What are the indications for vertebroplasty?
Percutaneous vertebroplasty is indicated primarily for the relief of pain related to vertebral compression fractures.  Most of the treated patients suffered from pathologic fractures related to osteoporosis.  However, vertebroplasty is also useful for relieving pain related to benign and malignant infiltrating vertebral lesions such as aneurysmal bone cysts, hemangioma, giant cell tumor, myeloma, or metastatic malignancy. In rare cases, vertebroplasty has been used for preoperative reinforcement of osteoporotic vertebrae prior to instrumentation.

What are the diagnostic requirements for evaluating indications?
Because of the frequency of multiple fractures in this population of patients, careful clinical and imaging correlation is required to determine the etiology and level of the patient's pain.  Findings on plain radiographs and MRI, particularly MR demonstration of edema within a fractured vertebral body, should correlate with the level of tenderness upon palpation of the spinous processes. MRI stir sequences are most useful for the depiction of edema.  A bone scan showing activity in the fracture is helpful for confirming the more recent fracture in a patient with multiple fractures over an extended period.

What is an Interventional Radiologist?
An Interventional Radiologist is a physician who uses x-rays, ultrasound, CT and MR to perform minimally invasive procedures designed to diagnose and/or treat medical conditions. For example, if an abnormality is seen on a CT scan, the best way to discover what it is would be to obtain a piece of it (biopsy). An Interventional Radiologist uses the CT scanner to guide a biopsy needle into the abnormality in order to obtain a biopsy. Another example is angiography (injecting dye into an artery). If a blocked artery is discovered during an angiogram, x-ray guidance can be used to direct a balloon through the blockage for angioplasty.

What equipment do is needed to perform this procedure?
Vertebroplasty should be performed under high quality imaging equipment such as an angio suite or CT Scan; digital imaging is superior to analog.  Bi-plane imaging facilitates the procedure, but is not required.  Portable C-arm units are acceptable; earlier versions of portable C-arms do not provide adequate imaging for safe injection of opacified cement.

Should this procedure be performed in the Operating Room?
Percutaneous vertebroplasty can be performed in the operating room using a high quality portable C-arm. General anesthesia is not necessary, and therefore the operating room forum may unnecessarily increase the expense of the procedure; mostly it is performed in the Interventional Radiology room.

Is the procedure performed in the hospital or outpatient surgery center?
The procedure is most often performed in the hospital; however vertebroplasty could be performed in an outpatient surgery center if adequate equipment were available.  This would include not only satisfactory imaging devices, but also state-of-the-art monitoring equipment for conscious sedation as well as resuscitation devices.

What cement is used?
Various polymethylmethacrylate cements have been used; however most physicians utilize a cement indicated for craniofacial defect repair mixed with commercially available Barium Sulfate to approximately a 30% barium mixture by weight. Adequate opacification must be achieved in order to perform the procedure safely.

What are the long-term effects of bone cement in the spine?
Polymethylmethacrylate has been used for over four decades as an orthopedic cement and the side effects have been studied. The strength of the bone cement and durability would be expected to outlast the native bone in elderly, osteoporotic patients. The long-term effects of bone cement in percutaneous vertebroplasty have been covered in numerous peer-reviewed journal articles. Refer to the Bibliography for more information

Do you recommend a venogram for cement injection?
A venogram is no longer recommended prior to cement injection. Experience has foundthat venography usually demonstrates rapid egress into venous structures. By mixing the cement to an appropriate thickness and by injecting in a controlled fashion, substantial filling of these veins can be avoided even without a prior venogram.  A venogram can also complicate the cement injection when contrast still remains in the vertebral body as it can erroneously be identified as opacified cement.

What published clinical outcome studies would you recommend?
More than 500 scientific papers have been published on vertebroplasty and can be located via Medline. The results of these studies suggest a remarkable benefit over conservative therapy. At least one randomized trial is underway to compare vertebroplasty to conservative treatment. Long-term studies also need to be performed to rule out the possibility of any long-term sequelae. Refer to the Bibliography to recent peer reviewed articles and other resources