Vertebroplasty

Vertebral fractures (vertebral body compression fractures) are common causes of severe and disabling back pain. Due to severe pain, protracted immobilization, kyphosis, lung deterioration, depression, and loss of independence, many patients may have significant morbidity and a lower quality of life. Patients with vertebral fractures (VF) are also more likely to develop persistent back pain and have higher mortality rates.

Osteoporosis is the most common cause of VF. Primary and metastatic cancers, trauma, hemangioma, and osteonecrosis are among the other reasons. In the United States, more than 750,000 osteoporosis-related VF cases are identified each year, leading to approximately 117,000 hospital admissions. VF affects 1.45 million individuals worldwide each year, with a lifetime risk of 17 percent for women and 5 percent for men.

Conservative medical therapy, which includes analgesics, bed rest, and external bracing, is the conventional treatment for symptomatic VF. Symptoms usually improve in four to six weeks, and around two-thirds of patients respond to conservative therapy alone. However, up to a third of patients receiving conservative medical treatment may not recover and will require other treatment.

Galibert and colleagues first described vertebroplasty (VP) in the 1980s, and it has since been a commonly used alternative treatment for symptomatic VF that has failed to respond to conventional therapy. VP is a minimally invasive image-guided technique that involves injecting bone cement into a vertebral body fracture to reduce pain and increase fracture stability. Polymethyl methacrylate (PMMA) is still the most extensively used cement.

Vertebroplasty Indications

Management of painful acute and subacute VF in patients who have failed to respond to a 4- to 6-week course of adequate medical treatment is the most common indication for VP. Minimal or no pain control with prescribed painkillers, or inadequate pain relief in individuals who are unable to take narcotics due to undesired side effects such as drowsiness, disorientation, and constipation.

Osteoporosis is by far the most frequent underlying cause of painful VF. Metastatic cancer, multiple myeloma, and painful aggressive hemangiomas are also common causes. Pain from osteonecrosis (Kummel disease), Paget disease, Langerhans cell histiocytosis, osteogenesis imperfecta, spinal pseudarthrosis, and intravertebral vacuum phenomena are among the less frequent indications for treatment. Prior to surgical stabilization, VP has also been used to treat painful Schmorl nodes and to reinforce pathologically weak vertebral bodies.

Vertebroplasty Contraindications

Therapy of asymptomatic VF and treatment of patients who are improving with conservative medical care are absolute contraindications. Prophylactic medication in people with osteoporosis who do not have a VF is not considered an acceptable indication. Uncorrectable coagulopathy and active local or systemic infection are also absolute contraindications. VP is not recommended if you are allergic to PMMA or other bone cement preparations. Disruption of the posterior vertebral body wall or tumor expansion into the spinal canal is a relative contraindication. A relative contraindication is a treatment of very badly compressed VF, which is described as vertebral body collapse to less than one-third of its original height. These fractures are more technically difficult to treat and are generally associated with a higher incidence of complications. Although there is research on how these patients respond to VP, a recent clinical study showed that individuals with severe compression fractures can be successfully treated and may improve after VP.

When to Consider Vertebroplasty?

The majority of spinal compression fractures do not require surgery. However, if the following conditions are met, vertebroplasty may be considered:

• Pain lasts for at least two weeks. If the pain does not improve within a week or two, surgery to fix the compression fracture may be a better option than other treatments. Vertebroplasty is usually done four to six weeks after the fracture occurs.
• Pain worsens with axial load. If pain worsens when weight is applied to the spine from above, such as when getting out of bed or carrying a heavy object, the vertebral compression fracture is more likely to be the source of the discomfort and would benefit from a vertebroplasty treatment.
• No associated neurologic deficits. Vertebroplasty is unlikely to improve neurological deficits such as tingling, numbness, weakness, and/or coordination issues if any component of the bone is pressing against the spinal cord or a nerve root and producing neurological impairments.
• No significant kyphosis or other spinal deformities. Vertebroplasty simply cements the vertebra in place, which is fine if the spine is near normal shape. A separate procedure called kyphoplasty may be recommended if one or more vertebral compression fractures have forced the spine to curve too far forward (kyphosis). Kyphoplasty is equivalent to vertebroplasty in that it helps restore injured vertebrae to their natural height, correcting kyphotic deformities. Other forms of deformities may necessitate a different surgery, such as a fusion.
• Fracture does not heal. Vertebroplasty is unlikely to help relieve discomfort if the compression fracture has previously healed.

Furthermore, the patient must be in good enough health to undergo surgery. If a bone infection is present, or if surgery would be difficult to tolerate, surgery should be avoided.

Vertebroplasty Preparation

The purpose of a vertebroplasty operation is to cease the painful motions of a spinal compression fracture by stabilizing it. Because vertebroplasty is performed by a tiny opening in the skin rather than an open incision, it is considered a minimally invasive procedure. A normal vertebroplasty treatment lasts approximately one hour.

If you have back discomfort, which is the most common sign of an injured vertebra, you will be recommended for vertebroplasty. However, it is important to confirm that the pain you are experiencing is due to a vertebral body fracture and not to other illnesses that might cause back discomfort, such as arthritis. A magnetic resonance imaging (MRI) scan is the most accurate way to determine the source of pain.

However, because MRI scanning uses magnetic fields, you will be unable to undergo an MRI if you have a pacemaker, metal pieces, valves, clips, or implants in your body. There are other causes why MRI scanning may not be appropriate for you, which you should address with your doctor.

Alternatives to MRI include computed tomography (CT) scans and nuclear bone scans, but if you have multiple fractures, it may be difficult to determine which one is causing your discomfort without an MRI.

Before the vertebroplasty procedure, medical disorders such as diabetes, hypertension, or anticoagulant (blood-thinning) medication must be controlled.

Because you will be given sedation to make you sleepy, you must fast for at least 6 hours before the surgery. It is not required to stop consuming clear liquids, but milk and other comparable liquids (including soups) should be avoided.

At the time of booking the procedure, a preparatory sheet with full instructions is usually provided.

You have to contact your doctor or the hospital or radiology clinic where you will be having the treatment if you have any questions about the procedure's preparation.

Vertebroplasty Procedure

While there are several differences in how vertebroplasty is performed, the following is the standard procedure:

• The patient is taken to an x-ray suite or operating theater, where he or she lies comfortably face down on a cushioned table for the surgery.
• The area of the back where the needle will penetrate has been sterilized.
• The patient is given local anesthetic and light sedation. Although there should be no pain in the area where the treatment is performed, the patient is usually awake and responsive throughout.
• A bone biopsy needle is guided into the broken vertebra by a tiny opening in the skin using contrast-enhanced fluoroscopy, which presents x-ray pictures on a video monitor in real-time. Fluoroscopy is required to place the needle inside the vertebral compression fracture without harming a surrounding vital structure, such as the spinal cord.
• PMMA, a specifically formulated bone cement, is injected into the damaged vertebra under pressure. The bone cement covers the gaps in the bone and acts as an internal cast to keep the vertebral bone stable.
• The needle is withdrawn, and the cement solidifies fast (in about 10 minutes), congealing and stabilizing the shattered vertebra fragments.
• A bandage is applied to the minor skin puncture.
• The patient is usually monitored for a few hours to ensure that the drugs have gone and the bone cement has solidified without causing problems. Before being allowed to carefully move around, some surgeons may want the patient to remain recumbent (laying down) for an hour or two.

The patient is allowed to leave the medical institution after the post-procedure observation period is completed and can return home the same day. Patients are typically advised not to drive themselves home on the day of the treatment, therefore, a friend or family member may be required to provide transportation. A short stay in the hospital may be indicated if the patient requires additional supervision after the treatment, is especially frail, or will require support at home.

Recovery from Vertebroplasty

Bedrest or taking it easy at home for the first 24 hours following vertebroplasty is frequently recommended. Most routine medications can be continued and activity levels can be progressively increased. There may be some discomfort at the puncture site for a few days, which can be eased with an ice pack.

Within 24 to 48 hours of surgery, the majority of patients experience pain relief. Returning to more rigorous physical activity, such as sports or heavy lifting, may be delayed for up to six weeks.

A few weeks after surgery, a follow-up visit with the doctor is usually planned to confirm that the recovery is progressing well.

Efficacy of Vertebroplasty

The medical literature on the effectiveness of vertebroplasty is varied, with some studies finding it to be successful while others are equivocal or even warn against surgery. The majority of current research suggests that, as contrasted to nonsurgical treatments, vertebroplasty is more effective at alleviating pain and improving function.

There's also mounting evidence that vertebroplasty can benefit persons who have had a spinal compression fracture live longer. The explanation behind this is unknown, and more research is needed.

Vertebroplasty Complications

Infection, allergic reactions, and excessive bleeding are all severe concerns associated with all procedures performed within the body and including medications. Other possible side effects of vertebroplasty include:

• Cement leakage. When bone cement escapes outside of the targeted vertebral compression fracture cracks, this problem can arise. Fortunately, complications from bone cement escaping outside of the fracture are uncommon, especially if the amount is minor. However, bone cement can leak onto a nerve root or the spinal cord, causing pain, tingling, numbness, and/or weakness, as well as function and movement issues. Bone cement has also been documented to migrate into a vertebral vein and cause problems, such as pulmonary embolism (artery obstruction in the lung).
• Paralysis. Because vertebroplasty is conducted near the spinal cord and other vital nerves, a mistake in the needle's positioning could cause injury to one or more limbs, resulting in weakness and/or paralysis.
• Failed pain relief. Even if no errors or difficulties occurred during the treatment, vertebroplasty may not relieve symptoms.

This isn't a comprehensive list of possible vertebroplasty side effects. Furthermore, it is unknown if vertebroplasty or kyphoplasty increases the chance of another spine or rib fracture, although it is known that a patient who has already suffered an osteoporotic fracture is at risk for further fractures.

Vertebroplasty Risk Factors

Many factors can increase the chances of a failed vertebroplasty, including:

• Delayed procedure. If vertebroplasty is not performed within 8 weeks of the initial fracture, it is less likely to provide considerable pain relief than nonsurgical options. One probable explanation is that the fracture might have started to heal after a few months.
• Low-quality fluoroscopy equipment. The surgeon's ability to view the placement of the needle as it enters the body and is put into the injured region of the spine is one of the most significant parts of vertebroplasty. There is some evidence that using low-quality fluoroscopy equipment, such as the portable ones seen in hospital operating rooms, increases the risk of vertebroplasty complications.
• Cancer-related compression fracture. The complication rate for vertebroplasty for cancer-related spinal compression fractures is approximately 11%. In comparison, the complication rate with vertebroplasty for compression fractures due to osteoporosis is only about 5%.

Other risk factors for vertebroplasty include the surgeon's level of experience and the fracture pattern.

Failed Vertebroplasty

Failed vertebroplasty indicates that the procedure did not completely relieve your back or neck pain, either in the short or long term. The pain could have been caused by a variety of factors, including:

• Surgical Mistake
• Acrylic Cement Leak
• New Fractures
• Infectious spondylitis
• Dislodgement of Cement

Poor patient selection may also be a factor in failed vertebroplasty, as not all individuals who have the procedure will benefit medically, even if the surgery was deemed successful. Furthermore, vertebroplasty does not address osteoporosis or any other underlying diseases that may have caused compression fractures. At any point, another fracture could occur. These are only a few of the potential reasons for unsuccessful vertebroplasty in patients who underwent this treatment.

How is Failed Vertebroplasty Treated?

When a patient has a failed vertebroplasty, the treatment should focus on the source of the discomfort. As indicated by the vast range of potential causes of vertebroplasty failure, this necessitates a thorough examination and diagnosis to identify any structural abnormalities that might benefit from revision surgery.

If no structural problems are discovered, conservative methods may be suggested. Physiotherapy, back strengthening exercises, braces and spine support, pain medications, and other treatments for controlling compressive discomfort and minimizing the risk of future fractures are among them. Compression fractures caused by osteoporosis and its complications may benefit from medications that prevent bone fractures.

Vertebroplasty at Home

Before being discharged from the radiology day unit, you will have been checked to make sure that you have recovered sufficiently from the sedative drug and that any discomfort you are experiencing is tolerable. For your first night at home, you should have a responsible adult with you.

Dressings. Steri-strips are placed over your puncture hole(s) and are covered by a dressing. If at all possible, keep this dressing dry. It can be changed with a similar clean bandage at home if it gets wet or unclean. After 48 hours, it can be withdrawn.

When you feel fully recovered from your sedative drug, you can begin to resume exercise today. It is recommended that you begin slowly and gradually return to your normal activity over the course of 2-3 days. Please discuss when you might be able to return to work with your doctor. Avoid stooping and standing for long periods of time.

Pain relievers. Please continue to take your pain relievers as directed. For the first 24 hours or so, you may experience pain around the treatment sites, but this should subside and you may be able to lower your pain medication. For additional pain management, consult your doctor.

Vertebroplasty vs Kyphoplasty

Vertebroplasty and kyphoplasty are minimally invasive surgeries for treating painful vertebral compression fractures (VCFs), which are fractures of the vertebral bodies that form the spine.

When a vertebral body breaks, the bone's normal rectangular shape is crushed, resulting in pain. Compression fractures are a typical outcome of osteoporosis and may include the collapse of one or more vertebrae in the spine. Osteoporosis is a disease that causes a loss of bone density, mass, and strength, resulting in a condition in which bones become increasingly porous and prone to fracturing. Cancer can wreak havoc on the vertebrae.

Physicians utilize imaging guidance, usually fluoroscopy, to inject a cement mixture into the shattered bone through a hollow needle during vertebroplasty. A balloon is first introduced into the cracked bone through the hollow needle to produce a cavity or space during kyphoplasty. When the balloon is withdrawn, the cement is administered into the cavity.

Conclusion

Percutaneous VP is widely recognized as a safe and effective treatment option for severe osteoporotic and malignant vertebral fractures that do not respond to standard medical treatment. To achieve the greatest results and avoid issues, thorough patient selection, pre-procedural assessment, and careful attention to the right technique are essential. Because existing trials have yielded conflicting results, more research will be required to definitively prove the efficacy of VP. Patients should be treated in the setting of a collaborative and multidisciplinary approach, with proper informed consent, until that time comes.