Vertebroplasty

What is Percutaneous Vertebroplasty?

Percutaneous vertebroplasty is a minimally invasive surgical procedure used for osteoporotic and tumor-related vertebral fractures. The method is now a standard procedure in many specialized clinics.

In osteoporosis, the bone substance is degraded, and bone quality deteriorates. As a result, the vertebral bodies become brittle and can collapse even in a minor fall or little weight-bearing. Sometimes the vertebral bodies even break spontaneously. A tumor can also weaken the bone structure so that the vertebras easily collapse.

Percutaneous vertebroplasty stabilizes these vertebrae. Cement is inserted into the vertebral body with a cannula. The hardened cement supports the vertebral body from the inside and prevents the vertebra from collapsing more. Stabilization is also intended to relieve pain because vertebral fractures caused by osteoporosis are often very painful.

The operation is short and not very stressful for the patient. In addition, weight-bearing and movement of the spine are possible shortly after surgery.

When Is Percutaneous Vertebroplasty Used?

Vertebral fractures in osteoporosis usually heal without surgery. However, they are generally painful, and it often takes several weeks for the discomfort to subside. It has been noticed the percutaneous vertebroplasty reduces pain in many patients immediately after surgery. Few risks and immediate ability to bear weight after surgery are other advantages in favor of the operation.

However, recent studies with placebo controls have concluded that surgery does not appear to help much better than an illusory surgery. Furthermore, few long-term studies to date show a benefit. Therefore, experts from the scientific osteological societies recommend that surgery should only be considered in cases of very severe pain and unsuccessful intensive conservative treatment. The doctor determines the time for surgery on an individual basis. If there is a risk that the vertebra will continue to sink in, it should not be waited too long.

For example, some tumor diseases, for example, multiple myeloma, also attack the bone substance of the vertebras, resulting in changes in the vertebrae with bone loss and even vertebral fractures. Therefore, percutaneous vertebroplasty is used here too, and several vertebras can simultaneously be treated in surgery.

In general, surgery should not be the choice of treatment if the vertebral fracture is not painful or conservative therapy works well. If there is additional damage to the spinal cord or spinal nerves, disc damage, or infection, other surgical methods or treatment options are more appropriate. Percutaneous vertebroplasty should not be used in these cases.

In cases of osteoporosis, it is not enough to treat only the vertebral fracture. It is also essential to treat the disease, for example, with calcium, vitamin D, and bisphosphonates, to prevent further damage. The same applies to tumor-related vertebral fractures: percutaneous vertebroplasty does not remove the tumor. Instead, it only stabilizes the fractured vertebra. Therefore, additional treatment, such as chemotherapy or radiotherapy, is always required.

What Are the Alternatives?

Stable osteoporotic vertebral fractures usually do not require surgery. Instead, they can be treated conservatively with painkillers. However, patients should start moving again at an early stage, which is sometimes very painful. In that case, patients an orthosis (support corset) that supports the spine might be helpful. Supportive measures such as posture training and physiotherapy are also part of conservative therapy.

In severely sunken vertebras, kyphoplasty can be used instead of percutaneous vertebroplasty, a surgical method where the vertebral body can be straightened again. As with vertebroplasty, the vertebral body is stabilized with cement. However, before the doctor inserts the cement into the vertebral body, a balloon catheter is placed in the vertebral body. The balloon is inflated and creates a cavity in the vertebra, which causes the vertebra to straighten. Then, the cement is inserted into this cavity.

Kyphoplasty can also be used for vertebral fractures caused by tumors. As with percutaneous vertebroplasty, the tumor is not removed.

There are different surgical methods for cancers of the spine. The process depends on the type of tumor, the extent of damage, and the treatment goal. If the tumor is to be removed during surgery, part of the vertebra must be removed as well. Then, the vertebras are stabilized with plates or implants. However, even with these methods, complete tumor removal is rarely possible, and additional treatment is usually necessary.

What Is the Procedure for Percutaneous Vertebroplasty?

Before the surgery, the doctor informs the patients about the procedure and risks and examines the patients.

The procedure can be carried out under local anesthesia or general anesthesia. Usually, local anesthesia is combined with light sedation. For the procedure, patients must lie on their stomachs, but it takes no more than an hour with preparation time. First, the doctor inserts a thick hollow needle through the skin into the vertebral body under X-ray monitoring. Next, the cement, usually polymethylmethacrylate (PMMA), is placed into the vertebral body with pressure through the hollow needle. The cement hardens within half an hour.

Patients are already allowed to move around under the guidance of a physiotherapist one day after the procedure.

What Are the Risks and Late Effects?

During the surgery, nerves may be injured, or the cement may not be placed correctly and leak next to the vertebra. The cement can also get into blood vessels and block them (cement embolism). If the vertebral body is accidentally punctured, large vessels can be injured.

Serious complications rarely occur with percutaneous vertebroplasty. However, it happens quite often that some cement leaks out of the vertebral body. This does not always cause problems and is usually only noticed at random during follow-up examinations. If small pieces of cement get into blood vessels, they can be transported further with the blood and deposit in small pulmonary vessels (pulmonary cement embolism).

In about 10 percent of patients, fractures occur in adjacent vertebras with weakened bone structure within one to two years, which happens even without surgery. However, there is evidence that these vertebral fractures are somewhat more common in patients who have undergone vertebroplasty. Overall, studies on long-term consequences are still lacking.

Sources :

• Buchbinder R et al. (2018). Cochrane Review – Vertebroplastie zur Behandlung von Wirbelkörperfrakturen durch Osteoporose. Cochrane Library. Link: tps://www.cochrane.org/de/CD006349/MUSKEL_vertebroplastie-zur-behandlung-von-wirbelkorperfrakturen-bedingt-durch-osteoporose. Aufgerufen am 17.03.2021
• Dachverband der Deutschsprachigen Wissenschaftlichen Osteologischen Gesellschaften e.V. (2017). Leitlinie Prophylaxe, Diagnostik und Therapie der OSTEOPOROSE bei postmenopausalen Frauen und bei Männern – Langfassung. AWMF-Register-Nr.: 183/001
• Delank, K-S et al (2011). Behandlung von Wirbelsäulenmetastasen. Deutsches Ärzteblatt 108(5): 71-80
• Josten B. (2013). Chirurgie der verletzten Wirbelsäule. Springer Verlag Berlin Heidelberg