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Percutaneous Vertebroplasty is indicated primarily for the reduction of pain related to vertebral compression fractures. Mose of the treated patients suffered from pathological fractures related to osteoporosis. However, Vertebroplasty is also useful for reducing pain related benign lesion (hemangionma), and malignant lesions (metastaic cancers, myeloma). Review detailed information about indications and contraindications.
Because of the frequency of multiple fractures in this population of patients, careful clinical and imaging correlation is required to determine the etiology and level of the patient's pain. Findings on plain radiographs and MRI, particularly MR demonstration of edema within a fractured vertebral body, should correlate with the level of tenderness upon palpation of the spinous processes. MRI stir sequences are most useful for the depiction of edema. A bone scan showing activity in the fracture is helpful for confirming the more recent fracture in a patient with multiple fractures over an extended period.
Vertebroplasty should be performed under high quality imaging equipment such as an angio suite; digital imaging is superior to analog. Bi-plane imaging facilitates the procedure, but is not required. Portable C-arm units such as the OEC 9600 or 9800 are acceptable; earlier versions of portable C-arms do not provide adequate imaging for safe injection of opacified cement.
Percutaneous vertebroplasty can be performed in the operating room using a high quality portable C-arm as described above. General anesthesia is not necessary, and therefore the operating room forum may unnecessarily increase the expense of the procedure.
Various polymethylmethacrylate cements have been used; however most physicians utilize a cement which is indicated for injection in the spine or craniofacial defect repair mixed with an opacifier such as Barium Sulfate to approximately a 30% barium mixture by weight. Adequate opacification must be achieved in order to perform the procedure safely.
Polymethylmethacrylate has been used for over four decades as an orthopedic cement and the side effects have been studied. The strength of the bone cement and durability would be expected to outlast the native bone in elderly, osteoporotic patients and is considered to be a lifetime implant by FDA. The long-term effects of bone cement in percutaneous vertebroplasty have been covered in numerous peer-reviewed journal articles. Refer to the Research Articles for more information.
A venogram is no longer recommended prior to cement injection. Experience has found that venography usually demonstrates rapid egress into venous structures. By mixing the cement to an appropriate thickness and by injecting in a controlled fashion, substantial filling of these veins can be avoided even without a prior venogram. A venogram can also complicate the cement injection when contrast still remains in the vertebral body as it can erroneously be identified as opacified cement.
Hundreds of scientific papers have been published on vertebroplasty and can be located via Medline. The results of these studies suggest a remarkable benefit over conservative therapy such as bracing and drug therapy. Long-term studies also need to be performed to rule out the possibility of any long-term sequelae. Refer to the Research Articles for more information.
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