Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 53, Num. 2, 2005, pp. 172-173

Neurology India, Vol. 53, No. 2, April-June, 2005, pp. 172-173

Invited Comments

Invited Comment

Cohen Jose E., Rajz Gustavo

Departments of Neurosurgery and Radiology, Hadassah Hebrew University Medical Center, Jerusalem
Correspondence Address: Departments of Neurosurgery and Radiology, Hadassah Hebrew University Medical Center, Jerusalem
jcohenns@yahoo.com

Code Number: ni05050

Related article: ni05049

Percutaneous vertebroplasty is a highly effective therapy for selected patients suffering from a variety of painful vertebral lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. This study and many other recently published series[1] have shown similar results: the procedure is technically simple, straightforward, and presents a high-cost effectiveness rate. No sophisticated equipments are needed, patients present a very low-procedural complication rate, and patient′s satisfaction is almost guaranteed.

However, as with many other neuroradiological techniques, in order to keep a high-efficacy-to-complication ratio a key issue is adequate patient selection. In order to do so, patients′ clinical history and physical examination are of paramount importance. Patients complaining of diffuse, not precise, chronic and irradiated type of pain usually do not benefit from this therapy. Second, a comprehensive evaluation of the very recently obtained neuroradiological examinations is required, anticipating eventual technical problems, limitations, or contraindications. Selection of the vertebral body to be treated is sometimes easy, but multilevel compromise will obscure (and miss) appropriate targeting. In these cases again, physical examination and eventually new neuroradiological studies will be of assistance. Pathological processes affecting vertebral bodies can be very dynamic and neuroradiological studies obtained 1 month ago cannot be realistic today.

Another point to be reminded is that a significant proportion of patients requiring vertebroplasty are aged and fragile, with long-standing incapacitating diseases. Pre-procedural examinations will be tailored according to every patient′s condition, i.e., coagulation studies are part of the routine examinations and sonographic evaluation of lower limbs will be required for immobilized patients.

A last but not least important point is the adequate management of patient expectations regarding pain relief. Vertebroplasty can be spectacular and magical for certain patients and disappointing and ineffective for others. This technique needs always to be part of an integral pain therapy program in a multidisciplinary team approach. Several factors have a role in defining the most ′satisfied client,′ and we are still far from understanding them all. We congratulate the authors for their preliminary experience.

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