3 Preprocedure Assessment Prior to Vertebral Augmentation
Summary
Vertebral compression fractures (VCFs) are common and are increasing in number with the aging of the population. Patients with VCFs are optimally treated by accurate and early diagnosis and treatment. The patients with asymptomatic fractures must be recognized to be different than those with fractures and moderate to severe pain or pain that is increasing as the latter patients typically are not effectively treated with nonsurgical management (NSM). Correct identification of VCFs via cross-sectional imaging is important and the preprocedure assessment includes such factors as risks, cost, and the patient’s ability to tolerate NSM or percutaneous vertebral augmentation (PVA). If the patient is provisionally deemed to be a candidate for PVA, there should be an assessment of the indications and contraindications. The ideal candidate for vertebral augmentation is a patient with a symptomatic fracture seen on cross sectional imaging than cannot tolerate NSM and has positive physical examination signs and no absolute contraindication. The PVA procedure should be done with the appropriate equipment and personnel and in a facility designed to accommodate these procedures. After the augmentation procedure the patient should undergo the appropriate follow-up to ensure the optimal recovery from both the fracture and the procedure and they should also receive appropriate therapy for the underlying disorder that originally predisposed them to the vertebral fracture.
3.1 Introduction
Vertebral compression fractures are common and becoming more common as our population ages. Appropriate early diagnosis and management is key to obtaining optimal outcomes for these patients. While many patients have fractures that are only incidentally seen on imaging at some point after the fracture, the presence of a single compression fracture substantially increases the risk for future fractures. In addition to the commonly seen asymptomatic fracture, there is a prominent subset of patients that present with moderate to severe pain that does not resolve with NSM. For these reasons, early identification and optimal management of compression fractures improve outcomes in these patients.
3.2 Anatomy, Radiologic Imaging, Identification, and Interpretation of Vertebral Compression Fractures
Selection of appropriate patients for PVA is essential to obtaining optimal outcomes. Traditionally, the patient populations considered to benefit most from PVA generally fall into three categories as follows: elderly osteoporotic individuals with acute or subacute VCFs, individuals with compression fractures refractory to NSM, and individuals with compression fractures secondary to malignancy.
Chronicity of a VCF is an important factor to consider when considering PVA. While patients with older painful fractures commonly derive substantial benefit from PVA in terms of pain relief and improved functionality after failing conservative management, the best outcomes are seen in more acute fractures with evidence of bone marrow edema or fracture nonhealing. 1
Identification of these fractures using current imaging technology is critical. The majority of osteoporotic VCFs occur at the thoracolumbar junction. Patient examination including palpation and percussion of the vertebral bodies can help identify the involved segment (see Chapter 4: Physical Examination Findings in Patients with Vertebral Compression Fractures). Imaging of the spine is ideally performed with magnetic resonance (MR) imaging. In cases of severe claustrophobia or MR imaging incompatibility (non-MRI compatible pacemaker, cochlear implant, etc.), imaging studies should include a computed tomography (CT) scan of the involved area. In order to distinguish between acute, subacute, and chronic fractures, the presence of edema on a sagittal T2 fat-saturated or short tau inversion recovery (STIR) sequence in combination with a sagittal T1-weighted sequence is the best indicator of an acute or subacute fracture. In cases of MR imaging incompatibility, CT scanning in combination with nuclear medicine bone scan or single-photon emission computed tomography (SPECT) imaging is usually required to distinguish between newer versus older fractures. 2 In cases of complex fractures, the imaging evaluation with MRI and/or CT of the spine optimizes visualization of the fracture and may allow for more specific and directed treatment.
3.3 Preprocedure Assessment
While individuals with acute or subacute compression fractures will likely achieve good outcomes after PVA, other factors for consideration include procedural risks, procedure cost, and the patient’s functional ability and ability to tolerate NSM.
The elderly osteoporotic patients with compression fractures are a group who derives a substantial benefit from PVA. Pain from a VCF is significantly limiting to patients of all ages, but the deconditioning associated with patient immobility is especially detrimental to the elderly population. Immobility places these patients at greater risk for pneumonia, pulmonary embolism, skin breakdown, and many other complications. Muscle atrophy from disuse is compounded by bracing and leads to decline in activities of daily life (ADLs), which is associated with increased mortality. 3 Narcotic medications used for analgesia of the severe pain are more poorly tolerated by the elderly. 4 When considering the risks of PVA as compared to the risks of immobility in this elderly osteoporotic population, the benefits of the procedure usually outweigh the risks and in elderly patients with moderate to severe pain the risks of NSM are usually greater than the risks of PVA. 5
For the younger patient with a traumatic VCF, NSM is typically attempted first. Younger patients tend toward greater resilience in terms of functional decline, toleration of pain medications, and ability to heal bony injuries. However, in cases of severe or ongoing pain refractory to NSM, PVA may be reasonable provided that imaging findings correspond to the patient’s clinical presentation and physical examination findings.
The third group who benefits significantly from PVA are patients with pathologic fractures due to neoplasia. 6 In cases of pathologic fractures (▶Fig. 3.1), if there is no known preexisting malignancy, bone biopsy performed at the time of the PVA can assist with diagnosis of the neoplasm.
3.4 General Indications, Contraindications, and Procedure Complications
As mentioned previously, compression fractures may be identified incidentally on imaging and are not causing pain (▶Fig. 3.2). However, in patients who present with substantial back pain and have a compression fracture, PVA may be appropriate. The major indications for vertebral augmentation are the presence of a symptomatic osteoporotic vertebral body fracture(s) that are refractory to medical therapy or that are too symptomatic for the patient to tolerate NSM and in vertebral bodies weakness or fracture due to neoplastic involvement. 7 These fractures include symptomatic nondisplaced vertebral body fractures (seen on MR imaging or nuclear bone scan but has no obvious loss of vertebral body height) and patients with fracture progression and progressive loss of vertebral body height. In patients with mild pain, no functional impairment, or pain that is managed well with NSM such as oral medications and bracing, PVA may be performed later or not at all.
Absolute contraindications to PVA are infection at this site of the vertebral augmentation and an untreated blood-borne infection. 8 A strong contraindication is osteomyelitis of the vertebral column. 8 A contraindication that is usually contraindicated is for women who are pregnant. 8 Relative contraindications that may or may not result in the discontinuation of the planned vertebral augmentation procedure include allergy to fill material, coagulopathy, spinal instability, myelopathy from the vertebral fracture, neurologic deficit, neural impingement, and fracture retropulsion with canal compromise. 8
Overall, PVA is a very safe and well-tolerated procedure. Despite its optimal safety profile, there have been a few case reports of procedural complications. These include infections of the soft tissues, disk (diskitis), and/or bone 9 – 14 (osteomyelitis), bleeding, and symptomatic extravasation of polymethyl methacrylate (PMMA). 15 – 21 Intradiskal leakage of PMMA has also been shown to increase the risk of adjacent-level fractures. 22
Related posts:
2 Vertebral Compression Fractures
10 Cervical and Posterior Arch Augmentation
14 Appropriateness Criteria for Vertebral Augmentation
18 Predisposing Factors to Vertebral Fractures
23 Number of Levels Appropriately Treated with Vertebral Augmentation
30 Vertebral Augmentation in Instrumented Spinal Fusions
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