Last Updated on November 24, 2023
Vertebroplasty is a minimally invasive procedure where the fractured vertebra is approached percutaneously (after making a small hole in the skin) and cement is injected into the fractured vertebra. Vertebroplasty was introduced to relieve the pain of osteoporotic fractures.
Vertebroplasty is also used as palliative treatment in painful spinal tumors and vertebral hemangioma to provide pain relief.
It was first described by Galibert and colleagues in 1987 and is considered a safe and minimally invasive procedure for vertebral compression.
Another procedure that aims to restore the height of the vertebra is kyphoplasty which is discussed separately.
Need for Vertebroplasty
Compression fractures occur because of axial loading and result in wedge-shaped vertebrae where the height of the anterior part of the body of the vertebra is reduced.
Compression fractures can be due to osteoporosis resulting in weakened bones. These are also caused by high-impact injuries and other pathologies that cause the weakening of the bone.
These fractures often can lead to severe and disabling back pain that could further lead to decreased quality of life and morbidity.
Most of these compression fractures can be treated by analgesics, rest, and other conservative means.
However, about 30% of the patients are not relieved by the conservative approach and
When Vertebroplasty Should Be Considered?
Indications
- Persistent Pain in Compression Fractures: If significant pain persists for more than 2-4 weeks and is not getting better, stabilization of the fracture may bring the pain relief quicker.
- Worsening Pain on loading: Some fractures get better with conservative measures but still pain when the spine is loaded as in a standing position.
- Painful metastasis
- Multiple myeloma
- Painful vertebral hemangiomas
- Vertebral osteonecrosis
- Strengthening of weak vertebral bodies in a pathology prior to surgical stabilization
The most common indicationof vertebroplasty by disease is an osteoporotic fracture. However, other conditions which have been treated by percutaneous vertebroplasty and can be considered are
- Multiple myeloma
- Metastatic disease
- Aggressive hemangioms
- Osteonecrosis [Kummel Disease]
- Paget disease
- Langerhans cell histiocytosis
The vertebroplasty is considered only if there is
- No neural deficit
- No kyphosis
- The fracture is still healing and has not already healed
Contraindications
Absolute
- A fracture without symptoms
- Healed fracture [in spite of pain, generally around 4-6 weeks after injury]
- Infection of the target vertebra
- Coagulation disorder that is not correctable
- Allergy to vertebroplasty cement or opacifying agent
Relative
- Significant central canal narrowing from retropulsion
- Breach of posterior vertebral wall
- Active systemic infection
- Myelopathy or radiculopathy from fracture level
Preprocedural Work-up
A clinical diagnosis is made and the need for the procedure is identified and discussed with the patient. Patients should undergo appropriate imaging to ascertain or rule out the suitability of the procedure.
MRI
MRI is able to confirm the fracture, tell about detailed fracture patterns, and may be able to exclude any concomitant conditions that may preclude the procedure.
CT/Bone Scans
These are considered in patients who cannot undergo MRI procedures. CT allows evaluation of bony integrity on the posterior wall of the vertebral body [a differentiation from burst fracture].
Bone scans may also be considered in patients not able to get an MRI done.
Lab Tests
Investigations for anesthetic fitness are done. The blood coagulation profile is very important.
Procedure of Vertebroplasty
Vertebroplasty is a minimally invasive procedure and it is performed under local anesthesia.
Patient is usually asked to fast for 6-8 hours before the scheduled time though sips of water are allowed till before two hours of the procedure. A change or stoppage of medications may be warranted as a requirement for anesthesia.
Steps
- Position – prone
- After preparation of the region for sterility, local anesthesia is given
- A small nick is made in the skin and a bone biopsy needle is guided into the fractured vertebra through it under the fluoroscopic imaging
- In severe compressions, two needles may be used for even distribution of cement
- PMMA (polymethyl methacrylate) is the cement that is commonly used for injecting so that it fills the cracks
- The cement volume will vary from 3-6 ml
- The goal is to deliver cement evenly
- Two needles may be used when distribution across the midline is not satisfactory
- The needle is removed and the wound is dressed
- Bedrest at home is advocated for 24 hours or so
- Strenuous activities are prohibited for 4-6 weeks
Procedure time varies from 30-120 minutes.
Patients report pain relief within 1-2 days
Complications of Vertebroplasty
As such the procedure is quite safe in properly selected patients. But like other invasive procedures, the procedure carries some risks including serious ones.
The potential complications that occur with the procedure are-
- Neurologic deficits including paralysis
- Injury to rib, vertebra
- Infection
- Allergic reaction
- Cement leakage
- Generally symptomless
- Root deficit if in the vicinity of the nerve root
- Pulmonary embolism
- Bleeding
- Pneumothorax or hemothorax
The following factors are associated with the risk of the procedure being unsuccessful
- Delay in the procedure
- If surgery is not done by 8 weeks because the fracture has started healing by then and procedure cannot have the desired effect
- Pathological compression fracture due to malignancy
- Associated with a higher rate of complication
Efficacy of Vertebroplasty
The verdict as of now is mixed. Some studies have found the procedure to be effective whereas others failed to find any benefit. However, an increasing number of current studies have emphasized that vertebroplasty could be effective at bringing pain relief and improving function quicker than conservative measures.
References
- Beall D P, Datir A, D’Souza S L. et al. Percutaneous treatment of insufficiency fractures : principles, technique and review of literature. Skeletal Radiol. 2010;39(2):117–130. [Link]
- Vallejo R, Benyamin R. Vertebral augmentation techniques for the treatment of vertebral compression fractures: a review. Reg Anesth Pain Manag. 2010;14(3):133–141.
- Cortet B, Cotten A, Boutry N. et al. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J Rheumatol. 1999;26(10):2222–2228. [Link]
