Vertebroplasty

What is Vertebroplasty?

Vertebroplasty is a minimally invasive procedure that strengthens a fractured or broken or vertebra, the small bones that make up the spinal column.

When a vertebra fractures, the usual rectangular shape of the bone becomes compressed and distorted, causing pain. These compression fractures, which may involve the collapse of one or more vertebrae in the spine, are a common symptom and result of osteoporosis. Osteoporosis is a disease that results in a loss of normal bone density, mass and strength, leading to a condition in which bones are increasingly porous or full or small holes and vulnerable to breaking. Vertebrae can also become weakened by cancer.

In vertebroplasty, physicians use image guidance to inject a special cement mixture through a needle into the fractured bone.

What are some common uses of the procedure?

Vertebroplasty is used to treat pain caused by compression fractures in the spine.

Typically, vertebroplasty is recommended after simpler treatment, such as bed rest, a back brace or pain medication, have been ineffective, or once medications have begun to cause other problems, such as stomach ulcers. Vertebroplasty can be performed immediately in patients who have severe pain requiring hospitalization or conditions that limit bed rest and medications.

Vertebroplasty is also performed on patients who:

• are too elderly or frail to tolerate open spinal surgery, or who have bones too weak for surgical spinal repair
• have vertebral damage due to a malignant tumor
• are younger and have osteoporosis caused by long-term steroid treatment or a metabolic disorder.

How should I prepare?

A clinical evaluation including diagnostic imaging, blood tests, a physical exam, spine x-rays and a radioisotope bone scan or magnetic resonance (MR) imaging will be done to confirm the presence of a compression fracture that is can be treated with vertebroplasty.

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin or a blood thinner for a specified period of time days before your procedure.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy because radiation can be harmful to the fetus. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.

If you are diabetic, you should ask your doctor for instructions on taking your blood sugar and medications.

On the day of the procedure, you should be able to take your usual medications with sips of water or clear liquid up to three hours before the procedure. You should avoid drinking orange juice, cream and milk.

In most cases, you may take your usual medications, especially blood pressure medications. These may be taken with some water in the morning before your procedure.

You may be instructed not eat or drink anything for several hours before your procedure.

You will need to have blood drawn and tested prior to the procedure to determine that your blood thinning medication has stopped working. If you are unable to stop taking this medication, a short in-patient stay for intravenous treatment with heparin may be required.

You may want to have a relative or friend accompany you and drive you home afterward.

You will be given a gown to wear during the procedure.

What does the equipment look like?

In this procedure, x-ray equipment, a hollow needle called a trocar, an orthopedic cement, barium powder and a solvent are used.

The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, a drawer under the table holds the x-ray film or image recording plate that captures the images.

The cement includes an ingredient called polymethylmethacrylate (PMMA) and resembles toothpaste.

A Foley catheter may be placed in your bladder.

Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.

How does it work?

Vertebroplasty involves injecting a cement mixture into the small holes in weakened vertebra to strengthen the spinal bones making them less likely to fracture again and to provide pain relief.

Using image-guidance, a hollow needle called a trocar is passed through the skin into the vertebral bone and a cement mixture is then injected into the vertebra.

How is the procedure performed?

Image-guided, minimally invasive procedures such as vertebroplasty are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.

This procedure is often done on an outpatient basis.

Vertebroplasty is generally performed in the morning.

You will be positioned lying face down for the procedure.

You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.

A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia.

You may be given medications to help prevent nausea and pain, and antibiotics to help prevent infection.

The area where the hollow needle will be inserted will be shaved, sterilized and covered with a surgical drape.

A local anesthetic will be injected into the muscles near the site of the fracture.

A very small nick is made in the skin at the site.

Using x-ray guidance, a hollow needle called a trocar is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra. An examination called intraosseous venography may be performed to make sure the needle has reached a safe spot within the fractured bone. Once the needle is in the proper location, the orthopedic cement is injected. Medical-grade cement hardens quickly within 20 minutes.

A CT scan may be performed at the end of the procedure to check the distribution of the cement.

The tiny incision will be closed with a strip of tape and covered with a bandage.

You will remain in the recovery room for an hour following the procedure.

This procedure is usually completed within two hours. The procedure will take longer if more than one site is being treated.

What will I experience during the procedure?

Devices to monitor your heart rate and blood pressure will be attached to your body.

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.

The intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.

The treatment area of your back will be cleaned, shaved and numbed.

During the procedure you will be asked questions. It is important for you to be able to tell your doctor whether you are feeling any pain.

The longest part of vertebroplasty involves setting up the equipment and making sure the needle is perfectly positioned in the collapsed vertebra.

You may not drive after the procedure, but you may be driven home if you live close by. Otherwise, an overnight stay at a nearby hotel is advised. Hospitalization is required only if the patient is unusually frail, has no one to help them at home, or requires further monitoring following the procedure.

Bed rest is recommended for the first 24 hours following vertebroplasty, though you may get up to use the bathroom. Increase your activity gradually and resume all your regular medications. Check with your doctor if you take blood thinners. You may be able to restart this medication the day after your procedure.

You should be able to move around again within 24 hours and may be able to reduce, or even eliminate, your pain medication.

For two or three days afterward, you may feel a bit sore at the point of the needle insertion. You can use an icepack to relieve any discomfort but be sure to protect your skin from the ice with a cloth and ice the area for only 15 minutes per hour. Your bandage should remain in place for several days (even during showers).

Who interprets the results and how do I get them?

Approximately one hour after the procedure, you should be able to walk. The interventional radiologist is often able to advise you as to whether the procedure was a technical success at that point. In some cases, it can take a few days for the doctor to be able to make this assessment.

What are the benefits vs. risks?

Benefits

• Vertebroplasty can increase the patient's functional abilities, allow a return to the previous level of activity, and prevent further vertebral collapse.
• The procedure is usually successful at alleviating the pain caused by a compression fracture; many patients feel significant relief almost immediately. After just a few weeks, two-thirds of patients are able to lower their doses of pain medication significantly. Many patients become symptom-free.
• About 75 percent of patients regain lost mobility and become more active, which helps combat osteoporosis. After vertebroplasty, patients who had been immobile can get out of bed, reducing their risk of pneumonia. Increased activity builds more muscle strength, further encouraging mobility.
• Usually, vertebroplasty is a safe and effective procedure.
• No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.

Risks

• Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
• A small amount of orthopedic cement can leak out of the vertebral body. This does not usually cause a serious problem, unless the leakage moves into a potentially dangerous location such as the spinal canal.
• Other possible complications include infection, bleeding, increased back pain and neurological symptoms such as numbness or tingling. Paralysis is extremely rare. Sometimes the procedure causes another fracture in the spine or ribs.

What are the limitations of Vertebroplasty?

Vertebroplasty is not:

• used for herniated disks or arthritic back pain.
• generally recommended for otherwise healthy younger patients, mostly because there is limited experience with cement in a vertebral body for longer time periods.
• a preventive treatment to help patients with osteoporosis avoid future fractures. It is used only to repair a known, non-healing compression fracture.
• used to correct an osteoporosis-induced curvature of the spine, but it may keep the curvature from worsening.
• ideal for someone with severe emphysema or other lung disease because it may be difficult for such individuals to lie facedown for the one to two hours vertebroplasty requires. Special accommodations may be made for patients with these conditions.
• for patients with a healed vertebral fracture.