Vertebroplasty - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Vertebroplasty is an interventional radiological procedure used to relieve pain in patients with vertebral compression fractures. This procedure uses a special cement called PMMA (polymethyl methacrylate) that hardens inside the vertebra to support the fractured site. Vertebral compression fractures are a condition in which cracks and deformities the vertebra causes severe pain and decreases the height of the vertebra.

Vertebral compression fractures can occur from osteoporosis (a condition that makes the bone weak and brittle), accidents, infection, or malignancy. The thoracolumbar spine (T2-L2) is most commonly affected, followed by the lower lumbar region (L2-L5). Primary treatment options for vertebral compression fracture are analgesics (painkillers), physiotherapy, bed rest, and external orthosis (a band or appliance applies pressure to alter the function of the neuromusculoskeletal system).

According to the guidelines of the standards of practice committee of the society of interventional radiology, vertebroplasty is recommended in patients having painful vertebral fractures along with osteonecrosis (death of bone due to lack of blood supply), painful vertebral fractures with considerable osteolysis or patients with osteoporotic vertebral compression fractures which cannot be managed by medical treatment.

How Do the Patients Prepare for the Vertebroplasty Procedure?

• Patients are advised to take any of the following imaging techniques, such as spinal X-rays, MRI (magnetic resonance imaging), or CT (computed tomography), before the procedure to confirm the vertebral fracture.

• Medical conditions and regular medicines of the patients should be informed to the doctor.

• The patient should inform if pregnant, prior to the procedure.

• For osteoporosis patients, a dual-energy X-ray absorptiometry scan is advised (DXA) to confirm the compression fracture.

• 1 gm of Cefazolin is given intravenously (IV) as a prophylactic antibiotic an hour before the procedure. In patients with Penicillin or Cefazolin allergy, 500mg of Vancomycin may be given as a substitute.

• Patients are instructed not to take food or drink six hours before the procedure. They can take a small sip of water two hours before the procedure.

• Patients might be advised not to drive or operate machinery for about 24 hours after the vertebroplasty procedure. They have to arrange for someone to bring them home.

What Are the Recommendations for the Vertebroplasty Procedure?

• Patients who are taking Clopidogrel (an antiplatelet drug- a medicine that prevents aggregation of platelets) should stop taking them five days before the procedure with their physician's advice.

• Patients who are taking low molecular weight Heparin (LMWH) are advised to skip one dose of Heparin (anticoagulant- a drug that prevents blood clot formation) before the procedure.

• INR (international normalized ratio) or prothrombin time should be less than 1.5.

• Transfusion is required when the platelet count is less than 50,000.

How Is the Vertebroplasty Procedure Performed?

• Vertebroplasty is usually done by an interventional radiologist.

• During this procedure, the doctor inserts an intravenous (IV) line into the veins in hand to deliver the sedative to make the patients feel relaxed and sleepy. The vertebroplasty procedure usually requires moderate sedation. Sometimes, patients with severe pain may require general anesthesia to help them hold in place and be comfortable during the procedure. The patient’s heart rate, BP (blood pressure), oxygen level, and pulse rate are monitored throughout the procedure.

• Patients are asked to lie flat with their faces down on the procedure table. Then the nurse sterilizes the area where the needle will be inserted during the procedure. After that, a small incision is made through which the procedure is performed. In order to confirm the entry point, an anteroposterior X-ray view is taken.

• With the guidance of imaging techniques such as contrast-enhanced fluoroscopy, a hollow needle or trocar is inserted into the front of the middle third of the vertebra, which is confirmed with a lateral X-ray view.

• After confirming the final needle position with fluoroscopy, the mixed cement is injected into the vertebral body. Before injecting the cement, they should attain a paste-like consistency to prevent leakage into the surrounding structures. The cement is delivered evenly throughout the vertebrae by pulling back the needle slowly. Generally, 2.5 to 4 mL of cement is required to provide a good filling to a vertebra in osteoporotic fractures. AP (anteroposterior) and lateral X-ray views confirm the even distribution and no extravasation of cement outside the vertebra. When the cement reaches the posterior vertebral body, injection of cement is stopped. The vertebroplasty procedure takes about one hour to complete.

• Patients are instructed to avoid aggressive exercises and lifting heavy weights for about six weeks after the procedure.

What Are the Contraindications of Vertebroplasty?

Vertebroplasty is not recommended under the following conditions:

• Herniated disks (bulging out of the disc located between the vertebrae).

• Arthritic back pain (swelling of the joints between the spine).

• Patients with healed chronic vertebral fractures.

• Scoliosis (abnormal lateral curvature of the spine) or kyphosis (abnormal forward curvature of the spine) results not from osteoporosis.

• Severe bleeding disorder.

• Local or generalized infection.

• Allergic to the orthopedic cement- PMMA (polymethylmethacrylate).

• A tumor (cancer) with spinal canal involvement.

• Asymptomatic vertebral fractures.

• The fracture extended up to the posterior vertebral body.

What Are the Complications Associated With Vertebroplasty?

• Infection.

• Bleeding at the injection site.

• Damage to the spinal cord or nerve root.

• Sometimes, patients may have pain at the injection site for two to three days after the procedure. Placing an ice pack on the injection site may comfort them.

• There might be extravasation (leakage) of cement into the spinal canal, neuroforamen, paravertebral veins, or intervertebral disc (rubbery discs located between the vertebrae).

• Chances of rare complications such as cement particles entering the lungs and spinal stenosis (narrowing of the spinal canal spaces) from cement extravasation.

• New fracture adjacent to the compression fracture site.

• The high temperature of cement during polymerization (85-degrees Celsius) causes thermal (heat) damage to surrounding tissues.

• Neurological symptoms such as tingling (prickling sensation) and numbness (loss of sensation in body parts), and rarely paralysis.

• Severe back pain.

Conclusion:

Vertebroplasty is used to relieve extreme pain in patients with vertebral compression fractures. This procedure prevents the need for painkillers for patients with compression fractures on a daily basis. Vertebroplasty improves the patient's movement and gives structural support to the vertebra. The major advantage of vertebroplasty over kyphoplasty (a procedure used to treat vertical compression fracture in which a balloon is inserted into the vertebra, which is then inflated to create space for cement) is that it can be performed under local anesthesia or conscious sedation and general anesthesia is not required in every case as in kyphosis. Vertebroplasty is cost-effective when compared to kyphoplasty. Vertebroplasty usually provides immediate relief from the symptoms of vertebral compression fracture, or it may take up to 48 hours, and it may vary sometimes.