Vertebroplasty: A Minimally Invasive Option for Older
Osteoporotic Patients
| Patients
at Risk for Vertebral Compression Fracture
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Osteoporosis is the most common metabolic bone disorder
and the leading cause of vertebral compression fracture
(VCF). Up to 700,000 VCFs occur each year in the United
States. Vertebroplasty is a relatively new, minimally
invasive technique that offers effective treatment for
VCF by utilizing bone cement to stabilize the fractures.
The procedure, which involves the minimally invasive
delivery of Polymethyl Methacrylate (PMMA), offers early
relief to older patients suffering osteoporotic compression
fractures and refractory pain, with studies reporting
over 80 percent success.(1)
Vertebroplasty is also used to treat steroid-induced
osteoporotic compression fractures, vertebral body hemangiomas
and metastatic disease of the spine.(2) “Vertebroplasty
is an interventional option for a patient population
that previously had no such option,” says Kenneth
S. Heiferman, M.D., associate director of the Institute
for Spine Care at Elmhurst Memorial Hospital. “The
benefit of vertebroplasty is that it is relatively easy
on the patient,” Heiferman explains. “It requires
minimal sedation, which is good for older patients.
And it offers rapid relief of pain. The patient can
return to normal function much quicker,” says Heiferman.
“Traumatic or spontaneous compression fractures
can change a patient’s entire life,” says
Marc A. Levin, M.D., medical director of CINN at Community
Hospital in Munster, Indiana. “If left untreated,
VCFs will continue to cause pain. Posterior displacement
of the vertebral body can occur, which can cause pressure
on nerves of the spinal cord and can lead to neurological
deficit,” Levin explains. “Vertebroplasty
stabilizes or hardens the fracture, thus reducing the
pain.”
Traditional treatments for VCF, such as bed rest, bracing,
narcotics and injections, are largely ineffective, as
they often do not provide significant pain relief and,
most importantly, do not address the underlying fracture
or prevent further collapse of the vertebral body. Vertebral
fractures can cause incapacitating pain lasting for
months with associated disability and potential morbidity.(3)
Considerations
In most cases, vertebroplasty should be considered
after 4-6 weeks of conservative therapy. However, some
experts advocate vertebroplasty in the acute setting
to relieve pain in elderly patients, since vertebroplasty
may pose less risk and discomfort than the potential
complications of immobility. Patients selected for vertebroplasty
often have multiple medical conditions. Some patients
with extensive pulmonary disease may not be candidates
for the procedure. Others may not tolerate lying prone,
which is necessary for the duration of the procedure.
An office trial, in which a patient is placed in a prone
position, can help identify those who may not tolerate
the procedure. Vertebroplasty should never be used as
the sole therapy in cases of spinal instability. Patients
with spinal instability, spinal cord compression or
epidural extension of pathology are candidates for surgery.
In cases of severe osteoporosis requiring spinal stabilization,
percutaneous Polymethyl Methacrylate (PMMA) injection
may augment pedicle screw fixation. Vertebroplasty is
not appropriate for patients with leg problems.(4)
Contraindications
Contraindications for the procedure include: severe
wedge deformity in which the vertebral body is less
than 10 percent the normal height; comminuted burst
fragment; severe pulmonary edema or chronic obstructive
pulmonary disease; coagulopathy; uncertain cause of
pain. Leg pain, tingling, numbness or weakness in the
legs implies nerve compression; vertebroplasty is not
an effective treatment for nerve compression.
Procedure Overview
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| Injection
of PMMA under constant fluoroscopic guidance. |
Vertebroplasty is generally performed under local anesthesia.
The patient is placed in a prone position with padding
under the torso and the hips in slight flexion. The
arms are positioned above the shoulder, pressure points
are padded, and joints are gently flexed. A needle is
placed in the vertebral body under direct visualization
using fluoroscopy. Polymethyl Methacrylate (PMMA) is
injected under high pressure and constant fluoroscopic
guidance. At the completion of the procedure the needle
is removed and a single subcuticular stitch or a Steri-Strip
is placed.(5, 6)
Postoperative Care
The patient is maintained in a recumbent position for
two hours following the procedure and then allowed to
sit and to ambulate with assistance. Pain relief is
significant and if percutaneous passage of the needle
was not accompanied by numerous redirections, paraspinal
muscle spasm may be minimal following the procedure.
Patients are discharged home with muscle relaxants and
nonsteroidal anti-inflammatory medications. If the procedure
is performed in the morning, the patient may be discharged
the same day and is encouraged to remain active by ambulating
and performing activities of daily living.(7)
Complications
Complications of vertebroplasty are relatively rare
in the treatment of osteoporotic compression fractures
(approximately 1.3 percent). The most common complications
following vertebroplasty are rib fracture and radiculopathy.(8)
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