Bed rest and strong pain medicine are no longer the only treatments for back pain caused by compression fractures of the spine. Now there is a breakthrough minimally invasive medical procedure called percutaneous vertebroplasty that uses bone cement to fill in the spaces of a broken or crushed vertebra.
Vertebroplasty is a pain treatment for vertebral compression fractures that fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable. Vertebroplasty stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. This reduces pain, and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty dramatically improves back pain within hours of the procedure, provides long-term pain relief and has a low complication rate, as demonstrated in multiple studies.
Percutaneous vertebroplasty strengthens the treated vertebra and gives pain relief in most patients. The term “percutaneous” means injecting a fluid through a needle. “Plasty” means to mold or form. Thus, vertebroplasty helps mold the vertebrae by injecting a fluid into the bone. In this case, the doctor injects a bone cement mixture of polymethylmethacrylate (the same cement used in joint replacement surgery), barium or tantalum powder (makes the cement visible on X-ray), an antibiotic, and a solvent into the vertebral body. The cement hardens within 15 minutes and stabilizes the fracture, like an internal cast.
Vertebrae are bones that form a flexible column to protect the spinal cord. A compression fracture occurs when a vertebra breaks or is crushed. When this happens, a person can feel extreme pain that may last a lifetime. Often the pain keeps the person from performing normal activities. Certain cancers, benign tumors, or osteoporosis of the spine can cause compression fractures.
Osteoporosis, the most common form of compression fractures, is the loss of bone mass. Osteoporosis is the most common cause of vertebral compression fractures in the United States. The National Osteoporosis Foundation (NOF) estimates that over 50 million Americans over the age of 50 currently have osteoporosis or low bone mass with serious risk of osteoporosis. A large portion of this population will suffer debilitating pain caused by vertebral compression fractures. It is most often found in women after menopause, and can also be caused by certain medications or diseases. Osteoporosis is the most common form of compression fractures. Nearly all vertebral fractures in otherwise healthy people are due to osteoporosis, and can occur from a minor impact, such as a bump or a fall, in those who suffer from this bone-weakening disease. People who have a spinal fracture often don’t realize that they may have osteoporosis, because the disease is asymptomatic until a fracture occurs. Many patients with compression fractures caused by Osteoporosis can be helped with this procedure.
Factors that increase the likelihood of developing osteoporosis include:
- Being female
- Being thin or having a small frame
- Advanced age
- A family history of osteoporosis
- Being past menopause
- Abnormal absence of menstrual periods
- Anorexia or bulimia
- A diet low in calcium
- Long-term use of medications such as corticosteroids or anticonvulsants
- Lack of exercise
- Excessive use of alcohol
Bone tumors and metastatic bone disease also lead to vertebral compression fractures. Diseases such as multiple myeloma and hemangioma (types of tumors) place patients at great risk for these painful fractures. High doses of steroids for the control of auto-immune diseases such as lupus and rheumatoid arthritis, as well as asthma or chronic pulmonary disease can also increase the risk of reduced bone mass and resulting fractures.
Percutaneous vertebroplasty may be done either as an inpatient or outpatient procedure, depending upon the severity of the fracture and the health of the patient. After suitable sedation is given, a needle is placed into the affected vertebra and fills the damaged area with bone cement.
In many patients, the pain is lessened or even gone within 24 hours. There are few side effects or problems. In some cases, increased pain and fever may occur for a short time. This is treated with anti-inflammatory drugs.
Other risks to the patient include infection and allergic reactions to x-ray dye or other medications. There is a very small risk that the cement could leak into areas outside of the vertebra at the time of the procedure, causing spinal cord or nerve damage. If leakage occurs, surgery could be required and the patient could have permanent nerve and organ injury.
For proper and thorough treatment, review your current medical history with your physician. Your physician may ask you to modify your current medication schedule. Be sure to tell your physician if you are taking blood thinners or have a history of a bleeding disorder, or if you are allergic to any medications, or if you have an infection in any part of your body
Rest well the night before the procedure. It is routine for patients undergoing outpatient surgery to be asked not to eat the night before the procedure. Due to the sedative medications given during the procedure, you will probably be asked to arrange to have someone drive you to and from the medical facility.
If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will either be at clinic facility or hospital for approximately 2-3 hours for your procedure. You will need to bring a driver with you.
During the Procedure
It is standard procedure to have an IV needle placed in your arm, and to be given a light sedative. After you are in position on the operating table, your back will be numbed with a local anesthetic. Under x-ray guidance, your physician will place an access needle into your vertebral body. You may experience mild discomfort during this part of the procedure. When the cement is injected you will have recreation of your regular back pain.
After the procedure
You must lay flat after the procedure. You will need to follow-up in the clinic after five to ten days.
Keep the area clean and dry to help prevent skin infection. Do not do any heavy lifting for 3 months (i.e. nothing heavier than a carton of milk). After that, you can gradually increase your lifting to normal. Walking is encouraged and you can bend within the restrictions of your brace.
You may experience some muscle discomfort where the needles were placed. This may be treated with a mild pain reliever such as Tylenol. Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation. Depending on how you feel, you may resume normal activities and return to work the next day.
Benefits: Immediate Relief from Pain, Improved Quality of Life
Following vertebroplasty, most patients (>90%) find a marked improvement in their pain, improved mobility and other quality of life improvements. Within a few days, many patients are able to reduce their pain medications significantly and return to the normal daily activities that had been inhibited by their painful vertebral compression fractures. Most patients report sustained pain relief, even years later.
What are the risks of Vertebroplasty?
The risks are minimal and in fact, few complications have been reported involving less than five percent of cases. As with any procedure, there is a risk of significant complications. The most common side effects from the nerve root block can include (but are not limited to):
- Allergic reactions to medications
- Infection (occurs in less than 1 per 15,000 injections)
- Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
- Depigmentation (a whitening of the skin)
- Local fat atrophy (thinning of the skin)
- Destruction of a motor or sensory nerve in the path of the needle
- Bleeding, nerve injury, organ injury and death are rare but possible
- Cement leakage is possible. The cement used in vertebroplasty is in a liquid form and is squeezed into the fractured vertebra under high pressure. Some of the cement commonly leaks out of the vertebra, but this usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.
- Ongoing pain may occur. Many patients get nearly complete relief of symptoms from vertebroplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your doctor about treatments that can help control your pain.