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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 71-74

Balloon kyphoplasty - Boon for vertebral compression fractures in metastatic cancer patients


Cheers Interventional Pain Management, Ahmedabad, Gujarat, India

Date of Submission30-Dec-2020
Date of Decision15-Mar-2021
Date of Acceptance16-Mar-2021
Date of Web Publication27-Apr-2021

Correspondence Address:
Dr. Bhuvna Ahuja
Cheers Interventional Pain Management, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_163_20

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  Abstract 

Vertebral compression fractures are common in the elderly population. Common aetiology includes, osteoporosis, metastatic disease, and trauma. Vertebral bone metastasis is not common in cases of pancreatic cancer. Here, we report how we managed a 78 year old, male patient, case of known pancreatic cancer having severe back pain (Numerical Pain score (NRS): 9), due to vertebral compression fracture over first lumbar vertebrae (L1). Percutaneous balloon kyphoplasty was performed with an injection of 5 ml bone cement at L1 level under local anaesthesia with sedation. The NRS had come down to 3 and the patient could walk. Our patient get benefited with early interventional pain management of metastatic vertebral compression fractures. Preventing the complications such as immobilization accompanied with adverse events such as musculoskeletal, respiratory, and cardiovascular systems. Providing with significant reduction of pain and leading a better quality of life.

Keywords: Balloon kyphoplasty, metastatic cancer, vertebral compression fractures


How to cite this article:
Munshi SA, Ahuja B, Gargia A, Shah P. Balloon kyphoplasty - Boon for vertebral compression fractures in metastatic cancer patients. Indian J Pain 2021;35:71-4

How to cite this URL:
Munshi SA, Ahuja B, Gargia A, Shah P. Balloon kyphoplasty - Boon for vertebral compression fractures in metastatic cancer patients. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:71-4. Available from: https://www.indianjpain.org/text.asp?2021/35/1/71/314693


  Introduction Top

Vertebral compression fractures are common in the elderly, leading to severe back pain and causing disability for daily life activities. The etiologies such as osteoporosis, metastatic disease, and trauma should be included in the differential diagnosis of severe back pain. Cancers such as breast, prostate, kidney, and lung metastasize to multiple bones, including the vertebrae, ribs, and femur.[1] Here, we report how we managed a case of known pancreatic cancer having severe back pain. In pancreatic cancer, liver and peritoneum metastases are frequent, but bone metastasis is less common.

Here, we report how we managed a case of known pancreatic cancer having severe back pain.[2],[3] The computed tomography (CT) of the spine showed lumbar vertebral compression fracture due to metastasis from pancreatic cancer and with osteoporotic bones. Bone metastasis can be diagnosed through history-taking, X-ray, CT, magnetic resonance imaging (MRI), and bone scans. Multimodal approach was applied to help the patient get relief of severe back pain and lead a better quality of life.


  Case Report Top

A 78-year-old man, doctor by profession, a known case of pancreatic cancer for the past 10 months, had been experiencing severe back pain for the past 3 months. We paid home visit to this patient on his request since he was a senior repudiated doctor. Pain was severe enough to cause restriction of any kind of body movements. It was 9 on 10 on numerical rating scale (NRS). The pain sensation was excruciating in quality, located over left spinal area, just above left iliac crest. He got mild relief on lying down. The patient had disturbed sleep due to exacerbation of pain at night. While examining, the patient was in good mental state. All four limbs had normal power with no sensory deficit. On local examination, the patient had tenderness over the left iliac crest. Local tenderness was also present over L1 vertebrae. Local kyphosis at the upper lumber region was observed. The patient was self-medicating by diclofenac with muscle relaxants twice daily. He also at times used to take injection diclofenac 75 mg. Injection lignocaine 1% was used for tender point injection. The MRI of the spine showed metastatic vertebral compression fracture of L1 vertebral body. [Figure 1] shows MRI findings. There was no retropulsion of the posterior wall of the vertebrae seen. Anterior and posterior longitudinal ligaments were normal. Hence, observing risk–benefit ratio, we opted for interventional management. After written informed consent, the patient was admitted to our hospital. On admission, laboratory data, such as complete blood count, electrolytes, liver function, renal function, and coagulation profile, were found normal. The tumor markers CA 19-9 and carcinoembryonic antigen were normal. Percutaneous balloon kyphoplasty was performed with an injection of 5 ml bone cement at L1 level under local anesthesia with sedation. Steps of percutaneous balloon kyphoplasty included as follows.

Figure 1: Magnetic resonance imaging scan of the vertebrae involved: T1, T2 coronal, and axial. There is a near-complete replacement of the L1 vertebral body by T1 hypointense and T2 mixed signal soft tissue (1) with associated loss of vertebral body height suggestive of metastasis. Mild paravertebral soft tissue (2) is also noted. Posterior vertebral convexity of the involved vertebra with epidural soft tissue (3) is causing mild cord and nerve root compression. On postcontrast images, there is diffuse heterogenous enhancement of the lesion. (4) There is also altered signal in the adjoining vertebral bodies ?reactive edema ?metastasis (5). An altered signal metastatic lesion is also noted in the right iliac bone with associated soft tissue (5). Few retroperitoneal (6) and paraesophageal (7) lymph nodes are also seen. Computed tomographic axial in bone window showing soft tissue involving the L1 vertebral body with cortical destruction (8) and perivertebral soft tissue (9)

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The patient was asked to lie in prone position. Area of needle insertion was made aseptic with betadine solution and spirit. Local anesthesia and light sedation were given to the patient, which allowed the patient to remain awake throughout the procedure without feeling any pain. A few millimeter incisions were made at the back. At the level of L1 vertebrae, a Jamshed needle was placed under fluoroscopy (X-ray guidance). It was carefully pushed along the path through the pedicle of the involved vertebra and into fractured site. A special balloon (called bone tamp) was then inserted through the needle and into the vertebrae and gently inflated. Once the balloon was inflated, it compacts the soft inner bone to create a cavity inside the vertebrae and returned the vertebrae to natural height. The balloon was them removed. Then, the cavity was filled with cement-like material called polymethylmethacrylate (PMMA). After PMMA was injected, the pasty material quickly hardens stabilizing the bone. [Figure 2] shows steps of percutaneous balloon kyphoplasty under fluoroscopy. After receiving percutaneous balloon kyphoplasty, the NRS had come down to 3 and the patient could walk. He was discharged the next day with advice to avoid straining exercises or work for 6 months and avoid prolonged sitting, forward bending, and weight lifting. Patient was also advised to use corset during sitting, standing, and walking. Injection teriparatide 20 units s/c daily was prescribed And antibiotics, analgesics was given for 5 days. Chemotherapy and radiotherapy continued as prescribed by an oncologist.

Figure 2: Step performed for balloon kyphoplasty

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  Discussion Top

Pancreatic cancer, an aggressive malignancy with a poor prognosis, is the seventh leading cause of cancer-related death, worldwide.[4] The 5-year survival rate for pancreatic cancer patient is <5%.[5] The current standard treatment for advanced pancreatic cancer is gemcitabine monotherapy, with a median survival rate of approximately 9–15 months for patients with locally advanced disease and 3–6 months for those who present with metastasis.[6]

Without suitable treatment, he would become bedridden and use support for normal day to day activities. If pain is not well managed, fatigue, insomnia, and depression will impede the aggressive rehabilitation. Moreover, joint contractures, muscle atrophy, pressures sores, pneumonia, cardiovascular problem, and decreased functional status can influence daily activities.

On basis of these findings, our concern was to reduce pain scores and provide a better quality of life. After initial conservative management which included a nonsteroidal anti-inflammatory, low-dose opioids, short period of bed rest followed by gradual mobilization with external orthoses.[7]

The current gold standard treatment for painful bone metastasis is radiotherapy and analgesic indication. The pain can be treated with medicine with severe side effects. The course of treatment is time-consuming for the patient, caregiver, and physician.[8] Radiotherapy has limitations, in terms of having no response at all, effect is delayed, and poor tissue tolerance. With such local painful condition, surgery would have not been a good option as the patient is fragile in terms of age and medical condition. We opted for interventional techniques because the patient was elderly with associated osteoporotic changes, bone metastasis, and pain being unbearable. Benefits of interventional techniques includes that it, could be done under local anesthesia, is less time consuming and helps in early recovery and good pain relief. In interventional techniques, percutaneous balloon kyphoplasty was chosen over percutaneous vertebroplasty. Percutaneous transpedicular approach was applied for kyphoplasty.

Kyphoplasty differs from vertebroplasty in that a balloon is first inflated in the vertebral body to create a cavity into which cement is then injected under low pressure. Thus, it increases vertebral height and reduces kyphotic deformity. More viscous cement can be injected, under low pressure so as to minimize extravasation of cement and prevent complications. Overall complication rates for both procedures are low; however, vertebroplasty appears to have a higher rate of cement extravasation with associated pulmonary emboli and compression of neural elements.[9] Cost of procedure was not a concern as our patient was affordable. The risk and complications of kyphoplasty can be prevented under carefully performing, patient selection, and radiology guidance with contrast. Kyphoplasty benefits in metastatic vertebral fractures.

However, all treatment in most cases with 33%–50% pain reduction is clinically meaningful.[10] Moreover, cancer would be almost out of control in long run with more severe pain.


  Conclusion Top

Our case highlights the benefits of early interventional pain management of pancreatic cancer patients with metastatic vertebral compression fractures. Our management, prevented the complications such as immobilization accompanied with adverse events such as musculoskeletal, respiratory, and cardiovascular systems. And provided with significant reduction of pain. Patient could lead a better quality of life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Colemann RE. Clinical features of metastatic bone disease and risk of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res 2006;12:6243-49.  Back to cited text no. 1
    
2.
Borad MJ, Sadaati H, Lakshmipathy A, Camphell E, Hopper P, Jamson G, et al. Skeletal metastasis in pancreatic cancer: A retrospective study and review of literature. Yale J Biol Med 2009;82:1-6.  Back to cited text no. 2
    
3.
Pneumaticos SG, Savidou C, Korres DS, Chatziioannou SN. Pancreatic cancer's initial presentation: Back pain due to osteoblastic bone metastasis. Eur J Cancer Care 2010;19:137-40.  Back to cited text no. 3
    
4.
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108.  Back to cited text no. 4
    
5.
Lunardi S, Muschel RJ, Burunner TB. The stromal compartment in pancreatic cancer: Are there any therapeutic targets? Cancer Lett 2014;343:147-55.  Back to cited text no. 5
    
6.
Vincent A, Herman J, Schulick R, Hruban RH, Goggins M, et al. Pancreatic cancer. Lancet 2011;378:607-20.  Back to cited text no. 6
    
7.
Gardner MJ, Demetrakopoulos D, Shindle MK, Griffith MH, Lane JM. Osteoporosis and skeletal fractures. HSS J 2006;2:62-9.  Back to cited text no. 7
    
8.
Lossignol DA, Dumitrescu C, breakthrough pain: Progress in management. Curr Opin Oncol 2010;22:302-6.  Back to cited text no. 8
    
9.
McCall T, Cole C, Dailey A. Vertebroplasty and kyphoplasty: A comparative review of efficacy and adverse events. Curr Rev Musculoskelet Med 2008;1:17-23.  Back to cited text no. 9
    
10.
Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, et al. American Pain Society recommendations for improving the quality of acute and chronic pain management. American Pain Society Quantity of Care Task Force. Arch Intern Med 2005;165:1574-80.   Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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