Percutaneous vertebroplasty for benign and malignant vertebral disorders I. Introduction Percutaneous vertebroplasty was first introduced in France in 1987 by interventional radiologist HerveDeramond and his collaborative group. It is a simple, minimally invasive surgical procedure that offers an effective treatment for patients who suffer from vertebral fractures and pain due to osteoporosis or tumors. This interventional technique involves imaging-mediated injection of bone cement into the fractured or destroyed vertebral body, the most commonly used bone cement being polymethylmethacrylate (PMMA). It has the advantage of achieving both pain relief and rebuilding the biomechanical strength of the bone. In the United States percutaneous vertebroplasty is the basic treatment for pain due to osteoporotic compression fractures. In addition to benign osteoporotic fractures, the main indications for percutaneous vertebroplasty include hematologic malignancies such as multiple myeloma and lymphoma, metastatic malignancies, and symptomatic benign spinal tumors (especially hemangiomas). The European experience with this procedure is more oriented towards the treatment of neoplastic diseases rather than osteoporosis. This technique is emerging in China and is gradually being promoted and gradually recognized by patients and physicians. Second, the preoperative evaluation and preparation of patients 1, the identification of the source of pain should be closely focused on and identified the source of pain. Patients targeted by percutaneous vertebroplasty often suffer from multiple diseases, such as osteoporosis-related vertebral fractures, which may be accompanied by herniated or bulging discs, slipped vertebrae, severe osteophytes and other co-morbidities, and vertebral tumors often combined with metastatic lesions of other organs and peri-vertebral masses. Only by strictly identifying the source of pain can we fully protect the efficacy and save patients from unnecessary surgical risks. 2. The most important imaging data for preoperative examination is derived from frontal, lateral and oblique radiographs to evaluate the degree of osteoporosis, bone compression and destruction, osteophytes, spinal canal, intervertebral space and intervertebral foramen. Plain radiographs also have important reference value in determining the first target pedicle. MRI is an important preoperative test to help detect evidence of epidural, intervertebral foramen or spinal cord compression and occupancy due to tumor, disc and fracture fragment protrusion, and the structure of surrounding soft tissues and tumor infiltration into surrounding tissues are also important to assess. CT is the best choice to observe the bony structures of the vertebral body and is important for access selection and design, and it can also clarify the vertebral body CT is the best choice to observe the bony structures of the vertebral body and is important for access selection and design. Third, intraoperative analgesia and sedation can be completed under local anesthesia for most patients, and a combination of sedation, analgesic anesthesia and local anesthesia is used for some patients. Patients remain awake during the operation, and the operator communicates with the patient at any time to understand the patient’s condition. Successful local anesthesia can greatly prolong the patient’s tolerance time and reduce the use of intravenous anesthetics and intraoperative comorbidities. Local anesthesia with 6-10 ml of 2% lidocaine is used during the surgical operation to provide extensive periosteal infiltration at the target vertebral arch, and this method is more reliable and safer than intravenous sedation for achieving nociceptive anesthesia. In a small number of patients, in addition to local anesthesia, sedation and analgesic anesthesia must be used simultaneously because of tension, anxiety, or pain. Imipramine (0.1 mg/kg) has a very good sedative effect; while the combination of dulcolax (0.5 mg/kg) and haloperidol (0.01 mg/kg) has a very good analgesic and sedative effect, but care needs to be taken to prevent the appearance of extrapyramidal symptoms; the combination of fentanyl (0.01 mg/kg) and haloperidol (0.01 mg/kg) also has an analgesic and sedative effect, compared with The combination of fentanyl (0.01 mg/kg) and haloperidol (0.01 mg/kg) also had analgesic and sedative effects, which were better than the previous combination. Most of the patients are weak and in prone position, and the analgesic and sedative drugs generally have the effect of depressing respiration, so respiratory function and oxygen saturation should be closely observed intraoperatively. Those with increased intraoperative blood pressure can be lowered with drugs such as nimodipine, nicardipine or pressure ninhydrin. Intraoperative monomer volatilization can cause discomfort such as nausea and dizziness in patients, and 5hydroxytryptamine blockers, such as ondansetron (4 mg), can be used to relieve symptoms. IV. Imaging guidance and needle access techniques 1. Imaging equipment Percutaneous vertebroplasty is safe only if it is performed under high-quality fluoroscopic X-ray guidance. Without clear visualization of the puncture needle path and cement distribution, the operator cannot control the operation, which can easily lead to complications. Most serious complications are related to the poor quality of fluoroscopic images. 2, arch root puncture positioning methods (1) single arch approach If the arch of the vertebral body is thicker and travels from the posterior to the medial side, there is more room for the needle route to tilt toward the midline of the vertebral body, so it is easy to complete the unilateral arch root approach, which is more common in the lumbar spine. Referring to the angle and thickness of the vertebral arch, making the puncture needle mildly inclined from the outside to the inside can more easily reach the vertebral body midline and achieve the unilateral concha root approach, but it should be emphasized that the tip of the puncture needle should never cross the medial side of the concha root under fluoroscopy before entering the vertebral body through the concha root under lateral fluoroscopy, with the arrow indicating the medial edge of the concha root. (2) double arch root approach but not all vertebral bodies can complete the single arch root approach, and some vertebral bodies, the arch root is relatively thin, the angle between the vertical line and the vertebral body median is small or even parallel, the margin of the needle route to the vertebral body midline inclination is relatively small, it is not easy to complete the unilateral arch root approach. 3, vertebral tissue biopsy When the puncture needle enters the vertebral body through the vertebral arch, the puncture needle core is removed. After removing the core of the biopsy needle, enter the vertebral body through the puncture needle and gently tap the biopsy needle with a bone hammer. When the biopsy needle penetrates deeper into the vertebral body, bony tissue or tumor tissue will enter the biopsy needle without the core. After the biopsy needle crosses the distance of more than 1 cm of the intended biopsy area, the biopsy needle is suctioned with a syringe to form a compound pressure, while the biopsy needle is gently rotated so that the tissue can stay inside the biopsy needle. V. Bone cement configuration and injection techniques 1. Modulation of bone cement modulation method: Most existing bone cement powder contains a developer equivalent to 10% barium, with a specific gravity approximating 1. (1) Roughly weigh 13-14 ml of powder (equivalent to 13-14 g) with a syringe during surgery and pour it into a stainless steel or plastic bowl; (2) then add 6 g of barium and mix it thoroughly so that the barium content is equivalent to Another alternative is to add 8 g of tantalum or tungsten powder; (3) add 10 ml of liquid monomer to the bowl; (4) stir the mixture with a spoon until the powder is completely dissolved, and the bone cement should have a “shiny” character when ready for injection; the bone cement-barium mixture is loaded from the rear into a 20 ml syringe; (5) add 6 g of barium to the bowl. The bone cement-barium mixture is loaded from the rear into a 20 ml syringe; it is then transferred from the rear into ten 1 ml syringes; the bone cement is ready for injection when it appears as a melted ice cream-like substance and can be dripped slowly from the head of the 1 ml syringe. The working time of the bone cement thus prepared is about 8 minutes. The viscosity of the mixture can be controlled by adjusting the content of the powder component, and by varying the viscosity, the bone cement can be adapted to different lesions to ensure the safety of the procedure. For osteogenic lesions requiring low viscosity bone cement, the powder content can be lowered to 11-13g; for severe infiltrative vertebral hemangioma or malignant tumor of the vertebral body with severe destruction, the powder content can be raised to 15-16g in order to increase the viscosity of the bone cement. The more severe the bone destruction is, the more viscous bone cement is needed, as this will reduce the incidence of unexpected leakage phenomenon. The degree of cortical destruction determines the viscosity of the bone cement that can be safely injected. The posterior margin integrity of the vertebral body is the most critical factor in preventing posterior leakage of bone cement and should be monitored continuously throughout the injection procedure. If the bone cement spreads into the posterior 1/4 of the vertebral body, the risk of cement leakage into the spinal canal is increased. If fluoroscopic monitoring reveals bone cement flowing from the periventricular vein, or in the direction of the posterior border or boundary of the vertebral body, the injection should be stopped for 30 seconds to 1 minute, and waiting for the initial solidification and thrombosis of the bone cement in the vein, and changing the direction of the puncture needle bevel orientation will allow the bone cement to change the direction of dispersion and flow in a safe direction. During the entry of the puncture needle into the vertebral body, the canal core needle can be removed intermittently to check for blood reflux, which is a simple method but should only be used as a reference. If the puncture needle is already connected to a large draining vein, a pathway to the vein is created within the vertebral body bone, and continuing to puncture forward rather than retracting the puncture needle gives hope that the needle tip will actually avoid the vein. Some authors have proposed the use of venography after the puncture needle is in place to evaluate the vertebral body-associated venous system and to pre-warn against dangerous venous communication before injecting bone cement. However, this method has been debated, with some considering it indispensable, others only in the treatment of vertebral hemangiomas, and others that this operation is not of much value. Cases in both Beijing Tiantan Hospital and JohnsHopkins Hospital were performed without the use of venography to ensure the safe completion of the procedure. In some cases, intravenous contrast has resulted in retention of contrast in the sinusoids of the vertebral body or in the tumor cavity, interfering with fluoroscopic monitoring of the vertebroplasty; intravenous contrast may have the potential for contrast VI. Percutaneous vertebroplasty for osteoporotic vertebral compression fractures exceeds 60% of menopausal women with abnormal BMD values, and it is estimated that nearly 40% of these women will experience osteoporosis during their lifetime. associated fractures. Vertebral compression fractures are the most common type of fracture that occurs in the osteoporotic population, and only 25% of these fractures have a clear history of trauma. Vertebral fractures can cause dysfunctional pain that lasts for months, which is enough to disable the patient and cause underlying disease. Clearly, menopausal women are at high risk for osteoporosis, and other clear risk factors include age, smoking, and premature menopause. High-risk groups also include patients on long-term corticosteroid therapy, patients with renal failure, or patients who are chronically inactive. The most common sites are the vertebrae of the thoracolumbar region, especially the T12 and L1 vertebrae, about 45-50%, and the other sites are T10 to T11, L2 to L4, etc. In Europe and the United States, scholars believe that percutaneous vertebroplasty should be performed once a symptomatic vertebral compression fracture occurs because it prevents further compression of the vertebral body and reduces the problems that may occur with conservative treatment. Whereas we believe that the timing of percutaneous vertebroplasty should be judged on a patient-by-patient basis, we recommend that most patients with compression fractures still attempt 2 weeks of conservative treatment along with diagnosis and evaluation, and pharmacologic treatment with narcotic pain medications and calcium supplements. The course of this two-week course should be closely observed: when pain recovery is rapid, pain medications can be gradually reduced, and the patient’s general condition is stable, we recommend that the patient continue conservative treatment; if pain relief is not significant or even worsens during conservative treatment, and the dose of analgesic medications increases, then percutaneous vertebroplasty treatment should be performed; some patients are rapidly bedridden resulting in depression or irritability, subjective inability to adhere to bed rest, or adverse drug reactions, are also indications for early surgical treatment; it is not advocated that the observation period is too long, otherwise complications such as venous thrombosis and pneumonia will occur and the opportunity for treatment will be lost; some scholars believe that the duration of the disease is more than six months and the treatment is not effective, and many authors have doubts about the treatment of vertebral compression fractures of advanced age, severity (compression degree more than 2/3), and long history (more than six months), and We believe that these are not absolute contraindications and that most patients can benefit from treatment; prophylactic percutaneous vertebroplasty for vertebrae at high risk of fracture has been proposed, but is widely debated. Absolute contraindications to surgery are: patients with a combination of infection in the surgical or adjacent area; patients with coagulation disorders; and fractures resulting in nerve root or spinal cord compression with significant neurological symptoms requiring surgical decompression. Most of the literature reports that the pain relief rate of percutaneous vertebroplasty for osteoporotic vertebral compression fractures is around 90%, and the rate of complications ranges from 0% to 10%, mostly around 1%. Of the 80 patients reported by Deramond et al, pain relief was obtained immediately after surgery in 90% of cases, and only one patient was treated with local closure for intercostal nerve pain. Heini et al reported 45 cases treated with clinical relief in all cases, and the results remained stable at 1-year follow-up, and leakage of bone cement occurred in 20% of cases, but did not cause any complications. Pain relief was obtained within 48 hours in 95% of the 70 treated cases reported by Bai et al. At 18 months follow-up, pain relief was complete in 63% of cases and significant in 32% of cases. 90 % of the 47 procedures in 29 patients by Cunin et al. resulted in postoperative pain relief and 2 rib fractures. cortet studied 16 patients with osteoporotic Cortet conducted an open prospective study of 16 patients with osteoporotic compression fractures causing severe and persistent pain who underwent vertebroplasty in 20 vertebrae and were clinically evaluated on postoperative days 3, 30, 90 and 180. Statistically significant pain relief was observed on day 3, and pain relief remained stable at the subsequent 6-month evaluation. Similarly there was a significant improvement in the patients’ general health status scores (Nottingham HealthProfile scale) over time, particularly in the areas of physical motor ability, emotional response, social integration and energy. No side effects were observed, and no vertebral fractures were detected at the 6-month follow-up. 372 patients with osteoporotic vertebral compression fractures were treated at JohnsHopkins Hospital and Titan Hospital, with 162 patients (43.5%) in complete symptomatic remission, 173 patients (46.5%) in significant remission, 23 patients (6.2%) in partial remission, and 14 patients % in inefficiency ( 3.7%). Seven, percutaneous vertebroplasty for vertebral hemangioma bone hemangioma occurs between 10 and 40 years of age, with a similar incidence in men and women, and is more likely to occur in the spine. vertebral hemangioma is also known as benign vascular endothelial cell tumor, and vertebral hemangioma is one of the more common types of benign tumors of bone appendage tissue, which is a misshapen tumor. Based on a review of serial autopsies and spinal plain films, the incidence of vertebral hemangiomas in the population is 10% to 12%, and most hemangiomas are asymptomatic. They are more common in the lower thoracic and upper lumbar spine, followed by the cervical and sacral spine, among others. According to the clinical and imaging characteristics, vertebral hemangioma can be divided into four types. type I: asymptomatic vertebral hemangioma without imaging malignant manifestations; type II: no imaging malignant manifestations but manifestation of severe back pain; type III: vertebral hemangioma without obvious symptoms but with obvious imaging malignant manifestations; type IV: vertebral hemangioma with obvious symptoms and imaging malignant manifestations, type IV It can be divided into two clinical subtypes, one with acute spinal or cauda equina compression symptoms (IVa) and the other with progressive pain, myelopathy, or cauda equina syndrome (IVb). type I patients do not require treatment, and type II patients require vertebroplasty with cement injection. type III patients can be treated with vertebroplasty or withhold treatment in favor of close clinical observation and imaging follow-up. IVa Patients require a combination of vertebroplasty and surgery, and IVb can be treated with alcohol sclerosis followed by vertebroplasty. Patients with IVa are treated with a three-step approach: (1) transarterial embolization (earlier used but now abandoned); (2) percutaneous vertebroplasty with cement injection to strengthen the vertebral body one day later and n-butyl acrylate injection into the pedicle to reduce intraoperative bleeding; and (3) alternate day surgical treatment, including laminectomy for decompression and epidural hemangioma removal. With this approach, intraoperative bleeding during laminectomy is minimal, removal of the epidural mass is easy, and the above approach also ensures stability of the vertebral body to prevent its collapse. Cohen et al. treated 31 cases (43 segments) of vertebral hemangioma, and 76% of patients showed significant improvement in symptoms and reduction or discontinuation of analgesic medication, which was slightly less effective than in concurrently treated vertebral compression fractures (87% of cases showed significant improvement). Gangi et al. reported that percutaneous vertebroplasty for vertebral hemangioma resulted in significant symptomatic improvement in 78% of patients, compared with 83% of vertebral Gangi et al. also used CT imaging to guide the treatment of 10 cases of symptomatic vertebral hemangiomas in earlier years, so all cases had significant relief without complications. JohnsHopkins Hospital 2000 reported 5 cases of symptomatic vertebral hemangiomas, and 4 cases had significant relief. In contrast, the treatment of one case reported by Barr et al. during the same period had no effect. To date, JohnsHopkins Hospital and Tiantan Hospital have treated a total of 25 cases of symptomatic vertebral hemangioma using percutaneous vertebroplasty, of which 12 cases had complete remission, 8 cases had significant remission, 3 cases were mildly effective, and 2 cases were ineffective without any complications. The preoperative 6-point pain score was 2.67±0.41 and the self-care ability score was 2.83±0.33 in a group of cases at Tiantan Hospital; the postoperative pain score decreased to 0.33±0.47 and the motor function score was 1.33±0.41, with significant differences between preoperative and postoperative by paired t-test (p<0.01). In conclusion, percutaneous vertebroplasty is a very effective treatment for vertebral hemangioma, but in some special cases, it needs to be combined with other treatment methods (radiotherapy, surgery, anhydrous alcohol injection) to achieve more satisfactory results. Percutaneous vertebroplasty for vertebral malignancies vertebral malignancies can be divided into several categories such as metastatic tumors, hematologic malignancies, spinal sarcomas and primary malignancies. Metastatic malignancies are the most common type of spinal malignancies, followed by malignancies of the hematologic system. The vertebral body is the best site for metastases, with approximately 30% of patients with malignancies presenting with symptomatic metastatic lesions to the vertebral body, 70% of which undergo osteolytic destruction resulting in vertebral fracture and collapse leading to severe pain. Other tumors that can metastasize to the vertebral body include liver cancer, stomach cancer, skeletal malignancies, and pancreatic cancer. Metastases are usually multiple, but it is not uncommon for them to occur in a single vertebral body in the early stage, and the most common sites are thoracic, lumbar, cervical and sacral vertebrae in order, and jumping is common. When multiple vertebrae are invaded consecutively, the discs are usually not invaded. Spinal malignancies of the hematologic system may originate from other parts of the body or may be primary to the spine. The spine is the best site for plasmacytoma, which can also occur in the ribs, pelvis, and skull. Malignant lymphomas of the spine include reticulocytic sarcoma, lymphosarcoma, Hodgkin's disease, and giant follicular lymphoma. Reticulocytic sarcoma most often occurs between the ages of 10 and 60, lymphosarcoma most often occurs in patients over the age of 40, and Hodgkin's disease most often occurs between the ages of 20 and 40 and can lead to severe vertebral bone destruction. Osteosarcoma is very malignant and is rare in the spine alone, but metastases to the spine are common. Congenital bone tumors include chordoma and teratoma, and the spine is not a favored site. Because of the high level of advances in tumor therapeutics, radiotherapy, chemotherapy, and surgical techniques, the survival time of patients is significantly longer, while the incidence of vertebral compression fractures in malignant vertebral tumors has been found to be significantly higher than in the past, and patients' demands for quality of life have increased. This places a demand on current techniques to apply minimally invasive techniques and improve patient symptoms. Indications for percutaneous vertebroplasty: cases with severe pain in which conservative treatment (including analgesics, bed rest, external fixation support, etc.) is ineffective; those who are not candidates for surgery because of frailty, comorbidities, or multi-segmental vertebral lesions; in asymptomatic patients, prophylactic treatment of osteolytic lesions, a high-risk factor for vertebral body collapse, is feasible.