Article
Vertebral Augmentation
Dr. Chris Beck • Updated Sep 16, 2021
Vertebral augmentation includes both vertebroplasty and kyphoplasty procedures. Both procedures are used for the treatment of benign and malignant painful spinal compression fractures. Although the mechanisms for each fracture can vary, both procedures involve the percutaneous injection of cement into the diseased vertebral body. The primary goal of treatment is pain relief. Secondary goals often include stabilization of the fracture and restoration of potential height loss. Vertebral augmentation surgery is one tool of many in the treatment arms for vertebral compression fractures. Vertebral augmentation surgery techniques and devices can vary between operators. However, a constant for this procedure is the importance of the preprocedural evaluation and workup, which are paramount for appropriate patient selection.
Table of Contents
Pre-Procedure Prep
Vertebral Augmentation Procedure Steps
Post-Procedure
Pre-Procedure Prep
Modalities
• 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
Vertebral Augmentation 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 vertebral augmentation contraindications:
• Disruption of posterior cortex
• Epidural extension of tumor
• Central canal narrowing without myelopathy
Pre-Procedural 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 MRI
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Vertebral Augmentation Procedure Steps
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
Post-Procedural 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
Additional resources
[1] 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
[2] 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
[3] 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
[4] 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
[5] 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
[6] 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
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