H Schober

[Interventional pain relief using balloon-kyphoplasty in patients with osteoporotic-based fatigue fractures of the os sacrum].

PURPOSE In older patients with reduced bone quality, fatigue fractures of the os sacrum are relatively common and are typically accompanied by strong, disabling pain. The aim of our study was to verify the feasibility and safety of sacroplasty using a balloon catheter as well as the reduction of pain. MATERIALS AND METHODS 25 patients were diagnosed with an os sacrum fracture in MRI. As a manifestation of an extant bone reconstruction process, all patients were diagnosed with distinctive edema on the basis of MRI strong T 2-weighted images. CT-controlled balloon sacroplasty was performed in all patients. To allow the cement to be dispensed at a longitudinal angle to the fracture, the balloon catheter is directed through a hollow needle in the os sacrum either from the caudal to the cranial direction or from the craniodorsal to the caudoventral direction. The thus created cavity was then filled with PMMA cement. A control CT and a conventional X-ray in two planes were then carried out. The pain intensity was defined by means of VAS before the intervention, on the second day, and 6 and 12 months after the intervention. RESULTS The balloon sacroplasty yielded good technical performance in every patient. The control CT and the X-ray control of the os sacrum showed adequate distribution of the cement, and cement leakage was not detected. Before the operation, the average pain encountered was in accordance with VAS 8.3. On the second postoperative day, a considerable reduction with an average of 2.7 was reported, and this remained stable with an average of 2.5 after 6 and 12 months. CONCLUSION Balloon sacroplasty is an effective treatment method for fast pain relief in patients with fatigue fractures of the os sacrum.

Osseous Consolidation of an Aseptic Delayed Union of a Lower Leg Fracture after Parathyroid Hormone Therapy - A Case Report.

The absence of osseous consolidation of a fracture within the normal time period is defined as delayed union or non-union. Both for the patient and from a socio-economic point of view, impaired fracture healing represents a major problem. Risk factors for a delayed fracture healing are insufficient immobilisation, poor adaptation of the fracture surfaces, interposition of soft tissue in the fracture gap, as well as circulation disturbances, metabolic disease, smoking and infections. In animal studies, a positive effect of parathyroid hormone (PTH) on fracture healing has been shown. PTH has a direct stimulatory effect on osteoblasts and osteoclasts. In addition, it appears to influence the effect of osseous growth factors. Few cases with the empiric off-label use of PTH that showed a tendency to support delayed or non-union fractures have been published. We report about a patient with a fracture of the lower leg and no osseous consolidation after 7 months. Four Months after therapy with 20 μg teriparatide per day for 8 weeks the fracture was consolidated and the patient had regained full and pain free weight bearing capacity of the leg with no reported side effects.

Therapy of aseptic nonunions with parathyroid hormone

The absence of osseous consolidation of a fracture for 9 or more months with no potential to heal is defined as nonunion. Both for the patient and from a socioeconomic point of view, nonunions represent a major problem. Hypertrophic, vital nonunions are distinguished from atrophic avital ones. Risk factors for a delayed fracture healing are insufficient immobilisation, poor adaptation of the fracture surfaces or residual instability, interposition of soft tissue within the fracture gap, as well as circulation disturbances and infections. The incidence of nonunions after fractures of the long bones lies between 2.6 and 16% depending on the surgical technique used. In human and animal studies, a positive effect of parathyroid hormone (PTH) on fracture healing has been shown. PTH has a direct stimulatory effect on osteoblasts and osteoclasts. In addition, it appears to influence the effect of osseous growth factors. In this prospective study, 32 patients with nonunions were treated with teriparatide to investigate the effects of PTH on fracture healing. Definitive healing of the nonunions following PTH treatment could be observed in 95% of the cases.

O-039 Comparison of the Medium-term Outcome of Two Different Methods for the Cement Augmentation of Insufficiency Fractures of the Sacrum

Introduction The objective of this prospective, randomized study was to test the feasibility and the clinical outcome of the different forms of treatment. Material and methods In 40 patients with a total of 57 sacral fractures, cement augmentation was performed with CT-guidance by means of balloon sacroplasty (BSP) or radiofrequency sacroplasty (RFS). For BSP, the balloon catheter was inflated and deflated in the fracture zone, and the hollow space created was then filled with PMMA cement. For RFS, a flexible osteotome was initially used to extend the spongious space in the fracture zone. The highly viscous PMMA cement, activated by radiofrequency, was then inserted into the prepared fracture zone. Pain intensity was determined on a visual analogue scale before the intervention, on the second day, and 6, 12 and 18 months after the intervention. The results were tested for significance by means of paired Wilcoxon rank-sum tests and Mann-Whitney U tests. Results BSP and RFS were technically feasible in all patients. An average of 6.3 ml cement per fracture were inserted in the BSP group and an average of 6.1 ml per fracture in the RFS group. Leakage could be ruled out for both procedures. The mean pain score on the VAS before the intervention was 8.6 ± 0.55 in the BSP group and 8.8 ± 0.58 in the RFS group. On the second postoperative day, a significant pain reduction was seen (p < 0.001), with an average value of 2.5 (BSP ± 0.28, RFS ± 0.38) for both groups. After 6 (12; 18) months, these values were stable for the BSP group at 2.3 ± 0.27 (2.3 ± 0.24; 2.0 ± 0.34) and for the RFS group at 2.4 ± 0.34 (2.2 ± 0.26; 2.0 ± 0.31). With regard to pain, exceedance probability values of p = 0.86 (6 months) and p = 1 (18 months) were seen, so that neither treatment method leads to differences in results. Conclusion BSP and RFS are interventional, minimally invasive procedures that enable reliable cement augmentation and achieve equally good clinical outcomes in the medium term. Disclosures R. Andresen: None. S. Radmer: None. J. Andresen: None. H. Schober: None.

Balloon sacroplasty as a palliative pain treatment in patients with metastasis-induced bone destruction and pathological fractures.

PURPOSE In the case of metastatic involvement of the sacrum with destruction and consecutive pathological fracture, intense disabling pain is one of the defining factors. The feasibility, safety and pain development with cement augmentation were to be investigated. MATERIALS AND METHODS CT-guided balloon sacroplasty was conducted in 10 patients with metastasis-induced bone destruction of the sacrum. After establishment of the entry point, a K-wire was first introduced as far as the central tumor lesion via the short, or transiliac axis. A cannula was then positioned over the wire. Under CT guidance, a balloon catheter was introduced through the cannula and inflated and deflated several times. The PMMA cement was then injected into the preformed cavity. The procedure was completed by a spiral CT control using the thin-slice technique. Pain intensity was determined using a visual analog scale (VAS) before the procedure, on the 2nd postoperative day and 6 months after the intervention. Finally, the patients were asked to state how satisfied they were. RESULTS Balloon sacroplasty was technically feasible in all patients. The control CT scan showed central distribution of the cement in the tumor lesion. On average 6 +/- 1.78 (4 - 10) ml of PMMA cement were introduced per treated lesion. A significant (p < 0.001) reduction in pain according to the VAS occurred in all patients from 9.3 +/- 0.67 (8 - 10) pre-operatively to 2.7 +/- 1.28 (1 - 5) on the 2nd postoperative day and 2.9 +/- 0.81 (2 - 5) 6 months after the intervention. All of the patients were re-mobilized after the procedure and underwent the further therapeutic measures as planned. CONCLUSION Balloon sacroplasty is a helpful therapeutic option in the overall palliative treatment of patients with tumor-induced destruction. It is a safe and practicable procedure that markedly reduces disabling pain.

P-013 Balloon Sacroplasty as a Palliative Treatment in Patients with Metastasis-Induced Bone Destruction and Pathological Fractures

Introduction In the advanced stages of malignant diseases such as breast cancer, prostate, bronchial, renal cell or thyroid carcinoma, multiple myeloma and lymphoma, metastases in the axial skeleton are common. They have a negative impact on the quality of life and worsen the respective prognosis of the patient. If the sacrum is affected, with destruction and consecutive pathological fracture, the cardinal symptom is disabling pain in the region of the lower lumbar spine and pelvis. Based on experiences with cement augmentation in patients with osteoporosis-induced insufficiency fractures, the aim of this research was to investigate the feasibility, safety and course of pain in patients with metastasis-induced bone destruction and pathological fractures. Materials and Methods CT-guided balloon sacroplasty was carried out in 10 patients with metastasis-induced bone destruction of the os sacrum (5 multiple myelomas, 1 bronchial carcinoma, 1 rectum carcinoma, 1 hepatocellular carcinoma, 1 renal cell carcinoma, 1 urothelial cell carcinoma). The indication for cement augmentation was established in an interdisciplinary case conference with oncologists/specialists in internal medicine, orthopaedic/trauma surgeons, neurosurgeons and interventional radiologists. The procedure was performed under intubation anaesthesia and anaesthetic monitoring. Patients were placed prone in the CT scanner. Single-shot antibiotic prophylaxis was routinely given (cefazoline 2g i.v.). After establishment of the entry point and usual preparation, a K-wire was first introduced as far as the central tumour lesion via the short, or transiliacal axis. A cannula was then positioned over the wire. Under CT guidance, a balloon catheter was introduced through the cannula and inflated and deflated several times, partly overlapping in a central to peripheral direction. The PMMA cement was then injected into the preformed cavity using the low-pressure technique under CT single slice guidance. The procedure was completed by a spiral CT control in the thin-section technique with coronal and sagittal reformation. Pain intensity was determined using a visual analogue scale (VAS) before the procedure and on the 2nd postoperative day. Results The balloon sacroplasty was technically feasible in all patients. The control CT scan showed a central distribution of the cement in the tumour lesion. No leakage of cement in the direction of the neuroforamina, iliosacral joints or visceral surface with venous and nerve plexus or into the intervertebral disk space L5/S1 occurred. On average, 6 (4–8) ml of PMMA cement were introduced per side treated. A significant reduction in pain according to the VAS occurred in all patients from 9.3 pre-operatively to 2.1 on the 2nd postoperative day. All patients could be re-mobilised after the procedure and could receive the further therapeutic measures as planned. Discussion Balloon sacroplasty is a helpful therapeutic option in the overall palliative concept for patients with tumour-induced sacral destruction. It is a safe and practicable procedure that markedly reduces the disabling pain, increases the patient’s quality of life and greatly facilitates the feasibility of further necessary measures such as radiotherapy and chemotherapy. Disclosures R. Andresen: None. S. Radmer: None. C. Luedtke: None. P. Kamusella: None. C. Wissgott: None. H. Schober: None.

O-006 Pain management of patients with fatigue fractures of the OS sacrum with balloon sacroplasty using different approaches

Introduction In elderly patients with reduced bone quality, insufficiency fractures of the OS sacrum are relatively common and are typically associated with intense, debilitating pain. The objective of our study was to determine the practicability of cement augmentation using a balloon catheter via individual approaches taking into consideration the complex anatomy of the sacrum and the course of the fracture, as well as the postinterventional determination of leakages and representation of the outcome pain. Material and Methods In 30 patients with severe osteoporosis (23 women with an average age of 72.4 years, seven men with an average age of 68.7 years), a sacral fracture was detected by CT and MRT. This fracture was unilateral in 17 women and bilateral in the other patients. In order to achieve a cement distribution longitudinally in relation to the fracture, the balloon catheter was inserted into the OS sacrum via a hollow needle either from caudal to cranial, from dorsal to ventral or from lateral transiliac to medial. The balloon catheter was then inflated and deflated 1–3 times along the fracture in the respective direction, and the hollow space created was then filled with PMMA cement using a low-pressure procedure. A conventional radiograph in two planes and a control CT were then performed. Pain intensity was determined pre-intervention, on the second day post-intervention and 6 and 12 months post-intervention, using a visual analogue scale. Results The balloon sacroplasty was performed successfully from a technical point of view in all patients. The radiographic and CT control showed sufficient cement distribution in the sacrum along the course of the fracture, whereby leakage could be ruled out. According to the visual analogue scale, the mean value for pain was 8.8 pre-intervention, there was a significant reduction in pain on the second postoperative day, with an average value of 2.7 (p<0.001), which was stable at 2.5 after 6 months and 2.3 after 12 months. Discussion Approaches that take into account the anatomy of the OS sacrum and the course of the sacral fracture enable reliable augmentation with an optimum amount of cement. This makes balloon sacroplasty an effective treatment that has few complications for rapid and significant pain relief in patients with a sacral fracture. Competing interests None.