Overview of Kyphoplasty in the
Management of Spinal Tumors
Surgical Technique and Application in
Multiple Myeloma
Sigurd Berven, MD
Assistant Professor in Residence
Department of Orthopaedic Surgery
UC San Francisco
Clinical Presentation of Patient
with Multiple Myeloma in the
Spine
Pain
Neural Impairment
Spinal Instability
Deformity
Multiple Myeloma
Multiple myeloma in the
spine characteristically
leads to osteolysis,
fracture, and progressive
kyphotic deformity
Clinical Presentation of Patient with
Multiple Myeloma in the Spine
Spinal Deformity:
Vertebral body infiltrated with tumor cells
Endplate fracture due to axial load
Potential retropulsion of the posterior
vertebral wall
Cervical/Lumbar spine: Symmetric collapse
Thoracic Spine:
Kyphosis
Clinical Presentation of Patient with
Multiple Myeloma in the Spine
Neural Impairment
<10% of patients present with neural deficit
Radiculopathy (lumbar)
Myelopathy/weakness (thoracic)
Sensory deficits
Bowel/Bladder dysfunction
Treatment Options
Critical Importance of Spinal Stability:
· The stable spine is able to withstand
physiologic loads without fracture, progressive
deformity, or risk to the neural elements.
GW
38-year-old with lymphoma, diagnoses in
6/01
Treated with chemotherapy and radiation
to spine
Patient with progressive back pain and
right leg weakness presents for urgent
evaluation
Treatment Options
Stable Spine:
· Radiation Therapy/Chemotherapy
Reliable for pain relief in responsive tumors
­ Myeloma/Solitary Plasmacytoma, Lymphoma, Breast,
Lung
Regional selectivity with cyberknife
Pre-treatment neurologic status is predictive of
post-treatment neural function
Radiation Therapy
May leave bone unstable
Radiation may increase risk of fracture1
· Up to 41% of patients who undergo
radiation experience bone fractures
Cannot correct an anatomic
abnormality such as a fracture2
1 Patel, B. and H. DeGroot III. Orthopedics. 2001; 24(6): 612-617.
2 Janjan, N. Seminars in Oncology. 2001; 28(4): 28-34.
Unstable Spine
Operative Stabilization may be the most
reliable methods for restoring stability to
the spine and correcting deformity due to
pathologic fracture.
· Open Reconstruction
· Kyphoplasty
Indications for Operative Care
Progressive neural deterioration
Progressive deformity of the spine
Osseous impingement of neural elements
Radio-resistant tumor
Diagnosis
Intractable pain despite nonoperative care
Spinal Column Reconstruction
En Bloc Excision
Marginal Excision
JP
54-year-old with open reconstruction and
XRT
Significant post-operative complications
Vertebral Augmentation as a
Minimally Invasive Technique
for the Management of Spinal
Tumors
JW
86-year-old
Progressive back pain and progressive
kyphotic deformity after fall in 12/00
History of multiple myeloma
Minimally Invasive Fracture
Reduction
Overview of Treatment Steps
1) The balloon is inserted into the fractured vertebral body
Minimally Invasive Fracture
Reduction
Overview of Treatment Steps
2) The balloon is inflated, reducing the fracture and elevating the
endplates
Minimally Invasive Fracture
Reduction
Overview of Treatment Steps
3) The balloon is deflated and withdrawn, leaving a cavity within the vertebra
CA
46-year-old
Diagnosed with MM in 6/02
Preparing for bone marrow transplant
Developed progressive back pain and
deformity to spine over 3 months,
hospitalized for pain management
MW
57-year-old
Diagnoses with multiple myeloma in 12/03
Treated with chemotherapy and XRT to
spine
Developed progressive spinal deformity
and neural compromise
Transferred for surgical evaluation
Vertebral Augmentation and
Multiple Myeloma
Indications:
· Adjuvant or supplement to radiation/chemotherapy
· Restoration of height and stability in vertebral body
affected by myeloma and fracture
· Treatment of pain related to vertebral insufficiency
· Role of prophylactic intervention to prevent
fracture?
Surgical Outcomes
Axial skeleton involved in majority of patients
Thoracic spine 59%
Lumbrosacral spine 31%
Cervical spine 10%
Spine involvement results in severe pain & progressive Kyphosis
Patient Demographics
· 242 levels treated in 52 patients with myeloma,
(May1999­September 2002)
· Mean age 60 years (34-82)
· Mean follow-up 6 months
· Mean duration of symptoms = 11 months
(Failed non-operative treatment)
Patients with Plasmacytomas & posterior cortical
insufficiency were excluded
First 18 patients published in Journal of Clinical Oncology, May 2002
Levels Treated
Multiple Myeloma Series
T6
1
1
4
T8
3
3
T10
9
T11
7
T12
8
L1
7
L2
4
5
L4
3
L5
Kyphoplasty Case
Multiple Myeloma
Depressed endplate
Buckled anterior cortex
Reduced
Augmented
Myeloma Patients Results
· All patients tolerated the procedure well
· Virtually all reported some immediate
relief of their symptoms
· Discharge >70% same day
SF-36 Outcome
Multiple Myeloma, n = 52 (242 levels, 6 month F/U )
80
Pre-op
SF36
70
60
50
40
Post-op
SF36
30
20
10
0
Age-matched
SF36
PF
RP
BP
GH
Vi
SF
RE
MH
VAS & ODI outcome scores
Multiple Myeloma, n = 52 (242 levels, 6 month F/U )
80
8
70
7
Pre-op
60
6
50
5
40
4
30
3
Post-op
20
2
10
1
0
0
ODI
VAS
Conclusions
An assessment of stability of the spine
Stable Spine
·
Radiation/chemotherapy
·
Vertebral augmentation for persistent pain
Unstable spine
· Open treatment for neural compromise
· Vertebral augmentation with or without
instrumentation with no neural deficit.
Algorithm for the Management of
Myeloma Involving the Spinal Column
Diagnosis and Staging
Solitary Tumor
Widely Metastatic Disease
Stable Spine
Unstable Spine
Radiation
Open Surgical Fixation
Radiation
Kyphoplasty
+/- kyphoplasty
UC San Francisco
Clinical Outcomes Research Program

Document Outline