Percutaneous vertebroplasty

Percutaneous vertebroplasty is a minimally-invasive therapeutic radiological procedure for the treatment of painful vertebral fractures due to osteoporosis and primary or secondary tumours.

A third of all vertebral fractures are due to osteoporosis, which in Italy amount to 100,000 cases (a third of which produce severe vertebral pain). "Conventional" treatment involves long immobilization (30-60 days), combined analgesic therapy, with the risk of complications (thrombo-phlebitis or pneumonia).

The first vertebroplasty was performed by Hervè Deramond in Amiens in 1984, due to an expanded angioma of the odontoid process. The operation consists of the percutaneous, CT-guided introduction of a needle of appropriate caliber through which, having reached the centre of the vertebral body, a few millilitres of cement is injected under arthroscopic control. The cement solidifies quickly and consolidates the vertebra almost immediately (Figures 1, 2 and 3). Percutaneous vertebroplasty is performed under local anesthesia.

In 2002 38.000 vertebroplasties were performed in the United States, a 28% rise in comparison with the previous year.

Indications

The main indications are:

  • Recent fracture due to osteoporosis, aching, unresponsive to the medical treatment
  • Primary or secondary tumour responsible for pain (metastases, lymphomas, plasmocytomas, myelomas, angiomas, etc.).

Side effects

  • Sepsis
  • Haemorrhagic dyscrasia 
  • Unstable fractures 
  • Posterior wall rupture

Osteoporotic fractures

In osteoporotic fractures multiple vertebrae can be treated, at the most three in the same session. The choice of vertebra or vertebrae to treat is not based only on how they appear on radiographic examination; magnetic resonance also highlights vertebrae with intracancellous edema, a sign that fractures are recent; this finding has then to be correlated with the precise location of the pain reported by the patient (to do this it is useful to palpate for pain with the fingers).

Most patients that have undergone this therapy have reported a reduction or resolution of the pain between the first hour and the 14th day, with a mean of 72 hours; this eliminates the need for wearing a corset, reduces or eliminates the assumption of analgesic drugs, and therefore improves the quality of life.

Metastases

In the vertebra involved by metastases vertebroplasty provides rapid stabilization and reduction/resolution of pain within 12-24h after treatment (radio- or chemotherapy achieve the objective of analgesia in 2-4 weeks) in 96-98% of cases, with significant improvement in the patient’s quality of life.

Primary vertebral tumours (expansive Angioma, Myeloma, Plasmacytoma)

As for metastases, vertebroplasty provided an immediate analgesic effect and the stabilization of the vertebra, thus avoiding the risk of its collapse.
In conclusion, vertebroplasty appears to be a very effective procedure in the treatment of vertebral fracture due to osteoporosis and tumour.

Figures

Figure 1 – 73-year-old patient affected by back pain for over 2 months, not controllable with medical therapy and corset. X-rays highlight on the sagittal plane subsidence of the upper body of the XII thoracic vertebra. Around this vertebra a strong pain was felt on palpation, and magnetic resonance in the STIR sequence showed the presence of intracancellous edema.

Figure 2 – The small size and sagittal orientation of the peduncles prompted a trans-costovertebral approach, which can be performed and monitored under CT guidance with extreme effectiveness and safety (as the figure shows ).

Figure 3 - The CT examination, performed after the injection of cement performed under arthroscopic guidance, reveals the correct diffusion of the cement inside the vertebral body and the absence of leakage

Content updated 22/11/2010 - 15:03
Content edited by: Ugo Albisinni, MD (ugo.albisinni@ior.it)
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