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Letters to the Editor recurrence of reflex sympathetic dystrophy in the same or another limb? Pain 1996;64:463–6. 4 Rocco AG. Sympathetically maintained pain may be rekindled by surgery under general anesthesia (letter). Anesthesiology 1993;79:865. 5 Viel EJ, Pelissier J, Eledjam JJ. Sympathetically maintained pain after surgery may be prevented by regional anesthesia (letter). Anesthesiology 1994;81:265–6. 6 Goldner JL. Causes and prevention of reflex sympathetic dystrophy (letter). J Hand Surg 1980;3:295–6. 7 Marx C, Wiedersheim P, Michel BA, Stucki G. Preventing recurrence of reflex sympathetic dystrophy in patients requiring an operative intervention at the site of dystrophy after surgery. Clin Rheumatol 2001;20:114–8.
The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29(6):602–8. Erratum in: Am J Ind Med 1996 Sep;30(3):372. 10 de Mos M, Sturkenboom MCJM, Huygen FJPM. Current understanding on the complex regional pain syndrome. Pain Pract 2009;9(2):86–99. 11 de Mos M, Huygen FJPM, van der Hoeven-Borgman M, et al. Outcome of the complex regional pain syndrome. Clin J Pain 2009;25:590–7. 12 Vas L, Pai R, Radhakrishnan M. Ultrasound appearance of forearm muscles in eighteen patients with complex regional pain syndrome 1 of the upper extremity. Pain Pract 2013;1:76–88. 13 Agur AMR, Dalley AF, eds. Grant’s Atlas of Anatomy, 11th edition. Philadelphia: Lippincott Williams & Wilkins; 2009:541.
8 Vas L, Pai R. Successful reversal of complex regional pain syndrome type 1 of both upper extremities in five patients. Pain Med 2012;13(9):1253–6.
14 Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;6:83–90.
9 Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected].
15 Simons DG. New views of myofascial trigger points: Etiology and diagnosis. Arch Phys Med Rehabil 2008;89:157–9.
Penetration Approach for Repeat Vertebroplasty Through the Previously Impacted Bone Cement Dear Editor, Vertebroplasty (VP) and kyphoplasty (KP) are effective treatments for painful vertebral compression fractures (VCFs) [1,2]. Although not common, subsequent refracture in the previously augmented vertebra causes persistent or recurrent pain [3]. Some reports have shown that repeat VP can control pain caused by refractures [3–5]. However, repeat VP is challenging because the previously impacted bone cement blocks the fluoroscopic views and access of procedure needles. A 57-year-old woman presented with severe pain (visual analog scale [VAS] 8/10) in her lower back and both thighs, which left her unable to sit or walk. She had a history of rectal cancer that had metastasized to the liver and lungs. Six months previously, metastasis to the fourth lumbar vertebra was detected and KP was performed (Figure 1). After the procedure, her pain reduced from VAS 8 to 2, but it recurred a week before her visit to our clinic. Magnetic resonance imaging (MRI) revealed further metastatic progression in the L4 vertebral body, and bone cement was located in front of the left pedicle (Figure 2).
After the failure of conservative treatments, we undertook repeat VP with a unilateral intrapedicular approach through the right pedicle. The patient lied prone on the procedure table. Under fluoroscopy, we aligned the endplates of the L4 vertebral body. Because the previous bone cement was blocking the fluoroscopic views, we set the target point by comparing the relative locations of the pedicles in the adjacent vertebrae. After local anesthesia with 1% lidocaine, we made a small skin incision, and inserted a 13-gauge bone access needle through the right pedicle of L4. After checking the anteroposterior and lateral fluoroscopic images, the needle was advanced into the vertebral body. We injected 4 mL of polymethylmethacrylate (PMMA), which fully filled the L4 vertebral body in the lateral view, but this failed to fill into the left side of vertebral body. After deliberation, we chose to insert another needle through the left pedicle to penetrate the previous bone cement. Under fluoroscopic guidance, we inserted the needle, using the same method as with the right side, until 1063
Hur et al.
Figure 1 A T2-weighted MRI before (A) and after (B) kyphoplasty (KP) in the L4. The spinal metastasis invaded mainly the left side of L4. KP was performed by bilateral intrapedicular approach injecting 1 and 1.5 mL of PMMA via the left and right needles, respectively. it touched the bone cement. Then, we meticulously hammered the needle to penetrate the cement. Upon confirming proper placement of the needle, we successfully injected 3 mL of PMMA until it leaked into the upper intervertebral space (Figure 3). During the procedure, the patient’s vital signs were stable and no adverse events occurred. The day after the procedure, her pain decreased to VAS 3 and she was able to ambulate without assistance. One month later, the patient was symptomfree and there was no fragmentation or migration of bone cements (Figure 4).
The optimal volume of bone cement to be injected into a fractured vertebra remains controversial. Some practitioners prefer to inject small volumes to prevent complications such as extravasation of bone cement and adjacent VCFs [6,7], but others prefer to inject a sufficient volume of bone cement to improve therapeutic effects and to prevent refracture of the treated vertebra [5,8]. Having encountered many cases of refracture of vertebrae previously with small volume of bone cement, we prefer to treat fractured vertebrae using as much cement as possible to the limit of cement leakage.
Figure 2 T1-weighted sagittal (A) and axial (B) MR images about 6 months after KP. The metastasis progressed further, invading more into the right side of vertebral body, the left pedicle and epidural space. The height of vertebral body also decreased. The left-side PMMA was blocking the pathway of a bone access needle. 1064
Letters to the Editor Repeat vertebral augmentation is challenging. Impacted PMMA not only obscures fluoroscopy views but also blocks conventional needle pathways. In addition, the risk of cement leakage can be greater because previously impacted bone cement occupies the intravertebral space. Several publications have described the effectiveness and methods of repeat vertebral augmentation [3–5,9,10]. Previously injected cement has been circumvented by using the intact contralateral pedicle or an extrapedicular approach. However, in our experience, bone injections using unipedicular approaches often do not allow enough PMMA to be injected, and extrapedicular approach can fail to bypass the previous injectate.
Figure 3 An antero-posterior fluoroscopic image after completion of bone cement filling. The newly injected PMMA through the right-side pedicle failed to fill the entire pathologic lesion. Then, another bone access needle was inserted through the left pedicle and penetrated the previous injectate. 3 mL of PMMA was injected enough until it leaked into the upper intervertebral space.
Frey [10] described inserting the needle above the previous injectate, but the new PMMA migrated into the intervertebral disc. He explained this caused little concern for any problems because the upper vertebra had already been treated. However, cement leakage into the intervertebral disc space is associated with increased risk of adjacent vertebral fractures [11,12]. Therefore, it is better to avoid needle insertion above or below the previous PMMA in order to prevent cement leakage into the intervertebral space. Using a penetration approach overcomes these limitations. Meticulous needle insertion and cement filling under real-time fluoroscopy made this repeat VP uneventful. In particular, the previous injectate did not migrate or fragment. without any migration or fragmentation of previous
Figure 4 Plain postero-anterior images after the initial KP (A and B) and one month after repeat VP (C and D). The filled nearly entire vertebral body without migration or fragmentation. 1065
Hur et al. injectates. The penetration approach can be an option for repeat VP, especially when the previous injectate blocks into the refractured vertebra. WONSEOK HUR, MD,* JAE JIN LEE, MD,† YOUNG JU WON, MD, PhD,* HYE YOON PARK, MD,* JUNG YOUNG YOO, MD,* MI KYOUNG LEE, MD, PhD,* and SANG SIK CHOI, MD, PhD* *Department of Anesthesiology and Pain Medicine Korea University Guro Hospital Seoul; † Department of Anesthesiology and Pain Medicine Korea University Ansan Hospital Seoul, Republic of Korea References 1 Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976) 2000;25:923– 8. 2 Jo JY, Suh JH, Shin HY, et al. Percutaneous pediculoplasty and balloon kyphoplasty in a vertebral metastatic cancer patient-A case report. Korean J Pain 2007;20:213–8. 3 Chen LH, Hsieh MK, Liao JC, et al. Repeated percutaneous vertebroplasty for refracture of cemented vertebrae. Arch Orthop Trauma Surg 2011;131:927–33. 4 Chiu YC, Yang SC, Chen HS, et al. Clinical evaluation of repeat percutaneous vertebroplasty for symptomatic cemented vertebrae. J Spinal Disord Tech 2012; 25:E245–53. 5 He SC, Teng GJ, Deng G, et al. Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels
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with osteoporotic vertebral compression fractures. Spine (Phila Pa 1976) 2008;33:640. 6 Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976) 2001;26:1537–41. 7 Kaufmann TJ, Trout AT, Kallmes DF. The effects of cement volume on clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2006;27: 1933–7. 8 Kim DJ, Kim TW, Park KH, Chi MP, Kim JO. The proper volume and distribution of cement augmentation on percutaneous vertebroplasty. J Korean Neurosurg Soc 2010;48:125–28. 9 Yang SC, Chen WJ, Yu SW, et al. Revision strategies for complications and failure of vertebroplasties. Eur Spine J 2008;17:982–88. 10 Frey ME. Redo kyphoplasty with vertebroplasty technique: A case report and review of the literature. Pain Physician 2009;12(3):645–9. 11 Cheung G, Chow E, Holden L, et al. Percutaneous vertebroplasty in patients with intractable pain from osteoporotic or metastatic fractures: A prospective study using quality-of-life assessment. Can Assoc Radiol J 2006;57:13–21. 12 Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: Cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004;25(2):175– 80.
Letters to the Editor recurrence of reflex sympathetic dystrophy in the same or another limb? Pain 1996;64:463–6. 4 Rocco AG. Sympathetically maintained pain may be rekindled by surgery under general anesthesia (letter). Anesthesiology 1993;79:865. 5 Viel EJ, Pelissier J, Eledjam JJ. Sympathetically maintained pain after surgery may be prevented by regional anesthesia (letter). Anesthesiology 1994;81:265–6. 6 Goldner JL. Causes and prevention of reflex sympathetic dystrophy (letter). J Hand Surg 1980;3:295–6. 7 Marx C, Wiedersheim P, Michel BA, Stucki G. Preventing recurrence of reflex sympathetic dystrophy in patients requiring an operative intervention at the site of dystrophy after surgery. Clin Rheumatol 2001;20:114–8.
The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29(6):602–8. Erratum in: Am J Ind Med 1996 Sep;30(3):372. 10 de Mos M, Sturkenboom MCJM, Huygen FJPM. Current understanding on the complex regional pain syndrome. Pain Pract 2009;9(2):86–99. 11 de Mos M, Huygen FJPM, van der Hoeven-Borgman M, et al. Outcome of the complex regional pain syndrome. Clin J Pain 2009;25:590–7. 12 Vas L, Pai R, Radhakrishnan M. Ultrasound appearance of forearm muscles in eighteen patients with complex regional pain syndrome 1 of the upper extremity. Pain Pract 2013;1:76–88. 13 Agur AMR, Dalley AF, eds. Grant’s Atlas of Anatomy, 11th edition. Philadelphia: Lippincott Williams & Wilkins; 2009:541.
8 Vas L, Pai R. Successful reversal of complex regional pain syndrome type 1 of both upper extremities in five patients. Pain Med 2012;13(9):1253–6.
14 Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;6:83–90.
9 Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected].
15 Simons DG. New views of myofascial trigger points: Etiology and diagnosis. Arch Phys Med Rehabil 2008;89:157–9.
Penetration Approach for Repeat Vertebroplasty Through the Previously Impacted Bone Cement Dear Editor, Vertebroplasty (VP) and kyphoplasty (KP) are effective treatments for painful vertebral compression fractures (VCFs) [1,2]. Although not common, subsequent refracture in the previously augmented vertebra causes persistent or recurrent pain [3]. Some reports have shown that repeat VP can control pain caused by refractures [3–5]. However, repeat VP is challenging because the previously impacted bone cement blocks the fluoroscopic views and access of procedure needles. A 57-year-old woman presented with severe pain (visual analog scale [VAS] 8/10) in her lower back and both thighs, which left her unable to sit or walk. She had a history of rectal cancer that had metastasized to the liver and lungs. Six months previously, metastasis to the fourth lumbar vertebra was detected and KP was performed (Figure 1). After the procedure, her pain reduced from VAS 8 to 2, but it recurred a week before her visit to our clinic. Magnetic resonance imaging (MRI) revealed further metastatic progression in the L4 vertebral body, and bone cement was located in front of the left pedicle (Figure 2).
After the failure of conservative treatments, we undertook repeat VP with a unilateral intrapedicular approach through the right pedicle. The patient lied prone on the procedure table. Under fluoroscopy, we aligned the endplates of the L4 vertebral body. Because the previous bone cement was blocking the fluoroscopic views, we set the target point by comparing the relative locations of the pedicles in the adjacent vertebrae. After local anesthesia with 1% lidocaine, we made a small skin incision, and inserted a 13-gauge bone access needle through the right pedicle of L4. After checking the anteroposterior and lateral fluoroscopic images, the needle was advanced into the vertebral body. We injected 4 mL of polymethylmethacrylate (PMMA), which fully filled the L4 vertebral body in the lateral view, but this failed to fill into the left side of vertebral body. After deliberation, we chose to insert another needle through the left pedicle to penetrate the previous bone cement. Under fluoroscopic guidance, we inserted the needle, using the same method as with the right side, until 1063
Hur et al.
Figure 1 A T2-weighted MRI before (A) and after (B) kyphoplasty (KP) in the L4. The spinal metastasis invaded mainly the left side of L4. KP was performed by bilateral intrapedicular approach injecting 1 and 1.5 mL of PMMA via the left and right needles, respectively. it touched the bone cement. Then, we meticulously hammered the needle to penetrate the cement. Upon confirming proper placement of the needle, we successfully injected 3 mL of PMMA until it leaked into the upper intervertebral space (Figure 3). During the procedure, the patient’s vital signs were stable and no adverse events occurred. The day after the procedure, her pain decreased to VAS 3 and she was able to ambulate without assistance. One month later, the patient was symptomfree and there was no fragmentation or migration of bone cements (Figure 4).
The optimal volume of bone cement to be injected into a fractured vertebra remains controversial. Some practitioners prefer to inject small volumes to prevent complications such as extravasation of bone cement and adjacent VCFs [6,7], but others prefer to inject a sufficient volume of bone cement to improve therapeutic effects and to prevent refracture of the treated vertebra [5,8]. Having encountered many cases of refracture of vertebrae previously with small volume of bone cement, we prefer to treat fractured vertebrae using as much cement as possible to the limit of cement leakage.
Figure 2 T1-weighted sagittal (A) and axial (B) MR images about 6 months after KP. The metastasis progressed further, invading more into the right side of vertebral body, the left pedicle and epidural space. The height of vertebral body also decreased. The left-side PMMA was blocking the pathway of a bone access needle. 1064
Letters to the Editor Repeat vertebral augmentation is challenging. Impacted PMMA not only obscures fluoroscopy views but also blocks conventional needle pathways. In addition, the risk of cement leakage can be greater because previously impacted bone cement occupies the intravertebral space. Several publications have described the effectiveness and methods of repeat vertebral augmentation [3–5,9,10]. Previously injected cement has been circumvented by using the intact contralateral pedicle or an extrapedicular approach. However, in our experience, bone injections using unipedicular approaches often do not allow enough PMMA to be injected, and extrapedicular approach can fail to bypass the previous injectate.
Figure 3 An antero-posterior fluoroscopic image after completion of bone cement filling. The newly injected PMMA through the right-side pedicle failed to fill the entire pathologic lesion. Then, another bone access needle was inserted through the left pedicle and penetrated the previous injectate. 3 mL of PMMA was injected enough until it leaked into the upper intervertebral space.
Frey [10] described inserting the needle above the previous injectate, but the new PMMA migrated into the intervertebral disc. He explained this caused little concern for any problems because the upper vertebra had already been treated. However, cement leakage into the intervertebral disc space is associated with increased risk of adjacent vertebral fractures [11,12]. Therefore, it is better to avoid needle insertion above or below the previous PMMA in order to prevent cement leakage into the intervertebral space. Using a penetration approach overcomes these limitations. Meticulous needle insertion and cement filling under real-time fluoroscopy made this repeat VP uneventful. In particular, the previous injectate did not migrate or fragment. without any migration or fragmentation of previous
Figure 4 Plain postero-anterior images after the initial KP (A and B) and one month after repeat VP (C and D). The filled nearly entire vertebral body without migration or fragmentation. 1065
Hur et al. injectates. The penetration approach can be an option for repeat VP, especially when the previous injectate blocks into the refractured vertebra. WONSEOK HUR, MD,* JAE JIN LEE, MD,† YOUNG JU WON, MD, PhD,* HYE YOON PARK, MD,* JUNG YOUNG YOO, MD,* MI KYOUNG LEE, MD, PhD,* and SANG SIK CHOI, MD, PhD* *Department of Anesthesiology and Pain Medicine Korea University Guro Hospital Seoul; † Department of Anesthesiology and Pain Medicine Korea University Ansan Hospital Seoul, Republic of Korea References 1 Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976) 2000;25:923– 8. 2 Jo JY, Suh JH, Shin HY, et al. Percutaneous pediculoplasty and balloon kyphoplasty in a vertebral metastatic cancer patient-A case report. Korean J Pain 2007;20:213–8. 3 Chen LH, Hsieh MK, Liao JC, et al. Repeated percutaneous vertebroplasty for refracture of cemented vertebrae. Arch Orthop Trauma Surg 2011;131:927–33. 4 Chiu YC, Yang SC, Chen HS, et al. Clinical evaluation of repeat percutaneous vertebroplasty for symptomatic cemented vertebrae. J Spinal Disord Tech 2012; 25:E245–53. 5 He SC, Teng GJ, Deng G, et al. Repeat vertebroplasty for unrelieved pain at previously treated vertebral levels
1066
with osteoporotic vertebral compression fractures. Spine (Phila Pa 1976) 2008;33:640. 6 Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of vertebroplasty. The effect of cement volume on mechanical behavior. Spine (Phila Pa 1976) 2001;26:1537–41. 7 Kaufmann TJ, Trout AT, Kallmes DF. The effects of cement volume on clinical outcomes of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2006;27: 1933–7. 8 Kim DJ, Kim TW, Park KH, Chi MP, Kim JO. The proper volume and distribution of cement augmentation on percutaneous vertebroplasty. J Korean Neurosurg Soc 2010;48:125–28. 9 Yang SC, Chen WJ, Yu SW, et al. Revision strategies for complications and failure of vertebroplasties. Eur Spine J 2008;17:982–88. 10 Frey ME. Redo kyphoplasty with vertebroplasty technique: A case report and review of the literature. Pain Physician 2009;12(3):645–9. 11 Cheung G, Chow E, Holden L, et al. Percutaneous vertebroplasty in patients with intractable pain from osteoporotic or metastatic fractures: A prospective study using quality-of-life assessment. Can Assoc Radiol J 2006;57:13–21. 12 Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: Cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004;25(2):175– 80.
