Another Look at Major Complications with Vertebroplasty

Just about the time a surgical procedure becomes fairly standard and accepted as an effective treatment approach to a problem, someone steps in and takes a look back to see if, indeed, all is well. In this case series (seven patients), major and minor complications of vertebroplasty for vertebral compression fractures are reviewed. Vertebroplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery.

Surgeons hold the fragmented bone in place by squeezing special cement into the broken bone. The cement strengthens and stiffens the vertebra, which reduces pain considerably and helps the patient return to normal activities. Unlike open surgery, vertebroplasty is a minimally invasive procedure. It requires small openings in the skin and small instruments.

This percutaneous (through the skin) approach lessens the chance of bleeding, infection, and injury to muscles and tissues. The surgeon uses a special real-time X-ray called fluoroscopy to see inside the body and accurately guide the needle used to inject the vertebral body with the cement. More than 80 percent of patients get immediate relief of pain with this procedure.

Patients with osteoporosis (brittle bones) are prone to compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities. Vertebroplasty is a quick and easy way to address this problem but it's not without a few complications of its own.

As the authors show in this seven case series, problems can develop from cement leakage, puncture of the meninges, and splitting of the fractured vertebral bone. Cement leaking into the space for the spinal cord or spinal nerve root can cause severe back and/or leg pain, loss of motor function, weakness, and other neurologic problems including paralysis. Puncture of the arachnoid layer of the meninges, a lining that covers the brain and spinal cord can result in infection and inflammation of this area. This condition called arachnoiditis is the name for the type of inflammation that can happen any time the meninges is punctured, even for well-controlled medical procedures such as vertebroplasty.

Treatment is according to the underlying problem. In the case of cement leakage, the surgeon must go back in and carefully remove as much of the cement as possible without disrupting or damaging the nerve tissue in the process. Arachnoiditis and any other infection or inflammatory process can be treated with antibiotics, steroids, and antiinflammatory drugs. For those patients who suffered paralysis, the treatment can restore the patient to full function but sometimes permanent paralysis remains. That was the case in one of these seven patients.

The authors also noted that other studies have reported adverse reactions to the bone cement, sudden drop in blood pressure during the operation, punctured lung, blood clot or fragment of cement to the lungs, and injury to a blood vessel with subsequent hemorrhaging. Sometimes the already compromised vertebral bone fractures again and collapses even further. As noted in this study, paralysis affecting patients from the waist down called paraplegia and even death can occur.

This study includes photographs of CT scans and MRIs showing the cement leakage, arachnoiditis, and compression fractures. Successful restoration of the spine with an alternate procedure called kyphoplasty was shown for the patient with the split vertebral body. Kyphoplasty is similar to vertebroplasty but with an added benefit: before the cement is inserted into the fractured site, a needle is placed inside the bone and a balloon inflated in the collapsed area. Once the balloon restores the vertebral height, then the cement is injected into the balloon. Vertebroplasty by itself just fills in the cracks of the fracture, it doesn't balloon the bone back into place or reshape it.

In summary, these seven cases reflect only the rare complications with vertebroplasty. Of the more than 65,000 adults who have this procedure every year in the United States, only 0.5 per cent ever has any significant problems. When the procedure is performed by skilled surgeons, neurosurgeons, radiologists, or anesthesiologists, it is considered safe and effective. Quality of life is improved dramatically, which is why the procedure remains a popular treatment approach to vertebral fractures of all types, not just compression fractures in the aging population from osteoporosis.

The authors caution against using vertebroplasty (or kyphoplasty) in young patients who do not have positive neurologic findings (muscle weakness, motor impairment, paralysis). They advise surgeons to order CT scans before performing the procedure and the use of fluoroscopy during the procedure in order to limit (avoid) major complications.

Murat Cosa, MD, et al. The Major Complications of Transpedicular Vertebroplasty. In Journal of Neurosurgery: Spine. November 2009. Vol. 11. No. 5. Pp. 607-613.

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