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Chapter25:Percutaneous ablation of bone metastases
Figure 25.6 Common anatomy to avoid.
Figure 25.7 Cryoablation in the proximity
of the obturator nerve.
Ideally, placement of the cryoprobes is based on the geometry of the target tumor so that the shape of the ice matches the
shape of the target tumor. Typically, the cryoprobes are placed
along the long axis of the tumor and at an angle to allow slow
growth of the ice in the direction of adjacent critical structures.
Many bone and so-tissue metastases are adjacent to critical structures. Understanding the path of major motor nerves
and the artery of Adamkiewicz is helpful for the performance
of safe ablation procedures.13 As illustrated in Figure25.6, these
structures can be clearly identied and avoided at the time of
the ablation procedure. An example of the use of cryoablation
in the proximity of the obturator nerve is shown in Figure25.7.
A so-tissue and bony metastasis involving the pubic bone
was treated with four cryoprobes placed through the tumor
to generate ice that matched the shape of the complex tumor.
e evolution of the ice ball showed complete coverage of the
tumor while avoiding the adjacent obturatornerve.
Following completion of the second freeze cycle, the cryoprobes are warmed with active heating with helium gas until
the temperature is >20°C. e cryoprobes can be withdrawn
at this point, although continued warming of the probes over
a period of approximately 10minutes may result in a reduced
risk of hematoma formation. Immediate postprocedural
pain is typically treated with intravenous fentanyl (Abbott
Laboratories, Chicago, IL) and midazolam (Versed; American
Pharmaceutical Partners, Los Angeles, CA). For patients with
249
Section VIII:Musculoskeletal
persistent pain, oral analgesics or a patient-controlled analgesia unit can be used and the dose titrated to provide adequate
pain relief.
Cryoablation pain palliation outcomes
Multiple reports have found that percutaneous cryoablation is
eective in treating painful primary and secondary bone neoplasms. With excellent visibility of the ice ball with both CT
and MRI, both imaging technologies have been employed for
treatment of painful metastatic disease. MR monitoring of the
cryoablation procedure oers the ability to visualize complex
structures, such as important motor nerves, in multiple imaging planes, although the environment restricts devices that can
be utilized. Sewell and colleagues reported the use of percutaneous cryoablation for palliation of 16 painful tumors in 14
patients using MR guidance and monitoring.26 ey found the
treatment provided a signicant reduction in patients’ pain in
the immediate postoperative period. is pain relief continued
over the long term with associated signicant improvement
in patients’ quality of life. Tuncali and colleagues reported the
use of MRI-guided and monitored cryoablation for treatment
of patients with refractory or painful metastatic tumors in
bone and so tissue adjacent to critical structures.27 Pain palliation was partially or completely achieved in 17/19 (89%) of
patients, with complete pain relief in six of these patients. One
patient experienced initial relief but subsequent recurrence of
pain. With the visibility of the ice ball with MRI monitoring
and with the use of additional measures to reduce the risk of
injury, including warming urethral catheters, intramedullary
rod placement, and skin warming, no immediate complica-
Table 25.2 Characteristics of patients treated with cryoablation in
a prospective multicenter trial
Number of patients
Female 22
Male 39
Age (years), mean (range) 61 (range 21–95)
Tumor type (number)
Lung 16 (31%)
Renal 10 (20%)
Colorectal 7 (14%)
Melanoma 4 (8%)
Prostate 4 (8%)
Squamous cell (non-lung) 3 (6%)
Transitional cell 2 (4%)
Paraganglioma 2 (4%)
Breast 2 (4%)
Other (one each) 11 (22%)
Tumor size (longest diameter; cm) 4.8 (range 1.0–11.0)
Tumor location
Rib/chest wall 33 (48%)
Iliac/ischium/pubic bones 20 (29%)
Scapula/clavicle/sternum 7 (10%)
Sacrum 5 (7%)
Extremity 2 (3%)
Vertebral body 1 (1%)
Mastoid 1 (1%)
tions were noted as a result of immediate thermal injury. One
patient suered a femoral neck fracture 6weeks aer cryoablation of a metastatic renal cell carcinoma in this location that
was not treated with an intramedullaryrod.
Cryoablation is compatible with methods to monitor and
avoid potential neural injury. Lessard and colleagues reported
the use of somatosensory-evoked potentials to monitor the S1
nerve during ablation of a painful recurrent Ewing sarcoma in
the mid and upper right hemisacrum. is treatment resulted
in pain palliation and avoided nerve damage in this distribution; however, the ablation caused incontinence of bowel and
bladder, possibly due to ablation injury of the S2–S4 nerve
roots bilaterally, compounded by prior extensive radiation
therapy and baseline nerve dysfunction.
28
Although MRI oers excellent so-tissue resolution and
tumor conspicuity, in most centers CT suites are more accessible for ablation procedures and have larger-bore diameters
than those available with current MRI systems. Ullrick and
colleagues reported the CT-guided and monitored use of cryoablation for the treatment of three patients with painful metastatic disease involving the pelvis and ribs, with palliation in
two out of three patients.
29
In a multicenter prospective clinical trial, 69 painful skeletal metastases were treated with cryoablation in 61 patients.30
e patient cohort in the cryoablation trial is similar to the
cohorts in the previous multicenter RFA trials for pain palliation due to metastatic skeletal disease (Table25.2). Figure25.8
shows the cryoablation treatment of a painful metastatic paraganglioma contained in a le rib with durable response to
treatment throughout the follow-up period. Mean pain scores
(worst pain in a 24-hour period using the BPI 10-point scale)
signicantly decreased from 7.1 to 5.1, 4.0, 3.6, and 1.4 at 1,
4, 8, and 24 weeks aer treatment, respectively (Figure25.9).
irty-nine of the 47 patients (83%) who reported opioid analgesic use prior to the procedure reported a reduction in their
use. Asingle patient experienced a major complication (2%),
with osteomyelitis occurring at the ablationsite.
A majority of patients received radiation to the treated site
and had failed to achieve pain relief prior to entry into the trial.
However, 23 of 61 patients (38%) patients had not received
radiation prior to treatment and a total of 13 of 61 patients
(21%) had received neither radiation treatment nor chemotherapy prior to cryoablation treatment. Importantly, there was
no signicant dierence in pain scores for patients who had or
had not received radiation prior to cryoablation treatment and
there was no signicant dierence in pain scores throughout
the follow-up period. Postprocedure pain control was managed
with patient-controlled intravenous opioid analgesia for 12 of
61 patients (20%) in the immediate posttreatment recovery
period. No patients required placement of an epidural catheter in the immediate postprocedure recovery period or during
their hospitalization. Hospitalization length of stay averaged
250
Chapter25:Percutaneous ablation of bone metastases
AC
BD
71
71
Figure 25.8 Cryoablation treatment
of a painful metastatic paraganglioma
contained in a left rib.
10
8
6
4
Mean Worst Pain
2
0
0
246810 12 14 16 18 20 22 24
N =615754474735323126222118171649
10
8
6
4
10
8
6
4
Mean Average Pain
2
0
0
246810 12 14 16 18 20 22 24
N =6156534746343231262221181
100
80
60
40
Mean Pain Relief
2
Mean Pain Interference
20
649
0
0
246810 12 14 16 18 20 22 24
N =625653474734323125222118171748
Weeks Weeks
0
246810 12 14 16 18 20 22 24
0
N =6056534647343231262221181
649
Figure 25.9 Mean pain scores.
251
Section VIII:Musculoskeletal
1.5days, with a range from 0 to 6days. No patients suered
an injury to a major motor nerve or reported neuropathic pain
following the procedure. Although the complication rate using
RFA for treatment of painful metastases is low, two of 55 (4%)
of patients suered neurologic injuries in a clinical trial.
16
Comparison of outcomes from RFA and cryoablation for
palliation of painful bone metastases is dicult, despite similar
cohorts of patients in clinical trials that were conducted with
consistent tools for measuring patient response. In general, the
clinical response rates and magnitude of pain palliation are
similar. Even though clinical outcomes may be similar following RFA, cryoablation can be performed on tumors more condently in close proximity to critical structures due to visibility
of the ice ball with non-contrast CT imaging. In the recent cryoablation study,30 the major complication rate was 2% (one of
61 patients), with the one complication due to an infection in
the treatment area. No patients suered an injury to a major
motor nerve or reported neuropathic pain following the procedure, as has been observed with RFA treatment. Although the
overall complication rate using RFA for treatment of painful
metastases is low, two of 55 (4%) of patients suered neurologic
injuries in a clinical trial.16 In addition, pain management following RFA can be dicult, oen requiring regional anesthetic
blocks or epidural catheters when possible, while postprocedural pain with cryoablation is readily managed with intravenous or oral opioid analgesia when necessary.
31
Comparison of patient response scores following percutaneous cryoablation to data reported from the treatment of
patients with radiotherapy is dicult, as the methods that have
been used in radiotherapy trials for measuring patient pain
response do not correspond directly with the BPI used in the
cryoablation study and the number of patients in the prospective cryoablation trial is small. However, some comparisons are
possible, as cryoablation results in signicant pain reduction,
with a 43% mean reduction in worst pain in 4 weeks, which is
considered to be clinically signicant.32 Patients also reported
that pain relief 4weeks following cryoablation ranged from
heat into the targeted tumor.
acoustic pathway to the target tumor is needed, as bowel or
neurologic structures intervening between the skin and skeletal tumor are at potential risk of injury.
Most recently, a prospective randomized clinical trial of
the use of MRgFUS for palliation of painful skeletal metastases
was conducted that included a measure of the placebo eect.38
is study involved a 3:1 randomization to treatment for 112
patients and a sham arm of 35 patients. MRgFUS was superior
to the placebo, with a drop in average worst pain from 7/10 at
presentation to 3.4/10 for the treatment arm versus a drop to
6.1/10 for the placebo arm at the 3-month time point. e most
common side eect of treatment was pain related to sonication
during the procedure (32.1% of patients), which ranged from
mild, to moderate, to severe in 6.2%, 10.7%, and 15.2%, respectively. Severity of adverse events was not reported, although two
fractures (one likely unrelated to the procedure), one instance
of neuropathy, and one third-degree skin burn werenoted.
Several additional thermal and non-thermal ablative technologies are available beyond RFA, cryoablation, and MRgFUS
to treat painful tumors and have been applied to skeletal metastases in limited series. Reports of the use of ethanol, laser ablation (or laser interstitial thermal therapy), and microwave
ablation have all shown that these focal therapies are eective
for palliation of painful metastases.
a heat-based technique similar to RFA, using percutaneously
placed antennae to transmit microwave spectrum of energy
(915MHz or 2.45GHz). Oscillation of water molecules within
tissue about the antennae leads to localized heating, which
reaches cytotoxic temperatures faster than RFA and should
also theoretically penetrate intact bone more eectively.42 Laser
ablation utilizes small-caliber, exible, Nd-YAG or diode laser
bers placed coaxially through a thin access needle. An advantage of laser ablation systems is MRI compatibility. e ablation size obtained with each laser activation is small and most
experience with laser ablation in bone has been in the treatment of osteoid osteomas.
36,37
However, a direct ultrasound
39,40,41
Microwave ablation is
43
50% to100%, which compares favorably to reported radiotherapy responses. Further conclusions about the relative benet
of ablation treatments and radiotherapy are not possible and
a randomized prospective trial comparing cryoablation and
radiotherapy would be necessary to determine the relative
response of patients’ pain to these treatments.
Summary
Treatment of patients with pain due to metastatic disease
involving bone or so tissue with focal therapies has proven to
be eective at palliation of pain and can be performed safely.
ese focal therapies are eective for patients who have refused
Emerging technologies
Recently, several reports have appeared describing the use of
MR-focused ultrasound (MRgFUS) for the palliation of painful skeletal metastases.
33,34,35
Focused ultrasound energy is
radiation therapy and for those who have failed to derive pain
relief or developed recurrent pain following radiation treatment. e quality of life for patients treated with these focal
therapies is also improved. Importantly, the pain reduction that
is achieved is durable over many months of observation.
directed at the target, using MRI guidance, that leads to focal
tissue heating and tissue destruction. is technique combines
excellent tumor delineation with MRI for targeting and thermal feedback for treatment monitoring, and has the advantage
of being a non-invasive tumor ablation treatment. Typically
the procedure is performed with conscious sedation, although
pain with sonication is best managed with the use of region
blocks or epidural catheter analgesia, where appropriate.35 e
high acoustic absorption of bone results in ecient transfer of
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254
Chapter
Cementoplasty and musculoskeletal interventions
26
Dimitri Filippiadis, Sean Tutton and Alexis Kelekis
Introduction
Nearly 60% of oncologic patients will eventually develop osseous metastasis with bone pain, potential fracture, and impaired
mobility. While the rst-line therapy for these patients is oen
medical, including narcotic analgesics, according to the World
Health Organization recommendations, and bisphosphonate
therapy such as zoledronic acid infusions, a signicant portion
of patients have intractable pain. Similarly, those patients who
are treated with palliative external-beam radiotherapy may have
incomplete pain relief that is not always durable.
1,2
Furthermore,
pain relief from radiotherapy can take up to 4weeks and can be
complicated by osteonecrosis or neural damage.
1,2
e high percentage of oncologic patients suering from painful metastatic
bone lesions and their fractures, compounded with suboptimal
results of conservative medical and radiotherapy, have been the
drivers for development of minimally invasive local treatments,
including embolization, ablation, and cement augmentation
(also known as cementoplasty or osteoplasty).
Percutaneous cementoplasty is a term referring to the injection of poly methylmethacrylate (PMMA), a polymer (similar
in certain ways to orthopedic cement) inside an osseous structure through a trocar under imaging guidance. When the technique is applied in the spine, the term used is vertebroplasty.
Alternatives to standard vertebroplasty include balloon kyphoplasty, augmented vertebroplasty by means of stents, nitinol
cages, and polyether ether ketone (PEEK) polymer cages, and
radiofrequency-mediated vertebroplasty or kyphoplasty.
2,3,4,5,6
When one of these techniques is applied to the sacrum the term
used is sacroplasty.
described by the term osteoplasty.
7,8
Cement injection in peripheral bones is
2,9,10
e rst ever description of
imaging-guided cement injection was performed by Galibert etal.
for the treatment of an aggressive cervical hemangioma.11 Awider
term now used to include all these percutaneous approaches of
material injection inside bone is bone augmentation.
Indications
When considering oncologic patients a strict denition of the
treatment goal is necessary for best practice and outcomes.
Palliative goals include cement injection for pain reduction
in patients with multiple metastases, some of which are pain-
12,13
ful.
Currently, new technologies and material allow us to
consider curative treatment, which can be performed in oligometastatic patients, aiming at both local control and necrosis of
the tumor as well as pain reduction and mobility improvement.
In the latter case, cementoplasty must be combined with other
therapies. such as radiotherapy, ablation, embolization, or surgical resection and/or xation.
12,13,14,15
Primary indications for cementoplasty in oncologic patients
include the presence of symptomatic metastatic lesions in an
osseous structure located anywhere from the spine to the peripheral skeleton. Denition of the treatment goal will determine
not only the technique, but also any potential combination therapies in addition to sequencing of the various techniques.
Symptomatic hematopoietic neoplasms (such as leukemia and
multiple myeloma) or symptomatic vascular tumors (hemangioma) respond well to percutaneous cementoplasty alone or in
combination with xation techniques, discussed later.
17,18,19
Contraindications
Absolute contraindications to bone injection in oncologic
patients include the presence of concomitant systemic or local
infection, uncorrectable bleeding diathesis, allergy to cement,
and insucient cardiopulmonary status to tolerate sedation.
Any kind of anticoagulation must be interrupted; duration of
interruption is according to the international guidelines for
each medication. In the presence of infection, bone augmentation must be postponed until the patient undergoes a full antibiotic course and becomes afebrile with normal white blood
cell values and negative blood cultures.
Relative contraindications include factors which technically increase the diculty of the procedure without rendering
it impossible. ese factors include posterior wall disruption
with or without tumor extension in the epidural space, myelopathy or radiculopathy secondary to tumor extension in the spinal canal or neural foramen, signicant loss of vertebral height
(vertebra plana), and inability to image the target lesion either
with uoroscopy or computed tomography (CT) guidance due
to various factors.
2,4,6,20
14,15,16
2,4,6
Interventional Oncology, Second Edition, ed. Jean-François H.Geschwind and Michael C.Soulen. Published by Cambridge University Press.
©Cambridge University Press2016
255
Section VIII:Musculoskeletal
Preproceduralcare
When evaluating the cancer patient, prior to performing bone
augmentation the interventional oncologist should be aware of
the tumor histology (benign or malignant), the patient’s general condition, and the degree of bone destruction. ese factors, along with the strictly dened treatment goal, will direct
a nal decision, which should be obtained at multidisciplinary
oncologic boards.
orough medical record examination is necessary in
order to exclude anticoagulation, evidence of infection, or
comorbidities that increase the mortality and morbidity rate
of the session. Laboratory workup should include complete
blood cell count, coagulation study, and screening of basic
metabolic panel. Electrocardiography, chest X-ray, and anesthesia evaluation are performed according to local practice
guidelines.
Physical examination is critical for proper patient selection.
e majority of oncologic patients will have more than one
metastasis; however, only symptomatic levels should be treated.
Point tenderness at the spinous process of the pathologic vertebrae assists in localizing and targeting treatment in patients
with multiple lesions. Localization can be precise, by placing
metallic markers at the level of point tenderness on the skin
and having a lateral uoroscopy image or a lateral radiograph
of the spine. Neurologic examination should be performed in
all patients. In the case of a patient with pre-existing neurologic decits, a baseline neurologic exam, repeated on the day
of procedure, is required to assess the patient’s neurologic function prior to any procedure. Achanging neurologic exam is
reason to consult a spine surgeon for possible decompression.
Radiographs can serve as initial imaging evaluation; however, they provide limited information in oncologic patients.
Magnetic resonance imaging (MRI) is the study of choice since
it best illustrates the presence of a lesion, bone edema, extraosseous tumor extension, and potential pressure upon nerve
structures. Total body diusion-weighted sequences illustrate
the extent of malignancy. If MRI is contraindicated (e.g., pacemaker or cochlear implant), CT scans combined with bone
scintigraphy can be performed.21 CT is superior in illustrating
the sclerotic/blastic character of the lesion and the integrity of
osseous cortex or vertebral body’s posteriorwall.
Technique
All cementoplasty techniques are performed under imaging guidance, antibiotic prophylaxis, and strict sterility.
Fluoroscopy is the imaging modality in most of the cases. When
high precision is necessary, multidetector CT or cone-beam CT
can be used as modality of choice.
In the spine, a posterolateral transpedicular approach is
more commonly used in the lumbar and thoracic spine. In the
upper cervical spine a transoral approach is preferred (Figures
26.1 and 26.2). In the mid and lower cervical levels an antero-
lateral approach through the vertebral body is performed in the
majority of the cases. Occasionally variations of the aforementioned approaches or alternative ones are performed depending on the location of the lesion to be treated and the treatment
goal. Since neoplastic lesions tend to be located in the posterior vertebral elements, occasionally the needle may need to
be placed within the pedicle for cement injection (pediculoplasty).22 For sacroplasty the two more common approaches
include passage through the sacroiliac joint targeting the S1
corridor or posterior approach parallel to and medial to the
sacroiliac joint. Approaches for peripheral osteoplasty vary
according to the location of the lesion to be treated and the
treatmentgoal.
Following needle placement, its position is veried, with
some operators choosing to inject contrast medium prior to
cementation. Despite the fact that cement and contrast medium
have dierent viscosities, it seems that contrast injection prior
to cementation provides valuable information for the potential distribution patterns of the cement and illustrates potential
leakagesites.
Cement injection can be likened to embolization with
direct communication to the vasculature and should therefore be performed under continuous uoroscopy.
2,4,6
In oncologic patients, the cement of choice is PMMA, which sets and
hardens via a polymerization reaction during which there is
exothermic release of heat sucient to cause a temperature
increase in the treated tissue.
Balloon kyphoplasty is a variant of vertebroplasty during
which a cavity is created by rst drilling followed by ination
of a balloon tamp in order to achieve height restoration and
reduce rates of cement leakage.
2,3,4,5,6
Currently, augmented
vertebroplasty by means of intravertebral nitinol cages,
stents, or PEEK polymer coils/cages is performed, aiming
to enhance safety and ecacy rates
2,3,4,5,6
(Figure26.3). ese
techniques are particularly useful in cancer-related pathologic
fractures when there is extensive osteolysis causing destruction of the posterior or anterior cortices as they can aord
additional protection by cement containment. Further, these
implant-based vertebral augmentation techniques rely on the
implant for structural stability and allow for employment of
biologically active tumoricidal cements currently in development. Early studies are promising, but additional studies of
these techniques in oncologic patients are necessary for their
superiority to be proven.
3
Oncologic patients typically suer from multiple lesions
requiring treatment. Ideally these lesions should be treated
within a single procedure and anesthetic session. Factors to be
considered for such treatments include PMMA or local anesthetic toxicity, fat pulmonary embolism (during cement injection marrow droplets are pushed into the circulation), and
duration of the procedure in the context of performance status.
Comparison of procedures up to and more than three treated
vertebral levels favors the latter for cost-eectiveness without
any expense of safety or ecacy.
23
In the setting of oligometastatic disease the goal of treatment can be curative. e question of when to oer ablation
alone, cementoplasty alone, or combination therapy has not
been adequately answered. Cementoplasty provides stabilization and pain reduction. e question whether PMMA alone
can provide enough cytotoxicity to destroy the lesion is still
under debate. In the non-surgical patient, ablation is steadily
256
Chapter26:Cementoplasty and musculoskeletal interventions
Figure 26.1 Breast Ca metastatic lesion in T7. (A) P-A fluoroscopic view illustrating bilateral transpedicular access. (B) Lateral fluoroscopic view illustrating bilateral
transpedicular access with the needles beyond the posterior vertebral wall. (C) Coaxially a bone biopsy needle was introduced for lesion sampling. (D) Lateral
fluoroscopic view illustrating bilateral transpedicular access with the needles in anterior third of the vertebral body. (E) P-A fluoroscopic view illustrating bilateral
transpedicular access with the needles towards the midline of the vertebral body. (F) Lateral fluoroscopic view illustrating vertebroplasty needles and cement
injection. (G) Lateral fluoroscopic view illustrating satisfactory filling of the vertebral body with the polymer extending from top to bottom and beyond the midline.
Figure 26.2 71-year-old patient post left nephrectomy with new L1 lesion. (A) CT scan, axial reconstruction illustrating lesion at L1 vertebral body.
(B, C) CT scan, axial reconstruction during RFA and vertebroplasty of the biopsy proven RCC metastasis in the L1 vertebral body. (D) Six month follow-up
contrast CT scan (coronal recostruction) showing local control of disease. (E) Six month follow-up contrast CT scan (axial recostruction) showing local
control of disease.
gaining ground as a treatment of choice. Ablation is discussed
in the previous chapter.
When performed in weight-bearing bones, unexpected
fractures can occur secondary to access holes in the cortex or
due to osteonecrosis induced by the ablation zone.24 In this
setting, cementoplasty with or without screw xation may be
combined to strengthen the underlying bone when there is concern about collapse or fracture. Cementoplasty should follow
ablation and enough time should be allowed between the two
techniques for internal bone temperature to return to normal
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Section VIII:Musculoskeletal
Figure 26.3 Multiple myeloma – lytic lesion in L4 vertebral body. (A) Lateral fluoroscopic view illustrating vertebroplasty needle in anterior third of the vertebral
body. (B) Lateral fluoroscopic view illustrating satisfactory filling of the vertebral body with the polymer extending from top to bottom and beyond the midline.
(C) P-A fluoroscopic view illustrating satisfactory filling of the vertebral body with the polymer extending from top to bottom and beyond the midline.
Figure 26.4 44-year-old patient with metastatic melanoma resulting in pain with ambulation. (A) CT scan, coronal reconstruction illustrating impending
acetabular fracture. (B) CT scan, axial reconstruction during RFA of acetabular lesion with articulating RF probe. (C) CT scan, axial reconstruction post PMMA
augmentation of the acetabular defect (D) CT scan, coronal reconstruction illustrating 8 mm cannulated screw fixation of acetabular defect with augmentation.
(E) CT scan, sagittal reconstruction of augmented screw fixation.
so as not to accelerate cement polymerization in the case of
heat-based ablation or have unpredictable cement ll due to
residual ice ball in setting of cryoablation. Cementoplasty has
been combined with multiple therapies, including radiotherapy, ablation, embolization, or surgery
12,13,14,15
(Figure26.4).
Injection of PMMA is a recognized augmentation strategy,
but also has been utilized as an embolic agent in malignant
vascular bone lesions. Specically for vertebral hemangiomas,
cementoplasty is both an embolic and an augmentation agent
whenever the lesion is contained within the vertebral body and
cement lls the whole lesion or at least its largest part; in case of
epidural extension direct puncture or microcatheter embolization should precede cementoplasty. In this setting digital subtraction angiography for localization of anterior spinal artery
(Adamkiewicz’s artery) provides critical information.
Ecacy and complications
e success rate of cementoplasty ranges from 60% to 85% with
respect to pain reduction and mobility improvement.
overall complication rate in oncologic patients is 5–10%.
Potential complications include cement leakage, pulmonary
embolism, hematoma/hemorrhage, infection, hypotension,
2,4,6
e
2,4,6
258