Introduction and indications. I want to thank Dr. John A. Scott, Interventional Neuroradiologist, Methodist Hospital of Indiana, Indianapolis, IN for providing the information and the impetus to add this page of information to the Men's Osteoporosis Support Group's Web site. He e-mailed me with the suggestion and then had Anne Oteham, RN, send me a very extensive package of information on percutaneous vertebroplasty (PV). For more information about PV, contact Anne Oteham at Radiologic Specialists of Indiana, phone number 317-923-3266 or 317-929-3180.
Although osteoporosis is considered a silent and painless disease, once the bone mineral density gets to a critical low level, spinal compression fractures can occur. At that point, it is no longer painless, and, in fact, it can become excruciatingly painful. One option to relieve this pain is PV, which was developed in France in 1987. According to Cotten A and others(6), "Vertebroplasty is an effective, new, radiologic procedure consisting of a percutaneous injection of a biomaterial, usually methyl methacrylate, into a lesion of a vertebral body. This technique allows marked or complete pain relief and bone strengthening in most cases"
Although this discussion is dedicated to the use of PV for osteoporosis, it is used in other conditions such as: spinal metastases, multiple myeloma lesions, and hemangiomas (tumors made of blood vessels). Note that the decision to perform PV should be made by a multidisciplinary team because choices include PV, surgery, radiation therapy, medical treatment such as drugs or pain pumps, or some combination therapy. Also, PV is generally indicated for acute spinal compression fractures, not something that has been bothersome for many months or years. It is most effective when the pain is localized to one area of fracture and not of a general nature throughout the spine.
Contraindications. If the vertebra is collapsed to less than one-third of its original height, this is a relative contraindication. Also, neurologic symptoms are a relative contraindication, while coagulation disorders are a full contraindication.
The Procedure. The radiologist uses special fluoroscopic machines to guide placement of the needle and the plastic bone cement that is injected into the vertebrae to stabilize them. The procedure is done under sterile conditions and using only local anesthesia. Poly methyl methacrylate (PMMA), which is radiopaque due to sterile barium powder, is injected into the bone with a large-gauge needle. About 6 cc of cement is injected, often on both sides of the vertebra to obtain complete filling and stabilization.
After the PV. A CT scan is done to verify the extent of cement filling of the vertebra and to look for leakage. X-rays may then be taken again at four and twelve months to assess changes. Patients are often released in just a few hours, or may be kept overnight if needed for observation.
Complications. If there is epidural or foraminal leakage, this can lead to spinal cord or nerve root damage. This may occasionally lead to the need for spinal decompressive surgery. Since the need for surgery can be an emergency procedure, the PV should only be done at a surgical center. Venous embolism is a possibility, but is very rare. The physicians do vertebral venography to help them avoid large areas of veins that could lead to embolism. The reported success in the literature is approximately 80% of people who get either total or partial pain relief. If relief occurs, it is normally within about three days. Note that means 20% get no relief, so you must be prepared for that possibility. I'm obligated to tell you that the one member of the Men's Osteoporosis Support Group who had the procedure done did not get relief, had increased pain after procedure, and had complications from excess cement. He asked me to let prospective patients know that the procedure took about three hours, a time period much greater than he had expected. And, his procedure was quite painful, in spite of the fact that most of the literature suggests the procedure is painless. Cotten and others(6) do, however, note that: "General Anesthesia or neuroleptanalgesia with additional local anesthesia (1% lidocaine) is needed because pain may intensify during cement injection." See the January and April 2000 Men's Osteoporosis Support Group Newsletter for details of one person's experience with vertebroplasty and its consequences. With PV, or any surgical procedure for that matter, you want to feel comfortable with the qualifications and training of your physician. Be sure you agree with the recommendations of the entire evaluating team, and then base your decision upon what is best for your particular situation.
Kyphoplasty. This is vertebroplasty with one additional step wherein the physician inserts and inflates a small balloon into the vertebra to expand its height before injecting the PMMA. For more details on this procedure see Spine-health.com. To locate a physician who does kyphoplasty see the Kyphon Web site.
An excellent series of X-ray photos of an actual PV procedure.
Oregon Health Sciences University, Department of Neurological Surgery patient information sheet.
1. Spine 2000 Apr 15;25(8):923-8. Barr JD and others, Percutaneous vertebroplasty for pain relief and spinal stabilization. This paper reviews 47 consecutive patients treated from 1995-1998 with PV, of whom 38 were treated for osteoporosis fractures. Sixty-three percent had marked to complete pain relief, 32% had moderate relief, and 5% had no significant change. Complications were minor and infrequent.
2. Bone 1999 Aug;25(2 Suppl):11s-15S. Martin JB and others, Vertebroplasty: clinical experience and follow-up results. UI:99385449. This study reports the results of 40 patients treated for 68 vertebral segments over 4 years. The authors report, "The results observed matched those reported previously with a success rate of approximately 80% and a complication rate below 6% per treated level." Additionally, they report, "Treatment failure was mostly related to insufficient pretreatment clinical evaluation, and complication due to excessive PMMA volume injection."
3. J Rheumatol 1999 Oct;26(10):2222-8, Cortet B and others, Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. UI:99456423. This prospective study evaluated VP on 16 patients and 20 vertebrae. All patients had significantly decreased pain and there were no adverse events from the procedure.
4. Am J Roentgenol 1999 Dec;173(6):1685-90, Cyteval C and others, Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients. This study found 75% complete pain relief within 24 hours after injection. Mild pain continued in three patients, and one patient had pain related to excess cement impinging upon a muscle.
5. Am J Neuroradiol 1997 Nov-Dec;18(10):1897-904, Jensen ME and others, Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. UI:98065709. This study reported on 29 patients and 47 fractures. They report 90% of patients had significant pain relief immediately after treatment. Two patients had nondisplaced rib fractures during the procedure, but no other complications were reported.
6. Radiographics 1998 Mar-Apr;18(2):311-20; discussion 320-3. Cotten A and others, Percutaneous vertebroplasty: state of the art. UI:98197544. This is an excellent overview of PV that includes indications, technique, complications, etc.