Percutaneous vertebroplasty – Technique and review of literature

Chandan B Mohanty

doi:10.4103/joss.joss_25_22

REVIEW ARTICLE

Year : 2022 | Volume : 9 | Issue : 3 | Page : 144-148

Percutaneous vertebroplasty – Technique and review of literature

Chandan B Mohanty
Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences; Department of Neurosurgery, BJ Wadia Children's Hospital, Mumbai, Maharashtra, India

Date of Submission	26-May-2022
Date of Acceptance	04-Jun-2022
Date of Web Publication	13-Sep-2022

Correspondence Address:
Chandan B Mohanty
Bombay Hospital Institute of Medical Sciences, 12 New Marine Lines, Mumbai - 400020, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joss.joss_25_22

Abstract

Percutaneous vertebroplasty (PVP) is an “outpatient” procedure mainly used in osteoporotic vertebral fractures. This article aims to describe the author's technique and clinical results of PVP and also provides a broad overview of the pertinent literature focusing on the current status, controversies, and recent advances in the field of vertebral augmentation in the form of a narrative review.

Keywords: Fracture, osteoporosis, review, vertebral augmentation, vertebroplasty

How to cite this article:
Mohanty CB. Percutaneous vertebroplasty – Technique and review of literature. J Spinal Surg 2022;9:144-8

How to cite this URL:
Mohanty CB. Percutaneous vertebroplasty – Technique and review of literature. J Spinal Surg [serial online] 2022 [cited 2023 Feb 1];9:144-8. Available from: http://www.jossworld.org/text.asp?2022/9/3/144/356022

Introduction

The incidence of osteoporotic vertebral fracture (OVF) is increasing worldwide with an aging population. It is estimated that one OVF occurs every 22 seconds worldwide.^[1] The prevalence of osteoporosis in the Indian population was noted to be between 24.7% and 42.7%.^[2],[3] Whereas the worldwide incidence of osteoporosis is estimated to be 18.3%.^[4] On the other hand, in a study of 2119 health-care professionals in India, alarmingly about 80% were noted to be deficient in Vitamin D.^[5] Not surprisingly, the incidence of OVF reported in urban India (Delhi) is reported to be 17.9% in older adults.^[6]

Vertebral augmentation includes the injection of polymethyl methacrylate into the vertebral body either by percutaneous vertebroplasty (PVP) or balloon kyphoplasty (BK) or placement of intravertebral body mechanical implants. Galibert et al. first described the procedure of PVP in a case of C2 hemangioma in 1987.^[7] PVP is a cheap and efficacious technique to achieve vertebral augmentation.

Biomechanics of Vertebral Augmentation

Disease in the vertebral body leads to its loss of stiffness and thus increases the susceptibility to deformation and subsequently leading to fracture.^[8],[9] Vertebral augmentation increases the stiffness of the vertebral body by increasing the elastic modulus and ultimate strength of the vertebral body.^[9] This leads to an improvement in the mechanical stability and elimination of the micromotion of the fracture fragments resulting in pain relief and maintenance of the vertebral body height thus preventing collapse.^[9],[10] This increased stiffness of the augmented level also leads to 13%–18% increase in the pressure transmission to the nucleus pulposus and the adjacent vertebral body.^[9] Even distribution of the cement in the vertebral body is important since unilateral cement distribution may lead to uneven weight transfer and toggle.^[8] Polymethyl methacrylate (PMMA) polymerization is an exothermic reaction which leads to the destruction of the nerve endings leading to analgesia and also leads to the destruction of the malignant cells when used in malignancy-induced pathological fractures.^[8]

Indications and Contraindications of PVP

PVP is currently most commonly used in OVF but it has also been employed in traumatic fractures, vertebral hemangioma, and lytic metastatic vertebral body disease as a means to provide anterior column support.^[8] Acute and subacute compression fractures which show marrow edema on short-tau inversion-recovery sequences of magnetic resonance imaging respond well to PVP.^[8] Clinically, patients with severe medically refractive pain and localized tenderness secondary to the vertebral fracture, leading to loss of ambulation are usually selected for PVP.

The presence of septicemia, active infection in the vertebral body or the disc, allergy to bone cement, and uncorrected bleeding disorders or coagulopathy are absolute contraindications for PVP.^[8],[9],[11]

The relative contraindications of PVP are the presence of significant retropulsion of fracture fragment causing the neurological deficit, presence of systemic infection, significant canal stenosis secondary to epidural tumor, and improving patient symptoms.^[8],[11]

Procedure – How I Do It

The author usually performs PVP under local anesthesia with or without sedation.^[11] The patient is placed in the prone position with adequate padding of the pressure points and is supported on bolsters or pillows ensuring patient comfort. An attempt is made to keep the spine in a lordotic position to correct the localized kyphosis secondary to vertebral body collapse. In the author's experience, a unipedicular approach is sufficient. A bipedicular approach may be rarely required to achieve a more uniform bilateral cement distribution in the vertebral body. The author prefers premedicating the patient with a single dose of 500 mg IV methylprednisolone to avoid a rare possibility of allergic reaction. A single dose of perioperative wide-spectrum antibiotic is also administered mainly to cover Staphylococcus species. Radiation safety measures are meticulously followed. The steps of PVP are outlined below.^[11]

A correct Anteroposterior (AP) X-ray of the affected level is obtained ensuring that the end plates are parallel to each other
The settings of the C-arm machine related to position, tilt, voltage, etc., to achieve the true AP image are noted by the technician to obtain consistently good quality images
The pedicle entry point is decided on the AP and lateral X-ray. This point is marked and sterile aseptic skin preparation is done
The preferred starting position is the 2 or 3'o clock position on the pedicle on the right side and 9 or 10'o clock position on the left pedicle side to achieve adequate medialization and to avoid inferior entry into the pedicle
Usually, the skin entry point is about 4 cm from the midline in the thoracolumbar junction. This distance, however, is dependent on the body habitus of the patient and the level which needs augmentation, and the final skin entry point is always based on fluoroscopy
The author usually prefers a left pedicular approach. Skin and subcutaneous tissue up to the periosteum are infiltrated with 1% lidocaine with a fine-gauge lumbar puncture needle
An incision is then made and a 10G (or 11G) Jamshidi needle is docked on the periosteum of the pedicle entry point described in point 4. The pedicle entry point is confirmed by fluoroscopy [Figure 1]a
The Jamshidi needle is then passed into the pedicle gently under fluoroscopy guidance.
A lateral X-ray is obtained once the medial border of the pedicle is reached to confirm that the Jamshidi needle has crossed the posterior vertebral cortex [Figure 1]b and [Figure 1]c
Forward passage of the Jamshidi needle is stopped once its tip reaches the center of the junction of the anterior 1/3^rd and middle 1/3^rd of the vertebral body and is equidistant from the upper and lower end plate of the affected vertebral body
Aspiration is routinely performed to obtain tissue for biopsy to rule out any latent malignancy or infection
PMMA cement is now prepared and cement is then filled in four 2cc syringes.
Cement is ready for injection once it attains a thick viscous wire or “toothpaste” consistency, which takes about 2–3 min after mixing the constituents.
Live/pulsed fluoroscopy is used to inject cement into the vertebral body in a gradual manner [Figure 2]a
During the entire injection process, the anesthetist monitors vital signs, and the injection process is immediately stopped if there are any signs of cardiovascular instability
About 3–4 ml of cement is injected into each vertebral level
Lateral and AP view X-rays are taken to ensure uniform and bilateral distribution of cement. The cement injection is immediately stopped if any intradiscal or epidural or intravascular leakage is noted [Figure 2]b. Cement injection can continue after 2–3 min to ensure complete solidification of the previous cement.
After satisfactory volume of cement is injected, it is important to reinsert the trocar into the Jamshidi needle to ensure that the residual cement in the needle does not track along the needle trajectory.
AP and lateral X-ray are obtained to confirm the correct cement position in the vertebral body [Figure 2]c
A single stitch with absorbable suture to close the stab incision with compression on the wound to prevent wound hematoma
The patient is constantly reassured during the procedure and any procedural pain is avoided by meticulous infiltration of local anesthesia

Figure 1: (a) AP X-ray shows the initial docking of the Jamshidi needle at 3'o clock position, (b) AP X-ray shows gentle advancement of the needle into the pedicle, (c) Lateral X-ray shows the needle tip has crossed the posterior vertebral border

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Figure 2: (a) Lateral X-ray showing initial injection of cement. (b) Lateral X-ray showing continued cement injection and filling up of the anterior part of the vertebral body. Cement injection was stopped since some filling of the disc space was noted. Cement injection is preferred in. the anterior part of the vertebral body to avoid cement leakage into the spinal canal. (c) AP X-ray shows good bilateral filling of the cement in the vertebral body

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Following the procedure, the patients are mobilized the next day with a custom-made brace and discharged the next day. The patient is advised to continue Vitamin D, calcium supplementation and teriparatide is initiated for at least 1–2 years in consultation with an endocrinologist.

Complications of PVP

Cement leakage into the epidural space leads to a neurological deficit or root compression. Similarly, cement injection may lead to cement or fat embolism, allergic reactions, and infection.^[8],[12] Death secondary to anaphylactic reaction, pulmonary cement emboli and fat emboli are rare.^[8],[12] Low cement viscosity at the time of injection, vasculature at the needle tip, posterior vertebral body disruption, poor quality of intraoperative fluoroscopy, poor fluoroscopy image interpretation, and wider diameter of the Jamshidi needle may all potentially lead to cement leakage.^[8],[11]. Fat embolism syndrome may occur due to the migration of fat in the bone marrow of the vertebral body into the veins.^[13] Myositis may occur due to paravertebral cement leak.^[14] The incidence of post-PVP infection is 0.3%–0.5%.^[15],[16] Cement injection should be ideally done in the anterior part of the vertebral body to avoid retropulsion of the fracture or tumor fragment into the spinal canal.^[8] The incidence of adjacent vertebral body fractures (ABVF) reported in the literature in patients with osteoporosis is about 8%–52%.^[8] The incidence of ABVF secondary to any cement augmentation procedure is extremely variable (3%–25%).^[8],[11] In a meta-analysis, it was shown that a minimally higher incidence of ABVF following PVP is seen although this was not statistically significant (16.43% vs. 15.83%).^[17] The highest incidence of postprocedural ABVF is noted in the first 3 months.^{[18],[19],[20]} Intradiscal cement leakage is also associated with higher ABVF.^[18],[20] Thus, there is some controversy if vertebral augmentation actually leads to a higher incidence of ABVF.

A brief overview of the author's results and complications is provided in [Table 1]. The main concern with the author's series is the lack of long-term follow-up (mean follow-up duration = 7 months). This problem has accentuated during the ongoing COVID-19 pandemic where 15/28 patients were lost to follow-up.

Table 1: Outcome of percutaneous vertebroplasty

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Current Status and Controversies of PVP

The use of vertebral augmentation has been somewhat controversial in recent times after two large randomized control trials published in 2009 showed no significant difference in pain outcomes for patients undergoing a sham procedure and vertebroplasty. ^[21],[22] This led to a 53% reduction in vertebroplasty procedures in the United States over the next 5 years.^[23] A Cochrane review published in 2018 suggested a similar pain relief of PVP compared to a sham procedure.^[24],[25] However, the critics claimed that the evidence of the beneficial effect of PVP may have been misrepresented.^[26] Lou et al. in their recent meta-analysis showed that PVP was most effective for fractures causing severe pain and < 6 weeks old.^[17]

A recent systematic review and meta-analysis comparing BK and vertebroplasty revealed that BK resulted in better radiological outcomes in terms of correction of kyphosis, better vertebral body height restoration, and decreased cement leakage.^[27] However, in terms of clinical parameters namely, the Visual Analog Scale scores and Oswestry Disability Index, PVP and BK had similar outcomes.^[27] Recent studies, however, have shown a much more important benefit of vertebral augmentation than just pain relief which is the reduction of overall morbidity and mortality. The reduction of 12-month mortality and morbidity by 19% and 36%, respectively, following vertebral augmentation has been shown in a recent meta-analysis.^[28] The survival benefit was proposed to be secondary to improved pulmonary function, reduced rates of infection from any origin, and improved pain reduction leading to the prevention of problems secondary to prolonged immobilization although the exact mechanism is still not clear.^[28],[29] Another large study comprising more than 2 million patients showed a reduction of 10-years mortality by 22% in patients undergoing vertebral augmentation.^[29] Thus, overall health-care costs are lowered significantly following vertebral augmentation.^[30]

However, it should be remembered that osteoporosis is a preventable systemic disease, and 40%–70% reduction of OVF can be achieved by vitamin supplementation and medications.^[31]

Newer Trends in Vertebral Augmentation

Traditional PMMA has a higher modulus of elasticity and hence may contribute to ABVF and augmentation failure of the treated vertebral body. Hence, mineralized collagen which has a nanostructure similar to native bone is being used in addition to PMMA.^[32] These enhanced biomaterials have been shown to restore and maintain vertebral body height better than PMMA alone.^[32] High-viscosity cement has also been used which shows lower cement leakage rates and better pain relief than the conventional low-viscosity cement.^[33]

Third-generation mechanical vertebral body augmentation implants such as Osseofix, SpineJack, etc., are being developed to achieve better kyphosis correction and maintain vertebral body height with lesser amount of cement to avoid problems associated with cement leakage.^[34]

Preliminary data also show that intravertebral mesh implants without the use of cement results in good pain control and healing at the level of an osteoporotic spine fracture.^[35] These implant-based mechanical vertebral augmentation devices currently are not widely used and long-term data regarding their safety and efficacy are still lacking.

Conclusion

PVP is a safe and cheap procedure to achieve vertebral augmentation in carefully selected patients. Newer long-term literature reveals that the benefit of PVP is not restricted to pain relief alone but also in the reduction of long-term morbidity, mortality, and hospital care costs of elderly patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17:1726-33.
2.	Modagan P, Silambanan S, Menon PG, Arunalatha P. Comparison of bone mineral density with biochemical parameters and prevalence of osteopenia and osteoporosis in South Indian population. Biomed Pharmacol J 2018;11:2209-14.
3.	Paul T, Asha HS, Mahesh DM, Naik D, Rajaratnam S, Thomas N, et al. The diagnosis of osteoporosis among subjects of southern Indian origin above 50 years of age – The impact of the Indian council of medical research versus Caucasian bone mineral density reference standards Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India. Indian J Endocrinol Metab 2012;16:S514-24.
4.	Salari N, Ghasemi H, Mohammadi L, Behzadi MH, Rabieenia E, Shohaimi S, et al. The global prevalence of osteoporosis in the world: A comprehensive systematic review and meta-analysis. J Orthop Surg Res 2021;16:609.
5.	Marwaha RK, Tandon N, Gupta Y, Bhadra K, Narang A, Mani K, et al. The prevalence of and risk factors for radiographic vertebral fractures in older Indian women and men: Delhi Vertebral Osteoporosis Study (DeVOS). Arch Osteoporos 2012;7:201-7.
6.	Beloyartseva M, Mithal A, Kaur P, Kalra S, Baruah MP, Mukhopadhyay S, et al. Widespread vitamin D deficiency among Indian health care professionals. Arch Osteoporos 2012;7:187-92.
7.	Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty. Neurochirurgie 1987;33:166-8.
8.	Khan M, Kuschayev SV. Percutaneous vertebral body augmentations: The state of the art. Neuroimag Clin N Am 2019;29:495-513.
9.	Baroud G, Bohner M. Biomechanical impact of vertebroplasty. Postoperative biomechanics of vertebroplasty. Joint Bone Spine 2006;73:144-50.
10.	Luo J, Adams MA, Dolan P. Vertebroplasty and kyphoplasty can restore normal spine mechanics following osteoporotic vertebral fracture. J Osteoporos 2010;2010:729257.
11.	Borkar SA, Sastri SB, Mohanty CB, Bansal T. Therapeutic spinal injections and percutaneous procedures – An overview. Curr Pract Neurosci 2022;4:1-24.
12.	Marden FA, Putman CM. Cement-embolic stroke associated with vertebroplasty. AJNR Am J Neuroradiol 2008;29:1986-8.
13.	Ahmadzai H, Campbell S, Archis C, Clark WA. Fat embolism syndrome following percutaneous vertebroplasty: A case report. Spine J 2014;14:e1-5.
14.	Maramattom BV. Extraosseous cement leakage after vertebroplasty producing intractable low back pain. Neurol India 2017;65:375-6. [PUBMED] [Full text]
15.	Abdelrahman H, Siam AE, Shawky A, Ezzati A, Boehm H. Infection after vertebroplasty or kyphoplasty. A series of nine cases and review of literature. Spine J 2013;13:1809-17.
16.	Liao JC, Lai PL, Chen LH, Niu CC. Surgical outcomes of infectious spondylitis after vertebroplasty, and comparisons between pyogenic and tuberculosis. BMC Infect Dis 2018;18:555.
17.	Lou S, Shi X, Zhang X, Lyu H, Li Z, Wang Y. Percutaneous vertebroplasty versus non-operative treatment for osteoporotic vertebral compression fractures: A meta-analysis of randomized controlled trials. Osteoporos Int 2019;30:2369-80.
18.	Lin EP, Ekholm S, Hiwatashi A, Westesson PL. Vertebroplasty: Cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004;25:175-80.
19.	Borensztein M, Camino Willhuber GO, Posadas Martinez ML, Gruenberg M, Sola CA, Velan O. Analysis of risk factors for new vertebral fracture after percutaneous vertebroplasty. Global Spine J 2018;8:446-52.
20.	Komemushi A, Tanigawa N, Kariya S, Kojima H, Shomura Y, Komemushi S, et al. Percutaneous vertebroplasty for osteoporotic compression fracture: Multivariate study of predictors of new vertebral body fracture. Cardiovasc Intervent Radiol 2006;29:580-5.
21.	Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009;361:557-68.
22.	Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009;361:569-79.
23.	Laratta JL, Shillingford JN, Lombardi JM, Mueller JD, Reddy H, Saifi C, et al. Utilization of vertebroplasty and kyphoplasty procedures throughout the United States over a recent decade: An analysis of the Nationwide Inpatient Sample. J Spine Surg 2017;3:364-70.
24.	Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev 2018;11:CD006349.
25.	Buchbinder R, Johnston RV, Rischin KJ, Homik J, Jones CA, Golmohammadi K, et al. Percutaneous vertebroplasty for osteoporotic vertebral compression fracture. Cochrane Database Syst Rev 2018;4:CD006349.
26.	Clark W, Bird P, Diamond T, Gonski P, Gebski V. Cochrane vertebroplasty review misinterpreted evidence for vertebroplasty with early intervention in severely affected patients. BMJ Evidence Based Med 2020;25:85-9.
27.	Wang B, Zhao CP, Song LX, Zhu L. Balloon kyphoplasty versus percutaneous vertebroplasty for osteoporotic vertebral compression fracture: A meta-analysis and systematic review. J Orthop Surg Res 2018;13:264.
28.	Cazzato RL, Bellone T, Scardapane M, De Marini P, Autrusseau PA, Auloge P, et al. Vertebral augmentation reduces the 12-month mortality and morbidity in patients with osteoporotic vertebral compression fractures. Eur Radiol 2021;31:8246-55.
29.	Hinde K, Maingard J, Hirsch JA, Phan K, Asadi H, Chandra RV. Mortality outcomes of vertebral augmentation (vertebroplasty and/or balloon kyphoplasty) for osteoporotic vertebral compression fractures: A systematic review and meta analysis. Radiology 2020;295:96-103.
30.	Francio VT, Gill B, Rupp A, Sack A, Sayed D. Interventional procedures for vertebral diseases: Spinal tumor ablation, vertebral augmentation, and basivertebral nerve ablation – A scoping review. Healthcare (Basel) 2021;9:1554.
31.	Ebeling PR, Akesson K, Bauer DC, Buchbinder R, Eastell R, Fink HA, et al. The efficacy and safety of vertebral augmentation: A second ASBMR task force report. J Bone Miner Res 2019;34:3-21.
32.	Luo K, Jiang G, Zhu J, Lu B, Lu J, Zhang K, et al. Poly (methyl methacrylate) bone cement composited with mineralized collagen for osteoporotic vertebral compression fractures in extremely old patients. Regen Biomater 2020;7:29-34.
33.	Luo AJ, Liao JC, Chen LH, Lai PL. High viscosity bone cement vertebroplasty versus low viscosity bone cement vertebroplasty in the treatment of mid-high thoracic vertebral compression fractures. Spine J 2022;22:524-34.
34.	Vanni D, Galzio R, Kazakova A, Pantalone A, Grillea G, Bartolo M, et al. Third-generation percutaneous vertebral augmentation systems. J Spine Surg 2016;2:13-20.
35.	Eschler A, Ender SA, Ulmar B, Herlyn P, Mittlmeier T, Gradl G. Cementless fixation of osteoporotic VCFs using titanium mesh implants (OsseoFix): Preliminary results. Biomed Res Int 2014;2014:853897.