Surgical interventions
Surgical interventions may be required to treat fractures, stabilise areas of bone before radiotherapy and those that are in danger of fracturing. In many cases, an orthopaedic opinion should be sought to determine whether prophylactic surgical intervention is required. Procedures of this type may include intramedullary rod placement or pins and screws may be used to surgically fix the bone.
Two additional procedures, Percutaneous Vertebroplasty and Balloon Kyphoplasty are also used to treat vertebral compression fractures.
Both involve minimally invasive procedures to repair and stabilise fractured vertebrae with the aim of improving mobility and relieving pain but are limited to patients for whom more conservative intervention has not been effective. The decision to undergo Percutaneous Vertebroplasty or Balloon Kyphoplasty should be made jointly by the multidisciplinary team.
Percutaneous Vertebroplasty
Percutaneous Vertebroplasty involves the injection of polymer bone cement under contrast-guided imaging with CT or CT fluoroscopy into one or more collapsed vertebrae. The aim is to stabilise and strengthen the damaged vertebra(e) and in doing so, rapidly relieve pain and enhance mobility.
The procedure is usually performed by either an interventional radiologist or spinal surgeon under local or general anaesthetic with patients coming into outpatients or day bed unit. Following the procedure, most patients are discharged within a few hours.
A number of vertebrae can be injected at one time. On average, Percutaneous Vertebroplasty takes about an hour for each vertebra injected. Recovery from the procedure is usually rapid, with most patients able to resume normal activities within a few days. Complications are rare but patients should be aware of the requirement to avoid strenuous activity for six weeks.
Balloon Kyphoplasty
Balloon Kyphoplasty is a similar procedure to Percutaneous Vertebroplasty but in addition to stabilising, aims to reshape and restore the height of the damaged vertebra to help reduce kyphosis. This is achieved by inserting a balloon (inflatable bone tamp) into the fractured vertebra and inflating it before the cement is inserted (see Figure 5).
Like Percutaneous Vertebroplasty, Balloon Kyphoplasty can be performed under general or local anaesthetic with each vertebra taking approximately an hour.
It is important to note that Percutaneous Vertebroplasty and Balloon Kyphoplasty are not interchangeable and are indicated for different clinical situations. In general, the procedures are limited to patients who have not responded to more conservative treatments and depend on the location of the pain, the nature of the fracture and the time elapsed since the fracture occurred.
The following criteria apply to both procedures when selecting patients:
- Conventional treatment for relieving bone pain such as analgesia and radiotherapy must be tried first
- Pain must have persisted for more than two months following conventional treatment
- Other causes of pain must be excluded
- Not applicable for severely compressed vertebrae
- Vertebral collapse must have taken place within the last 12 months
- Patients with other conditions may not be eligible e.g. if collapsed vertebra is causing neurological problems, or if patient has a bleeding disorder
Recommendations on the use of Percutaneous Vertebroplasty and Balloon Kyphoplasty are available from The Institute of Health and Care Excellence (NICE) (www.nice.org.uk).