Vertebroplasty

Vertebroplasty: A New Scaffold for the Vertebra

Vertebroplasty is a procedure involving the injection of a so-called bone cement or adhesive into a damaged bone. This substance, polymethylmethacrylate, is the same material used to anchor joint prostheses. By introducing a semi-liquid substance into the vertebra, it solidifies and strengthens the bone. A useful analogy is wood eaten by termites, which becomes fragile and prone to breaking. Injecting glue into the tunnels in the wood creates internal scaffolding, reinforcing the structure. Similarly, vertebroplasty-treated vertebrae can become even stronger than the surrounding bones.

Vertebroplasty: The Key Role of the Procedure

The primary indications for vertebroplasty include conditions that cause vertebral damage, such as weakened bone structure. The spongy bone of a vertebra can be thought of as a network of trabecular beams. When these beams thin out, as in osteoporosis, or are destroyed by cancer, or when a vertebra collapses due to fracture, injecting polymethylmethacrylate creates an additional skeleton within the structure. The vertebra is then filled with solid material, restoring its anatomical integrity. The main function of vertebral bodies is to bear axial loads, but when a vertebra softens, it fails to perform this role. Vertebroplasty aims to restore or reinforce the load-bearing function of the vertebral body.

Vertebroplasty and Cancer

Vertebroplasty is particularly beneficial for patients with cancer. When a cancerous lesion metastasizes to a vertebra, it can weaken the bone, making it susceptible to fractures. Proactively applying vertebroplasty before a fracture occurs can reduce the risk of breaks and provide pain relief by stabilizing the vertebra, thereby improving the patient's quality of life. Cancer patients, even those with terminal diagnoses, can greatly benefit from this procedure, as it enhances their comfort and mobility. One example involves a patient who knew he had only three months to live but wanted to remain ambulatory. Vertebroplasty, as a straightforward and low-impact procedure, allowed him to enjoy improved mobility and comfort during his final weeks.

Vertebroplasty for Myeloma and Lymphoma

Hematologic conditions like multiple myeloma and lymphoma often involve bone lesions, including multiple affected vertebrae. While hematologic treatments can extend life expectancy by 10–15 years, they often leave bones fragile and prone to fractures. Severe vertebral fractures can compress the spinal cord, causing lower limb paralysis. In such cases, vertebroplasty is an effective intervention. Although the prophylactic use of vertebroplasty in asymptomatic patients is debated, early intervention, such as in cases of newly diagnosed myeloma with visible vertebral damage, may prevent further progression and fractures.

Vertebroplasty and Osteoporosis

The use of vertebroplasty in osteoporosis is controversial. Most osteoporotic fractures heal on their own within six weeks, making the necessity of the procedure questionable in such cases. However, for elderly or immobile patients with fractured vertebrae, waiting for natural healing may lead to prolonged immobility, increasing the risk of complications such as thromboembolism, pulmonary issues, and urinary tract infections. In these instances, vertebroplasty can provide pain relief and vertebral stabilization, enabling faster recovery and mobility.

In younger patients, vertebroplasty is typically reserved for cases involving cancer or exceptionally large hemangiomas, which are increasingly diagnosed due to the widespread use of magnetic resonance imaging (MRI).

Vertebroplasty and Imaging

Successful surgical outcomes, especially in orthopedics, require careful assessment of indications and conditions. Vertebroplasty demands strict criteria for safe execution, including evaluating the integrity of the vertebral body walls. Optimally, patients should undergo not only X-rays but also CT scans. In practice, however, if obtaining a CT scan is challenging—such as with elderly patients—a skilled surgeon may rely on X-rays and experience to judge vertebral integrity. A CT scan, when feasible, provides quick and valuable confirmation of conditions and is highly recommended for optimal safety.

Vertebroplasty for Multiple Fractures

Patients with osteoporotic fractures may have multiple injuries, some of which have healed and no longer cause symptoms. Differentiating between old and new fractures can be challenging on X-rays. Errors may occur, such as treating an old, stable fracture instead of a fresh, painful one. MRI, though expensive and requiring patient immobility, can help pinpoint active fractures needing treatment. Proper imaging minimizes procedural errors and improves patient outcomes, reducing dissatisfaction with vertebroplasty results.

The Vertebroplasty Procedure

For an experienced surgeon, vertebroplasty is a relatively simple procedure. The patient lies on their stomach while the surgeon uses fluoroscopy to guide a needle through the vertebral pedicle into the vertebral body. When done skillfully, the process takes 10–15 minutes. Bone cement is then injected and allowed to set, a process that takes another several minutes. Patients can usually stand up and leave the clinic shortly afterward, although waiting a little longer is advisable to avoid putting immediate strain on the treated vertebra. Allowing the cement to fully harden reduces the risk of vertebral collapse during early mobilization.

Postoperative rehabilitation is typically unnecessary. On the contrary, vertebroplasty often facilitates rehabilitation of other injuries that were previously unmanageable due to pain or instability.

Vertebroplasty, or spinal cementation, is a valuable procedure that should be promoted—but only in specialized centers with experienced spinal surgeons.

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Bibliography:

• Percutaneous Vertebroplasty: Indications, Technique, and Results - Afshin Gangi, Stephane Guth, Jean Pierre Imbert, Horia Marin, Jean-Louis Dietemann - RadioGraphics - 2003
• Percutaneous Vertebroplasty for Pain Relief and Spinal Stabilization - Barr, John D. MD*†‡§; Barr, Michelle S. MD*‡; Lemley, Thomas J. MMS, MPAS, PA-C‡§; McCann, Richard M. RT (R)(CV) - Spine: April 15, 2000 - Volume 25 - Issue 8 - p 923-928
• National Library of Medicine - Vertebroplasty - Bryan Jay, MD1 and Sun Ho Ahn, MD - 2013