Vertebroplasty: Effective Treatment for Painful Vertebral Compressive Fractures

Before the Procedure
People suffering from persistent back pain caused by vertebral compression fractures are potential candidates for vertebroplasty. These patients can be referred for bone scans, MRI (magnetic resonance imaging), additional x-rays, and other tests in order to determine whether they are candidates for vertebroplasty. In consultation with an interventional radiologist or other physician who is specifically trained in vertebroplasty, the patient's history and other factors will be considered along with the results of their tests. Patients who are candidates for vertebroplasty will be advised of the process, benefits, and potential risks of the procedure.

During the Procedure
During vertebroplasty, the collapsed vertebra is stabilized using specially formulated acrylic bone cement that helps to provide pain relief and prevents further collapse of the vertebra (1). The procedure can be performed in the interventional radiology suite or an operating room. The delivery of the bone cement into the fractured vertebra requires constant image guidance, which is achieved using a "C-arm" x-ray machine (also called fluoroscopy). Many images are captured at multiple angles and used throughout the procedure.

Conscious sedation, administered through an intravenous (IV) line, is typically used to help the patient relax but remain awake. A local anesthetic (such as lidocaine) is used to numb the entire affected area prior to and during the procedure. Alternatively, some practitioners may use a general anesthetic for some patients. The patient lies prone (face down) on the table and the patient's back is "prepped" with alcohol and lidocaine. Antibiotics may be administered through the IV line prior to the start of the procedure.

Using constant x-ray/fluoroscopic guidance, the physician inserts one or two needles into the fractured vertebra through small incision(s) in the patient's back. The physician then injects a small amount of acrylic resin bone cement slowly into the vertebra, still using constant x-ray guidance. In order to observe the flow of the cement into the vertebral body, the physician will mix an opacifying agent such as barium into the medical cement (called polymethylmethacrylate, or PMMA). When the appropriate amount of cement has been delivered into the vertebral body, the physician will remove the needle(s) and cover the incision(s) with a small bandage.

Vertebroplasty takes about an hour for treatment of a single fractured vertebra; multiple vertebral fractures treated during the same procedure will take longer. Patients typically relax in a recovery room or observation area for two to three hours following vertebroplasty as the conscious sedation wears off. The physician may consult with the patient during this time to ensure that the patient's pain is relieved and there are no side effects or complications.

Benefits: Immediate Relief from Pain, Improved Quality of Life
Following vertebroplasty, most patients find a marked improvement in their pain. Within a few days, many patients are able to reduce their pain medications significantly and return to the normal daily activities that had been inhibited by their painful vertebral compression fractures. Most patients report sustained pain relief, even years later.

Recently published studies of outcomes from vertebroplasty show very high success rates (90% and higher) in significantly relieving pain associated with vertebral compression fractures, improved mobility and other quality of life improvements resulting from pain relief (2-5). The highest success rates occur in osteoporotic patients, who are also the largest group of patients receiving vertebroplasty in the United States.

Osteoporosis and Other Causes of Vertebral Compression Fractures
Osteoporosis is the most common cause of vertebral compression fractures in the United States. The National Osteoporosis Foundation (NOF) estimates that 44 million Americans over the age of 50 currently have osteoporosis or low bone mass with serious risk of osteoporosis. By 2010, an estimated 52 million Americans will be affected. A large portion of this population will suffer debilitating pain caused by vertebral compression fractures.

Bone tumors and metastatic bone disease also lead to vertebral compression fractures. Diseases such as multiple myeloma and hemangioma (types of tumors) place patients at great risk for these painful fractures. High doses of steroids for the control of auto-immune diseases such as lupus and rheumatoid arthritis, as well as asthma or chronic pulmonary disease can also increase the risk of reduced bone mass and resulting fractures.

Development of Vertebroplasty
Vertebroplasty was first performed in France in 1984 to treat a patient with a painful hemangioma. The patient's pain was completely relieved, and no complications were reported. The first seven cases were formally reported by Drs. Deramond and Galibert in 1987 (6); the exciting new treatment was discussed at medical conferences, and the first case in the United States was performed in 1994 (7). Standards for the practice of vertebroplasty were adopted within the medical community in the late 1990's. Interventional radiologists, who are specifically trained in image-guided, minimally-invasive procedures, lead the development of the procedure and practice guidelines. Research is ongoing to provide further improvements in the procedure and products that are used; hundreds of articles, findings, and clinical papers are available, with new papers being published monthly on the topic. An estimated 4,000 physicians currently practice vertebroplasty with 100 additional physicians being trained each year by the leaders in the field. Increasing success rates and extremely low complication rates (<3 % for patients with osteoporotic fractures) have made vertebroplasty the standard of care painful vertebral compression fractures.

References:

1. Hiwatashi, A, Moritani, T, et. al., Increase in vertebral body height after vertebroplasty, AJNR Am J Neuroradiol 23:185-189, February 2003.

2. J. Kevin McGraw, et al., Prospective evaluation of pain relief in 100 patients undergoing percutaneous vertebroplasty - results and follow-up, JVIR 2002: 13:883-886.

3. Zoarski, G, Snow, P, Olan, W, et. al., Percutaneous vertebroplasty for osteoporotic compression fractures: quantitative prospective evaluation of long-term outcomes, JVIR J Vasc Interv Radiol 13: 139-148.

4. Sehgal, M, Gilula, LA, Brown, DB, "Vertebroplasty in Patients with Symptoms for Greater than One Year in Duration," RSNA Annual Meeting, December 2002.

5. Jensen, ME, & Dion, JE, Percutaneous vertebroplasty in the treatment of osteoporotic vertebral body compression fractures, Neuroimaging Clinics of North America Vol.10, Num. 3, August 2000.

6. Galibert, P, Deramond, H, Rosat, P, et. al., Note preliminaire sur le traitement des angiomas vertebraux par vertebroplasty percutanee, Neurochirurgie 33:166-168, 1987.

7. Jensen, ME, Evans, AE, Mathis, JM, et. al., Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects, AJNR Am J Neuroradiol 18:1897-1904, 1997.