Asa Vertebroplastia

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The Treatment of CompressionFractures by the Anesthesiologist:

Vertebroplasty and Kyphoplasty

Philip S. Kim, MDDirector of Center for Pain Medicine

Director of St. Francis Pain CenterDepartment of Anesthesiology

St. Francis Pain and Spine CenterSt. Francis Hospital

Wilmington, Delaware

Osteoporosis is manifested by low mineral density orby the presence of fragility fractures. The occurrenceof an atraumatic vertebral fracture is sufficient

enough to establish a diagnosis of osteoporosis. In 1996,the incidence of osteoporotic vertebral compression frac-tures was 700,000, which surpasses the combined frac-tures of the ankle and the hip.1 For several decades,vertebral compression fractures were thought to be benignand self-limited. This view evolved from at least two-thirdsof fractures never being reported by patients to theirphysicians.2 If diagnosed, most patients underwent con-

servative treatment.Polymethylmethacrylate (PMMA) has been used in or-thopedic treatment and dentistry to fill voids and grout.Specific uses include fixation in total joint arthroplasty. Inspine surgery, PMMA has been used to reconstruct defectsfrom open corpectomy and transpedicular application of PMMA to improved screw purchase in osteoporotic bone.The first reported use of percutaneous application of PMMA was performed in 1984 by Galibert et al .3 for C2hemangioma.4 The use of modified angioplasty balloon toreduce a vertebral fracture and create a cavity for the pla-cement of PMMA was described by Mark Reiley.5,6

Over decades, the technique of percutaneous vertebral

augmentation has evolved with large-bore needles andmodified PMMA.

PATHOPHYSIOLOGY AND PATIENT EVALUATION

Vertebral compression fractures occur due to weakenedbone, causing severe pain and morbidity. These compres-sion fractures are typically induced by osteoporosis,tumors, or traumatic injury. Typically, these fracturesoccur where load bearing is the greatest. Certain factors and

habits which may frequently result in a loss of bone massfrequently may lead to osteoporosis. These factors includewomen of increased age, lack of calcium and vitamin D inthe diet, and the high intake of cigarettes and coffee.7

Vertebral compression fractures typically occur sponta-neously or as a consequence of minimal trauma, resultingfrom spinal loading during daily activities such as bending,lifting, and climbing stairs.8 The most common locationsare the midthoracic region (T7-8) and the thoracolumbarjunction (Figure 1).8 These correspond to areas of the spinewhere there is the greatest burden during these commondaily activities. When thoracic kyphosis develops, themidthoracic region receives tremendous load during

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flexion of the spine leading to potential compression frac-tures. Secondary contributors to osteoporosis includehypercalcemia, abnormal thyroid, and renal functions.7

Users of oral glucocorticoids have a 2.6-fold increase riskof fracture10 (Figure 2).

Osteolytic metastases and myeloma can cause the de-struction of vertebral bodies and fractures leading to painand disability. Patients with advanced cancer can presentwith bone metastases to the vertebral bodies. The incidenceof metastatic lesion to the spine depends on the primarycancer: 80% of patients with prostate cancer, 50% withbreast cancer, 30% with lung, thyroid, or renal cell cancer.11

Rarely, benign tumors such as spinal osteoid osteoma andaneurismal bone cysts can lead to instability and painfulcompression fractures. Vertebral augmentation can be usedto reinforce and stabilize fractures related to tumors.

The multiple consequences of vertebral fractures can lead

to increased morbidity and mortality. Pain and disabilityincreases with kyphosis and vertebral compression frac-ture.12 The physical consequences include pulmonary com-promise (Figure 3). Studies suggest that there is decreasedlung capacity and reduced pulmonary function with verteb-ral height loss and decreased lung volume.14 As the spinechanges with significant kyphosis, the downward angulationof the ribs leads to the 12th rib resting on the iliac crest. Thisresults in the abdomen protruding and canlead to symptomsof distension, constipation, early satiety, and eructation.Above all, the forward position of the thoracic spine leads to

strain of the posterior elements of the thoracic spine as the

patient attempts to straighten his or her spine.As seen by the investigator, the forward expansion of theabdomen leads to forward loading of the lumbar sacralspine thereby exacerbating discogenic pain. The limitedability of the sacrum to flex and extent may load the sa-croiliac joint and cause pain. Weakened physical functioncan lead to restricted daily activities resulting in requiredassistance from family or hired help. The psychosocialconsequences of the limitation of activities are seen withtheir reduced ability to fulfill their accustomed social rolesand dependency on others. This leads to poor self-esteem,depression, and social isolation.12,13,15 There is also in-creased incidence of sleep disturbances. The number of

depressive symptoms rises with the increased number of fractures. Studies reveal high mortality and reduced qual-ity-of-life years with vertebral compression fractures.12

In addition to a detailed history and examination, imag-ing evaluations are standard in confirming the diagnosis of acute compression fractures. The radiologic findings onplain films may show subtle height loss changes. Compar-ison films are helpful to determine acute versus chronic frac-tures. Unfortunately, occult vertebral fractures are commonwith false-negative rates of 27-45% by radiologists.16

Magnetic resonance imaging (MRI) is the study of choice with T1 and STIR sagittal sequences. Acute ver-tebral compression fractures are revealed with marrow

edema within the vertebral body. Assessment of spinalcanal compromise and fractures of the pedicles areimportant. Computed tomographic (CT) scan may be auseful alternative combined with a nuclear bone scan whenthe patient is not a good candidate for MRI. Bone scan maybe helpful in fractures more than 3-4 months in age wherethere is no marrow edema on MRI.

TREATMENT GOALS

The treatment goals of vertebral compression fracturesinclude pain management, rest, rehabilitation, and

Figure 1. Incidence of vertebral fracturesin the spine.Reprinted from Nevitt

M, et al.,9 with permission from Elsevier.

Figure 2. Risk of fracture from steroid use.10

Figure 3. The kyphotic spine. Reprinted from Gold DT,13 with permission

from Elsevier.

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restoration of mechanical stability. Pain managementusually involves use of opioids and nonsteroid anti-inflam-matories. Medical management may also include treatmentsfor osteoporosis: calcium, vitamin D, bisphosphonates, ornasal miacalcin.

Prolonged bed rest may allow the compression fractureto stabilize but can lead to loss of muscle strength, fatigue,and bone density in elderly patients.17 Other concerns of patients in prolonged bed rest are pressure sores and deepvein thrombosis in older patients. Back braces may offer

support and stabilize the vertebral compression fractures.Limited contact orthoses such as the tri-pad Jewett exten-sion brace are commonly used. Many patients do nottolerate the braces, citing discomfort and difficulty whenputting on and removing them. Rehabilitation should beplanned to strengthen bone density and increase corestrength.

Mechanical instability of vertebral fractures with neu-rologic compromise is possible. Open surgery such asanterior decompression and stabilization may be needed.Stable painful compression fractures may be treated by ver-tebral augmentation either vertebroplasty or kyphoplasty.

The mechanism of pain relief associated with vertebro-plasty and kyphoplasty is unknown. Fractured vertebralbodies lose both strength and stiffness. Strength is relatedto the ability of the vertebral body to bear load and stiff-ness limits micromotion within the compromised vertebralbody. Restoration of stiffness and strength is augmented byplacement of PMMA, reducing painful micromotion.18

Large amounts of cement are needed to restore stiffnessand less for strength.18 Other mechanisms of pain relief may involve the thermal and cytotoxic reaction of PMMA. Ithas been hypothesized that the heat of polymerization causesthermal necrosis of neural tissue, explaining pain relief inpatients. In vivo studies mapping temperatures from poly-

merization may rise greater than 501C leading to potentialdamage to interosseous nerves, periosteal nerves.19 Tem-perature may also play a role in slowing tumor growth andapoptosis in osteoblasts exposed to 481C for 10 minutes ormore. The cytotoxicity of PMMA may also have an anti-tumoral effect and could be potentially neurotoxic.20

Vertebroplasty is the percutaneous placement of cementin fractured trabecular bone leading to an ‘‘internal cast’’20

(Figure 4). The standard indication is for painful compres-sion fractures refractory to medical therapy. The typicalcauses include osteoporosis, metastatic disease, multiplemyeloma, and osteonecrosis. The contraindications are sys-temic and local infection, uncorrectable coagulopathy,retropulsion of vertebral body or tumor, posterior wall de-struction, and radicular symptoms. Benefits for the patientsare increased range of motion with pain relief. The proce-dure is typically done under monitored anesthesia care andas an outpatient procedure.

The alternatives are poor. These are conservative medi-cal management, that is, opioid therapy, physical therapy,bracing, and potential open surgery fixation. The cement isplaced through fluoroscopically or CT-guided trocars.

The most common access is the transpedicular approach.Other approaches can be para pedicular, anteriolateral(cervical), and posterior (sacral). The complications mayinclude the following: infection, bleeding, pulmonary em-bolus, local trauma, paralysis, and even death. Fortunately,these complications are rare.

Kyphoplasty has been introduced as an alternativeapproach21 (Figure 5). It is considered a ‘‘balloon-assistedvertebroplasty.’’ This procedure involves percutaneousplacement of a balloon in the vertebral body. Through thesame large bore needle, bone cement is placed into the cavitycreated by the balloon. The balloon is intended to restorevertebral body height in addition to creating the cavity.

Figure 4. Vertebroplasty. Courtesy of Stryker (Allendale, NJ).

65The Treatment of Compression Fractures



After reviewing published literature, a position statementon percutaneous vertebral augmentation by AmericanSociety of Interventional and Therapeutic Neuroradiology,

American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of SpineRadiology have determined that the clinical response ratecomparing kyphoplasty and vertebroplasty are similar.21

There is no proven advantage of kyphoplasty compared withvertebroplasty with regard to pain relief, height restoration,and complication rate.21

TECHNIQUE

Vertebroplasty and Kyphoplasty rely on small incisions to

place large-bore needles with radiographic guidance withfluroscopy or CT guidance. These procedures are eitherdone under general anesthesia or monitored anesthesiacare. The procedure itself is not painful especially if localanesthesia is placed, but the duration of the procedure andposition of the patient may necessitate at least intravenoussedation. Comorbidities such as poor cardiac dysfunctionmay need to be monitored. In patients with poor medicalcondition, medical clearance is advised. Anticoagulationsare stopped before the procedure. Preoperative antibioticsare usually given as with many surgical implants. Sterilesurgical preparation and draping are done.

The critical step is to have an

understanding and visualization of the

fractured vertebra.

The critical step is to have an understanding and visua-lization of the fractured vertebra. Poorly osteoporoticbone, especially in large patients, may offer a challenge.Spinal deformities such as scolosis may hamper proper vi-sualization of the bone landmarks to perform the proce-

dure successfully. If the bone is not visualized withconfidence under fluoroscopy, the case should be aborted.CT guidance is then suggested. The landmarks necessary to

perform the procedure under fluoroscopy are the pedicles,vertebral bodies, and disc space in the anterior-posterior,lateral, and oblique views.

There are multiple approaches to access the thoracic andlumbar fractures vertebral body.21 The most common isposterior tranpedicular approach. Bipedicular needles areusually placed at each level. Another approach is the para-pedicular. For cervical, the anteriolateral view is needed,a similar approach to cervical discography. For sacralfracture, a posterior approach is taken.

This investigator’s approach to lumbar and thoracicfractures is to square the endplates of the fractured vertebralbone on an anterior-posterior view. On the oblique view, thepedicle is identified with clear definition of the medial bor-der. The skin and tissue for the planned entry site are an-esthetized with a local anesthetic. The needle will be placedat ‘‘eye of the scotty dog’’ and placed ‘‘straight down thebarrel.’’ The needle is gently tapped with a hammer stayinglateral to the medial edge of the pedicle. Constant visuali-zation of the needle is needed with fluoroscopy to stay awayand lateral to the spinal canal. Needle position is usuallyanterior to the third of vertebral body on lateral view.PMMA is prepared to allow polymerization in a viscousconsistency that still allows passage through the needle. Thisreduces risk of extravasation. When confirmed in position

on the anterior-posterior and lateral views, the preparedPMMA is injected slowly watching its spread within thevertebral body, under constant fluoroscopy. When thespread is seen heading to the posterior third, the injection iscompleted.

As vertebroplasty, the same approach is taken withkyphoplasty. When access to the vertebral body is com-plete, a guide pin is placed where a large bore (8 gauge)cannula is placed. Through this cannulae, an inflatablebone tamp or balloon is advanced. A bipedicular approachis recommended. When both balloons are inflated and thefracture is realigned, a cavity is created. This is wherePMMA is placed.

Figure 5. Kyphoplasty. Courtesy of Medtronic (Sunnyvale, CA).

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Standards and guidelines in the vertebroplasty can befound in the American College of Radiology’s ‘‘Standardsfor the Performance of Percutaneous Vertebroplasty’’ andthe Society of Interventional Radiology’s ‘‘Quality Im-provement Guidelines for Percutaneous Vertebroplasty.’’22

CLINICAL RESEARCH

More than 100 studies have addressed the clinical outcomesof vertebroplasty.21 The type of studies range from small,retrospective, uncontrolled case series to prospectiverandomized studies. Literary reviews about the efficacy of vertebroplasty conclude that when used for patients withosteoporotic compression fractures, substantial and im-mediate pain relief, improved functional status takes place.Minimal short-term complications have been noted. In2007, there was a position statement on percutaneous ver-tebral augmentation. This consensus statement, developedby the American Society of Interventional and Therapeutic

Neuroradiology, the Society of Interventional Radiology, theAmerican Association of Neurologic Surgeons/Congress of Neurological Surgeons, and the American Society of SpineRadiology, concluded that the evidence supports vertebro-plasty as being beneficial for the relief of pain and improvedquality of life.21

An example of a study supporting this statement waspublished in 2002 by Zoarski et al.23 In this study, aMusculoskeletal Outcomes Data Evaluation and Manage-ment Scale spinal interventional questionnaire was done. Inthe study 30 patients with 54 symptomatic osteoporoticvertebral compression fractures had less than satisfactoryresponse to conventional therapies. In contrast, significantpostprocedure benefits of vertebroplasty were showed infour Musculoskeletal Outcomes Data Evaluation andManagement Scale modules: treatment score (Po0.0001),pain and disability (Po0.0001), physical function (P¼0.0004), and mental function (P¼ 0.0009). Long-term fol-low-up continued for 18 months. At the end of the study, 22of 23 patients remained satisfied with their outcomes.

A recent prospective of randomized studies, published inthe 2009 New England Journal of Medicine, showed thatcompared with control groups, vertebroplasty offered noproven advantage.24,25 The Buchbinder et al. and Kallmeset al. studies showed negative results which directly con-

tradicts hundreds of published studies showing positiveoutcomes. A common initial response to these findings wasone of disbelief and surprise. A commentary by NorthAmerican Spine Society serves to understand and explainthe findings. In both studies there are questions regardingpatient selection, enrollment, control group, and outcomes.

Both studies accepted patients with fractures of less than1 year and it is known that pain from osteoporotic frac-tures diminish over time. It is reasonable to conclude thatin 3-6 months fracture pain reduces naturally and wouldthen be comparable with relief from vertebroplasty. Theenrollment of patients was difficult in the Kallmes et al.study. Eighteen hundred and twelve patients were initially

screened and only 131 entered the study. The pain severityand functional compromise of those patients who refusedparticipation were not reported. Thus, there exists an un-quantifiable selection bias in the final patient group.

Both control groups in these studies were not reallysham groups. Injection of anesthetic into the facet capsule

and/or periosteum may have a beneficial effect in patientswith facet-mediated pain. Thus, another criticism takes usback to patient selection and outcomes. It is unclear if therewas an effort to determine if the back pain originated fromthe osteoporotic fracture site. With experienced spine careproviders, percussion and palpation of the spinous processesis critical to determine the level of maximum tenderness,that is, painful compression fractures. History, physicalexamination, and imaging are critical to determine if painis coming from a compression fracture, stenosis, facet, ordegenerative disc.

The clinical outcomes data for kyphoplasty are not asextensive as vertebroplasty.21 Lieberman et al.26 reported

in a phase I efficacy study of kyphoplasty in the treatmentof painful compression fractures. Thirty patients showedsignificant improvements in Short Form (SF)-36 bodily painscales from 11.6 to 58.7 (P¼ 0.0001). In 2009, a random-ized controlled trial comparing nonsurgical treatment of vertebral compressions to balloon kyphoplasty showed theefficacy and safety of the procedure.27 Three hundred pa-tients were randomly selected to receive kyphoplasty versusnonsurgical treatment. Quality-of-life measures, SF-36, andsafety measurements were taken over 12 months. Meanimprovements in SF-36 physical components were seen. Thefrequency of adverse effects did not differ between groups.There were two serious complications were noted (hemato-ma and urinary tract infection).

Currently, there is no published

investigation which has compared

vertebroplasty to kyphoplasty.

Currently, there is no published investigation which hascompared vertebroplasty to kyphoplasty. Thus, the 2007consensus statement on percutaneous vertebral augmenta-

tion developed by the American Society of Interventionaland Therapeutic Neuroradiology, the Society of Interven-tional Radiology, the American Association of Neuro-logic Surgeons/Congress of Neurological Surgeons, and theAmerican Society of Spine Radiology concludes that theclinical response to kyphoplasty and vertebroplasty areequivalent.21 There is no proven advantage with regard topain relief, vertebral height restoration, or complication rate.

COMPLICATIONS

Vertebroplasty and kyphoplasty have identical complica-tions.28 With kyphoplasty, there is a reported spinal




canal intrusion with the balloon tamp and cortical walldisruption from balloon misplacement. Complications canbe divided into medical and anesthesia-related complica-tions, instrumentation, extravasation of PMMA, and ad-jacent segment spinal fractures.

Medical and anesthesia complications are uncommon as

these minimal invasive procedures have minimal physio-logic impact. In patients with severe cardiovascular com-promise, laying in the prone position is difficult. Conversely,performing general anesthesia on these patients becomes agreater challenge. Cases of ileus, myocardial infarction, andcongestive heart failurehave been reported.4 Careful attentionto patient position is paramount as osteoporotic bones havefractured from sternum to ribs. Hemodynamic compromisehas been associated with packing of the PMMA during hipreplacement surgery. Transient systemic hypotension has beenreported with packing cement in vertebroplasty.29

Instrumentation complications exist from placing nee-dles outside the pedicles and into the spinal canal.28 Op-

erator inexperience, poor imaging equipment, and severespinal deformity are the usual explanations. Uncontrolledbleeding and infection are extremely rare.

The most frequently reported complication is PMMAcement extravasation.28 PMMA can exit out of any frac-ture line or cleft and vertebral venous plexus. Using viscousPMMA impregnated with barium, and under high qualityimaging, can reduce the incidence of these problems. ThePMMA is injected slowly under live fluoroscopy. Extra-vasation of cement has flowed into the spinal canal withsevere neurologic compromise. The rate of clinically sig-nificant leakage has been reported at up to 6%.30 Higherrates of leakage have been identified when trying to treatfractures related to angiomas and metastatic disease, 2.5-10%.4 It is likely that cortical destruction and occult frac-ture lines are to blame. PMMA leakage into the disc spacemay occur due to undetected fracture cleavage lines. Ratesof 0-65% have been reported but most are consideredclinically insignificant.4 Epidural leakage is more of aconcern leading to potential cytotoxic and exothermicdamage to nerve roots. Liquid PMMA may leak out intothe venous system resulting in a rare case of pulmonaryembolus. There is no published report of pulmonary em-bolus with kyphoplasty. The creation of a void in the ver-tebral body may compact the cancellous bone causing it to

act as a dam and prevent extravasation of the cement.An issue of increased risk of fracture at an adjacentlevel has been raised. Grados et al.30 found a slight butstatistically significant increase in adjacent segment fracturerisk in a long-term vertebroplasty follow-up study. It isnot known if this is due to placing a hard material, PMMA,in close juxtaposition to the soft, osteoporotic bone of the adjacent vertebral levels. It is also possible that theseadjacent fractures represent the natural progression of osteoporosis.

Overall, the complication rates of vertebroplasty andkyphoplasty are reported similar.21 Six major complicationswere reported in 531 patients (1.1%) treated with kypho-

plasty in a multicenter study.31 Four of these had neurologiccomplications. This is similar to the complication of verteb-roplasty (1.3%) when used for osteoporotic fractures.

Recommendations and evaluations of complications canbe found in the American College of Radiology’s Standardsfor the Performance of Percutaneous Vertebroplasty and the

Society of Interventional Radiology’s Quality ImprovementGuidelines for Percutaneous Vertebroplasty.22

CONCLUSION

Vertebral augmentation with vertebroplasty or kypho-plasty is a medically appropriate treatment for painfulvertebral compression fractures refractory to medicaltherapy.22 Vertebral compression fractures are commonand are often debilitating. Although most fractures healwithin a few weeks to months, a minority of patientscontinue to suffer pain that does not respond to con-

servative therapy.Vertebral compression fractures are often a leading

cause of admission to nursing and intermediate care facil-ities. These patients are rarely provided with open surgicalfixation due to the poor quality of bone for surgical fixa-tion and the patient’s tolerance of the surgery and an-esthesia. Percutaneous vertebral augmentation is nowestablished therapy and should be reimbursed by payers asa safe and effective treatment of compression fractures.

Newer augmentation techniques are now available totreat sacral fractures and sacroplasty. Robotic assistanceand alternative imaging may allow even safer placement of needles with reduced radiation exposure.28 Presently, a

number of alternative cements to PMMA are being testing.A number of companies have looked at alternatives toPMMA. A bioresorbable injectable cement called Cordishas been approved by the Food and Drug Administration.This bioactive material closely mimics the mechanicalcharacteristic of bone.

Further clinical studies and econometric analysis arebeing carried out to determine the financial impact on so-ciety. Further prospectives and randomized studies areneeded to establish the benefits of vertebroplasty andkyphoplasty over standard conservative treatment.

See also Supplemental Digital Content 1-5,http://links.lww.com/ASA/A25,http://links.lww.com/ASA/A26,http://links.lww.com/ASA/A27,http://links.lww.com/ASA/A28, andhttp://links.lww.com/ASA/A29, respectively.

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Asa Vertebroplastia