Vertebroplasty - treatment of compression fractures

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Vertebroplasty
(Non-Surgical Treatment of Compression Fractures)

BOCA RATON
COMMUNITY
HOSPITAL
rated as one of the
"TOP HUNDRED HOSPITALS
IN THE COUNTRY"
DEPARTMENT OF
NEURORADIOLOGY

Background
Osteoporosis affects more than 30 million Americans. Compression fractures occur in more
than 500,000 patients per year in the US, are more frequent than hip fractures, and often
result in prolonged disability. Risk factors include advanced age, Caucasian or Asian race,
low weight, diseases such as kidney failure, and medication use such as prednisone.
Current preventative measures include calcium and vitamin D supplementation, exercise,
smoking cessation, and medications such as biphosphonates.
Management includes pain control with acetaminophen (Tylenol), non-steroidals (Motrin),
narcotics (Percocet), and bracing. Unfortunately, the compression fractures often progress
and develop at other levels resulting in loss of height, disability, and secondary
complications from immobilization including pneumonia and pulmonary embolism.
Percutaneous vertebroplasty has recently been introduced into the US as an effective
therapeutic and preventative treatment for the pain and progressive loss of height in
compression fractures.

What is Vertebroplasty?

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Vertebroplasty literally means fixing

the vertebral body. A metal needle is
passed into the vertebral body and a
cement mixture containing
polymethylmethacrylate (PMMA),
barium powder, tobramycin, and a
solvent are injected under imaging
guidance by the physician. The
cement hardens rapidly and
buttresses the weakened bone. The
barium makes the cement visible on
x-ray and the tobramycin is an
antibiotic. The procedure was
originally developed in France in 1984
and has been further refined in the
US since 1995.

How is it performed?
Usually, the procedure is performed in an interventional radiology suite with special x-ray
equipment (c-arm fluoroscopy) with nurses and technologists to help sedate the patient and
operate the equipment. The patient is placed prone on the x-ray table and made as
comfortable as possible. Sedation usually includes a narcotic (fentanyl) and a
benzodiazopine (versed), which are short acting and can be reversed if necessary.
The skin and underlying
tissues are anesthetized
with lidocaine and a special
bone needle is passed
slowly through the pedicle
into the vertebral body using
a slightly angled posterior
approach.
When the needle is in
appropriate position, a small
test injection with x-ray
contrast is performed to
ensure that a vein has not
been entered.
This prevents the inadvertent passage of cement into a
vein and embolization to the heart and lungs. The
needle is repositioned if necessary and the cement
mixture is slowly injected during constant x-ray
monitoring. When the potential spaces within the
vertebral body are filled, the needle is slowly removed
and the other half of the vertebral body is then filled
with the cement.
It usually takes approximately 30-60 minutes to perform one level. More than one level can
be performed if necessary during a single session. After the procedure, the patient is

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allowed to carefully ambulate and can usually go home within several hours. Most patients
experience significant pain relief within the firsts 1-2 days. Many can stop their pain
medications.

The Tools

Bone needles - Specifically made for

Tobramycin- an antibiotic
smooth passage through bone, can also powder used added to the
be used for biopsy (Cook Medical Co.) cement to prevent infection

PMMA -polymethylmethacralate, A
synthetic quick setting cement FDA
approved for human use in surgical
procedures

Barium - an inert powder

added to the PMMA cement
to make it visible on xray. It
is manufactured by Bryan
Corp.

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Case Presentations
Case 1 - Osteoporosis
This patient suffered from painful compression fractures. One had already significantly
collapsed while the other was just starting to collapse.

These images
demonstrate injection of
cement into both of these
vertebral bodies
alleviating the pain and
preventing further
collapse.

Case 2 - Metastatic breast cancer

This patient had disseminated
metastatic breast cancer to
bone and had received both
chemotherapy and radiation
therapy. She developed
paralysis and incapacitating

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pain. The MRI images show

extensive bone tumor with
collapse of the T10 and T11
vertebrae resulting in spinal
cord compression. There was
also extensive tumor in the
T12, L2, and L4 vertebrae.
Surgery with metal rod
stablization was planned but
there was fear that further
vertebral body collapse would
occur. Vertebroplasty was
therefore performed at T12,
L2, and L4.

The patient's paralysis quickly resolved with steroid administration (decreased tumor
swelling) and her pain was markedly decreased following the vertebroplasty. She left the
hospital without having any surgery.

Risks of Procedure
1) Leakage of cement into veins and or lungs
2) Infection
3) Bleeding
4) Rib or Pedicle fracture
5) Pneumothorax
6) Worsened pain
7) Paralysis secondary to leakage of cement
It should be noted that there have been very few reports of serious

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complications form this procedure in the US.

What are indications for Vertebroplasty?

1) Painful compression fracture secondary to osteoporosis
2) Painful compression fracture secondary to tumor which does not respond to
conventional therapy
3) Prevent further compression fractures
4) Buttress weakened bone for spine fusions
Please note that the procedure is generally used for the first indication and is
rarely used for the others.

Relative Contraindications
1) Young patient - the long term effects of the cement mixture are unknown
2) Vertebral bodies above the T5 level - the procedure is riskier and more
difficult
3) Patients with prior unsuccessful spine surgery

Patient Evaluation
1) History and Physical Examination
2) Current x-rays
3) MRI +/- bone scan

Follow Up Care
1) Pain medications - usually tapered over several days after procedure
2) Muscle relaxants
3) Adjust medications to prevent further mineral loss

Vertebroplasty Statistics
1) >80% moderate to marked pain relief
2) <5% induced fractures from procedure
3) <1% symptomatic embolism or infection

Contact Information

Dr. Jonathan Wiener

Director, MRI and Neuroradiology
Boca Raton Community Hospital
Boca Raton, Florida USA

Phone: (561) 265-1106 Fax: (561) 265-2760

E-mail: JWiener@BocaRadiology.com

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Website: http://BocaRadiology.com

BOCA RATON COMMUNITY

HOSPITAL
DEPARTMENT OF NEURORADIOLOGY
800 Meadows Road
Boca Raton, Florida USA 33486
rated as one of the
"TOP HUNDRED HOSPITALS IN THE COUNTRY"

American Society of
Neuroradiology, a subspecialty
organization committed to
excellence in clinical care and
research in imaging and
therapy of neurological disease
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02/12/2003