Vertebroplasty

Abstract

Percutaneous vertebroplasty has become widely accepted as a safe and effective minimally invasive procedure for the treatment of painful vertebral body compression fractures refractory to medical therapy. In this article, the authors review the indications and contraindications for vertebroplasty, principles of appropriate patient selection, useful techniques to achieve optimal outcomes, and the potential risks and complications of the procedure.

Keywords: interventional radiology; kyphoplasty; osteoporosis; vertebral augmentation; vertebral compression fracture; vertebroplasty.

Figure 1

Sagittal CT reconstruction (A) showing multiple vertebral body fractures of unknown age. MRI T1, T2, and STIR images (B-D, respectively) confirm fractures, demonstrating marrow edema at L1 and L5 compatible with acute vertebral body fractures (black arrows). Lack of marrow edema at T12 and L2 suggests more chronic vertebral body fractures (white arrows).

Figure 2

(A, B) Nuclear medicine bone scan, with anterior, posterior, right anterior oblique (RAO), and right posterior oblique (RPO) views, in a patient unable to have an MRI, showing increased radiotracer uptake at T10 consistent with an acute vertebral body fracture (arrow). Uptake is seen to a lesser degree at the mid-thoracic spine compatible with a second acute fracture. Multiple rib fractures are also present.

Figure 3

(A, B) Ipsilateral oblique and lateral fluoroscopic views of a T10 vertebral fracture. The needle should be advanced at the upper and outer quadrant of the pedicle. The needle must be advanced without violating the inferior (white arrow) and medial (black arrow) walls of the pedicle to avoid potential nerve or cord injury. Intermittent lateral views should be obtained to ensure appropriate angle of entry into the vertebral body.

Figure 4

(A, B) Bilateral transpedicular access obtained for vertebroplasty. Needle positioning should be confirmed in both projections prior to the injection of cement. Ideally, the tips of the needles should be positioned as close to midline as possible at the junction of the anterior and middle third of the vertebral body.

Figure 5

(A, B) Satisfactory vertebroplasty endpoint with even distribution of cement.

Figure 6

(A-D) Left unilateral transpedicular approach with ideal needle positioning and cement distribution.

Figure 7

(A, B) Poorly filled mid-thoracic vertebral body after vertebroplasty. Notice the cement tail (black arrows) extending to the subcutaneous soft tissues. This can be avoided by clearing the needle of cement using the stylet, or by breaking the tail off by gently rocking and spinning the needle prior to removal. In this case, a small incision could be made to cut down on the tail and, using a hemostat, to physically remove as much as possible.

Figure 8

(A-C) Intradiscal extravasation of cement (arrows) in this case was asymptomatic, but uncommonly can be associated with pain. Cement injection should be paused when extravasation is encountered. Often waiting a minute or two will allow the cement more time to thicken and for the leak to seal.

Figure 9

(A, B) A rare case of massive pulmonary emboli related to PMMA from a vertebroplasty performed in an outpatient setting. This patient survived, but eventually developed pulmonary hypertension. Images courtesy of Dr. Michael Jay.

Figure 10

(A-D) Unipedicular vertebroplasty with extravasation of cement anteriorly via a vertebral vein and ultimately extending into the IVC (black arrows). Cement also extends beyond the posterior wall of the vertebral body and into epidural veins (white arrow). CT chest shows a small cement PE in the right middle lobe (white arrow head). The patient remained asymptomatic.