AOSpine Masters Series, Volume 8: Back Pain by Luiz Roberto Gomes Vialle

Author:Luiz Roberto Gomes Vialle
Language: eng
Format: epub
Publisher: Thieme Medical Publishing Inc.
Published: 2016-01-27T05:00:00+00:00

Vertebral Compression Fractures

In recent years different options have been proposed to treat vertebral compression fractures in elderly patients, but these different methodologies have engendered controversy. Several techniques have been developed to augment compressed vertebrae as a consequence of osteoporotic fractures (Fig. 9.8). The simplest is the so-called vertebroplasty, in which transpedicular injection of cement into a fractured vertebral body can stabilize it. However, this technique cannot reduce a fracture, except by positioning of the patient. This treatment entails several risks involved, and there has been considerable debate in randomized clinical trials about whether surgical augmentation is preferable to conservative treatment of these fractures.41,42

The major risk of this treatment is cement leak, most relevantly into the spinal canal through the posterior wall. Cement leak can also occur to the side or to the front, which is less problematic if it is only a small amount of cement. The second relevant risk is that cement can enter the venous sinuses of the vertebral body, and from there enter the venous system, causing cement thrombosis or embolism in the lung.43 Significant progress in cement technology has reduced these risks.

Vertebroplasty entails placing the working tubes through the pedicle into the vertebral body. There is a risk that the tubes inadvertently might be placed into the spinal canal or outside the pedicle and into the lateral paravertebral area, causing vascular damage. However, just as in pedicle screw placement, today's X-ray technology has made the percutaneous placement of a cannula into a pedicle a standard procedure, and so performing this procedure should not be a problem if the technique guidelines are followed.

The pedicle projection must be visualized carefully in the AP view, and the guiding Kirschner wire (K-wire) must be placed so that it projects completely within the oval contour of the pedicle in the frontal plane. The K-wire is slightly convergent toward the midline, and it can cross the inner wall of the pedicle projection contour when the K-wire tip is already in the vertebral body in the lateral view. Therefore, it is important to observe the forward drilling K-wire in the pedicle projection in the AP view by quickly checking the lateral view for each step, to follow the progress of the tip in the depths of the vertebral body. A Jamshidi needle can be used instead of the K-wire, which saves a step in the procedure.

Once the K-wire is placed, the Jamshidi needle or an analogue instrument like the working tube can be introduced over the K-wire and progressed into the vertebral body. When the working cannula is positioned properly in the posterior third of the vertebral body, the vertebral body can be drilled to prepare a seat for the balloon catheter or the cement applicator (in a simple vertebroplasty). Through this working channel, biopsies can also be taken. In cases of an additional kyphoplasty, the balloon catheter can be driven into the working cannula and placed in the prepared seat in the vertebral body. The same is true for the balloon catheter,

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