Indications And Contraindications

Percutaneous vertebroplasty can be utilized in both osteo-porotic compression fractures as well as neoplastic involvement of the spine. This chapter is focused primarily on osteoporotic compression fractures. The primary indication for vertebroplasty is for treatment of painful, osteoporotic compression fractures that have not responded to medical therapy (3-22). However, the definition of "failed medical therapy" is in flux at the present time. When the procedure was initially introduced, most patients were treated with vertebroplasty only after a relatively prolonged course of failed medical therapy, on the order of 6 wk to several months. With the increased use of vertebroplasty, the definition of failed medical therapy varies substantially from institution to institution. Indeed, some practitioners will even treat acute fractures in some cases, particularly when patients are unresponsive to narcotic analgesics or have developed complications from immobilization, for example, pneumonia or thrombophlebitis (17,18,23,24). However, in most cases patients have been given a course of medical therapy including bedrest and analgesics for at least several weeks. Only patients who fail this treatment are considered classically indicative for vertebroplasty. Some practitioners have considered chronic fractures several months to years in duration as not appropriate for vertebroplasty. However, recent data suggest that even patients with pain for up to 12 mo may derive substantial benefit from vertebroplasty (25).

Retropulsion of bony fragments represents a relative contraindication to vertebroplasty (17,24). Concern in cases of retropulsed fragments arises not only from the fear that cement extravasation into the spinal canal might occur, but also that surgical decompression, if needed, would be compromised by the presence of cement in these fragments. The exact degree of "acceptable" retropulsion, measured as the percent area compromise of the spinal canal, must be customized to each patient. For example, retropulsion in the mid- and lower lumbar spine, below the level of the conus, would be considered less risky than that in the thoracic spine, where damage to the spinal cord would be more likely. When treating vertebrae with retropulsed fragments, placing the needle as far ventrally as possible is desirable. Cement deposition should be terminated when the material extends dorsally to the midportion of the vertebral body.

Severe fractures, on the order of 70% collapse or greater, are considered by some practitioners to be inappropriate for vertebroplasty. However, other investigators have achieved good pain relief even in cases of vertebra plana (26,27). Special technical considerations must be used in severe fractures. Even small errors in angle of approach may result in the needle tip residing in the adjacent disc space rather than the marrow. The needle tip should be placed as far lateral as possible, as most severe fractures demonstrate near total obliteration of the central aspect of the vertebral body. The bipedicular approach and small volumes of cement for each hemisphere are more likely to be used in these cases.

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