03 June 2010
Overview
Vertebroplasty and kyphoplasty are procedures designed to treat vertebral compression fractures and other disruptions of the vertebral body. Vertebral compression fractures most commonly result from osteoporosis, but are seen in primary and metastatic spine neoplasms as well as benign bone tumors such as vertebral hemangiomas (1). The kyphotic deformities caused by vertebral compression fractures are associated with pulmonary dysfunction, constipation, and imbalance. Compared with age-matched controls, patients with vertebral compression fractures have higher mortality, increasing with the numbers of fractures as well as the duration of follow-up (1-4). Conservative treatment of vertebral compression fractures includes rest, bracing of the lumbar and thoracic spine, physical therapy, and oral medications. Unfortunately, these measures often do not provide sufficient pain relief and procedures such as vertebroplasty/kyphoplasty must be performed.
Vertebroplasty and kyphoplasty are minimally invasive techniques used to treat painful vertebral compression fractures. Vertebroplasty is the percutaneous injection of a vertebral body with bone cement, generally polymethylmethacrylate (PMMA). PMMA has been used in orthopedics since the late 1960s (5). Percutaneous vertebroplasty was first reported by a French group in 1987 for the treatment of painful hemangiomas (6,7). Since then, the indications for percutaneous vertebroplasty have expanded to include osteoporotic compression fractures, traumatic compression fractures, and painful vertebral metastasis (8, 9). Kyphoplasty is a modification of percutaneous vertebroplasty. It involves the percutaneous placement of balloons (called “tamps”) into the vertebral body with an inflation/deflation sequence to create a cavity before the cement injection. Percutaneous kyphoplasty may restore some of the vertebral body height and reduce the kyphotic angulation of the compression fracture before PMMA injection (10).
Live Vertebroplasty Video
Vertebroplasty is a procedure that offers relief to patients suffering prolonged pain from compression fractures in the spinal vertebrae. It involves injecting bone cement into the vertebrae to stabilize fractures, and results in significant pain relief and restoration of mobility in many patients.
Dr. Paul Lynch preforms a Balloon Assisted Vertebral Augmentation ( or vertebroplasty with balloon) to cure back pain due to a compression fracture.
Anatomy
The human spinal column is composed of 33 individual vertebrae. The spine can be divided into two columns which are called the anterior elements and the posterior elements. The anterior column has an intervertebral disc in between each vertebral body, which allows for the spine to bend. The posterior elements form a protective cage around the spinal cord and also provide strength and flexibility to the spine. The human spine is not straight, but rather has a number of curves that provide strength for load bearing. The thoracic spin has a kyphotic curve whereas the lumbar spine has a lordotic curve. When a disease process such as osteoporosis or tumor involvement cause weakening of the vertebral body, a fracture can occur. These fractures often occur in the anterior third of the vertebral body. If such fracture occurs in the thoracic spine, it exaggerates the kyphotic curve. Likewise, a fracture of a lumbar vertebral body can cause a reduction of the lordotic curve. In each case, pain is generated in two distinct ways: by the movement of the fractured portions of the bone themselves, and the stress placed on the posterior elements of the spine due to misalignment from the increased kyphosis/decreased lordosis.
Procedure
Vertebroplasty/kyphoplasty is usually performed with IV sedation. The patient is placed in a comfortable prone position on the operating table. The skin at the operative area undergoes sterile cleansing. An X-ray machine is then used to identify the precise location of the fractured vertebrae. Local anesthetic is then injected into the skin above the fractured vertebrae and also injected around the bone of the spine. This is done in an effort to minimize any discomfort that might be experienced. Trocars (or vertebroplasty needles) are then advanced into the vertebral body with guidance from the X-ray machine. During a vertebroplasty, once the trocar is in the correct position the cement is injected to strengthen the vertebral body. If the patient is undergoing a kyphoplasty, the additional step of placing kyphoplasty balloons is undertaken. The balloons are inflated to gain vertebral height and create a cavity for the cement. Once this is accomplished, the balloons are deflated and removed, and cement is then placed. The hardening of the cement is accelerated by natural body heat, and at this point the trocars are removed and the patient is ready to go to the recovery room.
Success Story Videos
For those suffering from significant back pain, you may have a fracture in your spine. Arizona Pain Specialists can help and vertebroplasty can change your life. We also treat a variety of pain from Neck Pain,lower back pain, upper back pain, headaches, migraine, and more. If you are in the Phoenix area, contact us today.
Are you in constant pain? Are you missing out on life because your pain gets in the way? Are you unable to play with your children or enjoy time with your loved ones? We treat a variety of pain from neck pain,lower back pain, upper back pain, headaches, migraine, and more. Call Arizona Pain Specialists today. Our physicians in Scottsdale and Glendale are passionate about helping you regain your life.
Benefits
Both vertebroplasty and kyphoplasty have a very high acceptance and use rate. There is substantial improvement in pain and significant improvement in function after treatment by either of these techniques. In multiple studies, percutaneous vertebroplasty has been shown to provide substantial pain relief and/or improved mobility in 75% to 92.4% of patients with osteoporotic vertebral compression fractures and in 50% to 86% of patients with pathologic vertebral compression fractures secondary to neoplasm (1,8,11). A recent study by Liu et al. demonstrates that both vertebroplasty and kyphoplasty are highly effective in reducing pain, demonstrating a reduction in pain scores from 8/10 to 2-3/10 for both vertebroplasty and kyphoplasty immediately postoperatively (12). This relief in pain has been shown to be long-lasting in numerous studies (1,3,8,12). Kyphoplasty improves height of the fractured vertebra and may improve kyphosis by over 50%, if performed within 3 months from the onset of the fracture (onset of pain). There is some height improvement, although not as marked, along with significant clinical improvement, if the procedure is performed after 3 months (13). Vertebroplasty may also increase the vertebral body height, but not to the extent of kyphoplasty (12).
Risks
The main risks of vertebroplasty and kyphoplasty are related to the placement of the needles or the injection of the cement. It is possible for the cement to flow posteriorly and press against the nerve roots or the spinal cord itself, potentially causing permanent damage. While this is a significant risk, it is rare and occurs in less than 1% of patients (13). A review of US Food and Drug Administration safety data revealed 58 reported complications from 1999 to 2003 out of approximately 200,000 procedures performed (14). Other risks of the procedure include bleeding, infection, and the possibility that pain is not relieved by the procedure.
Dr. Allen Burton currently is a professor and chairman of the Department of Pain Medicine at the prestigious MD Anderson Cancer Center, the nation's premiere cancer pain treatment facililty located in Houston, TX.
References
1. Stallmeyer MJB, Zoarski G: Patient evaluation and selection. In Percutaneous Vertebroplasty and Kyphoplasty, edn 2. Edited by Mathis JM, Deramond H, Belkoff SM. New York: Springer; 2006:60–61.
2. Huang C, Ross PD, Wasnich RD: Vertebral fracture and other predictors of physical impairment and health care utilization. Arch Intern Med 1996, 156:2469–2475.
3. Tosteson AN, Hammond CS: Quality-of-life assessment in osteoporosis: health-status and preference-based measures. Pharmacoeconomics 2002, 20:289–303.
4. Lindsay R, Silverman SL, Cooper C, et al.: Risk of new vertebral fracture in the year following a fracture. JAMA 2001, 285:320–323.
5. Charnley J: The reaction of bone to self-curing acrylic cement. A long-term histological study in man. J Bone Joint Surg Br 1970, 52:340–353.
6. Galibert P, Deramond H: Percutaneous acrylic vertebroplasty as a treatment of vertebral angioma as well as painful and debilitating diseases. Chirurgie 1990, 116:326–334; discussion 335.
7. Galibert P, Deramond H, Rosat P, et al.: Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987, 33:166–168.
8. Jensen ME, Evans AJ, Mathis JM, et al.: Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997, 18:1897–1904.
9. Kaemmerlen P, Thiesse P, Jonas P, et al.: Percutaneous injection of orthopedic cement in metastatic vertebral lesions. N Engl J Med 1989, 321:121.
10. Lieberman IH, Dudeney S, Reinhardt MK, et al.: Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures. Spine 2001, 26:1631–1638.
11. McGraw JK, Cardella J, Barr JD, et al.: Society of Interventional Radiology quality improvement guidelines for percutaneous vertebroplasty. J Vasc Interv Radiol 2003, 14:827–831.
12. Liu JT, Liao WJ, Tan WC, et al.: Balloon kyphoplasty versus vertebroplasty for treatment of osteoporotic vertebral compression fracture: a prospective, comparative, and randomized clinical study. Osteoporos Int 2010 21:359-364
13. Garfin SR, Yuan HA, Reiley MA: New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine 2001, 26:1511–1515.
14. Nussbaum DA, Gailloud P, Murphy K: A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site. J Vasc Interv Radiol 2004, 15:1185–1192.
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