What is Percutaneous Vertebroplasty?

What is percutaneous vertebroplasty?

Percutaneous vertebroplasty is a minimally invasive treatment developed by neuroradiologists for the treatment of painful spinal compression fractures due to osteoporosis.

What is osteoporosis and who is affected by it?

Osteoporosis refers to the loss of normal bone mineral that occurs with age. Osteoporosis is more pronounced in women. It leads to weakening of the bones and predisposes affected individuals to fractures.

Osteoporosis affects approximately 25 million Americans, and the number is expected to increase over time as our population ages. Approximately 80% of the affected population is female and 20% male. Fractures due to osteoporosis can occur in the extremities (especially the hip) and the vertebral column (ie, the spine). Fractures of the vertebrae are often called compression fractures because the vertebra becomes shorter in height, or compressed, as a result.

Vertebral compression fractures occur in 25% of Caucasian women older than 50 years and in 40% of Caucasian women 80-85 years old. The Asian population has a high rate of osteoporosis; the African-American population is not affected to nearly the same degree.

Approximately half as many men have vertebral compression fractures. In the United States alone, approximately 700,000 vertebral body fractures occur annually. The estimated lifetime risk of symptomatic (painful) vertebral fracture for women is 16% and 5% for men.

In 1986, the identifiable direct cost for vertebral osteoporosis was more than $600 million. The incidence of osteoporotic fractures is expected to increase fourfold worldwide over the next 50 years.

Osteoporosis can also occur in younger people, especially those have received long-term steroid treatment for various medical conditions and those who with a loss of kidney function. These patients are also at an increased risk for fractures.

How does a compression fracture happen?

In patients with normal bone strength (no osteoporosis), the impact of a large force such as that from a serious car accident or a severe fall, is required to fracture the spine. In patients with osteoporosis, however, the impact of minor force can cause a fracture. Examples of such minor forces are those involving twisting the back, lifting a heavy object, or even going over a large bump or pothole while riding in a car.

What happens when a compression fracture occurs?

Most compression fractures occur in the middle (thoracic) or lower (lumbar) spine.

Typically, the fracture causes a sudden, severe pain in the back at the location of the fractured or compressed vertebra. Less frequently, the pain may start at a lower level and ascend.

A large proportion of fractured vertebrae do eventually heal with conservative therapy such as bed rest and pain medication. This process usually takes 4-6 weeks. With healing, the pain disappears, but the vertebra remains collapsed, and this collapse may gradually increase over time.

Some fractures do not heal, even with conservative treatment, and they continue to cause disabling pain, which severely limits the patient's normal activities.

Once one compression fracture occurs, the risk of a second fracture occurring is 4 times as high as before.

What can be done to treat a compression fracture?

There are 2 primary choices for the treatment of a new compression fracture. One is conservative treatment and the second is vertebroplasty.

Conservative treatment consists of strict bed rest and immobilization of the spine, often by using a stiff back brace and strong narcotic pain relievers. This therapy is designed to let the fracture heal, and it usually takes 4-6 weeks. The disadvantage of this treatment is that patients can become physically deconditioned and debilitated as a consequence of a long period of inactivity. Additionally, the prolonged use of narcotics for pain relief may also cause adverse effects, including altered mood and constipation.

Vertebroplasty is a minimally invasive procedure developed by neuroradiologists to stabilize a fracture of the vertebra and to relieve the associated pain. During the procedure, one or two needles the approximate size of a cocktail straw are inserted through the skin into the fractured vertebra under X-ray guidance. Surgical cement (often also used for hip and knee replacements) is then injected into the fractured vertebra to stabilize the fracture. The needles are removed at the end of the procedure, and bandages are placed on the incision sites.

The procedure is performed with the patient under local anesthesia, with some mild sedation and pain control also provided, to ensure the maximum possible comfort during the procedure. The length of the procedure is 1-2 hours, depending on the number of vertebrae to be treated. Several compressed vertebrae can be treated at one time.

Vertebroplasty is usually performed as an outpatient procedure, and the patient can go home the same day, usually 2-3 hours after the procedure. For those patients who require more intensive care, usually because of other existing medical problems, an overnight stay is arranged.

Frequently asked questions about vertebroplasty

1. Question: Who is a candidate for vertebroplasty?
   Answer: People with compression fractures of the spine that cause moderate to severe pain and that seriously affect their mobility and quality of life are candidates for vertebroplasty, especially those in whom pain continues for longer than 4-6 weeks despite bed rest and pain medications. Occasionally, older fractures that continue to be painful can also be effectively treated with vertebroplasty, as long as the treating physician has determined that the pain is from a non-healed fracture. Other causes of back pain, such as arthritis or disk disease, cannot be treated with vertebroplasty.
   
   In patients with multiple fractures, imaging tests such as computed tomography (CT), magnetic resonance imaging (MRI), and bone scanning can help in depicting the acute (more recent) fracture and in identifying the source of the pain to guide treatment decisions.

2. Question: How successful is vertebroplasty?
   Answer: In those patients who are candidates for vertebroplasty, studies have shown that approximately 80% experience either significant or complete relief of their pain.

3. Question: How safe is vertebroplasty?
   Answer: Vertebroplasty has been performed in the United States since 1993, and radiologists in France have performed thousands of vertebroplasties since 1983. For the treatment of compression fractures due to osteoporosis, the overall complication rate is less than 2%. The bone cement has been in medical use for many years, and it is used for other procedures and surgeries such as hip and knee replacements. The imaging used to guide the procedure and to direct the cement into the correct location minimizes the risks.

4. Question: Can vertebroplasty restore the height of the fractured vertebra?
   Answer: Vertebroplasty cannot restore the full height of the fractured vertebra, but it stabilizes the vertebra at the height it was at the time of the treatment. However, in some cases in which the vertebral fracture fragments are unstable, vertebroplasty can restore some vertebral height. Without vertebroplasty, the compression of the vertebra gradually increases, with a progressive loss of height of the vertebra over time.

5. Question: Does vertebroplasty prevent additional fractures?
   Answer: No. Only aggressive medical treatment of the underlying osteoporosis can decrease the occurrence of new fractures.

6. Question: Can vertebroplasty be used to treat fractures of the spine due to tumor or to treat tumors of the spine causing pain?
   Answer: Yes. The procedure was originally developed for the treatment of painful spine tumors, and it has a high success rate in treating this problem.

New developments on the horizon

Several new approaches in vertebroplasty and minimally invasive treatments of spine fractures are being evaluated.

• Research is being performed to evaluate new cements, including those that act like natural bone and stimulates new bone growth and healing.
• Kyphoplasty is a procedure that may restore some of the loss of height of the vertebra. It has not been shown to be any more effective than vertebroplasty in providing pain relief.
• The role of vertebroplasty for preventative treatment of high-risk patients without fractures must still be evaluated.

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