Vertebroplasty & Kyphoplasty
What is Vertebroplasty?
Vertebroplasty is an image-guided, minimally invasive, non-surgical therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis, vascular malformatins or, less commonly, cancer. Vertebroplasty can increase the patient's functional abilities, allow a return to the previous level of activity, and prevent further vertebral collapse. It is usually successful at alleviating the pain caused by a compression fracture.
Under mild sedation anesthesia, a special bone needle is passed slowly through the soft tissues of the back. Image guided x-ray, along with a small amount of x-ray dye, allows the position of the needle to be seen at all times. A small amount of orthopedic cement, called polymethylmethacrylate (PMMA), is pushed through the needle into the vertebral body. PMMA is a medical grade substance that has been used for many years in a variety of orthopedic procedures. The cement is mixed with a powder containing barium or tantalum, which allows it to be seen on the X-ray. When the cement is injected it is like a thick paste, but hardens rapidly. Usually each vertebral body is injected on both the right and left sides, just off the midline of the back.
Within a few hours, patients are up and moving around. Most go home the same day.
What is Kyphoplasty?
Kyphoplasty is similar to vertebroplasty with some modifications. Kyphoplasty is a newer treatment for patients immobilized by the painful vertebral body compression fractures associated with osteoporosis. Like vertebroplasty, kyphoplasty is a minimally invasive procedure that can alleviate up to 90 percent of the pain caused by compression fractures. In addition to relieving pain, kyphoplasty can also stabilize the fracture, restore height and reduce deformity.
Kyphoplasty is also performed under mild sedation anesthesia. Using image guidance x-rays, two small incisions are made and a probe is placed into the vertebral space where the fracture is located. The bone is drilled and a specially designed balloon is inserted on each side. These balloons are then inflated with contrast medium (to be seen using image guidance x-rays) until they expand to the desired height and removed. The spaces created by the balloons are then filled with PMMA, the same orthopedic cement used in vertebroplasty, binding the fracture. The cement hardens quickly, providing strength and stability to the vertebra, restoring height and relieving pain.
Indications for Vertebroplasty & Kyphoplasty
- Pain caused by osteoporotic compression fractures.
- Pain caused by fractures due to vascular malformations.
- Pain caused by fractures due to tumors, which have invaded the vertebral body.
Limitations in the traditional treatments of vertebral compression fractures have led to the refinement of such procedures as vertebroplasty and kyphoplasty. These procedures provide new options for compression fractures and are designed to relieve pain, reduce and stabilize fractures, reduce spinal deformity and stop the “downward spiral” of untreated osteoporosis.
Older people suffering from compression fractures tend to become less mobile, and decreased mobility accelerates bone loss. High doses of pain medication, especially narcotic drugs, further limit functional ability. Vertebroplasty or kyphoplasty are often performed on patients too elderly or frail to tolerate open spinal surgery, or with bones too weak for surgical spinal repair. Patients with vertebral damage due to a malignant tumor may sometimes benefit from vertebroplasty or kyphoplasty. In rare cases, it can be used in younger patients whose osteoporosis is caused by long-term steroid treatment or a metabolic disorder. Typically, vertebroplasty or kyphoplasty is recommended after simpler treatments—such as bedrest, a back brace or pain medication—have been ineffective, or once medications have begun to cause other problems, such as stomach ulcers.
Vertebroplasty/Kyphoplasty can be performed right away in patients who have severe pain requiring hospitalization or conditions limiting bedrest and medications.
Additional benefits of these procedures include:
- Short surgical time
- Only general or local anesthesia required
- Average hospital stay is one day (or less)
- Patients can quickly return to the normal activities of daily living
- No bracing required
Both vertebroplasty and kyphoplasty utilize a cement-like material that is injected directly into the fractured bone. This stabilizes the fracture and provides immediate pain relief in many cases. Kyphoplasty has the additional advantage of being able to restore height to the spine thus reducing deformity. After either procedure, most patients quickly return to their normal daily activities.
*While vertebroplasty and kyphoplasty are encouraging developments, it remains essential that osteoporosis sufferers seek medical help and learn about ways to treat their condition as well as ways to prevent future problems.
For the most part, vertebroplasty and kyphoplasty are safe and effective procedures. However, rare, but serious complications associated with vertebral augmentation (vertebroplasty/kyphoplasty) procedures do exist.
A small amount of orthopedic cement can leak out of the vertebral body. This does not usually cause a serious problem, unless the leakage moves into a potentially dangerous location such as the spinal canal.
- Leakage into the spinal canal may lead to spinal cord or nerve root compression and damage. This is a very rare, but serious event.
- Leakage into a blood vessel may cause a clot in the lung called a pulmonary embolus. Serious lung complications are very rare, but the risk needs to be understood by both the patient and the treating physician.
*Overall, the risk of leakage is less with the use of kyphoplasty versus vertebroplasty.
Other possible complications include:
- Another fracture in the spine or ribs
The procedure cannot serve as a preventive treatment to help patients with osteoporosis avoid future fractures. It is used only to repair a known, non-healing compression fracture.
Vertebroplasty will not correct an osteoporosis-induced curvature of the spine, but it may keep the curvature from worsening.
It may be difficult for someone with severe emphysema or other lung disease to lie facedown for the one to two hours vertebroplasty requires. The healthcare team will try to make special accommodations for a patient with this type of condition.
Patients with a healed vertebral fracture are not candidates for vertebroplasty.
How do I prepare for the procedure?
First, you'll be clinically evaluated. The evaluation generally includes diagnostic imaging, blood tests and a physical exam. Diagnostic imaging such as spine x-rays, a radioisotope bone scan or magnetic resonance (MR) imaging will be done to confirm the presence of a compression fracture that is amenable to vertebroplasty. If an MR cannot be performed, because of a pacemaker or other medical factor, a CT scan can be substituted. In preparation for the clinical evaluation and physical exam, you should obtain and bring with you any previous diagnostic images, especially x-rays or MR films. Be sure to tell your doctor if you are allergic to x-ray contrast material, which contains iodine.
Do not eat for at least six hours before the procedure. If you are diabetic, you should contact your doctor for instructions on regulating your blood sugar and medications. On the day of the procedure, if your doctor instructs you to take your usual medications, swallow your medication with sips of water or clear liquid up to three hours before the procedure. Avoid drinking orange juice, cream or milk.
If you take an anticoagulation medication (blood thinners such as Coumadin), you will have to stop the treatment until coagulation becomes normal, usually within three to five days. Contact your doctor before stopping any medication to determine if it is safe for you. On the day of the procedure, patients who use blood thinners should report to the hospital a little earlier for a blood test to verify that their anticoagulant has stopped working. If you are unable to interrupt your anticoagulant regimen, a short in-patient stay for intravenous treatment with heparin may be required. All patients should arrange for an adult to drive them home after the procedure.
What will I experience during the procedure?
You'll lay face down throughout the procedure. Sedation medications will help you stay calm and minimize any discomfort you might feel during the vertebroplasty. You'll be conscious, though drowsy, and able to hear anything that's said in the room. During the procedure you'll be asked questions such as, "Does this hurt?" It's important for you to be able to tell your doctor if you feel pain. Because of the position you'll be in, you won't be able to see the image on the fluoroscope.
For two or three days afterward, you may feel a bit sore at the point of the needle insertion. You can use an ice pack to relieve any discomfort but be sure to protect your skin from the ice with a cloth; use the pack for only 15 minutes per hour. The tiny incision will be closed with a strip of tape and covered with a bandage that should remain on for several days. It's important that the injection site remain clean. You can shower while the bandage is still on.
Increase your activity gradually and resume all your regular medications. If you take blood thinners, check with your doctor, but you may be able to restart them the day after the procedure.