Percutaneous Vertebroplasty

Vertebroplasty is an image-guided therapy in which a cement, a fast-setting polymer, is injected into a pathologic vertebral body. The purpose of this procedure is to relieve pain and disability. It can be used in the setting of painful osteoporotic compression fractures, pathologic fractures from underlying neoplasms, or structurally compromised vertebrae. It has been used for osteoporotic or malignant fractures. The procedure was first described by Galibert et al [1] who found that the “internal casting” provided by polymethyl methacrylate (PMMA) injected into a symptomatic vertebral hemangioma provided substantial pain relief.

With clinical experience and landmark innovation, other indications have emerged. Vertebroplasty can increase patient mobility, decrease narcotic needs, prevent further vertebral collapse resulting in altered forces on intervertebral discs, and avoid the complications associated with prolonged immobility.

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Percutaneous vertebroplasty (PVP) usually involves percutaneous injection of PMMA into the vertebral bodies. Occasionally, PMMA has also been placed manually into vertebral lesions during open surgical operations.

Kyphoplasty is often mentioned alongside vertebroplasty. Kyphoplasty differs from vertebroplasty by adding an important additional step: insertion and inflation of a balloon before cement delivery, which also serves to restore vertebral body height and spine alignment. [2] Kyphoplasty is often used interchangeably with vertebroplasty and is considered a subset of vertebroplasty. Spine jack is a new system that corrects vertebral height, reduces the incidence of endplate damage by inserting an implant that mechanically augments the height of the vertebral body to better restore alignment followed by injection of cement.

Relevant anatomy

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A normal thoracic spine is immobile and consists of 12 vertebrae. There are important anatomic landmarks to consider including a body, pedicles, laminae, spinous processes, and facet joints. Importantly, thoracic vertebrae have prominent lateral processes that form the articulation with the paired 12 ribs on either side. The 12 vertebrae, 24 ribs, and sternum together form the chest cavity, allowing negative-pressure respiration and providing protection of the chest wall.

The lumbar spine is the next segment of the spine and is more mobile than the thoracic. The lumbar spine typically consists of 5 large vertebrae and important landmarks, including the body, pedicles, lamina, spinous processes, facet joints, and lateral processes. The lumbar spine is mobile with all articulations, contributing to flexion-extension, bending, and rotation allowing for truncal mobility.

This anatomy is important to consider in three-dimensional space and be easily identifiable on X-rays in order to facilitate optimal placement of the needle under fluoroscopic guidance. An important step in understanding these procedures is to have a grasp of radiographic anatomy. (See Technique.)

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