Vertebroplasty for Osteoporotic Fractures: What Surgeons Need to Know

Introduction to Vertebroplasty

Vertebroplasty is a minimally invasive surgical procedure designed to stabilize vertebral compression fractures (VCFs), commonly caused by osteoporosis, metastatic tumors, or trauma. By injecting medical-grade bone cement into the fractured vertebra, vertebroplasty provides rapid pain relief, prevents further collapse, and restores spinal stability. This procedure has evolved significantly since its introduction in the 1980s, becoming a critical tool in the management of VCFs.

Indications for Vertebroplasty

Vertebroplasty is indicated for patients experiencing significant pain due to vertebral compression fractures that do not respond to conservative treatment, such as bed rest, analgesics, and physical therapy. Specific indications include:

1. Osteoporotic Vertebral Compression Fractures (OVCFs): Osteoporosis is the most common cause of VCFs, leading to fractures from minimal trauma or even spontaneously.
2. Malignant Vertebral Fractures: Vertebral metastases or multiple myeloma can weaken the vertebrae, causing pathological fractures.
3. Traumatic Vertebral Fractures: In cases where conservative management fails, vertebroplasty may be considered.
4. Painful Hemangiomas: Although rare, vertebroplasty can be used to treat vertebral hemangiomas causing pain or neurological symptoms.

Preoperative Evaluation

Before proceeding with vertebroplasty, a thorough preoperative evaluation is essential. This includes:

1. Clinical Assessment: Detailed patient history and physical examination to assess the severity and impact of pain, as well as to rule out other causes of back pain.
2. Imaging Studies:
   • MRI: The gold standard for identifying acute fractures and ruling out spinal cord compression or other pathologies.
   • CT Scan: Useful in evaluating the extent of fracture and planning the procedure.
   • Bone Scintigraphy or PET-CT: In cases of malignancy, these studies help in evaluating the activity of the lesion.
3. Laboratory Tests: Routine blood tests, including coagulation profile, to assess the patient’s suitability for surgery.

Contraindications to Vertebroplasty

Vertebroplasty is contraindicated in certain situations, which include:

1. Absolute Contraindications:
   • Infection: Active infection at the site of the fracture or systemic infection.
   • Allergy to Bone Cement: Hypersensitivity to the components of the bone cement.
   • Unstable Fractures: Fractures with significant instability or neurological compromise that may require more extensive surgical intervention.
2. Relative Contraindications:
   • Spinal Cord Compression: Patients with significant spinal cord compression or radiculopathy may need alternative surgical approaches.
   • Coagulopathy: Patients with bleeding disorders or those on anticoagulants may require adjustment of therapy before the procedure.

Surgical Techniques and Steps

1. Preparation:

• Patient Positioning: The patient is placed in a prone position on the operating table. Proper padding and positioning are crucial to avoid pressure sores and ensure optimal access to the vertebrae.
• Anesthesia: Local anesthesia with conscious sedation is commonly used, although general anesthesia may be required in certain cases.

2. Imaging Guidance:

• Fluoroscopy or CT Guidance: The procedure is performed under real-time imaging to ensure accurate needle placement and cement injection.

3. Procedure:

• Needle Insertion: A specialized needle (trocar) is inserted into the fractured vertebra through a transpedicular or parapedicular approach. The entry point is determined based on the fracture location and vertebral anatomy.
• Cement Preparation: The bone cement, usually polymethylmethacrylate (PMMA), is prepared. It has a working time of a few minutes, during which it must be injected.
• Cement Injection: Under continuous fluoroscopy, the cement is slowly injected into the vertebra. The goal is to fill the fracture site and achieve adequate stabilization without extravasation into the spinal canal or veins.

4. Post-Injection Monitoring:

• Imaging Verification: Fluoroscopy is used to confirm the distribution of the cement and to ensure no leakage has occurred.
• Needle Removal: The needle is carefully withdrawn, and a sterile dressing is applied to the puncture site.

Postoperative Care

Postoperative care is crucial for optimal outcomes:

1. Monitoring: Patients are monitored in the recovery area for any immediate complications such as cement leakage, bleeding, or neurological changes.
2. Pain Management: Most patients experience significant pain relief within hours of the procedure. Analgesics may be continued as needed.
3. Activity Level: Patients are typically encouraged to gradually resume their daily activities, avoiding heavy lifting and strenuous exercise for a few weeks.
4. Follow-Up Imaging: Routine follow-up with X-rays or MRI to assess the stability of the treated vertebra and detect any adjacent level fractures.

Possible Complications

While vertebroplasty is generally safe, it is not without risks. Potential complications include:

1. Cement Extravasation: Leakage of cement into adjacent structures, which can cause pain, nerve compression, or embolism.
2. Infection: Although rare, there is a risk of infection at the injection site.
3. Bleeding: Vascular injury or coagulopathy may lead to hematoma formation.
4. Adjacent Level Fractures: The increased stiffness of the treated vertebra may lead to fractures at adjacent levels.
5. Neurological Complications: Nerve root or spinal cord compression due to cement leakage or needle injury.

Different Techniques

Various techniques and modifications have been developed to enhance the efficacy and safety of vertebroplasty:

1. Balloon Kyphoplasty: A variation where a balloon is inflated within the vertebra before cement injection to restore height and reduce kyphosis.
2. Radiofrequency Kyphoplasty: Uses radiofrequency to create a cavity within the vertebra, reducing the risk of cement leakage.
3. Augmented Vertebroplasty: Combines vertebroplasty with other treatments such as spinal fixation in cases of severe instability.

Prognosis and Outcome

The prognosis for patients undergoing vertebroplasty is generally favorable, with most experiencing significant pain relief and improved quality of life. The success rate is high, particularly in patients with osteoporotic fractures, with pain relief reported in 70-90% of cases.

Alternative Options

Alternative treatments for vertebral compression fractures include:

1. Conservative Management: Bed rest, analgesics, bracing, and physical therapy.
2. Kyphoplasty: As mentioned earlier, this is a variant of vertebroplasty with additional benefits in certain cases.
3. Surgical Stabilization: In cases of severe instability or neurological compromise, spinal fixation or decompression may be necessary.

Average Cost

The cost of vertebroplasty can vary depending on the healthcare system, geographical location, and whether the procedure is performed in an outpatient or inpatient setting. In the United States, the cost typically ranges from $3,000 to $10,000 per vertebra, not including associated hospital or anesthesia fees. In Europe and other regions, costs may be lower or covered by national healthcare systems.

Recent Advances

Recent advances in vertebroplasty include:

1. Biocompatible Cements: Development of new cements with better biocompatibility and lower risk of complications.
2. Image-Guided Navigation: Enhanced imaging techniques for more precise needle placement and reduced radiation exposure.
3. Combination Therapies: Combining vertebroplasty with other modalities, such as radiation therapy for metastatic fractures, is being explored.

Conclusion

Vertebroplasty remains a cornerstone in the management of vertebral compression fractures, offering rapid pain relief and stabilization. Understanding the indications, contraindications, surgical techniques, and potential complications is essential for surgeons to achieve the best outcomes for their patients.