Perioperative care for vertebral augmentation

Preoperative care

Various procedures are used today for vertebral augmentation, including percutaneous vertebroplasty, balloon augmentation, vertebral osteotomy augmentation, and kyphoplasty—for example, the SpineJack system (Stryker, Michigan, USA). Preoperative, intraoperative, and postoperative care for each procedure remains mainly similar but considerations for each procedure must be made. Prior to the procedure, a patient must meet the indications for undergoing a vertebral augmentation. Current guidelines state that a patient may be eligible for vertebral augmentation if the patient has severe limitation of function due to pain or hospitalization due to a vertebral compression fracture (VCF), a history of VCFs, and physical examination shows tenderness with palpation or percussion over the spinous processes that is further confirmed by imaging showing VCF. Contraindications for the procedure include patients with an underlying infection, osteomyelitis, or other surgical site infections. An additional contraindication is that patients with osteoporotic compression fracture may benefit from medication management as the use of kyphoplasty and vertebroplasty in acute osteoporotic compression fractures may have limited benefit per current research. Another relative contraindication for a kyphoplasty may be a VCF with a posterior cortical breach. Prior to the procedure, various labs and diagnostic tests are ordered for operative clearance: complete blood count (CBC), basic metabolic panel (BMP), prothrombin time and international normalized ratio (PT/INR), and review of all X-ray and magnetic resonance imaging (MRI). One reason for the lab workup includes ruling out reduced kidney function to avoid exacerbating the condition due to contrast-induced nephropathy. Prior to the procedure, anticoagulation and antiplatelet medications are put on hold per guidelines for spinal anesthesia. In many cases, aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are also held for 7 days and 2 to 3 days prior to the procedure, respectively.

Intraoperative care

In general, patients typically undergo a vertebral augmentation procedure in an outpatient surgical center. Patients typically receive local or mild sedation. However, in some situations, general anesthesia may be advised. The type of sedation administered typically will correlate to the procedure being done, number of compression fractures, and the length of the procedure. The treatment of a single-level VCF generally has a total procedure time of less than 1 hour and local anesthesia is typically used. In cases in which multilevel VCF treatment is being done, general anesthesia may be a consideration. Several complications can occur during and after both kyphoplasty and vertebroplasty procedures. Some complications include spinal cord compression, embolism, infection, and radicular pain. Local cement leakage is another complication with both vertebroplasty and kyphoplasty, with vertebroplasty showing a higher percentage of patients with local cement leakage.

Postoperative care

In general, postoperative care for vertebral augmentation includes the application of an adhesive bandage at the puncture site. After completion of the procedure, patients are typically discharged home from the post-anesthesia care unit or recovery room several hours after the procedure. During their stay in the recovery room, various signs indicating allergic reactions are closely monitored and appropriately treated. One of the most important parts of postoperative management after vertebral augmentation is the treatment of postoperative pain. The use of ice at the surgical site is recommended for pain relief and discomfort. In addition, a short course of opioids is the first-line treatment for post-procedural pain, with the goal of tapering those medications and transitioning to acetaminophen and NSAIDs for pain relief.