Vertebroplasty Procedure

Vertebroplasty denotes a shorter term for percutaneous vertebroplasty, which is an image-guided therapeutic practice used for the treatment of painful or unstable vertebral body compression fractures that are unresponsive to conservative therapy. In this procedure, a trocar is placed into a fractured vertebral body, followed by the application of an acrylic polymer that provides bone augmentation and prevents further collapse.

Before vertebroplasty was introduced, vertebral compression fractures were essentially the only type of fractures not treated orthopedically. They were treated conservatively, relying on bed rest and the administration of analgesics – neither of which are completely benign and without any adverse effects.

The principal aim of vertebroplasty is to alleviate pain and improve mobility of the patient, while vertebral body stabilization is considered a secondary goal. Thus this modality of treatment is directed towards affected individuals (and especially elderly patients) who had a reasonable course of medical therapy, but are still suffering pain.

Technical aspects of vertebroplasty

Vertebroplasty is most often performed in an outpatient basis, thus important preprocedure instructions should be provided at the time of the evaluation. This method of treatment should be avoided in individuals with known infections and fevers, but also in those with elevated white blood count. General anesthesia is usually not administered, but can be an option when dealing with uncooperative patients or patients in extreme pain.

Different vertebroplasty techniques emerged based upon predominantly North American and European experiences, although variations between them are mostly minor and related to the availability of equipment and products utilized, as well as the operator’s training and personal style.

Needle placement within the vertebral body has been guided either by standard fluoroscopy, CT-guidance or CT fluoroscopy. Regardless of the modality used to position the needle, acrylic injections is a venous embolization, thus it should always be performed under continuous, high-quality fluoroscopic observation.

Vertebroplasty can restore vertebral height in cases of fragment instability with intravertebral clefts, which indicates non-union of the fracture fragments. Vertebroplasty of the thoracic and lumbar spine is commonly performed by a transpedicular or parapedicular approach, and the patients are in the prone position.

A myriad of bone cement types are commercially available, although they vary in terms of cost, polymerization rate, radio-opacity and biocompatibility; polymethylmethacrylate is most frequently used for vertebroplasty. The end-goal is to deliver the cement evenly in the vertebral body in order to stabilize the fractured vertebra (increasing its mechanical strength), avoiding at the same time extra-vertebral cement delivery.

Postprocedural course

In an outpatients setting, the majority of patients that undergo vertebroplasty are observed for only two hours before being discharged. Individuals remain in supine position for one hour and are gradually allowed to sit up or stand over the next hour (under direct supervision of a physician or a nurse).

Most patients experience immediate pain relief, which can be a result of thermal necrosis and chemotoxicity of the intraosseous pain receptors, but also due to ischemia and mechanical stabilization of the vertebral body. Focal pain at the puncture sites lasting up to 48 hours is commonly observed.

Complication rates associated with vertebroplasty are low and range from 1 to 10% depending on the initial indications. They can include spinal cord or nerve root compression, rib fracture, pulmonary embolism, epidural abscess, paravertebral hematoma, and sometimes seizures or respiratory arrest due to oversedation.

Percutaneous vertebroplasty has gone a long way from an obscure treatment technique to a highly utilized technique that consistently benefits a significant proportion of patients around the world. The practice of vertebroplasty continually grows both in size and scope, fostering new research, developments and products.