Vertebroplasty

Introduction

• Minimally invasive percutaneous procedure

• Involves injection of a fast-setting polymer into a pathological vertebral body

• Vertebroplasty:

  • Injection of material (commonly PMMA cement) into the vertebral body

• Kyphoplasty:

  • Balloon inflation within the vertebral body before cement injection

  • Aims to restore vertebral height and reduce kyphosis

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Historical Background

• First percutaneous vertebroplasty performed in 1984

  • University Hospital of Amiens, France

• Deramond and Galibert injected PMMA into a C2 vertebra destroyed by aggressive hemangioma

• Concept of kyphoplasty developed in the early 1990s by orthopaedic surgeon Dr. Mark Reiley

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Indications

Painful Vertebral Compression Fractures (VCF)

• Osteoporosis

• Neoplastic conditions:

  • Multiple myeloma

  • Hematogenous metastasis

• Vertebral hemangiomas

Pain Without Compression Fracture

• Lytic metastatic vertebral lesions

• Chronic non-healing traumatic vertebral fractures

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Contraindications

Absolute Contraindications

• Active systemic or spinal infection

• Uncorrected bleeding diathesis

• Active osteomyelitis at fracture site

• Fracture-related spinal canal compromise causing:

  • Myelopathy

  • Radiculopathy

• Asymptomatic or healed compression fracture

• Significant central canal stenosis

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Patient Selection (Key to Success)

• 1–3 vertebral levels involved

• Focal pain and tenderness correlating with MRI edema

• Fracture age < 1 year

• Exclusion of other pain generators:

  • Disc herniation

  • Spinal stenosis

  • Facet joint disease

  • Sacroiliac joint pathology

  • Radicular pain

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Mechanism of Pain Relief

Pain relief following vertebroplasty occurs due to:

• Thermal ablation

  • Heat generated during PMMA polymerization affects:

    • Sinus vertebral nerve

    • Sympathetic nerve fibers

• Chemical neurolysis

  • Toxic effect of PMMA on nociceptive fibers

• Mechanical stabilization

  • Structural reinforcement of microfractures within vertebral body

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Pre-Procedure Evaluation

Clinical History

• Acute vertebral compression fracture typically presents with:

  • Sudden onset of deep, localized back pain

  • Pain worsens with weight bearing

  • Pain improves with recumbency

• Pain is:

  • Localized to fracture level

  • Non-radicular

• Assess:

  • Impact on activities of daily living

  • Overall quality of life and functional limitation

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Imaging Evaluation

Plain Radiographs

• Confirm presence and level of fracture

• Assess:

  • Vertebral height loss

  • Kyphotic deformity

  • Anatomic variants

• Comparison with prior films helps identify new fractures

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MRI (Imaging of Choice)

• Differentiates acute/unhealed fractures from healed fractures

• Identifies alternative pain sources

• Helps evaluate risk of cement leakage

• T2-weighted fat-suppressed sequences are most useful

  • Acute fractures show hyperintense marrow edema

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Bone Scan

• Used when MRI is contraindicated

• Helps differentiate acute vs healed fractures

• Recent fractures show increased uptake of Tc-99m medronate

• Useful for fractures that appear normal on MRI

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CT Scan

• Not routinely required for osteoporotic fractures

• Useful for:

  • Burst fractures

  • Metastatic disease

  • Assessment of posterior vertebral wall integrity

  • Post-procedure evaluation of unexpected symptoms

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Vertebroplasty Technique

Anesthesia & Sedation

• Procedure explained with informed consent

• Vertebroplasty:

  • Usually performed under local anesthesia with sedation

• Kyphoplasty:

  • Typically performed under general anesthesia

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Needle Placement Approaches

Two principal approaches:

1. Transpedicular Approach (Most Common)

• Needle passes completely through pedicle into vertebral body

• Advantages:

  • Protects nerve roots and vessels

  • Reduces risk of cement leakage along needle tract

  • Allows post-procedure soft tissue compression to reduce bleeding

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2. Parapedicular Approach

• Used when transpedicular approach is difficult (e.g., small pedicles)

• Needle enters lateral to pedicle and pierces cortex at pedicle-body junction

• Advantages:

  • Easier central vertebral filling with single injection

• Disadvantages:

  • Higher risk of:

    • Paraspinal hematoma

    • Pneumothorax

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Complications

• Most complications are transient and self-limiting

• Neurologic injury:

  • Spinal cord or nerve root injury in <1%

• Infection:

  • Rare

• Iatrogenic fractures:

  • Lamina fracture

  • Pedicle fracture

• Cement leakage:

  • Usually asymptomatic

  • Rarely symptomatic with neurologic compromise

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Key Take-Home Points

• Vertebroplasty is an effective minimally invasive treatment for painful vertebral pathology

• Proper patient selection is critical

• MRI is the most important pre-procedure investigation

• Transpedicular approach is safest and most commonly used

• Complications are uncommon when performed correctly