Solved on SIR Connect By Karl Chiang, MD, Jackson Bennett, MD, Mithil B. Pandi, DO, and Sudhen B. Desai, MD, FSIR Feedback on CT-guided sacroplasty
Original Post, lightly edited for flow:
bit.ly/2X64CJf
I performed CT-guided sacroplasty on a patient with bilateral trocars at S1, 2, 3 and used 13.4 cc of cement. That is more than my usual four trocars and 8–10 ccs of cement. The patient has reported no pain relief and claims that pain is worse. He wants to know if he can have it done again. I have been doing kyphoplasties and sacroplasties for almost 20 years and my partners thought I went above and beyond on this case. Any advice would be appreciated. I had pre-op CT and MRI which was positive for subacute sacral insufficiency fractures. Postprocedural pics are attached.
What challenges have you faced in performing CT guided sacroplasty with bilateral trocars? CT-guided sacroplasty has several challenges including delays with CT-fluoro and the cement drying too quickly. I usually use two trocars at S1 bilaterally and two trocars bilaterally at S2–3. Due to the short axis of CT, the large handles of the trocars end up touching each other or deflecting each other unless I try to stay slightly off the same axial level on same level trocars. The advantage of CT is easier guidance of placement of the trocars in the fractures more precisely. Many IRs use cone-beam CT with newer fluoro angio rooms, which we do not have available yet.
What specifically prompted you to reach out regarding this c ase/topic? This was the first time I have not achieved any clinical improvement after sacroplasaty. I wanted to know from experienced operators if repeat treatment would be reasonable.
What post or posts were most valuable to you and why? The most helpful post was from Douglas Beall, MD, FSIR, who is a world expert
34 IRQ | FALL 2020
Author name and contact information Karl Chiang, MD Greenville, N.C.
karlschiang@gmail.com
Author background and current practice preferences for CT-guided sacroplasty I have worked in a large subspecialized private practice for the past 27 years post fellowship, doing about 90% IR. I have been doing vertebroplasty and then kyphoplasty for the past 20 years. I gradually added sacroplasty about 10 years ago but started performing them in CT because I was never trained to do it under fluoro. There were no training workshops for sacroplasty, so CT seemed very easy to do without training.
on vertebral procedures. He sent articles and pictures of long axis techniques. Doug suggested I try again and add more cement.
Will you, or have you changed your practice patterns based off of responses on SIR Connect? Please describe any changes you are considering. I did repeat the sacroplasty procedure within a week and added almost the same amount of cement as the first time. However, the patient did not show any improvement clinically. Do I have regrets? No. The patient then knew I had tried everything. I will learn how to perform the long-axis fluoro technique that most other IRs do these days and have reached out to my device manufacturer’s rep to ask about training.
Additional commentary: Percutaneous sacral vertebroplasty (sacroplasty) is a safe and effective procedure for patients suffering
from back pain due to compression fractures secondary to osteoporosis, malignancy and hemangiomas.1,2,3,4,5 Analogous to vertebroplasty, which was highlighted by Dr. Beall in the summer 2019 issue of IR Quarterly (
bit.ly/31U6Wnx), sacroplasty provides pain relief and improved mobility in select patients.1,3,6
A cement acrylic polymer such as polymethylmethacrylate (PMMA)1
is
injected under short- and long-axis techniques that utilize image guidance with fluoroscopy or CT,1,5
as described by
the OP who attempted re-treatment in a patient who received sacroplasty for pain control. While an appropriateness algorithm for vertebroplasty has been presented and could be extrapolated for sacroplasty, a dedicated algorithm does not exist.6
Repeat sacroplasty
can be performed for patients with recurrent insufficiency fractures, though challenges may include the sacral medullary volume, access approach, placing trocars into fracture locations that do not bear cement, or hardening artifacts due to CT imaging.7
Percutaneous sacroplasty yields favorable outcomes for pain management, with 50% immediate post-op, pre-discharge pain relief in one prospective analysis.1,8
According
to a vendor-sponsored study referenced in the SIR Connect post, a retrospective multicenter analysis of CT-guided sacroplasty in patients with sacral insufficiency fractures and lesions demonstrated a reduction in pain scores (31% complete relief with average cement volume 4.1 ml).9,10 Another multicenter prospective study demonstrated pain relief seen in some patients within 30 minutes.10,11 A portion of patients see immediate relief, gradual pain improvement during a 1- to 2-week period, and up to 6–12 months to see complete symptom resolution and improved mobility.11–15
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40
