eMedicine Specialties > Clinical Procedures > Interventional Radiology

Percutaneous Vertebroplasty

Author: Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University
Coauthor(s): Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Contributor Information and Disclosures

Updated: Jun 30, 2006

Introduction

Vertebroplasty is a minimally invasive, image-guided therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis or, less commonly, cancer. It also relieves the pain. Initially, the major indication was aggressive spinal hemangioma, but with experience, other indications have emerged. Vertebroplasty can prevent further vertebral collapse, increase the patient's functional abilities, and help achieve to the previous level of activity.

PVP usually involves percutaneous injection of a cement, polymethylmethacrylate (PMMA), into the vertebral bodies. Occasionally, PMMA has been placed manually into vertebral lesions during open surgical operations.

PVP with PMMA was performed first in 1984 and has been promoted by Jensen and Dion at the University of Virginia in the United States.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Vertebral Compression Fracture.

Indications

PVP is indicated for any pathology that weakens the vertebral body, with or without resultant spinal pain.

PVP has two objectives, analgesia and stabilization (ie, solidification).

PVP initially was used for vertebral hemangioma. It now is used primarily for osteoporotic vertebral fracture and occasionally for vertebral malignancy.

Treatment with PVP can be curative or palliative.

Osteoporotic Vertebral Fracture

Osteoporosis is complicated by vertebral fracture either spontaneously or from minor trauma. As many as 2 of every 3 vertebral fractures may not come to medical attention.

In the United States, the incidence of compression fractures is more than 500,000 patients per year, which is higher than the incidence of hip fractures.

In the European Vertebral Osteoporosis Study, prevalence of radiographically defined vertebral deformities was approximately 13% in women and 12% in men aged 65-69 years.

These vertebral fractures are often highly painful and are treated by immobilization, analgesic drugs, and specific treatment of osteoporosis. Immobilization increases demineralization.

In spite of long-term medical treatment, some patients have severe, persistent, incapacitating pain.

Initial symptoms tend to disappear in 4-6 weeks. Recurrent episodes of vertebral fracture are common and are a cause of significant morbidity.

Later consequences of vertebral fracture are reduced height, kyphosis, and chronic back pain.

In these situations, vertebroplasty alleviates symptoms and reduces the duration of immobilization. Additionally, vertebral fracture eventually may lead to reduced height and kyphosis. Vertebroplasty can alleviate pain symptoms and reduce the duration of immobilization and the likelihood of kyphosis and height loss.

Spinal Tumor And Vertebral Hemangioma

Spinal tumors

In painful vertebral metastasis (ie, previously untreated), radiotherapy is useful in 70% of patients to alleviate spinal pain, but this effect is delayed and may require 2-6 weeks.

Radiotherapy does not prevent vertebral crush due to tumor necrosis and secondary spine deformity.

Vertebroplasty produces analgesia by solidification of the osteolytic lesion. It is only a palliative treatment.

Vertebroplasty results in vertebral consolidation and spinal stability as well as quick (1-3 d) disappearance of pain. Results are better if spinal pain is the major symptom; more than 70% of these patients experience significant relief of pain and return to activities of normal living.

The excellent analgesic effect of vertebroplasty encourages treatment of other metastatic lesions outside the spine, especially hip metastases, by a percutaneous approach.

Vertebral hemangioma

Vertebroplasty is indicated for radiologically or clinically aggressive spinal hemangioma, with the following objectives:

• Analgesia
• Assist in radiculomedullary decompression
• Stabilize spine to avoid secondary deformity
• Stop pseudotumoral vascular malformation

Vertebroplasty has been used successfully in severe focal spinal pain with radiologically unaggressive vertebral (body) hemangioma; it has had a 90% success rate in providing long-term pain relief.

Patients in whom conservative therapy has failed have been treated with vertebroplasty.

Every patient needs a detailed physical examination and MRI prior to the procedure. The MRI is necessary to confirm that a patient's pain is not secondary to disk herniation, spinal stenosis, or infection. MRI also helps in planning the procedure, especially if the vertebral body is compressed severely.

Discuss the procedure with the patient and carefully explain the benefit-risk ratio.

Procedure

Materials

A Stryker precision delivery system costs approximately $600-700; a physician can customize it for $200.00. Materials include the following (see Image 1):

• Six-inch needle (DBMNJ1106-11G, MD Technologies)
• PMMA cement (Howmedica Simplex)
• Barium (opacifying agent) - Sterile barium sulfate, 6-g packets (Bryant Corporation)
• Syringes - 1-cc Luer-Lok syringes

Procedure

• Procedure time varies from 30-120 minutes.
• Conscious sedation (midazolam and fentanyl) and local anesthesia are used in almost all patients.
• Review the patient's record, including plain films and MRI, to identify the vertebra to be injected.
• Place the patient in the prone position.
• Align posterior ribs to obtain a good lateral view.
• On the anteroposterior (AP) view, find the obliquity that projects the pedicle over the upper outer third of the vertebral body. Mark this point.
• Use lidocaine for local anesthesia.
• Confirm proper needle path with AP and lateral fluoroscopic views.
• For large pedicles (ie, lumbar, lower thoracic), use an 11-gauge needle; use a 13-gauge needle for smaller pedicles (ie, midthoracic).
• Direct the needle into the vertebral body, using AP and lateral views for verification (see Images 2-4).
• Place the tip of needle in the anterior third of the vertebral body, since that is the portion of the spine that supports most of a person's weight.

Polymethylmethacrylate mixing and injection procedure

• Mix PMMA and barium sulfate (opacifying agent) using a sterile tongue depressor. Slowly inject this mixture until the vertebral body is well filled, making certain to stop before PMMA leaks posteriorly into the epidural area or significantly fills a vein.
• Although the goal is to fill the vertebral body as completely as possible, good pain relief is also possible with a modest filling.

Postprocedure care

• Keep patients on bed rest for a few hours after the procedure, mainly to allow anesthesia to wear off; PMMA hardens a few minutes after injection.
• Administer analgesics for postoperative pain and muscle relaxant for significant muscle spasms as needed.
• The patient may sit and stand the morning after the procedure.

Complications And Results

Fortunately, complications are rare.

Risks of the PVP procedure include infection, bleeding, contrast reaction, rib or pedicle fracture, worsening pain (from leakage of PMMA to epidural or foraminal veins), and paralysis.

Chiras et al reported incidents and complications in 274 patients. These complications were more common with malignant spinal tumor (10%) and vertebral hemangioma (2-5%) than with osteoporotic lesions (1-3%). In these authors' experience with PVP for osteoporotic vertebral fracture at 21 levels, no major complications occurred.

If the patient complains of chest pain following the procedure, exclude rib fracture by obtaining a rib series and pulmonary embolus by obtaining a ventilation/perfusion scan. Pulmonary embolism was reported after vertebroplasty, and outcome was favorable following anticoagulant therapy. Severe back pain can indicate a fractured pedicle or transverse process, which is observed easily on CT scan.

New radicular pain can be caused by migration of PMMA into the epidural venous plexus. CT scan demonstrates this easily. Include the levels above and below to look for migration at adjacent levels. Nerve root blocks may be effective, or laminectomy may be required.

Paralysis has been reported but is very uncommon. Take precautions while injecting above L1, with attention to the posterior vertebral body wall; do not allow PMMA to flow into the epidural venous plexus.

In the authors' study of vertebroplasty at 27 levels, the following results were obtained:

• Outcome criteria
  • Efficacy criteria were the relief in pain (percentages) on short-term (third day) and long-term follow-up study.
  • Patients were observed systematically for any possible complications.
• Results
  • PVPs were performed for 27 vertebral levels (17 thoracic and 10 lumbar).
  • Prior to each procedure, the patient's pain level was rated on a numeric scale (0-10); these ratings ranged from 5 to 10, with mean of 9.15.
  • On short-term follow-up observation on the third postprocedure day, 4 patients had less then 50% pain relief while 14 patients reported 50-100% relief, with a mean of 78%.
  • On long-term follow-up observation, 15 patients reported 50-100% pain relief, with a mean of 72.66%. No complications were reported during the intraoperative and postoperative periods.

Conclusion

PVP is a minimally invasive procedure with promising results for the treatment of vertebral fracture. It provides significant pain relief with the potential for improving functional outcome.

Multimedia

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Media file 1: Materials and devices for percutaneous vertebroplasty - Needle (11G, 6" [DBMNJ1106]); polymethylmethacrylate (PMMA) cement (Howmedica Simplex Codman Cranioplastic Kit); barium (opacifying agent, sterile barium sulfate, 6-g packets); syringes (1-cc Luer-Lok syringes).

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Media file 2: Percutaneous vertebroplasty, transpedicular approach.

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Media file 3: Percutaneous vertebroplasty, transpedicular approach under fluoroscopic guidance, lateral view.

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Media file 4: Percutaneous vertebroplasty, transpedicular approach under fluoroscopic guidance, anteroposterior view.

Keywords

PVP, cement injection, polymethylmethacrylate injection, PMMA, spine, vertebral fracture, vertebral malignancy, vertebral hemangioma, percutaneous vertebroplasty

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