Vertebral Fractures
Vertebral Compression Fracture Treatment
Vertebroplasty/Kyphoplasty
Cement augmentation is the term that best describes vertebroplasty. Kyphoplasty is a balloon assisted vertebroplasty. Cement injected into the fractured vertebra acts like an internal cast. This stabilizes the fracture which prevents pain and strengthens the vertebra so no further fracture or collapse will occur.
Indications for Vertebroplasty or Kyphoplasty
Treatment of painful vertebral compression fractures that have not responded to conservative management. Specifically if bed rest, pain medications and bracing over a 4-6 week period are ineffective in relieving the pain and the fracture healing, cement augmentation may be indicated.
Some patients with severe osteoporosis are incapable of producing enough bone to heal the fracture.
Medications can not be used due to side effects such as stomach ulcers, confusion and severe constipation.
Patient presents with severe pain and requires hospitalization for pain control.
Younger patients who have osteoporosis due to steroid treatment or a metabolic disorder.
Contraindications to Cement Augmentation Procedures
Back pain caused by herniated disks, arthritis or other causes of back pain not due to vertebral compression fractures.
Prophylactic use i.e., to prevent future fractures in osteoporosis or vertebral cancer.
Healed or healing vertebral compression fracture
Uncorrectable bleeding disorders
The Procedure
Vertebroplasty or kyphoplasty are done on an outpatient basis. The procedure is typically performed in the morning by an interventional radiologist and the patient is discharged in the afternoon.
The patient is positioned face down and connected to heart rate and blood pressure monitors.
Sedative medication is delivered intravenously. General anesthesia may also be administered.
The area in which the trocar (hollow needle) will be inserted is sterilized and covered with a surgical drape.
Local anesthesia is injected into the skin, muscles and bone near the fracture site, if sedation rather than general anesthesia is used.
Fluoroscopy is used to guide the trocar through the spinal muscles until the tip is inside the fractured vertebra.
PMMA is injected into the fracture. It hardens in twenty minutes.
Vertebroplasty vs. Kyphoplasty
There has been a great deal of debate over which is better; Vertebroplasty or Kyphoplasty. While there have been over 500 peer-reviewed publications on both procedures, few have been controlled properly (Mathis, 2006). A careful review of 69 studies revealed little proof that one procedure was superior to the other (Hulme, Krebs, Ferguson, & Berlemann, 2006).
The most common advantage cited for Kyphoplasty is that it better restores vertebral height. However, recent studies on Vertebroplasty have shown that it has similar outcomes as Kyphoplasty for restoring vertebral height (Hiwatashi, Moritani, Numaguchi, & Westesson, 2003) (Teng, et al., 2003).
Most skilled interventional radiologists are competent performing either procedure. Some prefer kyphoplasty since it involves the injection of viscous bone cement into a preformed cavity and in their individual experience is safer is that cement flow is better controlled and thus leakage of cement is less likely to occur.
Verbtebroplasty: Side (A) and Front (B) views with needle in place & cement delivery into fractured vertebra
Kyphoplasty: Side views showing inflation of balloon with some vertebral height restoration. Once balloon is removed the cavity created will be filled with cement.
Immediate Pain Reduction
Vertebroplasty stabilizes the collapsed vertebra using a specially formulated acrylic bone cement. It is a typically outpatient procedure (no hospitalization, no surgery) and requires only a local anesthetic. Once the area of the spine is numb, the doctor inserts one or two needles through a small incision.
Most patients experience pain reduction within hours. Best of all, most patients are able to resume their daily activities within 48 hours.
If you or a loved one may be suffering from pain associated with a vertebral compression fracture, we encourage you to contact an interventional radiologist for a consultation.
Potential Complications
The risk of procedural complications is extremely low in experienced hands. During injection, leakage of cement into the spinal canal can cause compression of neural structures and may, potentially, require surgical removal. Most leakages are asymtomatic.
Rib fracture or pedicle fracture can occur during needle placement and there is a theoretical risk of precipitating an adjacent vertebral fracture, though this remains controversial.
Bleeding and infection are rare.
Treatment
Copyright © 2008, Joel Garris MD, FACR. All rights reserved.
INTERVENTIONAL RADIOLOGY
Minimally Invasive Alternatives to Surgery
