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Vertebral compression fractures (VCF) are frequent injuries mostly related to bone fragility1 and are successfully treated by cementoplasty, such as vertebroplasty or kyphoplasty.2 3 Vertebroplasty requires the use of two-dimensional (2D) imaging for intraoperative control of cement filling. Three-dimensional (3D) imaging with computerised navigation offers more accurate procedure.4 Ionising radiation level related to the use of imaging devices may be estimated with the calculation of the effective dose E.5 A 57-year-old female patient, known for a metastatic pancreas cancer since 2018, came to our office because of progressive back pain. The patient clinically presented with a pain on numeric rating scale (NRS) of 6/10 from the mid-thoracic region to the whole lumbar region, increasing with manual percussion on the midline, but she was neurologically intact. Thoracolumbar MRI showed multiple6 osteoporotic VCF from T9 to L5: three concave and six bow-shaped types according to Sugita et al (figure 1). A percutaneous multilevel vertebroplasty procedure was scheduled with 3D navigation aided by the O-arm (O-arm Surgical Imaging System, Medtronic, Minneapolis, Minnesota, USA), and X’Pede cement (Medtronic, Minneapolis, Minnesota, USA) was used. Two 3D acquisitions were required to cover first the vertebrae L2 to L5, and second the vertebrae T9 to L2. Each vertebra was accessed through an extrapedicular single approach of the Jamshidi-navigated needle (PAK Needle, Medtronic, Minneapolis, MN, USA) introduced in the vertebral body (figure 2) from an alternate side. For thoracic vertebrae, the needle position was at the junction of the transverse process and rib below the superior articular facet joint of the vertebra to be cemented,7 and for lumbar vertebrae, through a far lateral extrapedicular approach according to Ryu et al.8 2D mode of the O-arm was used for cement injection control, 18 cubic centimetres (cc) of viscous cement for the whole procedure (about 2 cc per vertebra). After removing all trocars, staples were used for skin closure. The whole procedure duration from incision to closure was 40 min. Blood loss was 20 cc. Effective dose (E, in mSv) was calculated with the dose length product (DLP, in mGy.cm) and the dose area product (DAP, mGy.cm2) according to the recommendations of the International Commission of Radiological Protection9 using conversion factors k=0.015 mSv/mGy.cm and w=0.26 mSv/Gy.cm2, such as E3D = DLP x k and E2D = DAP x w, leading to an overall E of 5.54 mSv. This result was slightly higher than annual natural irradiation in Switzerland (4.32 mSv).10 Postoperative radiographs showed adequate cement filling11 without any leakage (figure 1). Pain level decreased to 2/10 postoperatively on the NRS.
The most important finding in this case was the short operative time and blood loss, with good clinical and radiological results. 3D navigation was particularly effective to save time with a high accuracy.
Moulin et al12 reported results of 24 multilevel vertebroplasties through the same procedure on more than 6 levels of VCF in patients with cancer. Operative time was higher, with a mean of 167 min. The authors concluded as a safe and effective technique, similarly to the current case.
When I saw the senior surgeon at his office, I almost could not move because of progressive and intense back pain. I agreed for the surgery with the expectation of good pain relief. When I arrived at the clinic, my pain level was a continuous 6/10 and prevented me from walking in a normal position. I could only walk short distances with difficulty and bent forwardly. After the surgery, I felt less pain, 2/10, and my mobility immediately improved. I felt really relieved.
Percutaneous single-approach extrapedicular multilevel vertebroplasty was safe and effective.
Three-dimensional navigation helped to perform more accurate surgery and to save time.
Alternate-sided pattern helped performing effective and quick surgery, as no trocar was bothering or cumbersome on the operative field.
Patient consent for publication
Contributors MP designed the study, operated and followed the patient, collected data, wrote the first draft of the manuscript. DG followed the patient, performed critical revision of the manuscript. MPR performed critical revision of the manuscript. DB designed the study, operated and followed the patient, performed critical revision of the manuscript. All authors read and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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