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Percutaneous Vertebroplasty


INTRODUCTION:
Over the last few years, new techniques have been developed to deal with back pain linked to failure of the bony structure of the vertebral body.
 
The most common cause of fracture of a vertebra, apart from severe trauma, is represented by osteoporosis.
 
This is a very common condition in older individuals and especially in women.
 
The symptoms of an osteoporotic crush fracture may include back pain and stiffness, inability to change position rapidly, significant discomfort with re-assuming the erect posture after prolonged sitting and/or difficulties in performing any activities which may require stretching with either upper limb and/or bending.
 
The Xray may show some collapse and or wedging of the vertebra (Figure).
 
Rarer causes of spontaneous fracture may be represented by infiltration of the bone by cancer either primary to the bone or secondary to other tumours such as breast, bowel, renal, etc (Metastasis).
 
In selected cases it is possible to treat the pain linked to the fracture of the vertebra by injecting acrylic cement and/or other hardening substances through a small tube inserted percutaneously into the vertebra under special Xray control (Fluoroscopy).
 
This technique is called Vertebroplasty and has been used in Europe since the early 1990’.
 
The main indication for this technique, at present, is to treat acute and or subacute osteoporotic fractures of the spine, isolated neoplastic deposits into the vertebra in the absence of nerve compression and isolated post traumatic vertebral fractures with no involvement of the spinal canal and/or associated instability.
 
 



TECHNIQUE:
 
The patient is anaesthetised or heavily sedated in an operating theatre.   A small metal tube of the maximum diameter of approximately 6 mm is inserted into the vertebral body avoiding the nerves and the organs anterior to the spine.
 
The insertion of the tube requires a small stab incision, like an arthroscopy, lateral to the spinous process of the vertebra affected.
 
Following positioning of the tube, the acrylic cement and/or other substance is pushed into the vertebra through the tube with a syringe and a plunger under direct Xray control.
 
The material is radio-opaque allowing its visualisation at all times.
 
The cement quickly hardens inside the vertebra and this has the dual effect of strengthening the weakened bone and numbing the pain due to the effect of heat generated by the cement during its setting.
 
Following the procedure the small incision is dressed with a bandaid and the patient is allowed to mobilise as soon as he/she is awake.
 
In most cases this procedure can be performed on a day surgery basis although when the patients have other medical problems, it may be appropriate for them to spend a night in hospital.
 
In the presence of cancer it is possible to obtain a biopsy of the vertebra prior to inserting the cement.
 
The biopsy may also be performed if there is any suspicion that the fracture may be due to other causes rather than simple trauma or osteoporosis.
 
 


COMPLICATIONS:
 
The main possible neurological complication is represented by the risk of  leakage of the cement or other substance injected into the vertebra, into the spinal canal.
 
If the fracture extends into the posterior aspect of the vertebra it is possible in fact that the cement may leak into the spinal canal causing compression of either the spinal cord or the individual nerves.
 
As the cement is radio-opaque it should be possible to avoid this complication although cases have been described both overseas and in Australia, where, following the procedure, the patient has developed increasing neurological deficit.
 
This complication is more likely to occur if the fracture involves the back of the vertebral body.
 
Leakage of cement may also occur into veins draining the vertebra and/or the individual nerves.
 
Other possible neurological complications include damage to a nerve whilst positioning the tube and/or to the vessels anterior to the spine if the instruments are inserted too deeply.  Embolism may also occur as a result of small bubbles of cement and/or fat being pushed into the venous circulation with migration into the lungs.
 
In general terms however, Vertebroplasty is considered safer than open spinal surgery and is associated, due to its minimally invasive nature, with a speedier recovery.
 
 
RESULTS:
 
The international literature reports over 70% highly satisfactory results at 6 months.
 
Its main advantage in the treatment of osteoporotic fractures is the early mobilisation of the patient and the immediate relief linked to the strengthening of the vertebra and the numbing of the area from the cement itself.
 
It is also reported that, due to the heat generated by the chemical reaction at the time of the hardening of the cement, there is an inhibitory effect on cancer cells which may retard their growth.
 
It is unlikely however that Vertebroplasty may have any effect in prolonging cancer patients’ survival and/or improving their long term outcome.  In osteoporosis it has been reported that due to the increased stiffness of the treated vertebra/e, adjacent vertebral bodies are more likely to fracture over a two to three year period.
 
MULTIDISCIPLINARY APPROACH
 
Most of the conditions which are suitable for Vertebroplasty require ongoing medical treatment.
 
This procedure therefore is only one part of a multi-disciplinary approach, which may include chemotherapy, radiotherapy and other surgical procedures and for osteoporosis, oral medications, corsets/braces, exercise and appropriate dietary supplements.
 
 



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