The role of percutaneous vertebroplasty in spinal metastasis

Despite the widespread use of percutaneous vertebroplasty for myeloma and spinal metastases, the evidence of its safety, efficacy and cost to the health service is based mainly on retrospective studies with short and incomplete follow up. The aims of this thesis were to: (1) Perform a systematic review to examine the safety and efficacy of vertebroplasty in malignancy, and to determine factors that may be associated with an increased risk of complications or reduced efficacy; (2) To assess the outcome and complication rate of percutaneous vertebroplasty in a large cohort of consecutive patients with myeloma and spinal metastases treated over 9 year period and (3) To ascertain prospectively the health service cost of vertebroplasty on a cohort of consecutive patients with spinal metastases. Results: Thirty studies were included in the review, of which 8 were prospective. Most report performing the procedure under local anaesthesic and continuous fluoroscopic screening, and only two centres reported treating more than four vertebrae per session. Five deaths were attributable to vertebroplasty, with a further 19 patients suffering a serious complication related to the procedure. There is some evidence to suggest that the complication rate may be related to the higher cement volume used, although the data is not robust enough for meta-analysis. Pain reduction ranged between 47-87%, similar to results for osteoporosis. There is no correlation between pain reduction and cement volume. In our second study, 128 patients underwent percutaneous vertebroplasty for myeloma (n=41) or spinal metastasis (n=87) over a 9 year period. VAS scores fell from 7.75 +/- 1.88 pre-vertebroplasty to 4.77 +/- 2.69 post vertebroplasty (p=0.001). RDQ scores improved from 18.55 +/- 4.79 to 13.5 +/- 6.96 (p=0.001). Complications were recorded in three patients : cement extension to vena cava (n=1), local haematoma (n=1) and loss of sensation over T1 dermatome (n=1). The Kaplan-Meier estimate of 5 year survival post-vertebroplasty was 40% for patients with myeloma and 25% for those with metastases. In our final study, the majority of the procedures were performed on an outpatient basis (8/11). The median duration of the procedure was 60 minutes (range 40-80 mins) with a further 60 minutes spent in the recovery room (10-230 mins). Personnel involved included a consultant radiologist, a radiology registrar, four nurses and two radiographers. The average cost of vertebroplasty per patient, including consumables, capital equipment, hotel/clinic costs and staffing, was £2213.25 (95% CI £729.95). The mean EQ -5D utility scores increased from 0.421 pre-treatment to 0.5979 post-treatment (p=0.047). The visual analogue scale (VAS) of perceived health improved from a mean to 41.88 to 63.75 (p=0.00537). Conclusion: Percutaneous vertebroplasty is safe and effective when performed under local anaesthetic. There is good evidence that pain and disability are improved and this effect appears to persist for the duration of the patient’s life. Its cost to the health service is acceptable and in line with that of other palliative procedures.