British Journal of Radiology (2003) 76, 69-75
© 2003 British Institute of Radiology
doi: 10.1259/bjr/10254271
Percutaneous vertebroplasty: indications, contraindications, and technique
W C G Peh, FRCPE, FRCPG, FRCR1 and
L A Gilula, MD, FACR2
1 Department of Diagnostic Radiology, Singapore General Hospital, Outram Road, Singapore 169608 and2 Mallinckrodt Institute of Radiology, Washington University Medical Centre, St Louis, MO, USA
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Abstract
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Percutaneous vertebroplasty is an emerging interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a vertebral body under imaging guidance. This technique provides increased strength and pain relief in vertebrae weakened by a variety of bone diseases. The current indication for vertebroplasty is intractable non-radicular pain caused by compression fractures due to osteoporosis, myeloma, metastases and aggressive vertebral haemangioma. Contraindications include bleeding disorder, unstable fracture and lack of definable vertebral collapse. Our technique of percutaneous vertebroplasty is illustrated in this pictorial review.
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Introduction
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Percutaneous vertebroplasty, first described in 1987, is a radiologically guided procedure in which percutaneous injection of polymethylmethacrylate (PMM), a surgical bone cement, is injected into a vertebra under imaging guidance. This procedure has become increasingly accepted as a treatment option in patients with intractable back pain due to vertebral compression fractures. Over a 38 month period, since commencement of the procedure in June 1998, 482 percutaneous vertebroplasties have been performed in 244 treatment sessions on 213 consecutive patients at the Mallinckrodt Institute of Radiology, St Louis, MO. This pictorial essay aims to review and illustrate the indications, contraindications and our technique for performing this procedure. The potential complications and expected clinical outcome are also briefly reviewed.
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Indications
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The goal of percutaneous vertebroplasty is to provide pain relief and bone strengthening in painful vertebral body compression fractures. Selected patients should have focal, intense and intractable midline spinal pain at the level of, or within two vertebral levels below, the fracture, without evidence of definite radicular signs and symptoms, and have failed conservative management. Occasional exceptions are those patients with thoracic spine fractures with pain radiating to the ribs, and fractures at the level of the conus medullaris where pain may sometimes radiate to the hips without evidence of cord compression. Percutaneous vertebroplasty is usually performed in the thoracic and lumbar vertebrae, and rarely in the cervical vertebrae and cervicothoracic junction. Causes of compression fractures are osteoporosis, myeloma, metastasis and aggressive vertebral haemangioma [1–8].
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Contraindications
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The absolute contraindications to percutaneous vertebroplasty are bleeding disorder, unstable fracture due to posterior element involvement, and a lack of a definable level of vertebral collapse. Relative contraindications include patient inability to lie prone for the expected procedure duration (1–2 h), lack of surgical back-up or patient monitoring facilities, and the presence of neurological signs and symptoms caused by vertebral body collapse or tumour extension. Very severe vertebral compression may be technically difficult but is not a contraindication to the procedure [8].
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Technique
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The patient's radiographs are reviewed to assess the degree of vertebral compression, the location of osteolysis, extent and visibility of pedicle involvement, and presence of fracture or cortical destruction. CT is useful for optimally evaluating the sites of fracture defects and cortical wall destruction, bone tumour extension or bone fragment retropulsion into the epidural space or intervertebral foramen, and the vertebral body shape (Figures 1–2
). Recent bone scintiscan or MRI (Figure 3) helps determine the site of acute or healing fractures, particularly in patients with multiple levels of compression.
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Figure 1. Pre-vertebroplasty axial CT scan shows extensive osteolytic involvement of the L3 vertebral body in a 56-year-old woman with carcinoma of the breast. There is destruction of the left pedicle. The patient eventually underwent surgical stabilization.
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Figure 2. Pre-vertebroplasty CT scan reformatted in the mid-sagittal plane shows mixed osteolytic-sclerotic involvement of L1 vertebral body in a 65-year-old man with carcinoma of the colon. There is destruction of the posterior vertebral cortex. Vertebroplasty was successfully performed.
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Figure 3. Sagittal short tau inversion recovery (STIR) MR image shows mild wedge compression of L1 vertebral body. The affected vertebra is hyperintense, in keeping with an acute or subacute injury. There is no significant retropulsion into the spinal canal.
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For thoracic and lumbar percutaneous vertebroplasty, the patient is positioned in a prone position. The patient's blood pressure, electrocardiogram, heart rate and pulse oximetry are monitored continuously. Intravenous fentanyl (Sublimaze; Abbott Laboratories, North Chicago, IL) and midazolam (Versed; Roche Pharma, Manati, Puerto Rico) are administered to provide sedation and analgesia. 1g of cefazolin (Ancef, SmithKline Beecham Pharmaceuticals, Philadelphia, PA) is administered intravenously at the start of the procedure. Under strict sterile conditions, the skin overlying the vertebral body to be injected is cleaned and draped. Biplane fluoroscopy or a C-arm is required to guide needle insertion. Alternatively, CT fluoroscopy in combination with C-arm fluoroscopy is used [1, 3]. Local anaesthesia using 1% lidocaine and 0.25% bupivacaine hydrochloride is administered to the skin, subcutaneous tissues and periosteum at the puncture site.
After a small skin incision, an 11 G or 13 G disposable bone biopsy needle (Figure 4) is advanced until its tip abuts the pedicle. Under fluoroscopic guidance, the needle is guided through the centre of the pedicle, and then into the vertebral body. Biplane fluoroscopy, with frequent switching between the frontal and lateral projections, is required to ensure that the needle is correctly positioned (Figure 5). Ideally, the needle tip should be placed within the anterior one-quarter to one-third of the vertebral body, close to the midline (Figure 6). Biopsy, if indicated, can be performed before final needle placement (Figure 7). After stylet removal, intraosseous venography (Figures 8 and 9) using 0.5–2 ml non-ionic contrast agent (180 mg ml-1) is performed to determine whether the needle tip is positioned within a direct venous anastomosis to the central or epidural veins. The bone trabeculae should opacify before venous filling occurs. Venography also shows vertebral segment vascularity, and the site of the draining veins. This additional information helps to plan and monitor injection of the PMM.
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Figure 4. 11 G disposable bone biopsy needle used for percutaneous vertebroplasty. The stylet has a bevelled tip.
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Figure 5. C-arm in a horizontal position to check the lateral projection of the needle tip within the vertebral body. The vertebroplasty needle is held by sponge forceps (in the foreground) to lessen the radiation hazard to the radiologist's hand.
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Figure 6. Series of radiographs in a 69-year-old woman with metastatic deposits in L4 vertebra due to carcinoma of the breast. (a) Lateral radiograph shows mixed lytic-sclerotic involvement of a mildly compressed L4 vertebral body. (b) Slightly oblique prone radiograph shows the shaft of the needle maintaining a "target" or "bulls-eye" appearance within the left pedicle. (c) Lateral radiograph shows the needle tip in the anterior one third of the vertebral body. (d) PA prone radiograph shows the needle tip close to the midline. (e) PA prone radiograph shows polymethylmethacrylate (PMM) within the vertebral body. There is slight leakage of PMM adjacent to the left L3/4 disc annulus. (f) Lateral radiograph shows PMM opacification of most of the vertebral body.
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Figure 7. Lateral radiograph shows a 14 G quick core biopsy needle being placed coaxially through the outer 11 G vertebroplasty needle. This 79-year-old woman presented with painful compression fracture of L1 vertebral body and had a past history of carcinoma of the cervix. Vertebroplasty was subsequently performed.
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Figure 8. Photograph shows intraosseous venography performed via injection of non-ionic contrast agent through the connecting tube into the vertebroplasty needle placed within the vertebral body.
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Figure 9. Posteroanterior prone radiograph shows intraosseous venography performed through the vertebroplasty needle placed through the right pedicle. Opacification of the paravertebral veins is seen. The left half of the same vertebral body is filled by previous polymethylmethacrylate injection through the contralateral pedicle.
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The methylmethacrylate powder is mixed with one slightly heaped teaspoonful of sterile barium sulfate powder (E-Z-EM, Westbury, NY) to increase its opacity. Some practitioners use tungsten or tantalum powder for opacification [2, 4, 5]. Various types of methylmethacrylate powder are used at different institutions; we use Osteobond copolymer bone cement (Zimmer, Warsaw, IN). Previously we added antibiotic powder, 1.2 g tobramycin (Nebcin, Eli Lilly, Indianapolis, IN), to the mixture but currently administer only intravenous cefazolin. The liquid methylmethacrylate polymer is then added to the powder and mixed into a toothpaste-like consistency. The resultant PMM mixture is then backfilled into a screw type 10 ml syringe (LaVeen, Boston, Watertown, MA), taking care that air is expelled from the paste. A number of commercially prepared injection kits are also available.
The PMM material is injected under lateral fluoroscopic control until the PMM reaches the posterior one-quarter of the vertebral body (Figure 10), or the PMM leaks into the disc space or paravertebral tissues. Care should be taken to ensure that leakage into the surrounding soft tissue structures, particularly the veins and epidural space, does not occur. If leakage occurs, pressure on the injecting syringe is released rapidly and the injection is stopped for 1–2 min to allow the PMM to harden and plug the leak, or for needle repositioning. The other pedicle is entered if the injected material does not enter both sides of the vertebral body (Figure 11). Bilateral pedicular needle placement may be necessary for optimal opacification of a severely collapsed vertebral body [8]. A new needle is used for each pedicle. Paravertebral or costovertebral approaches may rarely be necessary for optimal needle placement, especially in the situation where a pedicle is too small or too destroyed for safe needle placement.
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Figure 10. (a) Lateral and (b) posteroanterior radiographs show even and near-complete polymethylmethacrylate (PMM) filling of a severely compressed T12 vertebral body in a 72-year-old woman with osteoporosis. (c) Post-vertebroplasty axial CT scan confirms near-complete PMM vertebral body filling. There is slight leakage of PMM into the anterior epidural space and paravertebral soft tissues.
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Figure 11. Posteroanterior prone radiograph shows bilateral pedicular punctures in a 67-year-old man with L3 osteoporotic compression fracture. The left needle had been removed following polymethylmethacrylate injection into the left half of the vertebral body.
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Potential complications
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The main complication of percutaneous vertebroplasty is inadvertent epidural and foraminal leakage of PMM. If this occurs, emergency surgical decompression may be required. Neurological complications are, however, uncommon [4, 5]. Small perivertebral venous, prevertebral soft tissue and intradiscal leakages (Figures 6e, 10c and 12) are usually not regarded to be clinically significant [4–6, 8]. If the venous system is opacified by PMM, the procedure should be discontinued as massive pulmonary embolism may potentially occur. The risk of infection can be minimized by a strict sterile technique and the routine use of antibiotics. PMM polymerization may produce transient worsening of pain and fever [2, 4]. Vertebroplasty is also associated with a small but definite risk of adjacent vertebral body fracture [9]. It should be noted that vertebroplasty is a "SERNIP C" category procedure in the UK and it is recommended that it should be undertaken only as part of an ethics committee approved study.
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Figure 12. Lateral radiograph shows polymethylmethacrylate (PMM) leakage into the T6/7 disc of a 76-year-old woman with T6 osteoporotic compression fracture. The patient did not suffer any ill-effect from the intradiscal PMM placement.
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Clinical outcome
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Pain relief and increased mobility are expected within 24 h post procedure [4]. However, it may occasionally take a few days before the patient can clearly state if the presenting pain is better. Significant pain relief has been demonstrated in more than 70% of patients with vertebral malignancies [2, 3, 5], in more than 90% of patients with osteoporotic fractures [3, 5, 7, 8], and in approximately 80% of patients with haemangioma [4, 5]. In the majority of cases, the amount of medication needed to alleviate the painful vertebral compression can be either significantly reduced, or stopped. Workers in this field need to monitor the progress of patients undergoing vertebroplasty, report adverse effects, and conduct audit studies. Long-term clinical trials of the safety and efficacy of this new procedure are also required.
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Conclusion
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Percutaneous vertebroplasty is an effective new technique that provides pain relief and stabilization in the majority of patients with painful vertebral compression fractures due to osteoporosis and metastasis. Complications rarely occur with meticulous technique. Percutaneous vertebroplasty should be incorporated into the management of patients presenting with painful vertebral compression fractures.
Received for publication October 23, 2001.
Revision received June 7, 2002.
Accepted for publication June 26, 2002.
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References
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Abstract
Introduction
