How is percutaneous vertebroplasty performed?

Updated: Jul 29, 2020
  • Author: Jeffrey P Kochan, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
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Vertebroplasty is a straightforward radiologic procedure that is performed on an outpatient basis in most institutions. The procedure is not painful and requires only mild sedation and analgesia, as described above in the Anesthesia section.

Lumbar vertebroplasty consists of the transpedicular placement of an 11-gauge bone biopsy needle into the affected vertebra under fluoroscopic or CT guidance (see images below). Thoracic vertebroplasty is performed via a transpedicular or peripedicular route by using a 13-gauge bone biopsy needle. Access to cervical lesions is via an anterolateral approach with a 13-gauge bone biopsy needle. Once positioned, methylmethacrylate is injected through the needle into the abnormal vertebral body.

Transpedicular placement of a trocar in the anteri Transpedicular placement of a trocar in the anterior third of the fractured vertebral body.
Lateral radiograph of fractured vertebra shows the Lateral radiograph of fractured vertebra shows the initial placement of the trocar.
Injection of methylmethacrylate through the trocar Injection of methylmethacrylate through the trocar in anterior one third of the vertebral body.

The acrylic is then prepared under sterile conditions for injection. The dry, powdered polymer is mixed with barium and tantalum or tungsten, which makes the compound more visible during fluoroscopy. The polymer-metal admixture is then mixed with a liquid monomer of methylmethacrylate to a consistency similar to that of toothpaste. The acrylic cement is then injected with either a 1-mL Luer-Lok syringe or high-pressure torque handle syringe through the trocar. Injection is continued until complete opacification of the vertebral body is achieved or the first sign of extension into the epidural venous plexus appears. See image below.

In a vertebral hemangioma after vertebroplasty, th In a vertebral hemangioma after vertebroplasty, the venous channels are now filled with acrylic.

Opacification of the paraspinous veins is common. When opacification occurs, the injection of acrylic is suspended for approximately 1 minute to allow the cement to harden within the vein. Injection may then be resumed, and the acrylic follows a new path of lower resistance. Opacification of the vertebral body need not be complete for successful vertebroplasty. If the acrylic reaches both the superior and inferior endplates and extends across midline, approximately 80% of the load-bearing benefit of a completely opacified vertebral body is achieved. [11] See image below.

Two adjacent vertebral hemangiomas causing continu Two adjacent vertebral hemangiomas causing continuous back pain as seen by MRI (A) and CT (B, C, D). Fluoroscopic appearance prevertebroplasty (E, F) and postvertebroplasty (G, H). The patient's pain had abated by the end of the procedure.

A small amount of methylmethacrylate is retained on the bench as a control. After approximately 10 minutes, the cement solidifies and becomes harder than the native bone. Once the control sample has solidified, the patient can be safely transferred to a stretcher. After the procedure, the patient remains supine for 1 hour; then, he or she can be discharged. Postprocedural medications are limited to Flexeril for muscle spasm and Tylenol for incisional pain.

Although no cases of infection are reported in the literature, the use of antibiotics in this institution is routine. All patients are pretreated with either 1 g of Ancef or 500 mg of vancomycin. In addition, in severely immunosuppressed patients, as much as 1.2 g of tobramycin can be added to the acrylic admixture in an attempt to further minimize the risk of infection. Other institutions perform vertebroplasty without apparent adverse results. The author believes that the benefit of antibiotic therapy outweighs the potential risk.

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