Aim

Identifying cervical spine injuries in confused or comatose patients with multiple injuries provides a diagnostic challenge. Our aim was to investigate the protocols which are used for the clearance of the cervical spine in these patients in English hospitals.

Vertebral compression fractures are very common. 250,000 are diagnosed annually in the United States with 80% due to osteoporosis¹. Symptomatic relief with conservative therapy is often difficult to achieve. The consequence of significant pain is deterioration in quality of life and often in level of function. They independently increase mortality rate¹.

Balloon kyphoplasty is a relatively new technique which stabilises the vertebral body and restores saggital spinal alignment. Excellent pain relief and improved functional outcome is reported^2,3. We aim to confirm this.

All patients receiving balloon kyphoplasty treatment at Derby Hospitals NHS Trust from April 2006 to August 2010 were entered prospectively onto a database. Visual Analogue Score (VAS) for pain and Oswestry Disability Index (ODI) for function were recorded. Technical data including number of levels, cement volume, screening time and kyphosis correction was recorded.

198 patients underwent balloon kyphoplasty between April 2006 and August 2010. Some data was incomplete. 105 patients had sufficient data for meaningful analysis. 170 levels were operated on in 105 patients. 65% (n=68) of patients were female and the average age was 74.

The average pre-operative visual analogue score (VAS) was 8.2. This decreased to 4.0 in the immediate postoperative period. This dramatic improvement remained and was 4.1 at 6 weeks, 3.3 at 6 months and 3.6 at 1 year. The average pre-operative Oswestry disability index (ODI) was 58. This improved to 47 in the immediate post-operative period. At 6 weeks this had improved further to 40 and further improvements were seen at 6 months (ODI 37) and 1 year (ODI 38).

Balloon kyphoplasty should be considered in all patients with ongoing pain following an acute vertebral compression fracture that doesn't respond to conservative treatment.

Consecutive case series

To evaluate the efficacy of a strict stepwise radioanatomical procedure protocol in avoiding neurological complications through tool malplacement in fluoroscopy guided percutaneous procedures of the thoracic spine.

Fluoroscopy guided percutaneous access to thoracic vertebral bodies is technically demanding. There is a trend towards computed tomography (CT) guidance on grounds of perceived lesser risk of spinal canal instrument malplacement. CT is however not always readily accessible and a safe technique for fluoroscopy guided procedures therefore desirable.

350 consecutive fluoroscopy guided percutaneous procedures (biopsy, vertebroplasty or kyphoplasty) covering all thoracic vertebral levels T1-T12 were performed according to a strict stepwise radioanatomical protocol. The crucial step of the protocol was not to advance the tool beyond the anterior-posterior (ap) projection of the medial pedicle wall until the tip of the instrument had been verified to have reached the posterior vertebral cortex in the lateral projection. The neurological status of patients was assessed through clinical examination prior to, immediately after the procedure and before discharge.

Percutaneous instrument placement in the targeted thoracic vertebral body was achieved in all cases and the stepwise radioanatomical protocol was followed in all cases. There was no case of neurological deterioration in the case series.

Conclusion: Attention to radiographic landmarks, specifically not crossing the ap projection of the medial pedicle cortex prior to reaching the posterior vertebral wall in the lateral projection, allows neurologically safe performance of fluoroscopy guided percutaneous procedures of the thoracic spine. This simple protocol is particularly useful when access to CT is limited.