1. One sessione multivel vertebroplasty: indications and results in 55 porotic patients M. Muto, P. Vassallo, R. Izzo, A. Lavanga, G. Di Gaeta, G. Ambrosanio UOC Neuroradiology - Cardarelli Hosp Naples ITALY XIX Neurosymposium Bologna 4-9 october 2010

2. Vertebral compression fracture Porotic lesions Metastatis Hemangioma Multiple myeloma Trauma (KP) Incidence: 438.750 for year (117 / 100.000) acute, subacute and chronic clinical symptomatology. VP and KP as STABILIZATION AND PAIN THERAPY to improve life quality.VP and KP as STABILIZATION AND PAIN THERAPY to improve life quality. Asymptomatic patient with VCF fracture is not an indication to the treatment.Asymptomatic patient with VCF fracture is not an indication to the treatment.

3. diagnostic algorithm acute pain Standard X-Ray RM (STIR T2) edema spongiosa normal metastasis hemangioma no VP MN TC VP VP

4. Skeletal pathology carachterized by reduction of bone resistance with increased bone fragility and predisposition to fractures. Bone resistance is a balance between quantity and quality of the bone. Consensus Conference, 2001 Definition: Osteoporosis:

5. New fractures to adjacent or distant metamer Risk of new vertebral fracture in the year following a fracture.Lindsay R. JAMA Jan 2001 5 times higher Kiphoplasty does not riduce di incidence of new fractures. Primary and secondary osteoporosis. Incidence of subsequent vertebral compression fracture after Kyphoplasty. 26 of 115 patients develops new fractures within a year. Harrop and coll. Spine 2004, 29,19 2120-2125 New symptomatic VCF within a year following VP in osteoporotic women. 20% of the patients. Syed and coll, AJNR June - July 2005

6. How many VP it is possible to perform in the same session? It is not written anywhere but usually it is suggested not to treat more than 3 levels in the same sessions.

7. Benneker LM and coll The effect of pulsed jet lavage in VP on injection forces of PMMA bone cement, material distribution, and potential fat embolism. A cadaver study. Spine 2008 nov 1;33(23);E906-10 Aebli N and coll Fat embolism and acute hypotension during VP: an experimental study in sheep. Spine 2002 27 460-6 Syed MI and coll Fatal fat embolism after VP; identification of the high risk patients. Case report AJNR 27, 343-345,feb 2006

8. Therapy of osteoporosis:targets a)Manteinance / increasing of bone mass (BMD) b)Prevention of fractures or re-fractures c)Control of spine pain related to fractures

9. Questions to submit to a patient with vertebral porotic fracture Which trauma has caused the pain ? Have you had steroid therapy for many years ? Have you had GI surgery ? I need to check your lab test Which is your regular habit diet ( Vit. D and Calcium) and physical activity?

10. Osteoporosis : current therapy ANTICATABOLIC ANABOLIC - Bisphophonates analog sinthetic of PTH: -Estrogens 1) PTH ( 1-34) o teriparatide -SERMs 2) PTH ( 1-84) (selective estrogen Stronzium Ranelate (?) receptor modulator) Ca + Vit.D

11. Activity of NRX Cardarelli hosp 2001 through 2009, 1250 patients for a total of 2850 metamers. 67 patients had multilevel VP to a number of 4 or more metamers, up to 10 metamers in the same session in 5 patients. In 55 patients were porotic fractures, in 10 case metastatis and in 2 cases vertebral haemangioma.

12. Indications Patients with multiple symptomatic porotic, metastatic o MM fractures (treating also unruptured sandwich metamer in patients with failure of medical therapy) Patients with atypic or symptomatic haemangioma Patients with steroid therapy since long time with multiple porotic iatrogenic fractures.(MS, Collagenopathies, allergic rhinitis, tumors)

13. Materials In 52 porotic and hemangioma pts we used normal PMMA In 5 porotic we used Cerament bone substitute In 10 patients we used high density cement (Confidence)

14. Risultati Osteoporosis 90% Metastasis 75% haemangiomas 100% In porotic fractures rate of refractures at 12 months, 5% (3 pts).

15. Anesthesist ‘s role Premedication : midazolam Treatment: remifentanil cloridrato Therapy related to the age, to the weight and clinical status

29. CONCLUSIONS Osteoporosis is a disease that can be prevented and cured with medical and interventional therapy There is a medical therapy that can reduce the loss of bone mass and influence the bone quality, reducing the risk of new fractures. multi-level VP can be performed in selected cases to treat VBF related to osteoporosis, metastasis or angioma and to prevent fractures or refractures.