Patient Selection

Ideal candidates for percutaneous vertebroplasty (PV) or percutaneous kyphoplasty (PK) have mostly activity-related axial pain corresponding to the level of a recent compression fracture. This pain lessens or disappears completely with recumbency and/or sitting still. Many clinicians use tenderness over the appropriate level as an indication for PV or PK, although recently researchers analyzed a series of 90 patients undergoing PV and found 10 who had experienced no tenderness preoperatively.

Subgroup analysis in that group of 10 patients revealed excellent outcomes; thus, these authors argue for a careful evaluation of the patient's history, MR imaging findings, plus possible bone scan findings, but not for making pain on palpation a necessary condition for PV. A complete neurological examination and evaluation of recent radiographic studies is mandatory. The MR image will demonstrate an increased T2signal due to bone edema at the level of a recent fracture. Bone scans have also been used to target the most recent break(s) in patients with multiple fractures. Spinal cord compression on MR images (in the absence of neurological findings) is a relative contraindication.

If on MR images there is a suspicion of a posterior cortical fracture, a computerized tomography scan will reveal more details of the bone architecture. Plain spine x-ray films may help give an idea of pedicle anatomy to aid in planning the procedure, that is, small pedicles may favor PV with a smaller needle instead of the larger trochar used with PK.

Before the procedure is performed, all anticoagulant regimens should be discontinued and the patient's coagulation profile should be normal. The platelet count should be at least 100,000 at the time of the procedure. Sepsis is a contraindication, as is active infection. Researchers recommend waiting at least 2 weeks after treatment of an infection to minimize infectious risks.

Informed consent should include information about the following possibilities: lack of pain relief, osteomyelitis, fracture of the vertebra or pedicle, extravasation of cement into the spinal canal or neural foramen, paralysis or nerve root damage, and venous embolism. Also, the need for open surgery should be discussed with the patient.

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