Treatment of Malignant Vertebral Fractures With Percutaneous Balloon Kyphoplasty. (KYPHOK)
Balloon Kyphoplasty is an alternative to vertebroplasty in the treatment of painful malignant vertebral fractures. This is a mini-invasive percutaneous treatment, aiming to stabilize the vertebral fracture, decrease of pain. This technique also improves patient function. Namely, bedridden patients are often able to resume walking in the days following vertebral cement injection. Advantage of Balloon Kyphoplasty as compared to vertebroplasty is the ability to inject the cement into the diseased vertebral body which shows cortical destruction with lower pressure, thereby possibly reducing cement leakage and related complications.
This is a multicentric, observational prospective study. Patients are evaluated before and after the procedure.
Sixty women or men older than 18 years, with 1 to 3 painful vertebral fracture(s) of malignant origin (due to multiple myeloma or osteolytic vertebral metastasis) will be enrolled. Each patient will be followed during 1 year after the procedure with 7 visits at D-8, D-1, D1, D15, D90, D180, and D360 or until the death of the patient.
The main evaluation outcome is patient self-global satisfaction regarding the procedure on a semi-quantitative satisfaction scale, 15 days after the Balloon Kyphoplasty.
Device: balloon kyphoplasty
|Study Design:||Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Assessment of Percutaneous Balloon Kyphoplasty in the Treatment of Malignant Vertebral Fractures (Multiple Myeloma and Osteolytic Metastases) : "Observational Study"|
- Percentage of patients having a residual pain of ≤ 35mm on a VAS scale or a 50 % decrease in daily morphine dose at day 15 after Balloon Kyphoplasty compared to day 0 (day of procedure). [ Time Frame: day 15 ] [ Designated as safety issue: Yes ]
- 1° Clinical Outcomes:· Pain evaluation using a visual analogic scale [ Time Frame: D-8-D-1, D2 to D5, d15, D90, D180; D360 ] [ Designated as safety issue: Yes ]
- quality of life evaluation (SF 12). [ Time Frame: D-8 to D-1, D2 to D5, D15, D90, D180; D360 ] [ Designated as safety issue: No ]
- Assessment of the pain due to the compression fracture using a VAS scale in the same position as at the inclusion visit (standing or lying down), [ Time Frame: D-8 to D-1, D2 to D5, D15, D90, D180; D360 ] [ Designated as safety issue: Yes ]
- Assessment of the patient global satisfaction score using a LICKERT Scale, [ Time Frame: D-8 to D-1, D2 to D5, D15, D90, D180; D360 ] [ Designated as safety issue: No ]
- Percentage of patients who estimate than the pain due to the compression has decreased by more than 50% after the procedure, [ Time Frame: day 15 ] [ Designated as safety issue: No ]
- · Percentage of patients who give a positive answer to the following question: "would you agree to undergo a new Balloon Kyphoplasty in case you need it?" [ Time Frame: D2 to D5, D15; D90 ; D180; D360 ] [ Designated as safety issue: No ]
- Time elapsed between Balloon Kyphoplasty procedure and patient get up. [ Time Frame: D2 to D5; D15;D90 ] [ Designated as safety issue: No ]
- Resumption of the upright position for patients confined to bed due to their vertebral fracture [ Time Frame: D2 to D5; D15 ] [ Designated as safety issue: No ]
- Local and general complications related to cement leakage at each vertebral level treated. [ Time Frame: each visit ] [ Designated as safety issue: Yes ]
- 2° Radiological Outcomes: · Modification of the regional kyphosis angle measured by the Traumatic Regional Angle (ART - STAGNARA and NIEDERMANN) for compression fractures of T10 to L5 [ Time Frame: D2to dJ5-d15-d90.-d180- d360 ] [ Designated as safety issue: No ]
- Modification of the global Thoracic and lumbar kyphosis angles. [ Time Frame: D2 to d5 - D15 - D90 - d180 - d360 ] [ Designated as safety issue: No ]
- 3° Therapeutic Outcomes :· Need for radiation at day 30 after Balloon Kyphoplasty in patient presenting with Multiple Myeloma. [ Time Frame: D30 ] [ Designated as safety issue: Yes ]
|Study Start Date:||October 2007|
|Estimated Study Completion Date:||November 2010|
|Primary Completion Date:||November 2009 (Final data collection date for primary outcome measure)|
Device: balloon kyphoplasty
A bilateral approach is chosen to insert working cannulas into the posterior part of the vertebral body through a posterior transpedicular approach.Once inserted, the balloons are inflated using visual, volume and pressure control to create a cavity.The balloons are then deflated and removed. The Bone Filler Device is then advanced through the working cannula towards the anterior part of the cavity and cement is slowly extruded by a stainless steel stylet, acting as a plunger. When the amount of cement from the first Bone Filler Device is delivered in the cavity, it is removed and another Bone Filler Device is advanced through the working cannula.
Vertebral compression fractures (VCF) represent an important source of morbidity in patients presenting osteolytic metastatic or myelomatous vertebral involvement. In addition, cancer treatments may induce osteoporosis with an additional risk of vertebral fractures.
- Current medical treatments are symptomatic. They do not treat the fracture itself.
- Vertebroplasty is an interventional radiological technique that consists of injecting, percutaneously, acrylic cement into the fractured vertebra under radiological guidance and local or general anaesthesia, in order to combine two effects: stabilization of the vertebral body fracture and pain reduction.
- Balloon Kyphoplasty is a variant of vertebroplasty which is performed using the KyphX® System (Medtronic., Sunnyvale, California). Balloon kyphoplasty aims at restore vertebral height of the fractured vertebra using an inflatable balloon prior to inject surgical polymethylmetacrylate (PMMA)cement,into the vertebral body to fix the fracture. It is an expensive technique costing around 4,000 euros for up to 2 vertebrae in the same patient. The surgical technique for the procedure has been described by LIBERMEAN et al: A bilateral approach is usually chosen to insert working cannulas into the posterior part of the vertebral body through a posterior transpedicular approach. In case of limited and asymmetric vertebral destruction, a single unilateral approach may be preferred. Fluoroscopy is used to insert the tools and control the procedure. With reaming tools, two working channels are created and the balloons are inserted. The balloons are available in lengths of 10, 15 and 20 mm.
The two balloons (one on each side) should ideally be centered at middle height between the superior and inferior endplates and in the anterior two-thirds of the vertebral body. Balloon placement into the vertebral body is checked using radiopaque markers at the two extremities of the balloon. Once inserted, the balloons are inflated using visual, volume and pressure control to create a cavity. Inflation is stopped when one of the following inflation endpoints is reached: pressure raised over 400 psi, balloon contacts one of the cortical bone of the vertebra or reaching maximal balloon inflation volume. The balloons are then deflated and removed. The mean balloon inflation volume is 2 to 3ml. The Bone Filler Device, filled before with 1.5 ml of PMMA, is then advanced through the working cannula towards the anterior part of the cavity and cement is slowly extruded by a stainless steel stylet, acting as a plunger. When the amount of cement from the first Bone Filler Device is delivered in the cavity, it is removed and another Bone Filler Device is advanced through the working cannula. This step is repeated till a complete fill of the cavity is obtained. The same procedure is repeated through the other working cannula at the contra-lateral pedicle. Filling of the cavity with highly viscous PMMA is performed under continuous fluoroscopic control.
The aim of this study is to quantify the analgesic and patient function improvement of Balloon Kyphoplasty together with complication types and rate in patients with malignant vertebral fractures due to metastatic disease or multiple myeloma.
|Hôpital Henri Mondor - Service de Radiologie|
|Creteil, Val de Marne, France, 94000|
|Hôpital Cochin - service de radiologie|
|Paris, France, 75014|
|Hôpital Lariboisière-service de radiologie ostéoarticulaire|
|Paris, France, 75010|
|Hopital Bichat -service de radiologie|
|Paris, France, 75018|
|Study Director:||Jean-Denis LAREDO, M.D.,PR.||Assistance Publique - Hôpitaux de Paris|
|Principal Investigator:||Antoine FEYDY, M.D., PhD||Assistance Publique - Hôpitaux de Paris|