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Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review

Clinical Radiology, 1, 66, pages 63 - 72

Aim

To establish the efficacy and complications associated with vertebroplasty in spinal metastases and myeloma.

Materials and methods

A literature search was performed from inception to April 2010. Thirty relevant studies were identified. Only one was a randomized, controlled trial and seven were prospective studies. Nine hundred and eighty-seven patients aged between 45 and 72 years were included in this systematic review.

Results

Most studies report performing the procedure under local anaesthetic 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 are not robust enough for meta-analysis. Pain reduction ranged between 47–87%, similar to the results for osteoporosis. There was no correlation between pain reduction and cement volume.

Conclusion

This systematic review reveals the paucity of good-quality, robust data available on the subject of percutaneous vertebroplasty in malignancy. It also highlights the apparent high risk of serious complication (2%). Further research into the subject is required in this group of patients.

Introduction

Percutaneous vertebroplasty was first described by Galibert and colleagues in 1987 as a minimally invasive treatment of painful vertebral haemangioma. 1 Since then, the use of vertebroplasty has expanded to include treatment for osteoporosis, spinal metastasis, and rarely in traumatic fractures. Vertebroplasty for malignancy is attractive as an adjunct to radiotherapy or chemotherapy due to its rapid efficacy in patients with intractable pain.

Vertebroplasty has been shown to be safe with few complications in the setting of osteoporosis.2 and 3 Concern remains regarding an apparent increase in complication rates for vertebroplasty in cancer patients. This is based mainly on published case series and technical review articles reporting neuropathy requiring emergency decompression and procedure-related mortality.4 and 5 The suggested reasons for an increased risk to patients with metastases include the loss of cortical integrity and tumour angiogenesis. 5 Critical evaluation of the current evidence is needed to quantify the efficacy and safety of the procedure in the context of malignancy.

The aim of this study was 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. Data were extracted and compiled based on available peer-reviewed publications to address these issues.

Materials and methods

MEDLINE (OVID), EMBASE (OVID) and CENTRAL databases were searched from inception to April 2010. No restrictions were placed on publication date within these databases. This review included English language studies only.

A search strategy was developed in collaboration with the University Subject Librarian using a combination of Medical Subject Headings (MeSH) and text words. Text words were truncated and were used to describe the intervention and disease; “vertebroplasty”, “cementoplasty”, “malignancy”, “oncology”, and “metastasis” ( Appendix 1 ). The search was tailored to each database. Search filters were used to target particular study types. The search output was reviewed to ensure the strategy detected relevant references.

All clinical trials and observational studies where patients with malignant disease underwent percutaneous vertebroplasty were included. There was no requirement for studies to have a comparator intervention. Studies were included if they reported on at least one of the following outcomes: technical efficacy, pain relief, functional quality of life, safety, cement leakage, and complication. Complication was defined as any event requiring medical or surgical intervention. Review articles and studies investigating percutaneous vertebroplasty in patients with non-malignant disease, such as osteoporosis, were excluded. Studies that included patients with benign and malignant disease were included if results were reported separately for each group. Similarly, if a study combined the use of percutaneous vertebroplasty with another intervention, such as radiotherapy or surgery, it was included if the data were reported for each intervention.

Two reviewers independently scanned the titles and abstracts of all references downloaded to the bibliographic software to identify potentially relevant articles. For all references that met the inclusion criteria a copy of the full article was retrieved. References that did not meet the inclusion criteria were coded according to the exclusion criteria. Any disagreement at the screening or retrieval stage was resolved by discussion; a third reviewer was available to be consulted, but was never used. Where appropriate, authors were contacted to clarify results between the malignant and benign patient cohort when the results were not explicit.

Data were collected for each included study using a pre-designed data extraction form. Information on study participants, the technical aspects of the intervention, the outcomes measures, and follow-up was recorded for each study. Study participant information included age, gender, description of malignancy (type and stage of disease), and the indication for percutaneous vertebroplasty. Technical information included cement volume injected, type of anaesthetic used, type of image guidance [computed tomography (CT) or C-arm image intensifier/fluoroscopy], the approach and the level and number of vertebra treated. The outcomes and outcome measures for the study were noted. These included quantifiable measures of pain, such as the visual analogue pain scale (VAS), analgesia used, and quality of life measures, such as ECOG performance status (Eastern Cooperative Oncology Group). Complications included cement leakage (asymptomatic and symptomatic), increased pain, wound infection, haematoma, decompression surgery, haemopneumothorax, pulmonary embolus, or death. Serious complications were defined as those that were potentially life-threatening [e.g., deep venous thrombosis (DVT), symptomatic pulmonary embolus, neuropathy requiring surgical decompression, haemothorax and haematoma requiring surgical decompression). The length of study follow-up and patient drop-out were recorded.

Data synthesis and analysis

Results were extracted where possible as raw numbers, plus any summary measures with standard deviations and confidence interval. VAS pain scores were adjusted to a 10-point scale where necessary.15 and 18 Data were summarized according to outcomes of interest. Meta-analysis was planned if appropriate data were available; if not, results were tabulated.

Results

Seven hundred and sixty abstracts were generated in the initial search. Forty-five papers were retrieved for evaluation, of which 29 were included for this review. Hand-searching identified one additional study ( Fig. 1 ). One author was contacted for clarification of data between the benign and malignant cohorts, and the study was included. 14 A summary of these studies is presented as a table of evidence ( Table 1 ).

gr1

Figure 1 Study selection flow diagram.

Table 1 Table of evidence

Author (year) Study type Patient/ vertebrae no. (level) Age (years) Mean Myeloma or metastasis Technical, local (LA) or general anaesthetic (GA) Cement volume (ml) Outcome measure Complications Follow up (mean)
Cotten 6 (1996) Prospective 37 / 40 (C/T/L) 58 Mixed LA & Fluoroscopy C: 2.5 T: 5.5 L: 7.0 Pain (McGill-Melzack)

CT % filling

Leaks
Neuropathy (3) 4 months
Weill 7 (1996) NA 21 / 28 (C/T/L) 61 Metastasis Mainly LA & Fluoroscopy NA Analgesia change

Stability
Neuropathy (2)

Hyperalgia (2)

Dysphgia (2)
7 months
Martin 8 (1999) Retrospective 22 / - (T/L/S) 67 Mixed GA mainly & Fluoroscopy NA Pain relief

CT % filling

Leak
DVT (1)

Death (2)
14 months
Barr 9 (2000) Retrospective 8 / 13 (C/T/L) 69 Mixed GA & LA

CT & Fluoroscopy
T: 2–3

4L: 3–5
Pain relief

Stability
None reported 10 months
Alvarez 10 (2003) Retrospective 21 / 27 (C/T/L) 58 Metastasis LA & Fluoroscopy 4.2 Pain (VAS)

Gait

Function
Radiculopathy (1) 5.6 months
Fourney 11 (2003) Retrospective 34 / - (T/L) 64 Mixed GA & LA Fluoroscopy 2–8 Pain (VAS)

Analgesia change

Function (Frankel)

Leaks
None reported 4.5 months
Martin 12 (2003) Retrospective 32 / 87 (T/L) 63.5 Mixed GA mainly Fluoroscopy NA Pain (VAS*)

Leak
None reported NA
Mousavi 13 (2003) Retrospective 9 / 14 (T/L) 60 Metastasis LA & Fluoroscopy NA Pain (Edmonton) Leaks Neuropathy (1) 1 week
Chow 14 (2004) Prospective 10 / - (T/L) 63 Metastasis LA & Fluoroscopy 3–6 Pain (Edmonton)

Analgesia change

Function (Townsend)
Neuropathy (1) 3 months
Diamond 15 (2004) NA 7 / 14 (T/L) 69 Myeloma LA & Fluoroscopy 1–6 Pain (VAS)

Analgesia change

Function

Vertebral height
None reported 6 weeks
Shimony 16 (2004) Retrospective 50 / 129 (T/L) 62.7 Mixed LA & Fluoroscopy NA Pain (VAS) Function Increased pain (7) 3 months (median)
Barragan-Campos 17 (2006) Retrospective 117 / 304 (C/T/L) 58 Mixed GA (preferred) Fluoroscopy 4.5 Complications Radicular pain (4)

PE (2)

Death (1)
30 days
Kose 18 (2006) Retrospective 16 / 28 (T/L) 63.7 Myeloma LA & Fluoroscopy 3.3 Pain (VAS) Analgesia use NA 1 year
Ramos 19 (2006) Prospective 12 / 19 (T/L) 66 Myeloma LA & Fluoroscopy NA Pain (VAS) Function (ECOG) None reported 3.2 yrs
Pflugmacher 20 (2006) Prospective 5 / 12 (C) 60 Myeloma GA & Fluoroscopy 1.8 Pain (VAS) Function (ASIA, NPDI, CSFS) Spinal height stability None reported 12 months
Camels 21 (2007) Retrospective 52 / 103 (C/T/L) 54 Metastasis LA & Fluoroscopy 4.5 Pain relief Leaks Neuropathy (3)

Radicular pain (1)

PE (2)

Haemothorax (1)
17 months
Anselmetti 22 (2007) Prospective 12 / 38 (T/L) 72.2 Mixed LA & Fluoroscopy 5 Pain (VAS)

Function (Oswestry)

Leaks
None reported 6 months
Barbero 23 (2008) Retrospective 37 / 53 (NA) 71.4 Mixed LA & CT & Fluoroscopy 2 Pain relief (Asymtomatic PE) No serious complications 7 months
Caudana 24 (2008) Retrospective 38 / 62 (T/L) 62 Mixed LA & CT & Fluoroscopy 5 Pain (VAS) Analgesia use Mobility NA 6.4 months
Masala 25 (2008) Retrospective 64 / 198 ( T/L ) 71 Myeloma LA & Fluoroscopy NA Pain (VAS) None reported 6 months
McDonald 26 (2008) Retrospective 67 / 114 (T/L) 66 Myeloma LA & Fluoroscopy NA Pain (VAS)

Function (Roland-Morris)

Subjective outcome
None reported 1 year
Thang 27 (2008) Retrospective 28 / 117 (T/L/S) 65 Myeloma GA usually & Fluoroscopy 3.1 Pain (VAS)

Opiate use

Function (ECOG)
Hyperalgia (1)

Shortness breath/ chest pain (2)
41 month
Trumm 28 (2008) Retrospective 53 / 86 (C/T/L/S) 62 Metastasis LA & CT C: 1.5 T: 3 L: 3.5 S: 6 Pain (VAS) Analgesia use No serious complication 9.2 month
Tseng 29 (2008) Retrospective 57 / 78 (C/T/L) 65 Metastasis GA preferred & Fluoroscopy 5 Pain (VAS) Analgesia use Neuropathy (3)

Haematoma (2)

Death (4)
NA
Lee 30 (2009) Retrospective 19 / 34 (T/L) 70 Metastasis GA preferred & CT preferred NA Pain relief Function (ECOG) Hyperalgia (1) 12 months
Mt’Alverne 31 (2009) Retrospective 4 / 5 (C) 45 Myeloma LA & Fluoroscopy 2.3 Pain relief Vertebral filling None reported 27 months
Chen 32 (2009) Retrospective 31 / 42 (T/L) 67 Mixed GA & Fluoroscopy NA Pain relief (VAS)

Quality of Life Improvement (Karnovsky)
None reported 12 months
Kobayashi 33 (2009) Prospective 33 / 42 (T/L) 62 Mixed LA & Fluoroscopy & CT Fluoroscopy 3.5 ± 1.8 Safety Pain relief (VAS) None reported 6 months
Yang 34 (2009) Randomised Controlled Trial (VP vs VP + Interstitial I125) 40 / 64 (T/L) 58.7 Metastasis LA & Fluoroscopy T: 4.5 L: 6 Pain relief (VAS)

Quality of Life Improvement (Karnovsky)
None reported 12 months
Saliou 35 (2010) Retrospective 51 / 74 (C/T/L) 62.5 Mixed LA or GA & Fluoroscopy NA Pain relief

Vertebral filling
Symptomatic cauda equina (1) 60 months

C, cervical; T, thoracic; L, lumbar; CT, computed tomography; NA, not applicable; DVT, deep vein thrombosis; VAS, visual analogue score; ASIA, American Spinal Injury Association score; NPDI, Neck Pain Disability Index; CSFS, Cervical Spine Functional Score; PE, pulmonary embolism; ECOG, Eastern Cooperative Oncology Group; VP, Vertebroplasty.

Of the 30 studies included, there was one randomized, controlled trial, seven were prospective, and 20 were retrospective studies. The study designs of two were unclear. The selection process is summarized in Fig. 1 .

The total number of patients undergoing vertebroplasty included in this review was 987. Mean age of patients varied between 45 and 72 years in the 30 studies. The main indication for vertebroplasty was pain. The procedure was performed predominantly for spinal metastases; however, eight studies reported outcomes for myeloma patients only.15, 18, 19, 20, 25, 26, 27, and 31

Most procedures were performed under local anaesthesia and continuous fluoroscopic screening with a C-arm image intensifier. Although general anaesthesia was preferred by many for treatment of cervical lesions, only one author used it exclusively. 20

The most commonly treated vertebral levels were thoracic and lumbar. Two studies described vertebroplasty for cervical spinal lesions only in nine patients.20 and 31 Most studies treated between one to four vertebrae per session, with only two treating more than four vertebrae simultaneously.17 and 27

Complications

Five deaths that could be attributed to vertebroplasty were reported in three studies.8, 17, and 29 Two were from chest infections following general anaesthesia, one from a cement pulmonary embolus and two from sepsis after emergency spinal decompression. A further two patients died of medical disease during hospitalization: one from ischaemic heart disease and one from respiratory failure. 29

Nine studies reported serious complications in 19 patients,6, 7, 8, 13, 14, 17, 21, 29, and 35 12 had neuropathy and one had a haematoma — all requiring emergency decompression surgery. One patient had a haemothorax, while another had a DVT and four had symptomatic cement pulmonary emboli ( Table 2 ).

Table 2 Studies reporting serious complications (excluding deaths)

Study no. of Patient Serious complication Neuropathy requiring decompression surgery Symptomatic DVT/PE Other (%)
Cotton 6 37 5.4% 2 0  
Weill 7 21 4.8% 1 0  
Martin 8 22 4.5% 1 0  
Mousavi 13 9 11.1% 1 0  
Chow 14 10 10.0% 1 0  
Barragan 17 117 1.7% 0 2  
Camels 21 52 11.5% 3 2 Haemothorax (n = 1)
Tseng 29 57 9.6% 3 0 Haematoma (n = 2)
1 requiring decompression surgery
Saliou 35 51 2.0% 1 0  

DVT, deep vein thrombosis; PE, pulmonary embolism.

Twelve studies reported both the mean cement volume used and complications.10, 17, 20, 21, 22, 23, 27, 28, 29, 31, 33, and 34 There is some indication that a cement volume of greater than 4 ml results in an increased number of complications ( Table 3 ).

Table 3 Studies reporting mean cement volume and complications/deaths

Author Mean Cement Volume (ml) Complications (%) 3Description of Complication
Yang 34 (2009) 5.1 ml 0%  
Tseng 29 (2008) 5 ml 12.2% 3 Neuropathy (3 decomp surgery, 2 died)
2 Haematoma (1 decomp surgery)
2 Deaths in hospital (1 respiratory failure, 1 ischaemic heart disease)
Barragan-Campos 17 (2006) 4.5 ml 4.2% 2 Hyperalgia
2 DVT/PE
1 Death
Camels 21 (2007) 4.5 ml 13.5% 3 Neuropathy (3 decomp surgery)
1 Hyperalgia
2 DVT/PE
1 Haemothorax
Alvarez 10 (2003) 4.2 ml 4.8% 1 Hyperalgia
Kobayashi 33 (2009) 3.5 ml (+/− 1.8 ml) 0%  
Trumm 28 (2008) 3.1 ml 0%  
Anselmetti 22 (2007) 2.5 ml 0%  
MtAlverne 31 (2009) 2.3 ml 0%  
Barbero 23 (2008) 2.0 ml 0%  
Pflugmacher 20 (2006) 1.8 ml 0%  

All studies reported small volume, local, intra-discal or paravertebral cement leaks; however, most were asymptomatic. No increase in complication was evident in series performing vertebroplasty on vertebrae with a posterior cortical breach. General anaesthetic was used preferentially only in eight studies,8, 12, 17, 20, 27, 29, 30, and 32 and thus a statistical association between the type of anaesthesia with complication rate could not be examined. However, the authors in the three studies that reported deaths all preferred the use of general anaethesia.8, 17, and 29 Similarly, insufficient data were reported to correlate complication with method of screening/guidance used or level of vertebra treated.

Efficacy: pain reduction

Fifteen studies10, 11, 13, 15, 18, 19, 20, 24, 25, 26, 27, 28, 29, 32, and 33 reported pain up to 1 month post-intervention with all showing a reduction in pain from baseline levels. Reduction in pain ranged from 20.3 to 78.9%. This effect appears to be sustained in eight studies11, 18, 19, 20, 25, 28, 29, and 32 (reduction in pain range from 46.9 to 86.6%) that went on to measure pain at 6 months ( Table 5 ). One study reported increased pain in seven of 50 patients. 16 Studies that used a cement volume averaging less than 4 ml reported a similar reduction in pain scores as those using larger volumes11, 18, 20, 22, and 27( Table 4 ). Results on technical efficacy, function, and quality of life were sporadically reported in the studies and were not significantly robust to be analysed.

Table 4 Studies reporting cement volume and pain score (VAS)

  Vertebrae level No. of patients Preop VAS Postop VAS Complications
Intervention Criteria     Mean (SD) Mean (SD)  
Studies used <4 ml cement volume Myeloma patients only
Mt Alverne C 4 - -  
Pflugmacher C 5 6.3 2.4  
Metastatic and other cancers
Kobayashi T/L 33 6.2 (2.1) 2.4 (2.3)  
Trumm C/T/L/S 53 6.4 5.1  
Anselmetti T/L 12 8.2 1.1  
Barbero NA 37 - -  
           
Studies used >4 ml cement volume
Metastatic and other cancers
Yang T/L 40 8.78 (0.54) 5.4 (0.94)  
Tseng C/T/L 57 8.1 (0.67) 3.8 (1.9) 3 Neuropathy (3 decomp surgery, 2 died),
2 Haematoma (1 decomp surgery),
2 Deaths in hospital (1 respiratory failure, 1 ischaemic heart disease)
Barragan-Campos C/T/L 117 - - 2 Hyperalgia, 2 DVT/PE, 1 Death
Camels C/T/L 52 - - 3 Neuropathy (3 decomp surgery),
1 Hyperalgia, 2 DVT/PE,
1 Haemothorax
Alvarez C/T/L 21 9.1 3.2 1 Hyperalgia

Table 5 Pain levels (VAS) Pre and Post vertebroplasty

  Mean VAS score (SD)
Study (no. of patients) Pre-Intervention Baseline 1 month 6 months
Alvarez 10 (21) 9.1 3.2  
Fourney 11 (34) 8 2 2
Mousavi 13 (9) 9.5 3  
Diamond 15 a (7) 7.6 1.6  
Kose 18 a (16) 7.4 3 2.4
Ramos 19 (12) 7.5 3.7 1.9
Pflugmacher 20 (5) 6.3 2.4 1.5
Anselmetti 22 (12) 8.2   1.1
Caudana 24 (39) 8.6 (0.71) 2.8 (1.34)  
Masala 25 (64) 8 (1.4) 1.8 (1.84) 1.9 (1.68)
McDonald 26 (67) 8.5 (0.35) 3.1 (1.25)  
Thang 27 (27) 7.5 2.1  
Trumm 28 (53) 6.4 5.1 3.4
Tseng 29 (57) 8.1 (0.67) 3.8 (1.9) 2.6 (2.0)
Chen 32 (31) 8.9 (0.93) 2.6 (1.71) 3.12
Kobayashi 33 (33) 6.2 (2.1) 2.4 (2.3)  
Yang 34 (40) 8.78 (0.54) 5.4 (0.94)  

a VAS score standardised to 10 point scale.

Discussion

This systematic review of vertebroplasty in patients with spinal metastases and myeloma revealed a paucity of robust data, and heterogeneity of available information ( Table 4 ). While meta-analysis was not possible secondary to this, this review has showed that serious complications of vertebroplasty in this patient group ranged from 0 to 11.5%. 21 The mortality for the procedure ranged from 0 to 7%. 29 An average cement volume of 4 ml or greater may be associated with a higher complication rate than for those who had less than 4 ml injected at vertebroplasty. Although this finding appears to be clinically relevant, the data need to be interpreted with caution, because they were based on a limited number of studies reporting on an average volume of cement injected. Correlation between the average amount of cement injected and overall complications has already been suggested.4 and 5 It is thought that the overzealous quest for complete vertebral body filling results in increased complications. 5

The reduction in pain VAS found in this review of patients with spinal metastases is of a similar level to that reported for patients with osteoporosis. 32 However, two recent randomized trials have shown a reduced effect of vertebroplasty in osteoporosis — with a two and three-point reduction, respectively, in pain on a VAS.2 and 3 Moreover, both studies have indicated that in the short term at least, the benefit of placebo, i.e., local anaesthesia with sham procedure, is as good. This finding may be particularly relevant for patients with spinal metastases and limited life expectancy as a less invasive method of pain control. Research is required to assess this and, if targeted local anaesthetic proves successful, this would have the added benefit of easy repetition if needed.

Kyphoplasty has also been performed for patients with spinal metastasis and myeloma. However, there is no good evidence that it is superior to vertebroplasty for either osteoporosis or tumour-related vertebral compression fractures. In a review of 74 vertebroplasty studies for osteoporosis, 35 kyphoplasty studies for osteoporosis and 18 vertebroplasty and kyphoplasty studies for tumour, McGirt and colleagues was unable to show superiority of one procedure over the other. 36 In a recent systematic review on kyphoplasty in malignant spinal fractures by Bouza et al. 38 no serious procedure-related complications were described. In that study, 741 levels were treated in 306 patients. Asymptomatic cement leak occurred in 6% of all treated levels, which is lower than that reported previously.32, 35, and 37

It was not possible to perform a meta-analysis using the outcome data from the review. The included studies were heterogeneous with variations in patient types and the intervention performed. More specifically, the lack of a comparator group prevented a meta-analysis for the safety outcomes. In order to explore the effect of certain technical aspects of vertebroplasty (for example, low versus high cement volume) on pain this would have required standard deviations to calculate a weighted mean difference. Standard deviations were reported in only seven studies.24, 25, 26, 29, 32, 33, and 34 The limitations of this review relate to the quality of information available; data were collected prospectively in only eight of the studies. The patients included had disparate underlying diagnoses and prognoses. While the primary end point was pain for most studies, only 17 reported pain using a VAS. Moreover, there was no standardization of when pain was measured, varying from 1 day to 6 months post-procedure. While most studies recorded serious complications (mainly neuropathy), precise detail on outcome was often lacking. In particular 30 day mortality (the accepted standard for invasive surgical procedures) was not reported in most studies.

In conclusion, this systematic review reveals the paucity of good-quality, robust information available on the efficacy of percutaneous vertebroblasty in malignancy and highlights the invasive nature of vertebroplasty for patients with spinal metastasis or myeloma. Over 2% suffered a serious complication, which appeared to be related to the volume of bone cement injected at the time of vertebroplasty. As there is no evidence that larger volumes have a greater impact on pain reduction, this finding has important implications for the management of these patients. Further research is required to examine the benefit of targeted local anaesthetic as this may be suitable for patients who are undergoing concomitant systemic or local treatment for metastatic cancer.

Acknowledgements

The authors thank Dr Helen Marlborough (Glasgow University Subject Librarian) for her help in developing the search strategy. Mr David Young (Department of Statistics, Strathclyde University) for his assistance. Dr E. Chow 14 (Sunnybrook Regional Cancer Centre, Toronto University) for his correspondence and clarification.

Search strategy

 

  • Medline (OBS) Search Strategy
    • 1. Epidemiologic studies/
    • 2. Exp case control studies/
    • 3. Exp cohort studies/
    • 4. Case control.tw.
    • 5. (Cohort adj (study or studies)).tw.
    • 6. Cohort analy*.tw.
    • 7. (Follow up adj (study or studies)).tw.
    • 8. (Observational adj (study or studies)).tw.
    • 9. Longitudinal.tw.
    • 10. Retrospective.tw.
    • 11. Cross sectional.tw.
    • 12. Cross-sectional studies/
    • 13. Or/1-12
    • 14. Exp Vertebroplasty/
    • 15. (Kyphoplasty or cementoplasty or vertebroplasty or sacroplasty).tw.
    • 16. Exp Bone Cements/
    • 17. Bone cement*.tw.
    • 18. 14 or 15 or 16 or 17
    • 19. Exp neoplasms/
    • 20. (Cancer* or carcin* or neoplas* or oncolog* or malignan*or metast* or tumour* or tumor*or myeloma*).tw.
    • 21. Spinal fractures/
    • 22. Spinal neoplasms/
    • 23. Fractures, compression/
    • 24. Compression fracture*.tw.
    • 25. (Spine or spinal).mp. and (fracture* or neoplas* or cancer* or carcin* or oncolog* or malignan* or metast* or tumour* or tumor* or *myeloma*/).tw.
    • 26. Osteoporosis/
    • 27. Osteoporotic.tw.
    • 28. 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
    • 29. 28 and 18 and 13
    • 30. Limit 29 to (english language and humans)
  • Medline (RCT) Search Strategy
    • 1. Randomized Controlled Trials/
    • 2. Randomized controlled trial.pt.
    • 3. Random allocation/
    • 4. Double-blind method/
    • 5. Single-blind method/
    • 6. Clinical trial.pt.
    • 7. Exp clinical trials/
    • 8. or/1-7
    • 9. (Clinic$ adj trial$1).tw.
    • 10. ((Singl$ or doubl$ or treb$ or tripl$) adj (blind$3 or mask$3)).tw.
    • 11. Placebos/
    • 12. Placebo$.tw.
    • 13. Randomly allocated.tw.
    • 14. (Allocated adj2 random).tw.
    • 15. or/9-14
    • 16. 8 or 15
    • 17. Case report.tw.
    • 18. Letter.pt.
    • 19. Historical article.pt.
    • 20. Review of reported cases.pt.
    • 21. Review, multicase.pt.
    • 22. or/17–21
    • 23. 16 not 22
    • 24. Exp Vertebroplasty/
    • 25. (Kyphoplasty or cementoplasty or vertebroplasty or sacroplasty).tw.
    • 26. Exp Bone Cements/
    • 27. Bone cement*.tw.
    • 28. 24 or 25 or 26 or 27
    • 29. Exp neoplasms/
    • 30. (Cancer* or carcin* or neoplas* or oncolog* or malignan*or metast* or tumour* or tumor*or myeloma*).tw.
    • 31. Spinal fractures/
    • 32. Spinal neoplasms/
    • 33. Fractures, compression/
    • 34. Compression fracture*.tw.
    • 35. ((Spine or spinal) and (fracture* or neoplas* or cancer* or carcin* or oncolog* or malignan* or metast* or tumour* or tumor*or myeloma*)).tw.
    • 36. Osteoporosis/
    • 37. Osteoporotic.tw.
    • 38. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37
    • 39. 28 and 38 and 23
    • 40. Limit 39 to humans
    • 41. Limit 40 to english language
  • Embase (OBS) Search Strategy
    • 1. Clinical study/
    • 2. Case control study/
    • 3. Family study/
    • 4. Longitudinal study/
    • 5. Retrospective study/
    • 6. Prospective study/
    • 7. Randomized controlled trials/
    • 8. 6 not 7
    • 9. Cohort analysis/
    • 10. (Cohort adj (study or studies)).mp.
    • 11. (Case control adj (study or studies)).tw.
    • 12. (Follow up adj (study or studies)).tw.
    • 13. (Observational adj (study or studies)).tw.
    • 14. (Epidemiologic$ adj (study or studies)).tw.
    • 15. (Cross sectional adj (study or studies)).tw.
    • 16. or/1-5,8-15
    • 17. Kyphoplasty/ or percutaneous vertebroplasty/ or cementoplasty/
    • 18. (Kyphoplasty or cementoplasty or vertebroplasty or sacroplasty).tw.
    • 19. Exp Bone Cement/
    • 20. Bone cement*.tw.
    • 21. 17 or 18 or 19 or 20
    • 22. Exp neoplasm/
    • 23. (Cancer* or carcin* or neoplas* or oncolog* or malignan*or metast* or tumour* or tumor* or myeloma*).tw.
    • 24. Spine Fracture/
    • 25. ((Spine or spinal) and (fracture* or neoplas* or cancer* or carcin* or oncolog* or malignan* or metast* or tumour* or tumor or myeloma*)).tw.
    • 26. Osteoporosis/
    • 27. Osteoporotic.tw.
    • 28. 25 or 22 or 24 or 23 or 26 or 27
    • 29. 21 and 28 and 16
    • 30. Limit 29 to human
    • 31. Limit 30 to english language
  • Embase (RCT) Search Strategy
  • 1. Clinical trial/
  • 2. Randomized controlled trial/
  • 3. Randomization/
  • 4. Single blind procedure/
  • 5. Double blind procedure/
  • 6. Crossover procedure/
  • 7. Placebo/
  • 8. Randomised controlled trial$.tw.
  • 9. Rct.tw.
  • 10. Random allocation.tw.
  • 11. Randomly allocated.tw.
  • 12. Allocated randomly.tw.
  • 13. (Allocated adj2 random).tw.
  • 14. Single blind$.tw.
  • 15. Double blind$.tw.
  • 16. ((Treble or triple) adj blind$).tw.
  • 17. Placebo$.tw.
  • 18. Prospective study/
  • 19. or/1-18
  • 20. Kyphoplasty/ or percutaneous vertebroplasty/ or cementoplasty/
  • 21. (Kyphoplasty or cementoplasty or vertebroplasty or sacroplasty).tw.
  • 22. Exp Bone Cement/
  • 23. Bone cement*.tw.
  • 24. 20 or 21 or 22 or 23
  • 25. Exp neoplasm/
  • 26. (Cancer* or carcin* or neoplas* or oncolog* or malignan* or metast* or tumour* or tumor* or myeloma*).tw.
  • 27. Spine Fracture/
  • 28. ((Spine or spinal) and (fracture* or neoplas* or cancer* or carcin* or oncolog* or malignan* or metast* or tumour* or tumor* or myeloma*)).tw.
  • 29. Osteoporosis/
  • 30. Osteoporotic.mp.
  • 31. 27 or 25 or 28 or 26 or 29 or 30
  • 32. 24 and 19 and 31
  • 33. Limit 32 to humans
  • 34. Limit 33 to english language

References

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Footnotes

a Department of Interventional Radiology, Gartnavel General Hospital, Glasgow, UK

b Section of Public Health and Health Policy, University of Glasgow, Glasgow, UK

c Department of Surgery, Western Infirmary, University of Glasgow, Glasgow, UK

Guarantor and correspondent: C. Chew, Department of Radiology, Gartnavel General Hospital, Great Western Road, Glasgow G11 0YN, UK. Tel.: +44 141 2112804; fax: +44 141 2111976.