Vertebroplasty

Authors: A/Prof Kenneth R Thomson*
                            Dr James Burnes *

What are the prerequisites for having a vertebroplasty done?

Confirmation of an active fracture without nerve root compression. This is most effectively done with an MRI study of the area. CT and nuclear bone scan are less reliable unless there is an historical imaging record showing progressive collapse. Bone scans may remain ‘hot’ long after a fracture has healed.

The posterior body should be intact to prevent escape of PMMA into the spinal canal.

In cases of severe multiple myeloma, kyphoplasty may be preferable to vertebroplasty. General anaesthesia is not required.
Vertebral fracture from vascular malformations respond to vertebroplasty but these conditions do not attract a CMBS rebate.

What are the absolute contraindications for a vertebroplasty?

Uncontrolled bleeding diasthesis.

Pain not clearly related to recent and ongoing vertebral fracture.

Active infection anywhere in the body.

Known allergy to PMMA.

What are the relative contraindications for a vertebroplasty?

Obesity sufficient to exceed table weight limits or image gantry aperture size, or unable to lie prone.

What are the adverse effects of a vertebroplasty?

Most complications associated with vertebroplasty are related to the extravasation or leakage of the cement beyond the confines of the vertebral body. The majority of these leakages are asymptomatic or not clinically relevant. Non-significant leakage without clinical sequelae occurs in about 1-2% of patients However, with leaks in to the systemic venous system there is the potential for pulmonary embolism or death.

Pulmonary embolism can be caused by cement emboli occluding the pulmonary artery. Further, it can be caused indirectly through PMMA facilitating a local inflammatory reaction in a vessel wall, leading to thrombosis.1 The risk of this event is <1:1000 in the absence of significant venous filling.

Similarly, in the action of filling the vertebral body the contents of the bone cavity are pressurised, and in some cases, air, fat and bone marrow can enter the medullary vessels and embolise the pulmonary vasculature.2 Fat and bone marrow embolisation is related to the number of vertebral bodies injected at one procedure. Three levels is not associated with significant fat or bone marrow embolism.

Further, with major (>5cc) cement leaks into the spinal canal there is the potential for permanent neurologic deficit, including paralysis.

In patients with osteoporotic vertebral compression fractures, subsequent fractures may occur adjacent to the level of the vertebroplasty. Anecdotal evidence suggests this is more likely if there is leakage of cement into the disc space. In the few studies of patients that had vertebral compression fractures of mixed aetiology, the subsequent fracture rate ranged from 2.6 – 36.8%. Higher rates of subsequent fracture were observed in those studies with longer follow-up periods.

Are there alternative imaging tests, interventions or surgical procedures to a vertebroplasty?

The most accurate imaging test prior to vertebroplasty is MRI.

Surgical alternatives are spinal surgery (fusion) if the patient’s general condition permits.

Medical therapy (rest and pain relief) should be tried prior to vertebroplasty as many fractures cease being symptomatic within 6 weeks.

Further information about Vertebroplasty:

MSAC Reference 27: Vertebroplasty and kyphoplasty for the treatment of vertebral compression fracture provides an in-depth review of vertebroplasty literature.

References:

Francois K et al. Successful management of a large pulmonary cement embolus after percutaneous vertebroplasty: a case report. Spine, 2003. 28: p. E424–425.
Chen HL et al. A lethal pulmonary embolism during percutaneous vertebroplasty. Anesthesia & Analgesia, 2002. 95: p. 1060–1062.

*The author has no conflict of interest with this topic.

Page last modified on 26/7/2017.