Introduction
Percutaneous vertebroplasty is an image-guided procedure for the injection of bone cement into the vertebral body. The benefits of vertebroplasty include bone strengthening and potential decompression of spinal nerves with increased mobility to improve quality of life.
Vertebroplasty is indicated for patients with osteoporotic vertebral body collapse and osteolytic metastases or myeloma who have severe pain refractory to conservative pain medication management. Vertebral body compression fractures are estimated to occur approximately 700,000 times each year. Vertebroplasty is recommended and performed by some providers for immediate pain relief and decompression shortly after vertebral body collapse. However, standard medical treatment includes analgesics, rest, and external bracing. Typical improvement occurs over 4 to 6 weeks and approximately two-thirds of patients will improve with only conservative management. The most common indication for vertebroplasty is treatment of acute vertebral body compression fracture for patients who do not respond to conservative medical therapy after 6 weeks.
Vertebroplasty and kyphoplasty are performed similarly. However, a kyphoplasty enables the option for a biopsy to be taken or a drill to be utilized to create a path for a balloon tamponade system. In contrast to vertebroplasty, kyphoplasty is usually performed via a bipedicular approach.
Indications
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Treatment of painful vertebral compression fractures secondary to osteoporosis refractory to conservative management
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Treatment of painful vertebral compression fractures secondary to metastatic neoplasia refractory to conservative management
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Patients are best identified by looking for the appropriate symptoms and signs, which include:
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Fractures that occur with little or no trauma
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Deep pain with sudden onset
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Midline location of pain
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Exacerbation of pain with axial loading
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Pain refractory to conservative management
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Pain exacerbated by motion (especially twisting)
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Point tenderness over fractured vertebra
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Vertebroplasty is not indicated for patients with mild to moderate pain responding to medical management. The American Society for Bone and Mineral Research advises to avoid vertebroplasty for patients with acute osteoporotic vertebral fractures.
Contraindications
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Active systemic infection
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Uncorrectable bleeding diathesis
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Insufficient cardiopulmonary health to safely undergo the necessary anesthesia
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Myelopathy secondary to epidural tumoral extension
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Allergy to bone cement
Perioperative considerations
All patients should not eat or drink for at least 6 hours prior to the procedure. The required level of sedation may vary from local anesthesia and moderate sedation to general anesthesia. That said, having the patient awake is desirable because it allows real-time feedback that can inform the practitioner of potential intraoperative complications or neurological dysfunction. In all cases, sedation and monitoring are performed by anesthesiologists, nurse anesthetists, or certified nursing personnel. For anticoagulation status and recommendations regarding antibiotic prophylaxis, refer to previously published guidelines.
Trajectory safety considerations
Anteroposterior view safety considerations
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Avoid spinal cord and thecal sac by staying lateral to medial border of the pedicle ( Fig. 4.1 ).
Fig. 4.1
Proper needle trajectory pathway from lateral view ( top ), anteroposterior view ( middle ), and axial view ( bottom ) with alignment correction recommendations.
(Courtesy Medtronic.)
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Avoid nerve roots and spinal nerves by staying within the pedicular borders ( Fig. 4.2 ).
Fig. 4.2
(A) Fluoroscopic image of a trajectory view with the affected L3 vertebral body “squared off” with the pedicle in line with the vertebral body. Cannulate the vertebral body in the trajectory view. (B) Radiopaque structures. (C) Radiolucent structures.
(From Furman MB, Frey ME. Sacral insufficiency fracture repair/sacroplasty. In: Furman MB, Berkwits, Cohen I, et al., eds. Atlas of Image-Guided Spinal Procedure . 2nd ed. Elsevier; 2018:337–348; Fig. 19.1.)
Lateral view safety considerations
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Once through the pedicle, view the cannula tip in the lateral view, which should be seen at the posterior vertebral body wall (see Figs. 4.1 and 4.3 ).
Fig. 4.3
(A) Fluoroscopic image of a lateral view with the osteo introducer cannula passing through the pedicle. (B) Radiopaque structures, lateral view. (C) Radiolucent structures, lateral view.
(From Furman MB. Sacral insufficiency fracture repair/sacroplasty. In: Furman MB, Berkwits, Cohen I, et al., eds. Atlas of Image-Guided Spinal Procedure . 2nd ed. Elsevier; 2018:337–348; Fig. 19.3.)
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Penetrating the anterior vertebral body could damage the aorta/inferior vena cava.
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Improper trajectory could penetrate the inferior wall of the pedicle resulting in possible spinal nerve damage.
Step-by-step procedural description
Pedicular advancement
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Confirm the vertebral level with the anteroposterior view.
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Craniocaudally tilt the C-arm to level the inferior end plate of the targeted vertebral body (see Fig. 4.2 ).
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Tilt the C-arm ipsilateral oblique, usually 10 to 20 degrees, with the pedicle appearing as a rounded clock face, so that the pedicle is superimposed within the outline of the vertebral body ( Figs. 4.4 and 4.5 ).
