history is an 86 year old female with a history of osteoporosis and prior vertebral compression fractures presenting to the emergency department with complaints of back pain after a recent fall.
Now she has point tenderness that was noted at the mid thoracic level, no discrete neurologic deficits like radiculopathy bladder or bowel symptoms or numbness was noted but she did have trouble ambulating without assistance which was not at her baseline and that was attributed mostly to her pain.
She had no history of malignancy, no prior surgeries and no evidence of any systemic or active infection. Given that she was an ED, they went straight to the CT. And here on the spatial view of the thoracic spine you can see multilevel compression fractures,
the one that's the most prominent is at the T6 level but given her underlying osteopenia and osteoporosis you really can't tell the acuity of these fractures, there were no real priors for comparison purposes. She was admitted to the general medicine inpatient service for pain control.
After 3 days of continued pain despite medical management as well as the inability to ambulate independently due to her pain intolerance our service was consulted for a possible vertebroplasty. We went up to see her , examined her,
found that she still had pain at that mid thoracic level and we recommended an MRI. Here we have the spacial view the thoracic spine which kind of correlates with the physical exam and her presenting symptoms. This is a star sequence which has a short tell in version recovery sequence that demonstrate the myeloma.
Not only have that T6 level, but one right below it at the T7 level. We kinda of see.>> I'm trying to put it that way. Is it this way? >> Yeah great.
Here and here. So given her presenting symptoms and what we see on imaging we proceeded with vertebroplasty. Here on the first image, you can kind of see on an oblique view, the outline of the pedicle which we go down the barrel making
sure not to violate the medeal wall. Once you are able to contact the posterior wall, the vertebral body, you can go on the lateral view, and go in. And here you kind of see in the thoracic level,
we went up both levels with 13 gauge needles. And we proceeded with cement insertion to the vertebral body. So at hospital admission her visual analog pain scale was 10 out of 10. 24 hours after vertebroplasty was reported that she had significant improvement in her symptoms,
rating at 2 out of 10. In addition, she was slowly able to ambulate without assistance, kind of going back to her base line level. 48 hours after the procedure,she
was discharged back to her skilled nursing facility. So, the scope of my presentation today is just gonna basically horn in on the things we do before you actually take a patient to vertebroplasty. In an inpatient setting,
really easy. The patient has being worked up, they're having persistent pain, they go to you. Pretty cut and dry but if you're having this patient referred to you, at an outpatient clinic,
being referred by a PA and PE or some urgent care clinic without the appropriate work up. It's really important to kinda see all the variables that are involved in the management of these patients before you take them to vertebroplasty. So that you can educate the patient as well as be a valuable resource to your referring providers.
So I'll talk a little bit about compression fractures.
with L1 with Kivaplast you see the Kivaplast down here. This implant, we have seen there also, right so this fracture was a bit older. So was not able to elevate the fracture,
but you see there is no leakage and I was able to elevate those fractures. And also I showed these at this German spine meeting, everybody was a big outcry, you have to correct the kyphotic angle. You have to cut and do a substraction/g you have to fuse the whole
patient, and then say come on this six to seven year old patient, might have been myeloma all over the bodies. And this is what we've given up with chemo and so on. You're not going to operate and the patient was pain free, and didn't die she went through the operation.
This is a slide from John Carlo/g [UNKNOWN] where he uses this implant
And this is the case. This is a preliminary experience,
so far we have treated only 5 patient and 18 patient were treated in Germany, all over the world. So this is a really new procedure, we are looking forward to enroll patient and to
study this patient. This is a patient with a painful kidney cancer mets in a T-10/g. And the patient was study with MRI and CT. What is important that, to treat this patient we need the collaboration of radiotherapists, physical doctor, or whatever because all the
therapy is pre-planned before the treatment. So we really know the dose we need, we really know the area we can irrigate, and compared to other ablation technique, this is really safe because we can avoid really all that they mention to the
tissues around the lesion we can really reach those we need to kill the tumor. So that's the patients and [COUGH] it's quite. It's quite a really simple procedure, we use the metronic ostin
to do sir, so the canal is bigger than standard veterbroplasty. It's like the first canular was used for balloon calfoplasty/g is eight gauge, and this is the properthery/g canular of the ice where you put the probe inside, so you achieve your approach,
transpediqual approach with standard vertebroplasty needle, then you put the [INAUDIBLE] guide wire then over the guide wire you use the ostin/g to do some by metronic coupled with the proprietary canular that's the final result, that's
the canular that you have. Through this canular, the nafture/g you need to have this device, this device with probe for radiotherapy so the probe goes inside the metastasis everything is controlled by this monitor and usually it takes three minutes of radiotherapy to reach very high curative zones,
those inside the lesion. We also evaluate all around the patient, there is no emission just because the radio therapy is inside the patients. Then after the probe is removed,
we use the system cannula of medtronic/g to inject bone cement and usually we try to fulfill the lesion with bone cement. That's the final results, we perform a CT after the procedure, you see that the lesion is completely full
filled of bone cement. The patient of same procedure can be discharged by the hospital without any pain and all the procedure is made percutaneous so you don't need any incision of the skin.
This a 75 year old gentleman, who had an invasive small cell liposarcoma.
He'd been operated on three times previously in an effort to get rid of this large retroperitoneal tumor. But as is often the case of retroperitoneal sarcomas, you really can't get them all out. So he had radiation and chemo
and the whole thing, but you can see this lesion is not only invaded the sacrum and iliac bone. You can see it's starting to invade the spine. So it's very extensive destruction and had unremitting radiating pain because he had lumbar nerves that were also encompassed by
this lesion. This is a cone beam CT image so what we did in this case is we put multiple probes. You can see the ice ball, here around the tip of the probes. So we destroyed as much of the deep portion of the tumor as we could.
And we reinforced the spine that was being invaded with some cement. So I told him that afterwards, I hope that his pain would improve, but he'll be unable to walk since I had to destroy three lumbar nerves completely. And he actually was able to walk afterwards with a walker,
but his pain was completely gone and that's really what he wanted. So these patients are very motivated as well and they're all quite tolerant of things that most of us would view us devastating side effects, and again
this is what this gentleman looked like with this multiple probes