微創(chuàng)治療椎體壓縮骨折新理念課件

1、Advanced Concepts in Minimally Invasive Vertebral Compression Fracture ManagementAgendaCurrent State of VCF ManagementPatient SelectionMaximizing Fracture ReductionMultiple Myeloma, Bone Metastases and Osteolytic LesionsCase Reviews16000220-01Managing VCFsPast, Present and FutureCourtney Brown, M.D.

2、16000220-01Are VCFs Benign?Fractures Deformity Kyphosis16000220-01KyphX Inflatable Bone TampDesign RationaleReduce fractureCreate a voidIs kyphosis the enemy?16000220-01Prevalence of VCFs700,000 Osteoporotic VCFs annually in the US1260,000 present as painful2Over 400,000 hospital days per year3 36,0

3、00 KyphX reductions through 20024What size population does your practice cover?1 NOF 20032 Cooper et al., JBMR 19923 Gelbach et al., Osteoporosis Int1 20034 Kyphon data thru Dec. 200216000220-01Are VCFs presenting?How many VCFs do you manage each year?Annual numbers in US 240 VCFs per 100,000 reside

4、nts 52 VCF hospitalizations per 100,000 residentsAre you seeing 1 VCF per week? 16000220-01Todays AudienceDisciplines presentExperience to date with VCF interventionCase experience with KyphXNumber of procedures required to build confidence and comfort 16000220-01Patient SelectionWhen do you offer i

5、ntervention?Dr. BonvalletDr. ScottDr. VaughtDr. Truumees16000220-01Patient SelectionWhen do you offer intervention?Dr. BonvalletDr. ScottDr. VaughtDr. Truumees16000220-01Medical vs Surgical ManagementWhat is meant by “conservative care?”O(jiān)piod side effects1Increasing kyphosis2Reduced pulmonary functi

6、on2,3Depression1Decreased quality of life4Increased mortality5,61 Mezanec et al. Clev Clin J Med 2003 2 Schlaich et al., Osteoporosis Intl 1998 3 Leech et al., Am Rev Respir Dis 1990 4 Gold Bone 19965 Cauley et al., Osteoporosis Intl 2000 6 Kado et al., Arch Int Med 199916000220-01Medical vs Surgica

7、l ManagementWhy not treat all VCFs surgically?What are your inclusion criteria for KyphX?16000220-01Inclusion/Diagnostic ConsiderationsFracture Age?Co-morbidities?Fracture location and configuration?Failure of Medical Management? 16000220-01Fracture Age and Ability to ReduceMany fractures progressiv

8、ely collapseAmount of reduction to be expected depends on acute component of FxAug 31, 2000Sept 3, 2000Lieberman et al., Spine 200116 kyphosis25 kyphosis16000220-01Fracture Age and Ability to ReduceKushwaha and Lalibert, NASS 2002Looked at fracture reduction abilityacute (6 mo.)Time since initial fr

9、acture alone does not predict ability of balloon to reduceMRI reveals local edema and acute component of fracture16000220-01Co-MorbiditiesFragile patient populationAnesthesia considerationsGeneral vs. LocalFluid management considerationsOther concerns?16000220-01VCF MorphologyFracture Classification

10、sSuperior compressionInferior compressionBiconcaveVertebra PlanaPosterior Wall InvolvementDisplaced bony fragments (burst fractures)Intact but bowed posterior wall16000220-01Vertebra Plana, 1 year oldPatient:89 YO FemaleDiagnosis:Primary osteoporosisFracture Location:T-7Courtesy of Wade Wong, DO, La

11、 Jolla, CAStage 1 InflationStage 2 Inflation16000220-01Vertebra Plana, 6 months oldPatient:73 YO FemaleDiagnosis:Primary OsteoporosisFracture Location:L1Courtesy of Mohammad Majd, M.D., Jeffersonville, IN 16000220-01Reduction of Thoracic LevelsChallengesPedicle size and orientationVisibility limitat

12、ions above T5Utilization of the extrapedicular approach16000220-01554321154324321Extrapedicular Approach16000220-01Maximizing Fracture ReductionImages courtesy of Vivek Kushwaha, M.D., Houston, TX16000220-01How Do You Define Success? Fracture Reduction? Deformity Correction? Parallel endplates? Angu

13、lation change? Void creation? Pain Relief?16000220-01Patient Positioning Postural ReductionTowel RollsReducing pressure on the fracture site16000220-01Balloon MechanicsFPEndplate Separating Force = Pressure x AreaA16000220-01Balloon Mechanics: F = P x AA longer balloon provides more areaGive the bal

14、loons time to expand in diameterIncrease the force by increasing the area:AA16000220-01Balloon Mechanics F = P x AIncrease the force by increasing the area:Bilateral approachTwo balloons DOUBLE the endplate separating force!Maximize the potential for reductionAA16000220-01Balloon Mechanics F = P x A

15、Increase the force by increasing the pressure:Gradually increase the pressure until the balloon exceeds the cancellous bone compressive strength As the bone yields the balloons expand and pressure decaysGive the balloons time to expandFP16000220-01Inflation Endpoints: Treatment goal achieved (Fractu

16、re reduction/void creation) Maximum volume Maximum pressure Cortical wall contact16000220-01Inflation EndpointsWhich endpoints do you routinely encounter?Treatment goalVolumePressureCortical wall contactSuperior or inferior endplate?Lateral wall? Anterior or posterior wall?16000220-01Underlying Dise

17、ase States:OsteoporosisPrimary OsteoporosisSteroid-Induced OsteoporosisFracture risk is increased up to 6 fold1 fracture risk increased with dosage and ageUp to 50% will develop fractures2More likely to sustain additional fractures31 van Staa et al., JBMR 15(6) 20002 Adachi Am J Med Sci 313(1) 19973

18、 Harrop et al., NASS 200216000220-01Beyond Osteoporosis:Metastatic Bone Disease and Multiple Myeloma16000220-01Decrease both bone strength and stiffnessCharacterized by increased bone resorption, causing swiss cheese type lesions on boneExamples:Multiple MyelomaMetastatic osteolytic carcinoma Osteolytic Lesions16000220-01Multiple Myeloma70-100% of patients have bone involvement at presentation.1Axial skeleton involved in majorit