Vertebroplasty: A Case Study
Compression fractures of the vertebrae interfere with the quality of life of millions of Americans each day. The public health cost has been estimated at 250 million dollars or more per year. There are many reasons for compression fractures of the vertebrae (Figure 1).
These include osteoporosis, cancer or tumor, dialysis and trauma. This discussion will focus on osteoporosis. Osteoporosis is defined by the World Health Organization as a bone density test of 2.5 standard deviations below the mean for young normal people.
Osteoporosis affects millions of Americans each year with women outnumbering men. It has been reported that 50% of women and 10% of men over the age of 50 will have osteoporotic-related fractures in their lifetime. Fragility fractures are seen in the wrist, hip, pelvis, and vertebrae, which lead the health care practitioner to suspect osteoporosis.
Risk factors include women more than men, Caucasian or Asian ancestry, cigarette smoking, hysterectomy without hormone replacement, and chronic steroid therapy.
Non-surgical management involves pain management, bed rest, bracing, and prevention of further disease by supplementing the diet with calcium and Vitamin D.
Vertebral fractures can affect the independence and quality of life in those inflicted. One report stated that 77% of women with vertebral fractures took a month or more to return to their activities of daily living. Twenty-seven percent (27%) of those with vertebral fractures stated it took more than a year and they still had not returned to their normal activities. Vertebral fractures can have a devastating and lasting affect on the quality of life.
The History of Vertebroplasty
This procedure was developed in France by Deramond et al in 1984. The procedure has been perfected in the United States since 1995. The stabilization of the collapsed vertebra seems to alleviate the pain.
What to Expect
The procedure consists of injecting a mixture of cement mixed with barium, methyl methacrylate, and injecting it into the fractured vertebral body. Some doctors also include an antibiotic in the mixture.
You would arrive at the hospital the day of the procedure. The procedure is performed in the Radiology Department in a Special Procedure room or the operating room (Figure 2).
The patient observes the standard preoperative instructions: nothing to eat or drink after midnight before surgery and the discontinuation of any blood thinning medications like ibuprofen and coumadin one week before the procedure. You are sedated with intravenous sedation. The surgeon then prepares the skin with antiseptic solution and a local anesthetic is administered. A hollow needle is inserted into the vertebrae under fluoroscopy (Figure 3), which allows the surgeon direct visualization of the needle placement. The vertebral body is injected with a biomaterial called methyl methacrylate once the needle placement has been confirmed by fluoroscopy (Figure 4).
This strengthens the vertebral body and thus relieves pain (Figure 5). The needles are removed after the methyl methacrylate has been injected into the vertebral body. The patient is required to lie flat for one to two hours in the recovery room. When the patient is stable another adult may drive them home.
There are no stitches to be removed and you may take a bath or shower 24 hours after the procedure. The patient then returns to clinic in six weeks to see the physician.
Case Study I
B.R. is a 65-year-old Hispanic woman who has been on renal dialysis for five years. When bending over to pick up her purse, she experienced excruciating lower back pain. X-rays revealed a fourth and fifth lumbar vertebral fracture. Conservative therapy was attempted for nine months with poor results. B.R. was confined to a wheelchair and had constant pain.
Vertebroplasty was performed in September 2000. The patient was able to walk short distances and her pain medication was reduced. She stated her quality of life has improved since the procedure.
Are you a candidate for Vertebroplasty?
You must have:
(1) Vertebral fracture less than one year old
(2) Back pain for less than one year
(1) Unable to stop blood thinners
(2) Tumors invading the epidural space
(3) Improvement with medical therapy
(4) Extensive fracture of surrounding bony structures
Understanding the Risks
(1) Rib fractures
(3) Biomedical substance entering the blood stream
(4) Allergic reaction to the injected material
(5) Spinal cord compression
You and your physician may discuss whether you are a candidate for Vertebroplasty. You must weigh the pros and cons. General anesthesia is usually not used with this procedure, which opens the possibility to patients with other health problems and older in age than those who might not be considered for other invasive procedures.