Questions and Answers

• What are the indications for vertebroplasty?
• What are the diagnostic requirements for evaluating indications?
• What equipment do I need to perform this procedure?
• Can I perform this procedure in the OR?
• Is the procedure performed in the hospital or outpatient surgery center?
• What cement is used?
• What are the long-term effects of bone cement in the spine?
• Do you recommend a venogram for cement injection?
• What published clinical outcome studies would you recommend?
• What are the benefits of vertebroplasty to kyphoplasty?
• Where would you recommend receiving training to perform this procedure?
• What are the CPT codes for reimbursement?
• I'm a referring physician, how can I learn more about doctors in my area which offer this procedure?

What are the indications for vertebroplasty?

Percutaneous vertebroplasty is indicated primarily for the relief of pain related to vertebral compression fractures. Most of the treated patients suffered from pathologic fractures related to osteoporosis. However, vertebroplasty is also useful for relieving pain related to benign and malignant infiltrating vertebral lesions such as aneurysmal bone cysts, hemangioma, giant cell tumor, myeloma, or metastatic malignancy. In rare cases, vertebroplasty has been used for preoperative reinforcement of osteoporotic vertebrae prior to instrumentation. For more detailed information about indications and contraindications.

What are the diagnostic requirements for evaluating patients?

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.

What equipment do I need to perform this procedure?

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.

Can I perform this procedure in the OR?

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.

Is the procedure performed in the hospital or outpatient surgery center?

In the past, the procedure has often been performed in a hospital setting; however, as of January 1, 2004, CMS has added the "non-facility" (office) setting as an acceptable site of service if adequate equipment is available (see the Federal Register dated January 7, 2004 at www.gpoaccess.gov/fr). Necessary equipment includes not only satisfactory imaging devices but also state-of-the-art monitoring equipment for conscious sedation as well as resuscitation devices.

Percutaneous Vetebroplasty is not included in the Medicare-approved ASC list and therefore, there is no separate payment of the ASC facility fee. However, per Medicare Program Memorandum dated July 18, 2001 (www.cms.hhs.gov/manuals), physicians may bill Medicare for procedures performed in the ASC but not listed on the Medicare-approved ASC list. Reimbursement will be made to the physician at the non-facility (office) rate. Physicians may find that they need to negotiate a payment with the ASC in order to properly compensate the facility for its costs.

When determining this payment, consideration must include staffing time, suppliers, overhead/equipment and liability insurance. Physicians may want to consider block scheduling for these procedures and negotiate payment based on use of the ASC for designated day/day-parts.

What cement is used?

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.

What are the long-term effects of bone cement in the spine?

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.

Do you recommend a venogram for cement injection?

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.

What published clinical outcome studies would you recommend?

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.

Where would you recommend receiving training to perform this procedure?

What are the CPT codes for reimbursement?

Please review our coding section for more information on this issue.

I'm a referring physician, how can I learn more about doctors in my area which offer this procedure?

Please visit locate a physician for a list of doctors performing vertebroplasty in your area or complete our information request form.

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