Filling the vertebral body through the skin (percutaneous vertebroplasty)

Surgery may become necessary in case of a vertebral body collapse if other methods are not effective and there is a risk for condition deterioration. The type of the surgery depends on multiple factors, based on which the physician determines the method to be used.

What does a vertebral compression fracture mean?

The spine consists of vertebrae and intervertebral discs. The front part of the vertebra is called the vertebral body. A compression injury occurs when the vertebral body fractures and collapses. A cause of it is usually bone loss, and more rarely, it is tumoral involvement. Vertebrae with pathological or normal bone structures react differently to the forces; a vertebra with normal bone structure only fractures when it is affected by great forces, which will more likely cause compression on the nerve structures. A vertebral body with pathological bone structure will collapse on its own, and this process may occur due to minimal forces too.

The spine will get shorter, and it will bend forward due to the vertebral compression fracture. A forward leaning posture (kyphosis) will develop, which will overload the rest of the vertebral bodies, and this means that their fracture risk will increase. Additionally, the stability of the spine is disrupted at the affected level, and this will be the direct cause of the developing pain.

Which are the potential symptoms of a vertebral compression fracture?

• Intensive local pain, which decreases when lying down, and increases on loading.
• A structural disorder (spinal deformity), which enhances hunching.
• Breathing difficulties
• Loss of appetite
• Disturbed sleep
• Depression
• Vertebroplasty cannot be performed on its own if lower limb symptoms are present: pain, numbness, clumsiness, or weakness of the limbs, or if symptoms are radiating around the chest, and the abdomen.

Imaging studies which are used during investigation:

• Conventional X ray scan (in standing). This is the most suitable imaging study to comprehensively evaluate the spine, and to analyze the statical and morphological changes.
• Magnetic resonance imaging (MRI), which helps to accurately identify any edema, which may be present in the fractured vertebral body, i.e., whether this could be the cause of the pain. It is only worth it to use this surgical method on edematous i.e., recovering vertebral bodies.
• Computerized tomography (CT), which helps to analyze the state of the rear wall (from the spinal canal’s side) of the fractured vertebral body. It could be decided based on this, whether the surgery can be safely performed.
• Isotope scan, which may help to differentiate any tumoral metastases, if necessary.

What are the treatment options?

Basically, there are two types of treatment options available:

Non surgical (conservative) treatment:

Conservative treatment is used in all cases, when the patient’s ability to walk and load capacity are maintained, the pain can be well controlled by drugs and physical therapy treatments, the vertebra is not flattened and the spine is not significantly deformed, or when the stability of the spine could be restored by physiotherapy.

The aims of conservative treatment:

• Reducing pain.
• Restoring the stability of the spine, creating the muscle brace.
• Preventing spinal deformation.
• Pharmacological treatment of osteoporosis (bone loss), regular control of the results.

Conservative treatment methods

• Bed rest in the first few days of the treatment (3-4 days).
• Pharmacological treatment and other physical therapy, and alternative methods.
• A back brace or rigid brace may improve the stability and load capacity of the spine already in the early phase, it may help to return to the normal lifestyle, while decreasing the load on the fractured vertebra. It only makes sense to wear a rigid brace in the first 6 8 weeks. However, the experience of a practiced physician is that patients with osteoporosis rarely tolerate the tightness, warmth, and most of all, the weight of a back brace, so it often cannot be used.
• The patient may get a so called active back brace after 6 8 weeks that consists of metal support, which is adjusted to the spine that was straightened as possible, a belt with a hook and-loop fastener, which constricts the pelvis, and straps, which pull the shoulders to the metal plate that is adjusted to the spine.

In the long term:

• Changing the lifestyle: reducing (eliminating) alcohol consumption, and smoking, changing the eating habits, reducing the overweight, preventing stress, etc.
• Elimination of sleep disturbances, treatment of associated psychosomatic diseases (as early treatment and cure as possible for e.g., chronic gynecological, cardiovascular diseases).
• Restoring the mental resilience and mood.
• Increasing activity: performing regular physiotherapy, and gait exercises.

Surgery is necessary if improvement is not detected in terms of the pain despite the non surgical treatment with adequate quality and duration, or repeated X ray scans confirm the progressive morphological deformity of the fractured vertebra.

Surgical treatment:

The aims of the surgical intervention:

• Tissue biopsy taken from the collapsed vertebral body for a histopathological analysis in order to identify malignant tumors, or diseases affecting the hematopoietic organs.
• Stabilization of the fractured vertebra and providing immediate pain relief by this.
• Restoring the height of the collapsed vertebral body as much as possible.
• Correcting the spine deformity as much as possible (restoration of a straighter posture).

These result in a reduced risk for a new vertebral fracture, and the improvement of the quality of life.

Filling the vertebral body through the skin (percutaneous vertebroplasty) cannot be performed in the following cases:

• If the MRI scan confirms that the fracture has healed – In this case, there is no point in performing the surgery, and if the morphological deformity is associated with severe symptoms, an open corrective surgery can be performed.
• If the act of filling has technical (local) contraindications: e.g., the back wall of the vertebral body is not intact, the narrowing of the spinal canal is too large, and there is a risk that this surgery may increase that, etc.
• If the patient is unfit for anesthesia or surgery e.g., having poor general condition, hemophilia, or anemia, etc.

If the fractured vertebra is otherwise fit for the surgery, but signs of neurological compression, or the narrowing of the spinal canal are present. An open technique should be used in a case like this, if possible.

What happens in the operating room?

Multiple technical solutions are suitable to fill and stabilize the collapsed and fractured vertebral body through the skin (percutaneously). The type of the intervention is determined by the physician individually, and by each vertebra. The material that is used to fill up the fractured vertebral body could be polymethylmethacrylate bone cement, silicone “cement”, and materials which transform into bone tissue during recovery.

The aspects of selecting the material to be used: bone remodeling cannot be expected in older age and especially in case of chronic fractures, but the aim is the attainable primary stabilization of the fracture with taking the reduced load capacity of the porous bone into consideration.

What happens if the justified surgical treatment is not performed?

• The condition may lead to chronic pain syndrome, it could occur that the spine can be loaded for continually shorter periods of time with more and more pain, or that loading is not possible.
• The quality of life may deteriorate further.
• A surgery performed later may become more difficult technically, and its effectiveness may decrease.