Percutaneous vertebroplasty is a minimally invasive technique in which polymethyl methacrylate (PMMA), anacrylic bone cement is injected under radiological guidance into a vertebral body to relieve pain and provide strength and stability to the spine. First performed in France in the mid-1980s to treat an aggressive variant of vertebral hemangioma, this low-risk procedure is commonly used for treatment of symptomatic osteoporotic compression fracture and in the treatment of metastatic disease of the spine. The technique of percutaneous vertebroplasty using PMMA has been shown to produce excellent pain relief in patients whose discomfort is refractory to conservative measures. Percutaneous transpedicular access of the diseased vertebral segment facilitates minimally invasive delivery of PMMA. Complications of the procedure are uncommon but are most frequently related to cement leakage and can be avoided through meticulous technique.

34.2 Patient Selection

34.2.1 Indications

As a result of aging of the population, increasing numbers of patients are sustaining vertebral compression fractures due to osteopenia. At particular risk for the development of osteopenia and secondary compression fractures are postmenopausal women, individuals maintained on steroid therapy, and those subjected to lengthy periods of immobilization. Vertebral fractures can cause incapacitating pain lasting for months and are associated with disability and potential morbidity. The traditional indication for percutaneous vertebroplasty is a painful osteoporotic fracture that has not responded to a 4- to 6-week course of conservative management (external bracing, opioid medications, and observation). Because of recent evidence, it is not recommended for routine care but in refractory cases. Age of the fracture and time from the onset of symptoms are not predictive of procedure-related success or failure.

Vertebroplasty is also useful for the treatment of aggressive, symptomatic vertebral hemangiomas, as initially described. These lesions are characterized by a constellation of signs, including progressive involvement of the vertebral body, extension to the neural arch, vertebral body collapse, increased soft tissue mass, and an irregular honeycombed pattern on radiographs. Transpedicular injection of ethanol for sclerosis of the hemangioma may be useful if done before vertebroplasty.

Metastatic tumors are the most common painful tumoral lesion involving the spine. Percutaneous vertebroplasty is particularly useful for palliation of symptoms in patients with contraindications to surgical removal or those in whom multifocal lesions are present. Because the main aim of vertebroplasty is to provide pain relief, oncologic surgery, radiation therapy, and other tumor-specific therapies should be administered in conjunction with vertebroplasty when appropriate.

Cement augmentation of pedicle screws can also remain an option through a vertebroplasty-like approach where instead of a percutaneous needle, a cannulated pedicle screw facilitates the injection of PMMA into the vertebral body. This is used in cases of severe osteoporosis or poor bone quality to increase screw pullout strength.

34.2.2 Contraindications

Preexisting infection (particularly in tissue overlying the expected needle track), epidural extension of metastatic tumor with encroachment on neural structures, and coagulopathy represent absolute contraindications. The presence of cardiovascular compromise that precludes sedation and the inability to lie in a prone position for the duration of the procedure (1 to 2 hours) are relative contraindications. Percutaneous vertebroplasty should never be used as the sole therapy in cases of spinal instability; however, PMMA injection may augment pedicle screw fixation and provide a platform for the placement of stabilization constructs. In cases of severe vertebral body compression in which access is technically difficult, vertebroplasty may yield suboptimal results, but this condition is not an absolute contraindication to the procedure for infection prophylaxis.

34.3 Preoperative Preparation

A physical examination is performed to determine the patient’s general health and ability to tolerate the prone position. It is also essential to document a concordance between the imaging level of the fracture and the location of the patient’s pain. Both back pain and osteoporotic fractures are common in the elderly population, and it is not reasonable to assume causality. The procedure is performed in an angiographic suite or operating room after the administration of local anesthesia and neuroleptanalgesia, or general anesthesia, with imaging guidance obtained through a single or biplane fluoroscopy unit. Intravenous fentanyl and midazolam are generally used for analgesia. The patient’s blood pressure, electrocardiogram, heart rate, and oxygen saturation are continuously monitored throughout the procedure. Oxygen is administered via nasal cannula when indicated. One gram of cefazolin is intravenously administered at the start of the procedure.

34.4 Operative Procedure

For thoracic and lumbar percutaneous vertebroplasty, the patient is placed in a prone position with the hips slightly flexed; padding is placed under the torso. Arms are positioned above the shoulder to avoid interference with lateral fluoroscopic imaging, pressure points are padded, and joints are gently flexed ( ▶ Fig. 34.1). The appropriate thoracic or lumbar region is prepared and draped in a sterile fashion. ▶ Fig. 34.2 shows the equipment necessary for successful performance of PMMA vertebroplasty.

Fig. 34.1 Proper patient positioning and the planned trajectory of needle placement. The trajectory for pedicle cannulation is indicated by the arrow. Note that the hips are slightly elevated and the arms are brought forward to avoid interference with lateral fluoroscopy. (Reproduced wih permission from Fessler RD, Guterman LR, Lanzino G, Gibbons KJ. Vertebroplasty. In: Rengachary SS, ed. Operative Atlas of Neurosurgery. New York: American Association of Neurological Surgeons; 2000:233–240.)

A radiopaque marker may be positioned on the back to aid localization of the appropriate vertebral level. Many patients are extremely kyphotic or scoliotic with severe osteopenia, making localization of the appropriate level difficult. In such cases, it is important to maintain proper alignment relative to the vertebral body being treated; that is, the pedicles and spinous process are clearly squared relative to the anteroposterior (AP) plane. The pedicle of the vertebral body to be treated is localized in both AP and lateral projections. Most surgeons are right handed and will find it more comfortable to work from the patient’s left side. A 10-mL syringe with a 2-inch, 25-gauge needle is used to locate the medial third of the pedicle in the AP projection ( ▶ Fig. 34.3); the appropriate trajectory is verified on the lateral fluoroscopic image. The skin, soft tissue, and periosteum are infiltrated using lidocaine with epinephrine. The syringe is then removed, and the needle is left positioned on the pedicle. A small incision is made 3.0 to 3.5 cm from the midline. A disposable 11-gauge bone biopsy needle is introduced along the same pathway as the 25-gauge needle. The tip of the biopsy needle is imbedded 1 to 2 mm into the pedicle. Patients will find this portion of the procedure to be the most painful. Administration of the analgesic and sedative hypnotic agents just before entering the pedicle is recommended. A lateral fluoroscopic image is obtained, and the craniocaudal trajectory of the 11-gauge needle is directed along the axis of the pedicle. Frequent switching between the AP and lateral projections is required to ensure that the trajectory and positioning are correct. The pedicle entry point starts at 10 o’clock for the left pedicle or 2 o’clock for the right pedicle. The posterior cortical margin of the vertebral body should be assessed while the needle tip is still within the medial outline of the pedicle ( ▶ Fig. 34.4). The needle tip is then positioned in the anterior third of the vertebral body ( ▶ Fig. 34.5). As the pedicle–vertebral body junction is broached, resistance to forward motion will decrease. If necessary, bone biopsies can be obtained during placement of the needle.

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