rad guy are hosed. Pass it of to the surgeon- if the chip moves, he takes it out during the kyphoplasty. Yes, that means cutting open and laminoplasty or laminectomy.

Agree. Rads might be able to visualize additional retropulsion better than you with a CT but the patient is just as screwed. I'd send it to surg. The world has enough heroes.

 

[painrelief]

Thanks for the insight folks... perhaps I should just do facet injections, and hope for the same pain relief outcome 🙂

 

[clubdeac]

Thanks for the insight folks... perhaps I should just do facet injections, and hope for the same pain relief outcome 🙂

It worked in those NEJM articles 😉