You are in: eMedicine Specialties > Neurology > Headache and Pain Percutaneous VertebroplastyArticle Last Updated: Jun 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Jashvant Patel, MD, Medical Director, Department of Pain Medicine and Comprehensive Rehabilitation, Medical College of Pennsylvania Hahnemann University Jashvant Patel is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, and Medical Society of the State of New York Coauthor(s): Manish K Singh, MD, Assistant Professor, Pain Management, Department of Neurology, Drexel College of Medicine, Hahnemann University hospital Editors: Jorge E Mendizabal, MD, Consulting Staff, Corpus Christi Neurology; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center; Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital; Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants Author and Editor Disclosure Synonyms and related keywords: PVP, cement injection, polymethylmethacrylate injection, PMMA, spine, vertebral fracture, vertebral malignancy, vertebral hemangioma, percutaneous vertebroplasty INTRODUCTIONSection 2 of 10
  Vertebroplasty is a minimally invasive, image-guided therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis or, less commonly, cancer. It also relieves the pain. Initially, the major indication was aggressive spinal hemangioma, but with experience, other indications have emerged. Vertebroplasty can prevent further vertebral collapse, increase the patient's functional abilities, and help achieve to the previous level of activity. PVP usually involves percutaneous injection of a cement, polymethylmethacrylate (PMMA), into the vertebral bodies. Occasionally, PMMA has been placed manually into vertebral lesions during open surgical operations. PVP with PMMA was performed first in 1984 and has been promoted by Jensen and Dion at the University of Virginia in the United States. For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Vertebral Compression Fracture. INDICATIONSSection 3 of 10
PVP is indicated for any pathology that weakens the vertebral body, with or without resultant spinal pain. PVP has two objectives, analgesia and stabilization (ie, solidification). PVP initially was used for vertebral hemangioma. It now is used primarily for osteoporotic vertebral fracture and occasionally for vertebral malignancy. Treatment with PVP can be curative or palliative. OSTEOPOROTIC VERTEBRAL FRACTURESection 4 of 10
Osteoporosis is complicated by vertebral fracture either spontaneously or from minor trauma. As many as 2 of every 3 vertebral fractures may not come to medical attention. In the United States, the incidence of compression fractures is more than 500,000 patients per year, which is higher than the incidence of hip fractures. In the European Vertebral Osteoporosis Study, prevalence of radiographically defined vertebral deformities was approximately 13% in women and 12% in men aged 65-69 years. These vertebral fractures are often highly painful and are treated by immobilization, analgesic drugs, and specific treatment of osteoporosis. Immobilization increases demineralization. In spite of long-term medical treatment, some patients have severe, persistent, incapacitating pain. Initial symptoms tend to disappear in 4-6 weeks. Recurrent episodes of vertebral fracture are common and are a cause of significant morbidity. Later consequences of vertebral fracture are reduced height, kyphosis, and chronic back pain. In these situations, vertebroplasty alleviates symptoms and reduces the duration of immobilization. Additionally, vertebral fracture eventually may lead to reduced height and kyphosis. Vertebroplasty can alleviate pain symptoms and reduce the duration of immobilization and the likelihood of kyphosis and height loss. SPINAL TUMOR AND VERTEBRAL HEMANGIOMASection 5 of 10
Spinal tumors In painful vertebral metastasis (ie, previously untreated), radiotherapy is useful in 70% of patients to alleviate spinal pain, but this effect is delayed and may require 2-6 weeks. Radiotherapy does not prevent vertebral crush due to tumor necrosis and secondary spine deformity. Vertebroplasty produces analgesia by solidification of the osteolytic lesion. It is only a palliative treatment. Vertebroplasty results in vertebral consolidation and spinal stability as well as quick (1-3 d) disappearance of pain. Results are better if spinal pain is the major symptom; more than 70% of these patients experience significant relief of pain and return to activities of normal living. The excellent analgesic effect of vertebroplasty encourages treatment of other metastatic lesions outside the spine, especially hip metastases, by a percutaneous approach. Vertebral hemangioma Vertebroplasty is indicated for radiologically or clinically aggressive spinal hemangioma, with the following objectives:
Vertebroplasty has been used successfully in severe focal spinal pain with radiologically unaggressive vertebral (body) hemangioma; it has had a 90% success rate in providing long-term pain relief. Patients in whom conservative therapy has failed have been treated with vertebroplasty. Every patient needs a detailed physical examination and MRI prior to the procedure. The MRI is necessary to confirm that a patient's pain is not secondary to disk herniation, spinal stenosis, or infection. MRI also helps in planning the procedure, especially if the vertebral body is compressed severely. Discuss the procedure with the patient and carefully explain the benefit-risk ratio. PROCEDURESection 6 of 10
Materials A Stryker precision delivery system costs approximately $600-700; a physician can customize it for $200.00. Materials include the following (see Image 1):
Procedure
Polymethylmethacrylate mixing and injection procedure
Postprocedure care
COMPLICATIONS AND RESULTSSection 7 of 10
Fortunately, complications are rare. Risks of the PVP procedure include infection, bleeding, contrast reaction, rib or pedicle fracture, worsening pain (from leakage of PMMA to epidural or foraminal veins), and paralysis. Chiras et al reported incidents and complications in 274 patients. These complications were more common with malignant spinal tumor (10%) and vertebral hemangioma (2-5%) than with osteoporotic lesions (1-3%). In these authors' experience with PVP for osteoporotic vertebral fracture at 21 levels, no major complications occurred. If the patient complains of chest pain following the procedure, exclude rib fracture by obtaining a rib series and pulmonary embolus by obtaining a ventilation/perfusion scan. Pulmonary embolism was reported after vertebroplasty, and outcome was favorable following anticoagulant therapy. Severe back pain can indicate a fractured pedicle or transverse process, which is observed easily on CT scan. New radicular pain can be caused by migration of PMMA into the epidural venous plexus. CT scan demonstrates this easily. Include the levels above and below to look for migration at adjacent levels. Nerve root blocks may be effective, or laminectomy may be required. Paralysis has been reported but is very uncommon. Take precautions while injecting above L1, with attention to the posterior vertebral body wall; do not allow PMMA to flow into the epidural venous plexus. In the authors' study of vertebroplasty at 27 levels, the following results were obtained:
CONCLUSIONSection 8 of 10
PVP is a minimally invasive procedure with promising results for the treatment of vertebral fracture. It provides significant pain relief with the potential for improving functional outcome. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Percutaneous Vertebroplasty excerpt Article Last Updated: Jun 30, 2006 | ||||||||||||||||||||||||||||
