İİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİİ Vertebroplasty Movie
Approximately 700,000 vertebral, or spinal bone, fractures occur each year from osteoporosis and 80% of those fractures occur in women, usually over the age of 60. Researchers estimate that at least 25 percent of women and a somewhat smaller percentage of men over the age of 50 will suffer one or more spinal fractures. Younger people also suffer these fractures, particularly those whose bones have become fragile due to the long-term use of steroids or other drugs to treat a variety of diseases such as lupus, asthma and rheumatoid arthritis. Of particular concern are spinal fractures caused by a progressive weakening of the bone -- a condition called osteoporosis. The pain and loss of movement that often accompany bone fractures of the spine are perhaps the most feared and debilitating side effects of osteoporosis. For many people with osteoporosis, a spinal fracture means severely limited activity, constant pain and a serious reduction in the quality of their lives.
Fractures of the vertebrae have traditionally been much more difficult to manage than broken bones in the hip, wrist or elsewhere. These broken bones can rarely be successfully treated with surgery due to the fragile nature of adjacent bone. Because surgery on the spine is extremely difficult and risky, it has typically not been used to treat vertebral fractures associated with osteoporosis except as a last resort. Until recently, reduced activity and pain medications, many of which cause problematic side effects, or invasive (and often unsuccessful) back surgery were virtually the only treatments available. Today, however, there is a non-surgical treatment called vertebroplasty (ver-TEE-bro-plasty) that has been shown to be extremely effective in reducing or eliminating the pain caused by spinal fractures.
Percutaneous vertebroplasty (PV)
is a new treatment that involves injecting a special liquid cement into
fractured vertebral sections. PV is being used to fill holes in the spinal
column left from osteoporosis, a degenerative bone disease.
Spinal compression fractures are a common problem for women with osteoporosis
and may cause spine deformities, pain, and the potential loss of sensation,
mobility, and bowel or bladder continence. PV helps stop the deterioration
ofİ the collapsed vertebral body and
relieves pain and pressure. In a recent study, 29 of 30 patients experienced
significant pain relief immediately after the procedure and 80% of the patients
reported lasting pain relief.
There are many causes of back pain,
such as muscle spasm, disc disease, joint disease, infections, tumors and fractures.
The fractures typically are caused by osteoporosis, but occasionally fractures
due to trauma and tumors such as metastases, multiple myeloma and hemangiomas
can be treated to reduce the associated pain. The most common cause of
vertebral compression fracture is osteoporosis. Each year about 250,000 people
suffer from 700,000 vertebral compression fractures due to osteoporosis.İ With an average of 4,110 osteoporotic
fractures per day, osteoporosis can be a primary disorder of bone, but may also
result from the long term use of certain medications for other disorders, such
as long term steroid or heparin therapy.
Vertebral
body compression fractures are a common cause of chronic back pain and
disability. The leading etiology of vertebral compression fractures is
osteoporosis, particularly in older individuals. Other causes include trauma,
osteolytic metastatic vertebral lesions, aggressive vertebral hemangiomas, and
vertebral body involvement by multiple myeloma.
Osteoporosis is the leading cause of vertebral fracture.
In osteoporosis, there is progressive bone loss, creating structural weakness
and skeletal fragility. After menopause, women become especially susceptible to
bone loss and the development of fracture. Osteoporotic fractures most commonly
involve the hip, wrist and spine. Lifetime risk of any symptomatic fracture is
40% in women, and 13% for men. Lifetime risk of symptomatic vertebral fracture
is 16% in women and 5% in men. Eighteen per cent of women over 50 years old and
27% over 65 years old will suffer one or more symptomatic vertebral fractures
due to osteoporosis.
Until recently, treatment options for
these fractures were limited to management with pain medications, reduced activity,
bracing or invasive back surgery. But now, vertebroplasty is available. As with
all of these therapies, it is important that there be continued medical
management of the underlying cause of the fracture, eg; osteoporosis or tumor
etc.
Until
recently, treatment of vertebral compression fractures has consisted of
conservative measures including rest, analgesics, and dietary and medical
regimens to restore bone density or prevent further bone loss. In some cases of
malignant and aggressive hemangiomatous lesions, radiation therapy has been
beneficial. In severe cases that have not responded adequately to conservative
treatment, surgical stabilization has been advocated. However, in the last few
years percutaneous vertebroplasty (PVP) has emerged as an important new tool
for treating patients with painful vertebral compression fractures due to
osteoporosis or aggressive bone lesions. The aim of PVP is to alleviate pain by
stabilizing vertebral microfractures with methyl methacrylate cement. In addition
to stabilizing the existing microfractures, the cement strengthens the
vertebral body and may help to prevent further progression of disease.
No. Vertebroplasty is intended to treat the pain of
compression fractures. Old fractures that are no longer painful would not
benefit from vertebroplasty. This procedure is NOT intended for those patients
who suffer from the pain associated with degenerative disc disease or
degenerative joint disease of the spine.
Candidates
for the procedure include men and women who have chronic back pain (at least 6
weeks) and debilitation due to vertebral body fracture. Patients often have
limited mobility and cannot perform routine daily activities, such as bathing,
dressing and walking. Vertebroplasty is usually performed after conservative
treatments (bed rest, back brace, oral pain medications) have failed. Most
patients are elderly (average age 70 years), but younger patients with
osteoporosis, due to metabolic disorders or long-term steroid treatment, may
also benefit from vertebroplasty. Some patients with vertebral destruction from
malignant tumors are also candidates for the procedure.
1) Painful compression fracture
secondary to osteoporosis
2) Painful compression fracture secondary to tumor which does not respond to
conventional therapy
3) Prevent further compression fractures
4) Buttress weakened bone for spine fusions
Please note that the procedure is
generally used for the first indication and is rarely used for the others.
More common treatments for osteoporosis include hormone replacement therapy or treatment with a variety of drugs such as raloxifene (brand name, Evista), alendronate (brand name, Fosamax), or calcitonin (brand name, Miacalcin).
Osteoporosis
is a degenerative bone disease that primarily affects post-menopausal women. A
loss of bone
density causes bones to become brittle, and in turn, leads to
frequent fractures and other serious effects. According to researchers, when a
spine fracture occurs from osteoporosis, 20% to 30% of the damaged vertebral
section is typically lost. Within weeks, more fractures may occur which can
lead to a loss of height. Older women who are affected by osteoporosis-induced
spinal fractures generally lose weight and develop a hunched back.
The spine is made up of bones called vertebrae that are linked together. When these bones become weakened, one or more can break and start to flatten out. This is known as a compression fracture. There are many causes for weak bone. The most common is Osteoporosis, where the bone becomes soft from loss of calcium. When osteoporosis becomes severe, the vertebrae can break very easily. Something as simple as a sneeze can cause a fracture. Most fractures heal with time, but some do not heal well. The fractures may continue to be a source of pain and make the activities of daily living like walking or using the bathroom difficult. Vertebroplasty was developed to help these people. Bone cement is injected into the vertebrae to strengthen it and also to decrease the pain.
The PVP procedure consists of a
fluoroscopically guided percutaneous transpedicular puncture into the affected
vertebral body. Methyl methacrylate cement is then injected directly into the
vertebral body using sufficient pressure to force the cement into the fracture
fissures. In some cases the entire vertebra can be filled with cement from a
unilateral injection. More commonly, however, bilateral injections are
necessary to insure adequate filling of the entire vertebral body. PVP is a
relatively easy outpatient procedure that can be performed by most pain
physicians experienced in invasive radiological techniques.
Vertebroplasty is the injection of cement-like material
(bone mineral substitute) into a collapsing vertebral body. The procedure is
performed to reinforce the fractured bone, alleviate chronic back pain and
prevent further vertebral collapse. The cement-like material stabilizes and
strengthens the crushed bone.
Vertebroplasty is a minimally invasive technique that involves the
injection of a bone cement into abnormal vertebral bodies of the spine. The
procedure is performed to treat painful vertebral compression fractures that
have not responded to conventional therapies such as bed rest, bracing or
analgesia. The procedure offers significant relief of acute pain. Studies
indicate that 85-90% of all patients experience pain relief.
Usually
provides pain relief and increased mobility within 48 hours. Over several
weeks, two-thirds of patients can expect a marked decrease in their doses of
pain medications. Many patients become symptom-free. Three-quarters of patients
can expect to increase their mobility and activity levels. Vertebroplasty
cannot correct curvature of the spine caused by osteoporosis, but may help to
prevent worsening curvature. The procedure treats only the fractured vertebra.
It does not prevent future compression fracture at other levels.
Until vertebroplasty, treatment options for vertebral compression fracture were
limited to bed rest, pain management with strong oral or intravenous medications,
reduced activity, back bracing or invasive spine surgery. Vertebroplasty may
prevent the need for placement of rods and screws to support the spine.
1) >80% moderate to marked pain
relief
2) <5% induced fractures from procedure
3) <1% symptomatic embolism or infection
Vertebroplasty
is a non-surgical procedure that is performed using state-of-the-art imaging
(fluoroscopic) guidance. The procedure is usually performed in the morning.
Patients must be able to lie face down for 1-2 hours. Some patients with severe
emphysema or other lung diseases may have difficulty lying in this position.
Our team of professionals will make you as comfortable as possible. An
intravenous line is placed in the arm to decrease anxiety and control pain.
Intravenous antibiotics are also administered to prevent infection.
After using a local anesthetic to numb the skin and muscle, a needle is
positioned in the collapsed vertebral body. We inject a radiology contrast
agent (contains iodine) to confirm proper needle placement, followed by the
cement-like material. The longest part of the procedure is setting up the
equipment and positioning the needle in the collapsed vertebral body. The
actual injection of cement takes only 10 minutes. Medical-grade cement is
similar to epoxy or glue. It is injected in a liquid form that quickly hardens
over 10-20 minutes. We usually obtain a CT scan after vertebroplasty to
evaluate the distribution of cement.
Once injected, the liquid cement takes approximately 20 minutes to harden. When it hardens, it becomes a permanent spinal reinforcement. In many cases, a second needle puncture is needed to fill the other side of the vertebra. According to Gregg Zoarski, MD, who recently conducted a study on PV, the liquid cement does not affect the mobility of the spine, and patients are able to move freely once it is in place.
The procedure usually takes about one hour per vertebra. After the liquid cement has been injected into the spine, patients will typically be instructed to rest on their back for an hour before getting up. The majority of patients can leave the hospital or outpatient facility within two hours after the procedure. It may take several weeks before patients can resume full activity. In some cases, physicians will recommend a short course of physical therapy.
According to Dr. Zoarski, percutaneous vertebroplasty (PV) may also help prevent severe deformity from repeated spinal fractures. If a patient undergoes the procedure soon after each fracture, deformity could be minimized. To determine which patients might be candidates for PV, physicians perform magnetic resonance imaging (MRI) exams to be certain a patientís back pain is not due to other back problems such as herniated discs or spinal cord tumors.
Percutaneous Vertebroplasty (PV)
is being performed at select hospitals, medical centers, and physiciansí offices
across the
When the needle is in appropriate position,
a small test injection with x-ray contrast is performed to ensure that a vein
has not been entered.
This prevents the inadvertent
passage of cement into a vein and embolization to the heart and lungs. The
needle is repositioned if necessary and the cement mixture is slowly injected
during constant x-ray monitoring. When the potential spaces within the
vertebral body are filled, the needle is slowly removed and the other half of
the vertebral body is then filled with the cement.
This patient suffered from painful
compression fractures. One had already significantly collapsed while the other
was just starting to collapse.
Conventional radiography, computed tomography, and magnetic resonance imaging
studies are obtained prior to PVP to identify all levels of involvement, assess
the extent of vertebral collapse, and evaluate the paravertebral tissues. When
multiple compression fractures are present, correlation of imaging data with
physical examination is necessary to limit treatment to the symptomatic
lesions. PVP is performed under fluoroscopic guidance with general or local
anesthesia. A 10 or 11 gauge needle is utilized for thoracic or lumbar vertebroplasty.
A transpedicular approach into the vertebral body is used to avoid potential
injury to segmental spinal nerves and to decrease the risk of leakage of methyl
methacrylate into the paravertebral tissue. The needle is advanced under
fluoroscopic guidance through the pedicle and into the anterior one-third of
the vertebral body. Following entry into the vertebral body a biopsy can be
performed coaxially through the existing needle if clinically indicated.
Vertebral venography may then performed in the frontal and lateral projections
to evaluate the paravertebral venous drainage and to assure that there is no
direct filling of large veins. Although we routinely perform vertebral
venograms, this is not the case at all centers. Some investigators believe that
the information gained from the venogram is only of marginal value given the
marked difference in the viscosity of contrast media and the methyl
methacrylate cement.
We
prepare the methyl methacrylate polymer using approximately 20 grams of polymethylmethacrylate
powder, 7-10 ml of solvent (methyl methacrylate monomer) and 6 grams of sterile
barium sulfate for radiographic visualization of the cement. Tantalum or
tungsten powder can be substituted for the barium sulfate if desired.
Polymerization begins as the solvent is added to the polymethylmethacrylate
powder. When the mixture assumes a paste-like consistency, it is filled into
syringes and injected through the needle. Injection of the cement is monitored
with continuous lateral fluoroscopy. If venous leakage is identified the
injection is terminated immediately. Otherwise, the injection continues until
the cement approaches the posterior vertebral body or firm resistance is met. A
total of 2-10 ml of cement is typically injected. At the conclusion of the
injection AP and oblique fluoroscopy and/or spot films are used to assess the
adequacy of vertebral body filling. When filling is complete the needle is
removed. In many cases a contralateral puncture will be necessary to achieve
adequate filling of both sides of the vertebral body. The contralateral
puncture and injection are performed as described above. Upon completion of the
injection(s), spot films are obtained in the frontalİ and lateral projections to document good
filling and evaluate for extravasation of the methyl methacrylate cement. The
entire procedure usually can be performed in 1-2 hours per vertebral body. No
more than two vertebral bodies are done per day.
The vertebroplasty is performed in a special x-ray
room in the Radiology department (x-ray department) by trained interventional
pain physicians. During the procedure, you will lie face down on a table that
can be moved in all directions. Above the table is a fluoroscope that uses
x-rays so that the physician can "see" what he is doing. Your pain
physician will give you medication that will make you sleepy and relax you. The
technologist will thoroughly clean the skin over the back. Everyone in the room
will be wearing a cap and mask for your protection. The physician will find the
broken vertebra and numb the area with a medication that will sting when
injected. Once the area is numb, your doctor will place needles into the broken
vertebra using x-rays to guide him. You may feel pressure on your back.
Contrast media (x-ray dye) is then injected into the vertebra through the
needles to make sure they are in good position. When good needle position is
confirmed, cement is then injected until the vertebra has been filled. The
cement does two things. First, it stabilizes the fracture. Second, the cement
gets hot as it hardens; this heat is thought to destroy the pain producing
nerve endings in the vertebra. The needles are then removed and the small
needle holes are bandaged.
In vertebroplasty, an acrylic
"bone cement" is injected through a needle into the collapsed
vertebral body of the spine to reinforce the bone. About 10 minutes later, the
cement solidifies and actually becomes harder than the native bone. The crushed
bone fragments are fused together and no longer abrade against nerve endings
when you move. This is one of the mechanisms by which it alleviates your pain.
The
vertebroplasty procedure, in most cases, is done on an outpatient basis. It
takes about an hour per vertebral body treated and patients usually go home the
same day.
Although vertebroplasty is safe and effective in most cases, the procedure should be performed only if a patient has back pain that significantly impairs mobility and quality of life. Potential complications include bleeding, infection, and worsening of pain. In patients with severe osteoporosis, rib or vertebral fracture can occur. Since the cement is injected as a liquid, it can leak out of the vertebral body into surrounding tissues and veins. Surgery is rarely required to remove the cement that has leaked, although it is a possibility.
Any invasive procedure may have complications. One possible complication is allergy to the medicines or the contrast media. The contrast media has an iodine base. Tell your nurse or physician if you have had a reaction to other x-ray dyes, iodine or any medications. Cement is injected into the vertebra during the procedure. Sometimes, the cement can leak outside the vertebra and press on nerve roots or the spinal cord. In addition, it can migrate to the lung. If these things happen, cement injection is stopped immediately and usually there are no problems; however, in a small percentage of cases these adverse events can lead to worsened pain, paralysis, or require surgery to remove the cement. Any procedure that breaks the skin can result in bleeding or infection.
Some of the risks include:
1.
Leakage of cement into veins and or lungs
2.
Infection
3.
Bleeding
4.
Rib or Pedicle fracture
5.
Pneumothorax
6.
Worsened pain
7.
Paralysis secondary to leakage of cement
8.
Pain or
Weakness
9.
Pulmonary
Embolism
10. Death
Not
all patients with vertebral fracture are appropriate candidates for
vertebroplasty. Careful screening is critical to ensure that symptoms are due
to the vertebral fracture, rather than another problem. It is not enough that
patients have a vertebral fracture, since a healed fracture should not cause
pain. Thus, it is necessary to exclude other potential explanations for back
pain, such as disc herniation, severe arthritis and compression of the spinal
cord or nerve roots
1.
Asymptomatic stable fracture.
2.
Patient clearly improving on medical therapy.
3.
Prophylaxis in osteopenic patients with no evidence of acute fracture
and no planned spinal destabilization procedure.
4.
Osteomyelitis of target vertebra
5.
Acute traumatic fracture of nonosteoporotic vertebra.
6.
Uncorrectable coagulopathy or hemorrhagic diathesis.
1.
Radicular pain radiculopathy, significantly in excess
of vertebral pain, caused by compressive syndrome unrelated to vertebral body
collapse. Specially in the presence of a disk herniation in the corresponding
dermatome. In such circumstances, preoperative vertebroplasty may be indicated
if a spinal destabilization procedure is planned, in a severely osteoporotic
patient.
2.
Retropulsion of fracture fragment causing significant
spinal canal compromise.
3.
Tumor extension into the epidural space with
significant spinal canal compromise.
4.
Severe vertebral body callapse (Vertebra Plana).
5.
Stable fracture known to be more than two years old.
6.
Young patient - the long term effects of the cement
mixture are unknown.
7.
Vertebral bodies above the T5 level - the procedure
is riskier and more difficult.
8.
Patients with prior unsuccessful spine surgery.
9.
Symptomatic spinal stenosis.
All
patients must be evaluated by one of our staff prior to vertebroplasty.
Patients must be seen in person. The evaluation includes a directed history and
physical examination and blood tests. Often, patients can point to a single
painful spot. If the location of pain matches the level of fracture seen on
standard radiographs (x-rays), then there is a good chance that vertebroplasty
will be successful.
If a patient is receiving anti-coagulation treatment (coumadin), it is
necessary to stop the medication until coagulation returns to normal. In
patients who cannot discontinue their coumadin, it may be necessary for brief
hospitalization and intravenous treatment (heparin).
At our initial evaluation, patients should bring any imaging studies that were
not performed at our institution. It is essential that all patients have recent
plain radiographs, Bone Scan, and MRI. If MRI cannot be performed (due to a
cardiac pacemaker, for example), CT scan is necessary. Some patients may need
examination under fluoroscopy or bone scan.
You will need to consult with our
doctor to see if you are a candidate for vertebroplasty. You will also need
some tests to identify which vertebrae are affected and whether the procedure
can be performed safely and with a high degree of success. These tests include
x-rays, a Bone Scan, an MRI scan, and sometimes a CAT scan. If you are a
candidate for the procedure, you will have some blood tests done to avoid
problems with bleeding. Do not eat or drink anything six hours prior to your
procedure.
Take
your usual medicines on the day of the procedure, with just a sip of water.
Call your doctor if you take insulin shots. Your doctor may change the insulin
dose for the day of the procedure. Usually to half of your normal dose. Your
pain physician will give you medication to help you relax and feel comfortable
during the procedure.
1.
History
2.
Physical Examination
3.
Current x-rays
4.
MRI
5.
Bone Scan
Patients
usually recover after a few hours and can go home with an adult if the trip is
short. Otherwise, patients should plan on staying overnight in a local hotel.
Hospitalization is not required unless the patient is extremely frail or
requires additional monitoring after the procedure.
There may be dull aching at the needle puncture sites during the first 24 hours
following the procedure. An ice pack can help with this discomfort. Tylenol or
non-steroidal anti-inflammatory medication is usually sufficient. Narcotic pain
medications should be minimized. You should call us if you develop severe or
increasing chest or back pain, fever, or neurological symptoms.
Patients are called at home approximately 24-48 hours following vertebroplasty.
Patients will receive follow-up care from their pain physician and referring or
primary care physicians. To hasten recovery and regain satisfactory levels of
activity, patients may benefit from physical therapy or short-term back
bracing. Osteoporosis should be treated by your primary care physician, if
medical therapy has not already been instituted.
1) Pain medications - usually
tapered over several days after procedure
2) Muscle relaxants
3) Adjust medications to prevent further mineral loss
Early studies of PVP have indicated favorable outcomes with a majority of
patients reporting marked reduction to near complete resolution of symptoms. A
study by Jensen, Evans, et al reviewed 29 patients who underwent PVP for
osteoporotic vertebral compression fractures. 26 patients (90%) reported
significant pain relief immediately after treatment (3). A study by Cortet,
Cotten, et al reviewed their results in 37 patients who underwent
vertebroplasty. This series included 29 patients with bone metastases and 8
with multiple myeloma. 36 patients (97.3%) reported a decrease in pain 48 hours
following the procedure. Five of these patients (13.5%) were completely free of
pain, 20 (55%) were significantly improved, and 11 (30%) were moderately
improved (4).
Patients
with neurologic symptoms secondary to compression fractures should be treated
cautiously to avoid leakage of cement that could potentially worsen symptoms.
Vertebroplasty can be technically difficult in cases of severe vertebral
collapse and/or vertebral body destruction. Potential complications of the
procedure include epidural and foraminal leakage of cement that can lead to
spinal compression or nerve root injury (1). Leakage into paravertebral veins should
be aggressively avoided as this could lead to pulmonary embolism, although
reported cases of this complication are rare. Because leakage of cement could
potentially result in acute spinal cord compression, the procedure should be
performed at a center with neurosurgical or orthopedic support available (2).
The
mechanism of pain relief after vertebroplasty is poorly understood. Destruction
of sensitive nerves secondary to chemical, mechanical, thermal, and vascular
forces as well as reduction of mechanical forces and stabilization of
microfractures probably combine to alleviate pain. Strengthening of the
vertebral body by the methyl methacrylate polymer also serves to eliminate
further progression of vertebral collapse. PVP has proved to be a simple yet
efficacious alternative treatment for symptoms related to vertebral body
pathology and can be performed as an outpatient procedure by most radiologists
with experience in interventional radiological techniques.
Most major insurance companies cover
the procedure.
Talk to your physician about vertebroplasty. Search the internet or go to your
nearest library.
1.
Cotton A,
Boutry N, Cortet B, et al: Percutaneous Vertebroplasty: State of the Art.
Radiographics 18:311-320, 1998
2.
Deramond H,
Depriester C, Galibert P, Le Gars D: Percutaneous Vertebroplasty with
Polymethylmethacrylate. Radiologic Clinics of
3.
Jensen M,
Evans A, Mathis J, Kallmes D, Cloft H, Dion J: Percutaneous
Polymethylmethacrylate Vertebroplasty in the Treatment of Osteoporotic
Vertebral Body Compression Fractures: Technical Aspects. American Journal of
Neuroradiology 18:1897-1904, 1997
4. Cortet B, Cotten A, Boutry N, Dewatre F, Flipo R, Duquesnoy B, Chastanet P, Delcambre B: Percutaneous Vertebroplasty in Patients With Osteolytic Metastases or Multiple Myeloma. Revue Du Rhumatisme 64:177-183 1997