Vertebral Augmentation

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Overview

Overview content for Vertebral Augmentation is not yet available.

Pre-Procedure

Vertebral augmentation: injection of cement into vertebral body
Vertebroplasty: augmentation with acrylic cement into vertebral body
Kyphoplasty: balloon catheter following by injection of acrylic cement
Vertebral compression fracture (VCF)

Indications:
• Painful vertebral compression fracture
• Painful osteolytic metastasis
• Painful hemangioma
• Kummel's disease
Some argue the above are indications only in the setting of failed conservative treatment
Patients requiring hospital admission and/or IV narcotics may warrant earlier treatment

Time frame of treatment:
• Varies with different clinical scenarios and location of VCF
• Consider 4-6 weeks of conservative treatment before intervention

Conservative treatment:
• Bed rest
• Pain control with medications
• Medical treatment of underlying osteoporosis
• Physical therapy
• Bracing - no good data to suggests this works except in specific circumstances
Must consider risk of immobility with conservative management:
• Bone loss
• Strength loss
• Contractures
• Pressure sores
• Increased risk of DVT

Contraindications:
• Spinal infection
• Uncorrectable bleeding diathesis
• Myelopathy related to spinal canal stenosis from retropulsed compression fracture
• Radiculopathy related to neuroforaminal stenosis from compression fracture
• Asymptomatic VCF

Relative contraindications:
• Disruption of posterior cortex
• Epidural extension of tumor
• Central canal narrowing without myelopathy

Preprocedural evaluation:
• History: description of pain; attempt to tease apart different pain and pain sources. Ask patient what pain is most bothersome/lifestyle limiting
• Physical exam: identify and characterize neurological deficits
• VCF: typically midline pain, sudden onset and exacerbated by motion
• Preprocedure MRI is gold standard. CT with bone scan often helpful if patient with contraindication to MR




Procedure

Antibiotic:
• 1-2 g cefazolin (Ancef) IV
• Vancomycin for PCN allergy

Patient positioning:
• Prone best
• Can sometimes be done in prone obliquity or decubitus
• Locate the level to be treated and correlate with preprocedure imaging
• Flatten the superior and inferior endplates with craniocaudal tilt of image intensifier

Approach:
Posterior for thoracic and lumbar; anterior for cervical
Transpedicular vs parapedicular

Transpedicular:
• Less risk of injury to structures between skin and pedicle
• Refluxed cement contained within pedicles
• More common
Parapedicular:
• Needle placed lateral to the pedicle
• Can obtain more medial needle placement

Needle placement:
Target needle placement for cement deposition within anterior third of vertebral body. Try and administer cement along fracture line
Biplane extremely helpful
Use 22 g spinal needle to administer lidocaine to periosteum. Helps with trajectory planning

Ipsilateral oblique: view pedicle en fosse "down the barrel"
• Center needle trajectory on pedicle
• Avoid transgressing inferior or medial cortex of pedicle
• Confirm AP direction with biplane
Anterior-posterior projection
• Position spinous process in center of vertebral body
• Skin entry site superior and lateral to pedicle: ~1 cm superior and 2 cm lateral to pedicle
• Confirm AP direction with biplane
• Can maintain AP projection for contralateral side when performing bipedicular needle placement
Once beyond posterior cortex of vertebral body, needle can cross medial cortex of pedicle
Diamond tip and bevel tip needles for maneuverability once seated within bone

Cement administration
• Mix cement
• Monitor cement administration under fluoroscopy
• Try to fill cement within fracture plane
• Some attempt to fill endplate to endplate and front to back: biomechanics and pain relief
• Evaluate for extravasation outside of vertebral body
• Confirm adequate coverage
• Cement volume: 4.5 mL is predictor of pain relief

Replace trocar and remove needles
Sterile dressings to skin entry site

Post-Procedure

Postprocedural care:
• Bed rest 2-4 hours
• Bed flat
• Follow up physical exam with neurologic evaluation and pain level
• Avoid strenuous activity x 24 hours

Follow-up:
• Clinic visit in 2-4 weeks
• If symptoms resolved, no additional follow-up or imaging necessary
• Need treatment and education related to bone mineral density

Complications:
< 1% major complication rate for benign VCF
< 5% major complication rate for cancer-related fractures
• Hematoma
• New fracture of rib, transverse process, pedicle or vertebral body
• Infection
• Cement extravasation
• Nerve injury
• Cord damage, possibly paralysis or new neurologic deficit
• Pneumothorax
• Increase in pain or failure to resolve pain

Important Trials:
• EVOlVE Trial 2017
• VAPOUR Trial 2016
• FREE study 2009
• Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009

Related Procedures

No related procedures.

 

References

[1] Katsanos, K., Sabharwal, T., & Adam, A. (2010). Percutaneous cementoplasty. Seminars in Interventional Radiology, 27(2), 137–147. http://doi.org/10.1055/s-0030-1253512
[2] Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361(6):557‐568. doi:10.1056/NEJMoa0900429
[3] Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures [published correction appears in N Engl J Med. 2012 Mar 8;366(10):970]. N Engl J Med. 2009;361(6):569‐579. doi:10.1056/NEJMoa0900563
[4] Papanastassiou ID, Phillips FM, Van Meirhaeghe J, et al. Comparing effects of kyphoplasty, vertebroplasty, and non-surgical management in a systematic review of randomized and non-randomized controlled studies. Eur Spine J. 2012;21(9):1826‐1843. doi:10.1007/s00586-012-2314-z
[5] Bousson V, Hamze B, Odri G, Funck-Brentano T, Orcel P, Laredo JD. Percutaneous Vertebral Augmentation Techniques in Osteoporotic and Traumatic Fractures. Semin Intervent Radiol. 2018;35(4):309‐323. doi:10.1055/s-0038-1673639
[6] Eckel TS, Olan W. Vertebroplasty and vertebral augmentation techniques. Tech Vasc Interv Radiol. 2009;12(1):44‐50. doi:10.1053/j.tvir.2009.06.005

Join The Discussion

 

Demos

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Vertebroplasty & Kyphoplasty Demonstration

Vertebroplasty and kyphoplasty demonstrated by Dr. Glen David during the 2nd Annual Spine Trauma Summit.

 

Tools

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Literature

Literature is not yet available for this procedure.

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American Journal of Neuroradiology (Dec 2014)

A Randomized Trial Comparing Balloon Kyphoplasty and Vertebroplasty for Vertebral Compression Fractures Due to Osteoporosis

The safety and efficacy of balloon kyphoplasty and vertebroplasty is studied in osteoporosis patients with vertebral compression fractures.

Seminars in Interventional Radiology (Jun 2010)

Percutaneous Cementoplasty

Patient selection and the fundamentals of image-guided lesion access and cement injection during percutaneous cementoplasty.

 

Podcasts

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Please check back soon.

Innovation in Spine Interventions BackTable Podcast Guest Dr. Douglas Beall

Dr. Douglas Beall

Dr. Michael Barraza

Dr. Douglas Beall discusses his drive for innovation in minimally invasive spine interventions, as well as the inspiration behind his new comprehensive book on Vertebral Augmentation.

&

Dr. Venu Vadlamudi

Dr. Kumar Madassery

Our IR's talk practice building, techniques, and equipment, as well a candid discussion of vertebroplasty versus kyphoplasty.

&

Spinal Ablation Therapies Podcast with Dr. Peder Horner

Dr. Peder Horner

Dr. Sabeen Dhand

Dr. Sabeen Dhand interviews Dr. Peder Horner on how he built a spinal tumor ablation practice in Denver, CO, including tips/tricks on equipment and patient selection.

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RF Ablation Therapy for Bone Metastases BackTable Podcast Guest Dr. Jason Levy

Dr. Jason Levy

Dr. Sandeep Bagla

Dr. Jason Levy and Dr. Sandeep Bagla discuss palliative treatment of bone metastases with radiofrequency ablation, as well as recent results from the OPuS One trial.

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Blog Articles

Blog articles are not yet available for this procedure.

Please check back soon.

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Setting Expectations for Pain Relief and Recovery After Vertebral Augmentation

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Perioperative Management for Vertebral Augmentation Procedures

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Kyphoplasty Versus Vertebroplasty in the Treatment of Spinal Compression Fractures

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Using Curved Balloons and Needles for Improved Cement Distribution

Currently there are numerous needle options available for cement delivery to vertebral compression fractures. Vertebral augmentation veterans Dr. Kumar Madas...