SURGICAL MINIMAL INVASIVE TECHNIQUE for VERTEBROPLASTY in PONDERAS HOSPITAL , BUCHAREST

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Vertebroplasty is a pain treatment for vertebral compression fractures that fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable. A compression fracture occurs when pressure on a vertebra causes it to break or crack, often because of osteoporosis. Compression fractures are often extremely painful, and can cause abnormal spine curvature that leads to other serious health problems.

Vertebroplasty, a nonsurgical treatment performed by interventional radiologists using imaging guidance, stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. The cement hardens, stabilizing the fractures and supporting your spine. This reduces pain, and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty dramatically improves back pain within hours of the procedure, provides long-term pain relief and has a low complication rate, as demonstrated in multiple studies.

When vertebroplasty is successful, the cement mixture injection stabilizes the vertebra and allows you to return to normal activity after a recovery period.

If the vertebra isn’t shored up, it can heal in a compressed or flattened wedge shape. Once this occurs, the compression fracture cannot be treated effectively. It is very important for someone with persistent spinal pain lasting more than three months to consult an interventional radiologist, and people who require constant pain relief with narcotics should seek help immediately.

Fractures and osteoporosis

The fractures may be as a result of bone weakened by osteoporosis, trauma, or tumors such as metastases, multiple myeloma, and hemangioma. Osteoporosis, however, accounts for most fractures. Once a vertebral compression fracture occurs, the risk of additional fractures in adjacent vertebrae increases 5-fold.

Vertebral compression fractures are twice as common in females. For reasons not clearly understood, only one third of spinal compression fractures are painful; most of these are refractory to medical management. The remaining patients report a history of significant spinal pain in the past or do not have pain at the time of diagnosis.

Dozens of diseases and conditions predispose individuals to osteoporosis and secondary vertebral compression fracture. Examples include the following:

Advanced age

Asthma

Cirrhosis

Diabetes mellitus

Emphysema

Menopause

Oophorectomy, bilateral

Renal disease, chronic

Rheumatoid arthritis

Transplants

Tumors, parathyroid-related peptide

Vitamin D deficiency.

In addition, certain drugs are also associated with osteoporosis, as follows:

Anticonvulsants

Cytotoxic drugs

Alcohol

Thyroid replacement drugs

Steroids

Heparin.

Patients with compression fractures typically present with a sudden onset of intense back pain, often after a relatively benign activity. Many patients refer to intractable pain after a sneeze or a cough. The pain tends to be debilitating. Patients find it difficult to find a comfortable position, and therefore, they have difficulty sleeping. Many patients refer to sleep in a seated or semireclining position.

Diagnosis

Most often, the radiographic diagnosis of compression fracture is made by using plain-film radiographs of the spine. MRI is essential in identifying cord compression as a consequence of a posteriorly displaced or retropulsed bone fragment. MRI findings are most informative in evaluating the spine at the levels where the spinal cord is present (eg, from the cervical spine through the second lumbar vertebra). CT is the most sensitive means of identifying a linear fracture through the posterior vertebral cortex.

Indications

The main reason you would need a vertebroplasty is treat a fractured vertebra in your spine that’s causing pain and reduced function. Not all people with fractured vertebrae are candidates for a vertebroplasty, however. Your doctor may try other, more conservative methods of treating the pain first: bed rest, pain relievers, muscle relaxants, back braces, or physical therapy.

These are reasons that your doctor may consider a vertebroplasty for your fractured vertebra:

Traditional methods of treating your fractured vertebra or back pain fail.

You suffer from severe or prolonged pain or immobility.

The fractured vertebra has led to more serious complications, such as deep vein thrombosis, acceleration of osteoporosis, respiratory problems, loss of height, or other emotional or social issues.

Your compression fracture is less than six months old, and imaging tests (X-rays, MRI and bone scan) can pinpoint the location and age of the compression fracture.

Your bones are not so weakened (porous) that your ribs might break as a result of lying facedown during the procedure.

Vertebroplasty may also be applied prophylactically to an at-risk vertebra between 2 other abnormal vertebra.

Vertebroplasty has several benefits:

  1. Return to normal activity. Many people with compression fractures are unable to do everyday tasks because of the pain. Vertebroplasty stabilizes the fracture, allowing most people to resume previous levels of activity within a few days.
  2. Reduced pain medication. Vertebroplasty reduces and sometimes eliminates the need for pain medication.
  3. Prevention of further fractures. The cement fills the spaces in bone weakened by osteoporosis. The treated bone is less likely to crack or fracture again.

Contraindications

Because the injection of acrylic under pressure is likely to pass through the fracture into the spinal canal, a posterior cortical defect is considered a relative contraindication for vertebroplasty.

Cord compression, radiculopathy.

Vertebroplasty also is contraindicated in cases involving a bone infection such as diskitis with osteomyelitis.

The presence of a burst fracture with loss of integrity of the posterior vertebral cortex and retropulsion of a fracture fragment into the spinal canal is considered exclusionary.

Fever and/or sepsis.

Coagulopathy.

Procedure

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Vertebroplasty is a minimally invasive procedure, wich is performed by a specially trained interventional radiologist or neuroradiologist in an interventional radiology or neuroradiology suite, or occasionally in the operating room. You will be positioned lying face down for the procedure. You may be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.

Depending on your needs, the doctor will give you sedation medication to relax you and keep you calm during the procedure. If you are in severe pain, general anesthesia may be required. You may be given medications to help prevent nausea and pain, and antibiotics to help prevent infection.

The area through which the hollow needle, or trocar, will be inserted will be shaved, sterilized and covered with a surgical drape.

A local anesthetic is then injected into the skin and deep tissues, near the fracture. A very small skin incision is made at the site.

Using x-ray guidance, the trocar is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra.

In vertebroplasty, the orthopedic cement is then injected. Medical-grade cement hardens quickly, typically within 20 minutes and becomes harder than the native bone. Depending on how the cement enters the vertebra, a second injection might be needed to completely fill it. Opacification of the vertebral body need not be complete for successful vertebroplasty.

X-rays and/or a CT scan may be performed at the end of the procedure to check the distribution of the cement. The trocar is removed after the cement is injected.

Pressure will be applied to prevent any bleeding and the opening in the skin is covered with a bandage. No sutures are needed.

After the procedure, you will be probably lie flat on your back for 1 hour while the cement hardens, then, he/she can be discharged.

Vertebroplasty does not restore the height of the compressed vertebral body. A related procedure, kyphoplasty, is intended to restore lost height by inflating a balloon tamp within and between the fracture fragments prior to the infusion of methylmethacrylate. The procedures result in similar relief of pain due to vertebral compression fractures.

More info: Ponderas Hospital

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