Vertebroplasty and Kyphoplasty

Martin G. Radvany

Kieran Murphy

Percutaneous vertebroplasty (PV) and kyphoplasty (KP) are safe and effective, minimally invasive techniques for treatment of patients suffering from back pain due to osteoporotic and tumor-related vertebral body (VB) compression fractures (1,2) as well as hemangiomas (3).

With PV, a needle is advanced into the VB under image guidance. Th rough this needle, the bone cement is injected into the vertebral body under real-time image guidance. KP is a more involved procedure as compared to PV. With KP, a needle/pin is advanced into the VB under image guidance. A stylet and cannula are advanced over the pin into the pedicle. The cannula serves as a working channel for the remainder of the procedure. A drill is inserted through the cannula to create a larger channel in the bone. An inflatable bone tamp (balloon) is inserted into the channel and inflated within the VB; this compacts the bone and creates a cavity. Bone cement is injected into the cavity under real-time image guidance.

Contraindications

Absolute (1,2)

1. Asymptomatic VB compression fractures

2. Patient improving on medical therapy

3. Ongoing local or systemic infection

4. Retropulsed bone fragment resulting in myelopathy or neurologic symptoms

5. Spinal canal compromise secondary to tumor resulting in myelopathy

6. Uncorrectable coagulopathy; prothrombin time (PT) (international normalized ratio [INR]) greater than 1.3 × control, partial thromboplastin time (PTT) greater than 1.3 × normal, platelets less than 70,000 per µL

7. Allergy to bone cement or opacification agent

Relative (1,2)

1. Radiculopathy in excess of vertebral pain caused by a compressive syndrome unrelated to vertebral collapse. Occasionally, preoperative PV or KP can be performed before a spinal decompressive procedure.

2. Asymptomatic retropulsion of a fracture fragment causing significant spinal canal compromise, and thus increasing the possibility that if any cement gets in the epidural space, the patient will be acutely symptomatic.

3. Asymptomatic tumor extension into the epidural space

Preprocedure Preparation

1. Patient evaluation: Evaluate patient records, history, physical examination, and prior imaging studies to determine need for and the feasibility of PV or KP. Order additional studies as needed to evaluate levels to be treated. The cross-sectional imaging will also help determine the size of needle to be used for PV or KP.

a. At a minimum, plain films should be reviewed to evaluate level and degree of VB compression.

b. Magnetic resonance imaging (MRI) has the advantage of documenting additional spine conditions which may contribute to the pain syndrome, in particular spinal degenerative disease.

c. Some patients may have contraindications to MRI such as a pacemaker or spinal instrumentation that compromises image quality. In these patients, nuclear medicine bone scans can help localize symptomatic levels amenable to treatment (4).

d. Computed tomography (CT) is essential to identify fractures that are potential routes of cement extravasation. Furthermore, pedicle fractures are best seen on CT, and this can determine which pedicle will be available for access.

2. Preprocedure visit: The risks, benefits, alternatives, and objectives should be discussed with the patient. Written informed consent should be obtained. Specific instructions should be given to the patient on how to prepare for the procedure and what to expect during and after the procedure. This should include discussion of the possibility of adjacent level fracture particularly in people with severe osteoporosis and Kummell disease, which is essentially a VB bone infarct resulting in large cleavage planes in the VB that are like vacuum clefts.

a. Perform a physical exam to include heart, lungs, and airway, as required for sedation. Document neurologic status to include lower extremity strength, sensation (i.e., light touch and/or pinprick), and proprioception.

b. Dietary adjustment as per institutional protocol, for example, nothing by mouth except medications for 8 to 12 hours before the procedure

c. Most PV procedures are performed on an outpatient basis; KP can be performed on an inpatient or outpatient basis, depending on medical need.

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