Vertebroplasty and Kyphoplasty

Vertebroplasty and kyphoplasty

Vertebroplasty is the injection of bone cement into the vertebral body in order to relieve pain and/or stabilise the fractured vertebra.

Kyphoplasty is a variation of the procedure using a high-pressure balloon inside the vertebral body to create a space in which to put the cement, and sometimes to try to restore or increase the height of the vertebral body to normal or nearly normal.

These procedures are done through a tiny incision on the skin- one or two for each bone that is treated.  A needle is placed into the vertebral body using X-ray guidance and the procedure is carried out through the needle. This can avoid a large scar and greater physical trauma of open surgery.

The first vertebroplasties were carried out in France in 1984 for the treatment of compression fractures caused by bone tumours. Later it was also used to treat fractures caused by osteoporosis. Since 1997 percutaneous vertebroplasty has become a widely used procedure. It is carried out by a specialist doctor called an Interventional Radiologist.

How does vertebroplasty work?

Vertebroplasty stabilises fractured or collapsed vertebrae, to reduce or stop the pain caused by the bone rubbing against the periosteum (the thin layer of connective tissue that covers the outer surface of the bone). The painful pressure on the vertebral joints caused by a collapsed vertebra is also reduced considerably. Most patients experience immediate pain relief after the procedure. For many patients vertebroplasty is the only method that can enable them to leave bed and participate in physiotherapy, which shortens their hospital stay.

When is vertebroplasty carried out?

Vertebroplasty is considered:

• For a painful osteoporotic fracture when the pain has not been adequately controlled after 3 weeks of other treatment (painkilling medication etc.)
• For a painful benign vertebral tumour such as a haemangioma or giant cell tumour
• For a painful vertebra due to a malignant tumour- vertebroplasty is only to treat the pain and other specific tumour treatment must be considered and will very likely be used
• For a painful VCF where there is osteonecrosis, non-union or cystic degeneration
• For reinforcement of a vertebral body or pedicle in conjunction with a surgical procedure to treat the posterior (rear) part of the vertebra

These are referred to as the “indications” for the procedure, or reasons why it might be carried out.

The main aim of the procedure is to control pain. It may also prevent further collapse of the vertebra. A kyphoplasty procedure is sometimes used to try to increase the height of a collapsed vertebra.

Vertebroplasty is not carried out if

• The patient is at more risk of bleeding than normal (due to a medical condition or certain medications)
• There is infection in blood or at the site of the procedure
• The patient already has decreased use of limb(s), bowel or bladder
• Heart, breathing or other problems mean that general anaesthetic or sedation are not safe
• The VCF is not causing symptoms, or is improving with pain relieving medications etc.

These are referred to as “contraindications” - the reasons why the procedure would not be carried out.

Patient preparation

You will be asked not to eat or drink before the procedure for at least 4 hours, possibly up to 8 hours

You should tell your doctor about all medications that you take and any allergies that you know you have. If you have had any problem with surgical or other medical procedures in the past, please also mention these.

The procedure can sometimes be done using “conscious sedation”.  This is using medication to make you drowsy and make you feel less pain.  You are awake enough to breath for yourself and to respond to instructions.

Some hospitals use a general anaesthetic for all procedures.

A kyphoplasty procedure is slightly longer and more uncomfortable and almost always requires a general anaesthetic.

In the UK most patients are asked to stay in hospital overnight after the procedure.

Risks and complications

The main potential adverse effects (complications) of the procedure are extravasation of cement (leaking of cement into blood vessels) and compression of the spinal cord due to leaking of cement backwards out of the body of the vertebra and into the space around the spinal cord.

Pulmonary embolism is when cement leaks into veins and then travels in veins to the lung. It is rare. Nerve damage and infection are also rare.

Overall complication rate for osteoporosis or benign tumours is 1-3 %, and for malignant tumours 1-10%.

Patients who have had one VCF have a higher chance than other people of having another fracture in the future. It is important to treat the cause of the fracture e.g. osteoporosis.

NICE guidance

The National Institute for Health and Clinical Excellence (NICE) is an NHS organization that was set up in 1999 to try to ensure equal access to medical treatments and high quality care across England and Wales.

NICE produces recommendations on specific treatments such as vertebroplasty and kyphoplasty and the treatment of osteoporosis. 

NICE guidance on vertebroplasty:

“Current evidence on the safety and efficacy of percutaneous vertebroplasty appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.”

See the NICE website for more information:  http://guidance.nice.org.uk/IPG12  

NICE guidance on kyphoplasty

“Current evidence on the safety and efficacy of balloon kyphoplasty for vertebral compression fractures appears adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance.”

See the NICE website for more information: http://guidance.nice.org.uk/IPG166      

NICE guidance on osteoporosis: http://guidance.nice.org.uk/Topic/Osteoporosis

New advances

The most commonly used cement is acrylic. Newer cements such as calcium phosphate based cement and polymer based compounds can be useful for specific problems.

A stent is a strong metal device that can be placed inside the vertebral body through the needle described for kyphoplasty/vertebroplasty. The aim is for the metal device to restore strength to the bone.

Links

Information for patients about vertebroplasty from the Radiology Society of North America and the American College of Radiologists

http://www.radiologyinfo.org/en/info.cfm?pg=vertebro

Information for patients about vertebroplasty from the Society of Interventional Radiology

http://www.sirweb.org/patients/vertebroplasty-osteoporosis/

Information for patients about vertebroplasty from the Cardiovascular and Interventional Radiology Society of Europe

http://www.cirse.org/index.php?pid=98&PHPSESSID=3dc88ae63c30f97e08389f9742d66da3 

Information on vertebroplasty from the University Louis Pasteur, Strasbourg, France

http://www.openradiology.org/zosirws/old_website/girws/d-vertebro2/b-eng/vert2/vert.htm

Information from NHS choices on osteoporosis

http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx

Information from NHS choices on back pain

http://www.nhs.uk/conditions/Back-pain/Pages/Introduction.aspx 

The patient information section of the British Society for Rheumatology

http://www.rheumatology.org.uk/Patient_Information/ 

The National Osteoporosis Society has lots of information on osteoporosis

http://www.nos.org.uk

National Osteoporosis Society information leaflets on osteoporosis.

http://www.nos.org.uk/NetCommunity/Page.aspx?pid=466 

NICE guidance on vertebroplasty

http://guidance.nice.org.uk/IPG12  

NICE guidance on kyphoplasty

http://guidance.nice.org.uk/IPG166    

 NICE guidance on Alendronate, etidronate, risedronate, strontium ranelate and raloxifene for preventing bone fractures in postmenopausal women with osteoporosis who have not had a fracture

http://www.nice.org.uk/nicemedia/pdf/TA160publicinfo.pdf 

NICE guidance on Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for preventing bone fractures in postmenopausal women with osteoporosis who have already had a fracture

http://www.nice.org.uk/nicemedia/pdf/TA161publicinfo.pdf

The website of the Royal College of Radiologists

http://www.rcr.ac.uk 

Macmillan Cancer Support’s information on bone cancer

Macmillan Secondary Bone Cancer information

http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Bone/Bonecancer.aspx