Vertebroplasty: Non-Surgical Treatment of Compression Fractures - Part 2 of 2

Jonathan Wiener, M.D.
Director, MRI and Neuroradiology
Boca Raton Community Hospital
Boca Raton, FL

The Tools

 

Bone needles - Specifically made for smooth passage through bone, can also be used for biopsy (Cook Medical Co.)

Tobramycin- an antibiotic powder used added to the cement to prevent infection

PMMA -polymethylmethacralate, A synthetic quick setting cement

Barium - an inert powder added to the PMMA cement to make it visible on xray. It is manufactured by Bryan Corp

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.

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

Fig. 1	Fig. 2
Fig. 3	Fig. 4
Fig. 5

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 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.

Fig. 1	Fig. 2
Fig. 3	Fig. 4

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 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

Thomas G. Lowe, M.D.



After reviewing the article on vertebroplasty by Dr. Jonathan Wiener, I have several comments to make. Certainly the results of vertebroplasty for relief of pain are very good. The author neglected to mention a newer technique for the treatment of compression fractures in the elderly, namely kyphoplasty. Kyphoplasty has eliminated many of the complications that surfaced from the use of vertebroplasty.

The technique of performing vertebroplasty is nicely described in the manuscript. Because the methylmethacrylate is injected directly into the vertebral body, there is a significant risk of inadvertent injection into the spinal canal resulting in spinal cord injury. With the kyphoplasty technique, two balloons are inserted through the pedicles and inflated reducing the fracture and creating a cavity in the vertebral body for junction of methylmethacrylate after removal of the balloons. The walls of the cavity are compressed cancellous bone, which reduce the likelihood of methylmethacrylate being inadvertently injected into the spinal canal.

In conclusion, both vertebroplasty and kyphoplasty are 70% - 90% successful in relieving pain. However kyphoplasty is a better solution because it results in correction of the deformity and minimizes the risk of neurological injury from methylmethacrylate being inadvertently injected into the spinal canal.

• Discharge Instructions for Vertebroplasty
• Osteoporosis: The Silent Thief
• Vertebroplasty: A Case Study
• Spinal Fractures: The Three-Column Concept
• Minimally Invasive Bone Grafting
• Kyphoplasty and Vertebroplasty: Treatments for Spinal Compression Fractures