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Vertebral body reconstruction:

Review and update on


vertebroplasty and kyphoplasty

A. Orlando Ortiz, MD, MBA, FACR

V
ertebroplasty is an invasive
spine procedure that involves
the injection of bone cement
under fluoroscopic or computed tomo-
graphic (CT) guidance into a vertebral
body that has been damaged as a result of
either an osteoporotic vertebral compres-
sion fracture or neoplastic infiltration.
Kyphoplasty, a derivative of vertebro-
plasty, entails the temporary placement
and subsequent inflation of balloon
tamps within the vertebral body prior to
cement deposition. Vertebroplasty was
first performed in 1984, while kypho-
plasty was first performed more than a The vast majority of osteoporotic ver- A primary goal of vertebral augmenta-
decade later in 1998.1-3 Both procedures tebral compression fractures occur tion, therefore, is to stabilize the frac-
have quickly become established as effi- within the thoracic and lumbar spine, tured vertebra, reinforcing the anterior
cacious treatments for patients experi- particularly at the thoracolumbar junc- column and any endplate fractures,
encing back pain related to osteoporotic tion. The fracture destabilizes the verte- thereby alleviating pain. Another pri-
or pathologic vertebral compression bral body, and macro- and micromotion mary goal is to try to restore, as much as
fractures.4 This article will not only at the fracture site causes pain. These possible, spinal alignment and function
review these procedures, but will also fractures impact on the normal biome- to the prefracture status by restoring the
discuss the rationale for the clinical util- chanical alignment of the spine by caus- vertebral body height, reducing angula-
ity of vertebral body augmentation or ing the patient’s center of gravity to tion at the fracture level, and minimizing
reconstruction, review the clinical expe- move forward and, thus, simultaneously kyphotic deformity. A secondary objec-
rience with vertebroplasty and kypho- creating a large anterior bending mo- tive of these procedures is to prevent
plasty, and discuss advances in the field ment.5 This alteration has significant further vertebral body height loss. Not
of vertebral body reconstruction. Finally, adverse sequelae in that it places addi- only is this associated with progressive
this article will emphasize the active role tional stress on the posterior paraspinal kyphosis, but it is also associated with
of the radiologist in the management of muscles and ligaments, predisposes to a fractures at adjacent levels. The odds
patients who present with vertebrogenic loss of balance, and places additional ratio for the development of new verte-
back pain, both prior to and after their stress on the anterior column such that bral compression fractures increases to
fractures have been treated. adjacent and other vertebrae are at risk 20.6 when the patient’s actual height
for compression. Longitudinal studies decreases >4 cm.7
Dr. Ortiz is a Professor and Chairman, have shown that in the absence of any With >700,000 osteoporotic verte-
Department of Radiology, Winthrop- treatment the subsequent fracture risk in bral compression fractures occurring
University Hospital, Mineola, NY. a patient with an osteoporotic vertebral each year in the United States alone, it
fracture is 20% within the first year.6 must be kept in mind that not all of

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VERTEBROPLASTY AND KYPHOPLASTY

A B C

FIGURE 1. An 86-year-old woman


presented with a recent history of
D E severe low back pain. (A) A lateral
radiograph of the lumbar spine shows
L1 and L2 vertebral compression
deformities (arrows). (B) A T1-
weighted sagittal MR image shows
hypointense signal throughout the L1
vertebral body and within the superior
endplate of the L2 vertebral body
(arrows). (C) A T2-weighted MR
image shows hyperintense signal
throughout the L1 vertebral body and
within the superior endplate of the L2
vertebral body (arrows). (D) Static
images with anterior and posterior
views during skeletal scintigraphy
show focal radiotracer uptake within
the L1 greater than within the L2 ver-
tebrae (arrows). (E) A lateral projec-
tion during fluoroscopic evaluation
confirms the presence of painful L1
and L2 vertebral bodies (arrow).

A these patients require an invasive treat-


B
ment.8 In fact, some of these patients are
not even aware that they have experi-
enced a fracture. The potential candidates
who could benefit from these procedures
are those patients who are symptomatic
and who have had an imaging study that
shows a fracture that is responsible for
their back pain symptoms.

Patient evaluation
FIGURE 2. A 67-year-old man with a 3-month history of persistent thoracic pain that radiates
to the right anterior rib cage. (A and B) Axial images from a contrast-enhanced CT of the chest
The role of imaging in the evaluation
show a lytic lesion within the posterior aspect of the vertebral body (T6) involving the right of a suspected vertebral compression
pedicle (arrows). fracture is extremely important in terms

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VERTEBROPLASTY AND KYPHOPLASTY

A B

FIGURE 4. Photograph of sawbones verte-


FIGURE 3. An 85-year-old woman with abdominal pain was initially suspected of having rup- bra model showing an 8-gauge bone needle
tured abdominal aorta aneurysm. (A) An unenhanced axial CT image through the upper inserted via a transpedicular approach
abdomen shows a normal-sized aorta with calcification. Mild paraspinal soft tissue swelling is (black arrow) through the posterior aspect of
identified (arrows). (B) A similar image in a bone window algorithm shows multiple fracture the pedicle. An alternative approach is to
lines (arrows) within the vertebral body. Subsequent evaluation confirmed the presence of a insert alongside the pedicle, or parapedicu-
painful vertebral compression fracture that responded to vertebral augmentation. lar (white arrow). The latter approach allows
for a more medial location of the needle tip.

A B

FIGURE 5. A 75-year-old woman with a painful L5 vertebral compression fracture. (A) Simultaneous biplane frontal and lateral fluoroscopic projec-
tions show bilateral needle insertion through a transpedicular approach. (B) The second part of a vertebroplasty procedure entails the careful injection
of radio-opaque acrylic bone cement (arrow) into the vertebral body. (C) Postvertebroplasty frontal and lateral projections show cement within the ver-
tebral body providing anterior column stabilization. The patient experienced immediate pain relief. (D) Photograph of cement delivery system, cement
polymer powder vial, and cement liquid monomer that were used in this case (courtesy of Advanced Biomaterial Systems, Chatham, NJ).

of patient selection. Many of these in the absence of prior studies, it might formities in their reports of patients who
patients initially undergo radiographic be difficult to distinguish an acute frac- undergo chest or abdominal radiographs.
evaluation. Plain radiographs can be ture in the presence of multiple vertebral It is quite possible that the vertebral com-
helpful, as they may quickly identify an compression deformities in the spinal pression deformity, unbeknownst to the
isolated fracture in a patient with acute axis. Several studies have commented on referring clinician, might be at least one
severe back pain (Figure 1). Neverthe- the underreporting of vertebral compres- cause of the patient’s clinical presenta-
less, plain radiographs are insensitive sion fractures on radiographic studies.9 tion. Alternatively, this might facilitate
and can miss acute fractures that have not Radiologists should comment on the further screening for osteoporosis, in the
yet resulted in height loss. Furthermore, presence of vertebral compression de- form of bone density testing, leading to

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VERTEBROPLASTY AND KYPHOPLASTY

reformations can be performed (Fig-


A B C D ure 2). The CT scan is also helpful in
identifying fracture lines, which may be
a potential route for cement extravasa-
tion through the vertebral endplate or
elsewhere. Vertebral endplate fractures
are a very common component of osteo-
porotic vertebral compression fractures
and may account for the increased rates
of intradiscal cement extravasation that
have been reported in the literature.11
Like plain radiographs, CT may also not
be able to identify an acute fracture.
Radiologists should always examine the
spine in bone window settings in
E F G patients who undergo chest or abdomen
CT examinations for unexplained
symptoms that may be related to spine
pathology (Figure 3). Skeletal scintigra-
phy can be used to identify acute or sub-
acute vertebral compression fractures.
These present as foci of increased
uptake on the static images (Figure 1).
Skeletal scintigraphy can be helpful in
the evaluation of patients with sus-
pected underlying malignancy.
A fluoroscopic study can be extremely
FIGURE 6. A 73-year-old woman with severe osteoporosis and prior radiation therapy for lung
cancer presented with acute upper-back pain. The patient had undergone prior T6 vertebral aug- useful in the evaluation of patients with
mentation with pain relief but was not able to initiate a recommended change in osteoporosis suspected painful vertebral compression
treatment. (A) A lateral projection from a kyphoplasty procedure shows a transpedicular needle fractures. This author evaluates all of his
insertion with the tip of a 10-gauge bone needle near the posterior vertebral body (arrow). (B) A patients with fluoroscopy as part of his
frontal radiograph shows the needle tip simultaneously approaching the medial margin of the
initial consultation in order to determine
pedicle (arrow) confirming a safe trajectory for this needle insertion. (C) A hand twist drill (arrow)
is used to create a working channel. (D) Inflation of the inflatable balloon tamp (arrow) with a con- if they meet the selection criteria for a
trast agent at 125 psi shows partial height restoration. (E) A radiolucent working cavity (arrow- vertebral augmentation procedure. The
heads) is seen following deflation of the balloon tamp. (F) Well-opacified acrylic bone cement is patient is placed in the lateral decubitus
carefully injected into the working cavity using a bone filler device (arrow). (G) A posttreatment position; the spinous processes of the
lateral fluoroscopic image shows vertebral body reconstruction with partial height restoration and
thoracic and lumbar spine as well as the
kyphosis correction as compared with the pretreatment lateral image.
sacral ala are palpated. Sites of pain
the initiation of osteoporosis treatment foci located adjacent to a compressed provocation are subsequently examined
for the patient and the prevention of addi- vertebral endplate. Additionally, MRI under fluoroscopy (Figure 1). The pa-
tional fractures. can assess for spinal canal compromise tient is then placed in the prone position,
Magnetic resonance imaging (MRI) by displaced fracture fragments and is and the examination is repeated. In gen-
is the most accurate examination that is capable of identifying other potential eral, if there is pain provocation at the
available when evaluating patients with pain sources such as disc herniations or level of the patient’s vertebral compres-
suspected vertebral compression frac- facet pathology. In many instances, MRI sion fracture, then that patient is a likely
tures.10 Acute and subacute fractures can can also be used to differentiate between candidate for vertebral augmentation.
be readily identified because of the pres- osteoporotic and pathologic vertebral Fluoroscopic evaluation is extremely
ence of marrow edema, which manifests compression fractures. sensitive in identifying painful vertebral
as hypointense signal on T1-weighted When MRI is contraindicated or can- compression fractures. The vertebral
images and hyperintense signal on not be tolerated by the patient, or when a compression deformity can also be fur-
T2-weighted and inversion recovery neoplastic process is suspected and there ther evaluated in terms of morphology,
sequences (Figure 1). Vertebral body is concern for the cortical integrity of height loss, presence or absence of cleft,
clefts, the result of avascular necrosis, the vertebral body, especially the poste- location in the vertebral column, and size
are seen as fluid and/or air-containing rior wall, a CT scan with multiplanar of pedicles. The visibility of the bony

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VERTEBROPLASTY AND KYPHOPLASTY

landmarks can also be quickly assessed


in patients with poor bone mineralization A B
and/or large body habitus. Lastly, fluo-
roscopy is able to dynamically evaluate
patients with fracture instability associ-
ated with endplate motion, a phenomena
that is sometimes seen in the thoracic
spine and is related to respiratory motion.
A couple of specific situations may con-
found this clinical fluoroscopic evalua-
tion. Patients who have recently taken
analgesics may not complain of pain. In FIGURE 7. An 86-year-old woman with painful L1 and L2 osteoporotic vertebral compression
fractures (the same patient as shown in Figure 1). (A) Frontal fluoroscopic image shows multi-
this situation, the examination can be
directional bone curette (arrow) used to create a working cavity in the anterior and median
repeated when the analgesics are with- aspect of the vertebral body. (B) The curette created a path of least resistance for subsequent
held for a brief period of time. Lastly, the balloon tamp inflation (arrow).
examination may be difficult in patients
suffering from dementia, but careful
evaluation in this clinical setting usually A B
identifies the symptomatic fracture.

Indications and contraindications


Vertebral augmentation procedures
such as vertebroplasty or kyphoplasty
are indicated for the treatment of pain
related to vertebral compression frac-
tures associated with osteoporosis, osteo-
necrosis, or osteolytic tumor infiltration C
(eg, multiple myeloma, metastasis).
Patients with symptomatic sacral insuffi- FIGURE 8. An 89-year-old woman with severe
ciency or pathologic fractures may also low back pain that is worse with sitting. Fluoro-
be candidates for vertebral augmentation scopic evaluation raised a concern for possible
(sacroplasty) of the sacrum or coccyx sacral insufficiency fracture. (A) An inversion
recovery coronal image of the sacrum shows
(coccygeoplasty).12,13 These invasive diffuse hyperintense signal comparable with
spine procedures are contraindicated in edema (arrows). (B) An axial CT image in a
patients who have uncorrected coagu- bone window algorithm shows acrylic bone cement being injected through 11-gauge bone needles
lopathy or pre-existing spine or systemic into bilateral fractures of the sacral alae (arrows). (C) Axial CT image in bone window algorithm fol-
infection, or in patients presenting with lowing sacroplasty shows cement deposition with the fracture planes of the sacral alae (arrows).
The patient experienced symptomatic improvement over the course of several days.
acute neurologic deficits related to the
fracture. In the United States, these pro- renal profiles. Informed consent is anesthetic agents. It is the hope of this
cedures are currently not indicated for obtained prior to the procedure. The author to dispense with the myth that
the treatment of nonpathologic, trau- major risks of both procedures are kyphoplasty is always performed under
matic vertebral fractures in young, non- extremely rare and well under 1% as general anesthesia. Each procedure can
osteoporotic patients. compared with the potential benefit of be performed on an outpatient or an inpa-
significant pain relief in >90% of prop- tient basis, depending upon the clinical
Patient preparation erly selected patients. situation. Whether or not a patient is pre-
Vertebroplasty and kyphoplasty medicated with antibiotics prior to the
share many similar features, yet do Technique procedure is at the clinician’s discretion.
have some significant differences. Both Vertebroplasty and kyphoplasty can It is very important that all vertebral
are invasive procedures and require that be performed using either general intra- augmentation procedures are per-
the patient receive nothing by mouth venous anesthesia or intravenous seda- formed using strict aseptic technique.
for at least 8 hours prior to the proce- tion and analgesia. In specific situations These procedures are performed with
dure. Laboratory parameters that are in which patient comorbidities prevent imaging guidance—usually a multidi-
often analyzed prior to the procedure the use of sedatives and analgesics, either rectional single or biplane fluoro-
include hematologic, coagulation, and procedure can be performed using local scope—but some operators prefer to

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VERTEBROPLASTY AND KYPHOPLASTY

perform them using CT or CT fluo-


A B roscopy. It is critical that the operator
has access to high-quality imaging
guidance so that key bony landmarks,
such as the spinous process, pedicle,
vertebral endplates, and posterior ver-
tebral body wall are clearly visible,
even in very osteopenic patients.
The patients are carefully placed in
the prone position, and every attempt is
made to bolster the patient so as to facili-
tate hyperextension at the level of the
vertebral compression fracture. This
maneuver has been reported to predis-
pose to height restoration even with ver-
tebroplasty.14 Both vertebroplasty and
kyphoplasty are performed using either
FIGURE 9. Endplate fractures. (A) A lateral fluoroscopic image obtained during balloon tamp
inflation shows a portion of the balloon herniating through a large inferior endplate defect a unilateral or bilateral approach, with
(arrows). (B) By using several small aliquots of thick cement, it was possible to seal this defect the goal being to reach the anterior and
(arrows) and reconstruct the endplate without extravasation into the disc space. paramedian aspect of the vertebral body.
Either procedure can be performed via
a transpedicular or parapedicular ap-
proach. The former approach is most
A B
commonly used, as it allows a relatively
safe passage of the bone needle into the
vertebral body (Figure 4).
Both procedures are performed with
bone needles. Vertebroplasty is often
performed with an 11- or 13-gauge bone
needle, whereas kyphoplasty can be per-
formed with a 10- or 8-gauge bone nee-
dle. When indicated, a bone biopsy can
FIGURE 10. Bone biopsy in a patient with prior be performed using either procedure, as
history of cancer. (A) A biopsy cannula (arrow) is either needle system is amenable to the
deployed coaxially through a working cannula in
order to obtain a biopsy specimen. (B) A close-up
coaxial insertion of a biopsy cannula.
photograph of biopsy specimen obtained from Vertebroplasty is performed in 2 steps:
this patient shows a very large bone core (arrow). bone needle placement and cement injec-
tion (Figure 5).15-17 Kyphoplasty is
performed in 3 steps: bone needle place-
ment, temporary placement of an inflat-
able balloon tamp, and cement injection
(Figure 6).2,18,19 Despite the additional
step, kyphoplasty does not take signifi-
cantly longer to perform than vertebro-
plasty. Many of the steps in the ky-
phoplasty procedure can be performed in
parallel by an assistant operator, thereby
reducing the procedure time. In our prac-
FIGURE 12. A 68-year-old woman with a painful tice, a single-level vertebroplasty takes an
L2 vertebral compression fracture. Frontal fluo- average of 20 to 30 minutes, and a single-
FIGURE 11. A 79-year-old woman with a roscopic image shows the stacked appearance level kyphoplasty takes an average of
painful L1 vertebral compression fracture. of sequentially injected wafers (small arrows)
This lateral fluoroscopic image shows an into the vertebral body through an introducer port
30 to 45 minutes to perform. The time
arcuate device (arrows) being used to cre- (large arrow) that was inserted via an extrapedic- factors are noted to emphasize proce-
ate a working cavity. ular approach. dural efficiency.

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A B C

D E

FIGURE 13. A 74-year-old woman with a painful L1 vertebral compression defor-


mity. (A) A T2-weighted sagittal MR image shows a partial vertebral deformity that
contains foci of low signal (due to gas) and high signal (due to fluid) (arrow) resulting
from avascular necrosis. (B) Lateral fluoroscopic image obtained during fluoro-
scopic evaluation 2 weeks later shows further height loss at L1 (arrow), with exten-
sive gas in the vertebral body. (C) An oblique fluoroscopic image shows bone
allograft material (arrows) that has been injected into the vertebral body with bone
filler tubes that are sequentially coaxially placed through a working cannula. (D) A
posttreatment lateral fluoroscopic image shows bone graft material within the verte-
bral body (outlined by arrows and arrowheads), elimination of intravertebral body
gas, and partial height restoration. (E) A lateral photograph of a sawbones model
shows acrylic mesh sac (arrows) that has been filled with bone allograft materal.

As each patient and each level are be introduced and used to remove foci of placed within the anterior and parame-
unique, treatments must be performed sclerotic bone or to facilitate the direc- dian aspect of the vertebral body, the bal-
safely with an emphasis on meticulous tion of balloon tamp inflation (Figure 7). loon tamp is gradually inflated, initially
needle placement techniques and imag- The balloon tamps are currently avail- to 50 psi and subsequently in 25 psi
ing monitoring, regardless of the amount able in 3 lengths (10-mm, 15-mm, and increments, using a pressure manometer
of time that is required to achieve this. 20-mm) and 3 styles (standard multi- and a low osmolar nonionic iodine con-
Additional types of equipment are avail- directional, unidirectional, and bidirec- trast agent. Endpoints for the termination
able with kyphoplasty that enable the tional). At present, the curette, 20-mm of balloon tamp inflation include height
creation of a working channel and work- balloon tamp, and uni- and bidirectional restoration and close proximity of the
ing cavity; these present an opportunity tamps can be used only with the 8-gauge balloon tamp to a cortical margin. Once
for vertebral body reconstruction. A bone needle system. The balloon tamps the balloon tamp is deflated, a working
manual twist drill can be used to create a are capable of sustaining high inflation cavity is created within the vertebral
working channel and can help in advanc- pressures (300 or 400 psi depending on body that will serve as the principal site
ing the bone needle. A bone curette can the size and style of the tamp). Once of cement deposition.

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VERTEBROPLASTY AND KYPHOPLASTY

A B C D

FIGURE 14. A 65-year-old woman with a history of myeloma and back pain. (A) A T1-weighted sagittal MR image shows the marrow replace-
ment process within a mildly compressed T8 vertebral body (arrow). (B) A lateral fluoroscopic image shows balloon tamps (arrow) that were
inflated in order to create room for the subsequent placement of a radiofrequency probe. (C) A lateral fluoroscopic image shows the coaxial
deployment of the radiofrequency probe within the vertebral body (arrows) for subsequent radiofrequency thermal ablation. (D) A lateral fluoro-
scopic image shows stabilization of the vertebral body with acrylic bone cement (arrow). During 2 years of follow-up, the patient has been pain
free and the T8 level has maintained a stable appearance.

The majority of vertebral augmenta- plunger is used to carefully extrude warrant a treatment with the shortest
tion procedures use acrylic bone cement into the anterior aspect of the procedure time. Vertebroplasty can be
cement—polymethylmethacrylate that working cavity. In general, the larger used throughout the entire spinal axis,
is impregnated with sterile barium sul- size of the bone filler cannula allows including the cervical spine, where the
fate (~30% wt/vol barium sulfate the operator to use a thicker or more first vertebroplasty was performed via a
added to polymethylmethacrylate viscous cement preparation, as com- transoral approach.1,12,13 Sacroplasty
powder) for adequate radio-opacifica- pared with the 11- or 13-gauge verte- entails the deposition of bone cement
tion.17 Several cement preparations are broplasty cannula. In both procedures, within sacral insufficiency fractures that
commercially available and offer rea- the goal is to deposit cement within the often involve the sacral alae (Figure 8).
sonable working times (defined as the vertebral body in order to stabilize the Small vertebrae and small pedicles
time from completion of cement mix- anterior column. It is not necessary, within the upper thoracic spine can be
ing of the polymer powder and a liquid and, in fact, may be disadvantageous, treated with this procedure. Patients
monomer to the time the cement has to attempt to fill the entire vertebral with acute vertebral compression frac-
hardened and cannot be injected) with body with bone cement. Biomechani- tures with minimal height loss are also
the cement product. cal studies have shown that only a candidates for vertebroplasty.
All cement injections should be per- small volume of cement (in the range It is challenging to control cement
formed with detailed imaging surveil- of 2.5 to 4.5 mL) is required in order to injection with vertebroplasty. Care must
lance in order to avoid cement restore vertebral body strength.17 The be taken to avoid or minimize cement
extravasation into critical areas such as endpoints for cement injection include extravasation. The cement injection will
the spinal canal or paraspinal veins. adequate filling of the anterior column tend to follow a path of least resistance
Cement injection with vertebroplasty portion of the involved vertebral body, and will go along fracture planes. It is not
is performed either with 1 mL syringes cement entering the basivertebral uncommon for the fracture planes to
or with a commercially available venous plexus, or cement extending extend to the vertebral endplate, hence
cement delivery system (a device with beyond a vertebral body cortical mar- this phenomenon may account for the fre-
a screw-in plunger that extrudes the gin in any direction. quent reports of intradiscal cement.11
cement from a reservoir through an Vertebroplasty and kyphoplasty each Minimizing intradiscal cement extravasa-
extension tube). In kyphoplasty, the have advantages and disadvantages. tion is important, as there is some evi-
cement preparation is placed into bone Vertebroplasty uses smaller-gauge bone dence that suggests a relationship be-
filler devices, which can be coaxially needles and can be used to quickly treat tween cement extravasation and new
introduced into the working cavity. A a patient whose medical condition may fractures at adjacent levels.20,21 The

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VERTEBROPLASTY AND KYPHOPLASTY

reported complications for vertebroplasty


and kyphoplasty include bleeding, infec- A B
tion, neural injury due to needle place-
ment or cement extravasation (including
radiculopathy and paralysis), fractures
(ribs, sternum, other vertebrae) due to
mishandling of fragile osteoporotic pa-
tients or altered biomechanics of a treated
vertebra, pulmonary cement embolism
due to venous extravasation of cement,
severe idiosyncratic reactions to the bone C
cement, and death.4 Fortunately, major
complications are extremely rare and, as
with many procedures, tend to occur less
frequently in the hands of experienced
operators. Predisposition to new vertebral D
fractures at adjacent vertebral body levels
is a potential complication of all vertebral
augmentation procedures. Retrospective
studies that have addressed the rates
of subsequent vertebral fractures show FIGURE 15. A 67-year-old man (the same patient as
a variable incidence of 12% to 52% at shown in Figure 2) with thoracic pain despite analgesic
1-year follow-up.22 This remains a diffi- and prior radiation therapy. (A) A T1-weighted axial
cult and controversial topic to analyze, as MR image shows a hypointense mass within the verte-
bral body and right pedicle (arrow). (B) A lateral fluoro-
it is difficult to control for the natural his-
scopic image shows the coaxial deployment of a
tory of patients with osteoporosis, whose coblation device (arrow) into the right side of the poste-
fracture risk significantly increases fol- rior vertebral body. (C) Frontal and lateral biplane fluo-
lowing their first fracture event, and roscopic images show bilateral balloon tamp inflation
where the fracture site tends to cluster at within the superior aspect of the T6 vertebral body
(arrows). (D) A lateral fluoroscopic image shows
the thoracolumbar junction, a known
cement within the vertebral body (arrow) and right
level of increased loading and biome- pedicle (arrowhead). At 3-week follow-up, the patient
chanical stress.4 Furthermore, it has been noted a partial reduction in his analgesic requirement.
observed that the subsequent fracture rate A biopsy at the time of the procedure established the
is greater in patients with steroid-related presence of metastatic lung adenocarcinoma.
osteoporosis, and some of the retrospec- augmentative procedure. The opportu- is that different measurement techniques
tive studies do not account for this cohort nity to restore the height of a compressed have been utilized, making it difficult to
nor do they stratify their patients accord- vertebra is possible with kypho- compare outcomes.27 Similarly, the stud-
ing to bone mineral density.23 plasty.19,24,25 Acute and subacute fractures, ies that show height restoration with ver-
Kyphoplasty is utilized at the thoracic within 6 months of fracture occurrence, tebroplasty do not provide a detailed
and lumbar spine levels. Acute and suba- have the greatest likelihood of being description of their hyperextension and
cute vertebral compression fractures with reduced with kyphoplasty.26 Height bolstering techniques, so that it is not
height loss can usually be treated with restoration has also been reported by a possible to reproduce this outcome in
kyphoplasty. The larger-gauge system few authors using the vertebroplasty pro- other procedure labs.14,27,28 Studies on
employed in the kyphoplasty procedure cedure.14 Since one of the objectives of cadaveric vertebral bodies, however, do
enables the use of multiple tools and kyphoplasty is height restoration, the show some evidence of height restora-
devices for the purposes of vertebral body procedure can be particularly helpful at tion, which was seen to a greater extent
augmentation (Figure 7). This instrumen- the thoracolumbar junction, where following kyphoplasty.29,30
tation does add incremental cost to the height loss is often associated with The vertebral endplate is often dam-
procedure. It might be difficult, if not kyphosis and a wedge deformity of the aged in a significant number of vertebral
impossible, to use these instruments via a fractured vertebra. Height restoration body compression fractures. This is seen
transpedicular route in the upper thoracic improves the alignment in this location either directly with avascular necrosis
spine and in patients with small pedicles. with a favorable impact on spine biome- that involves the endplate or as the
The potential to reconstruct the verte- chanics. The difficulty in evaluating the sequelae of an osteoporotic compression
bral body is a desirable endpoint for any scientific literature on height restoration fracture. The damaged endplate may

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A B C

FIGURE 16. A 75-year-old man with increasing back pain and


anorexia 10 days after L2 kyphoplasty. (A) A fluoroscopic image
of L2 (arrow) after the original procedure. (B) This follow-up T2-
weighted sagittal MR image shows increased signal within the L2
(arrow) and L3 (arrowhead) vertebrae as well as within the inter-
vening disc space. (C) A static frontal image from a gallium scan
at 48 hours following the procedure shows increased radiotracer
uptake within the lumbar spine (arrow) and adjacent soft tissues
(arrowhead), which is consistent with spine infection. The patient
refused biopsy and was treated empirically with antibiotics.

take on an angled configuration that is identifies large endplate defects; these cannula is too large to enter the pedicle.
associated with a kyphotic deformity. defects can be a site for cement leak but A small amount of acrylic bone cement
Correction of this endplate deformity can then be carefully sealed with thicker is then injected anterior and posterior to
with height restoration is possible with consistency cement (Figure 9). Another the implanted wafer stack (Figure 12).
balloon tamp inflation. This can help to advantage in kyphoplasty is the opportu- Other techniques have been used in an
reduce the kyphotic deformity that is nity for a greater specimen yield with the attempt to restore height to a com-
often observed at the level of the frac- larger biopsy cannula when performing pressed vertebra. One such modification
ture. Endplate defects are often seen in a biopsy (Figure 10). entails the transpedicular placement of
association with vertebral compression bone needles into the vertebral bodies
fractures. These defects are essentially Other vertebral augmentation that are located above and below the
fractures in the endplate. Endplate de- techniques compressed vertebra.31 During cement
fects can potentially generate pain as the Other tools and percutaneous tech- injection, the operator and his/her assis-
disc impinges on the damaged endplate niques have recently been developed to tants will push on the stabilizing needles
during motion; these defects are also a treat vertebral compression fractures. A in order to hyperextend the spine seg-
potential site of cement extravasation coaxial needle system with a side port ment at the fracture site in an attempt to
due to compromise of this barrier. Every and an arc-shaped insert that protrudes maximize height restoration. In this pro-
attempt should be made to keep cement for a variable distance beyond the nee- cedure, acrylic bone cement is injected
within the vertebral body. Controlled dle margin can be used to facilitate the not only into the compressed vertebra
cement delivery is readily achievable creation of a working cavity within the but also into the adjacent vertebrae.
with the kyphoplasty procedure by cre- vertebral body (Figure 11). Although In addition to tool innovations and
ating a working cavity for the initial this tool remodels the center of the ver- technique modifications, acrylic bone
deposition of thick cement. The use of tebral body, it does not significantly cement modifications and injectable
bone filler devices enables the applica- alter or reconstruct the cortical margins. agents other than acrylic bone cements
tion of thicker cement that is less prone A relatively new technique entails the have been developed for vertebral aug-
to extend beyond the vertebral body sequential stacking of special PEEK mentation.32 A hydraulic injection sys-
margins. A smaller-gauge version of wafers within the vertebral body in tem has been devised for the injection of
these bone filler devices is now available order to reinforce the vertebral body and thicker acrylic bone cement with the
for coaxial use with 10.5-gauge bone provide height restoration. This proce- objective of controlling cement deliv-
needles that are used with vertebro- dure is performed using a unilateral ery. A different cement preparation con-
plasty. Balloon tamp inflation often parapedicular approach, as the insertion sists of acrylic cement in conjunction

22 ■ APPLIED RADIOLOGY ©
www.appliedradiology.com December 2008
VERTEBROPLASTY AND KYPHOPLASTY

with a ceramic agent that requires an patients, so extreme care must be taken particularly on MRI. It is not uncom-
instantaneous mixing of 2 agents from to avoid a complication. Combined mon to see residual abnormal signal
2 syringes that are connected to a single therapies have also been used to treat within the vertebral body. This often
injection chamber. The mixing of these aggressive lesions of the spine, includ- represents the sequelae of healing and
2 agents within the injection chamber ing the use of radiofrequency ablation should not be interpreted as new or
and tube forms a composite cement that or coblation therapies prior to the unresolved pathology. Furthermore,
can be delivered in controlled aliquots, administration of acrylic bone cement bone cement is hypointense on all
as only what is mixed is what is deliv- (Figures 14 and 15). The objective of sequences and should not be misinter-
ered into the bone needle. these hybrid therapies is to reduce the preted as gas or sclerotic bone. There
Previously, several attempts to de- tumor volume and facilitate cement may also be slight progression of height
velop and use biologic materials instead injection for stabilization.35 loss following vertebral augmentation.
of acrylic bone cement for vertebral body In many patients, their postprocedure
augmentation have met with limited suc- Postprocedure Patient Management back pain is often related to weakened
cess. It is now possible to insert mor- Vertebral body reconstruction tech- paraspinal muscles that easily go into
selized particles of bone allograft into a niques are quickly evolving; neverthe- spasm, hence the rationale for physical
compressed vertebra utilizing a percuta- less, vertebroplasty and kyphoplasty therapy. Patients are also referred for
neous, unilateral, parapedicular approach remain established procedures for the physical therapy with an emphasis on
with a moderate-sized coaxial cannula treatment of painful vertebral compres- spine rehabilitation. The latter manage-
system.33 A shaper device creates a work- sion fractures. The care of the patient, ment should focus on both anterior and
ing cavity within the vertebral body, and however, does not stop once the proce- posterior core muscle conditioning and
a synthetic polymeric mesh sac is placed dure is completed. The patient’s underly- improvement in balance and gait.
within this cavity. Bone allograft is ing osteoporosis or neoplastic condition A large number of patients who pre-
sequentially tapped into the sac using must be fully characterized and subse- sent with painful osteoporotic vertebral
bone filler tubes that are coaxially placed quently managed. Furthermore, it is not compression fractures are not receiving
through the working cannula. This tech- uncommon for a patient who experi- adequate medical management for their
nology offers a few advantages, includ- ences pain relief after vertebral augmen- condition. The need for active osteoporo-
ing controlled delivery, use of a biologic tation to develop back pain that is related sis management in this patient popula-
material, and vertebral body reconstruc- to one or more nonvertebrogenic pain tion cannot be overemphasized.38,39 All of
tion with height restoration (Figure 13). generators in the spine. These patients these patients should undergo bone den-
This method, however, uses a large- perceive that their procedure has failed or sity testing to properly assess their bone
caliber access port that may not be suit- that they have a new fracture. mineralization status. Patients with clini-
able for use in the upper thoracic spine. For these reasons, it is our practice cally proven osteoporosis should receive
Moreover, the durability of the bone to see patients in follow-up at 3 weeks, appropriate treatment for this condition.
material over time will require further 3 months, and 12 months after their pro- It has been shown that there is a signifi-
study. Maximal pain relief reportedly cedure. Patients are assessed for degree cant reduction in fracture risk when
takes a couple of weeks with this tech- of pain relief and are further evaluated osteoporosis management is instituted.40
nique. Some operators are placing their for persistent pain or new severe pain. Thus familiarization not only with verte-
patients on short-term parathyroid hor- The patient is examined, under fluoro- bral body reconstruction techniques but
mone (teraparatide) therapy in order to scopic guidance if necessary, and their also with osteoporosis as a disease entity
improve bone healing and bone forma- outcome is clearly established. In cer- will facilitate the appropriate evaluation
tion at the treatment site. tain instances, further imaging with and management of patients with frac-
Vertebral augmentation is also used MRI, CT, or skeletal scintigraphy may tures that affect the axial skeleton.
to treat fractures and vertebral lesions be necessary in order to assess for a
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24 ■ APPLIED RADIOLOGY ©
www.appliedradiology.com December 2008