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Percutaneous Vertebroplasty¹

¹ From the Department of Radiology, University of Virginia Health Sciences Center, PO Box 800170, Charlottesville, VA 22908. Received March 26, 2002; revision requested June 5; revision received September 26; accepted November 6. Address correspondence to M.E.J. (e-mail: mej4u@virginia.edu).

View larger version (101K): [in a new window]   Figure 1a. Images in an elderly woman with low back pain. (a) Lateral radiograph shows multiple lumbar compression fractures of indeterminate age. Clinical examination demonstrated nonfocal tenderness over the lower back. (b) Posteroanterior and oblique bone scan images show marked uptake at L1 (arrows). After treatment of this single vertebra, the patient’s pain was relieved.

View larger version (105K): [in a new window]   Figure 1b. Images in an elderly woman with low back pain. (a) Lateral radiograph shows multiple lumbar compression fractures of indeterminate age. Clinical examination demonstrated nonfocal tenderness over the lower back. (b) Posteroanterior and oblique bone scan images show marked uptake at L1 (arrows). After treatment of this single vertebra, the patient’s pain was relieved.

View larger version (83K): [in a new window]   Figure 2a. Images in a 50-year-old woman being treated with high-dose steroids who presented with worsening back pain. (a) Lateral radiograph shows multiple thoracic and lumbar compression fractures of indeterminate age. Sagittal (b) T1-weighted (750/12) and (c) turbo spin-echo T2-weighted (4,500/112) MR images show no evidence of edema to indicate a new fracture; however, (d) posteroanterior bone scan demonstrates intense radionuclide uptake at L3 (arrow). (e) Fluoroscopic spot image. After injection of polymethylmethacrylate (PMMA) (arrows), the patient noted marked relief of her pain.

View larger version (100K): [in a new window]   Figure 2b. Images in a 50-year-old woman being treated with high-dose steroids who presented with worsening back pain. (a) Lateral radiograph shows multiple thoracic and lumbar compression fractures of indeterminate age. Sagittal (b) T1-weighted (750/12) and (c) turbo spin-echo T2-weighted (4,500/112) MR images show no evidence of edema to indicate a new fracture; however, (d) posteroanterior bone scan demonstrates intense radionuclide uptake at L3 (arrow). (e) Fluoroscopic spot image. After injection of polymethylmethacrylate (PMMA) (arrows), the patient noted marked relief of her pain.

View larger version (98K): [in a new window]   Figure 2c. Images in a 50-year-old woman being treated with high-dose steroids who presented with worsening back pain. (a) Lateral radiograph shows multiple thoracic and lumbar compression fractures of indeterminate age. Sagittal (b) T1-weighted (750/12) and (c) turbo spin-echo T2-weighted (4,500/112) MR images show no evidence of edema to indicate a new fracture; however, (d) posteroanterior bone scan demonstrates intense radionuclide uptake at L3 (arrow). (e) Fluoroscopic spot image. After injection of polymethylmethacrylate (PMMA) (arrows), the patient noted marked relief of her pain.

View larger version (47K): [in a new window]   Figure 2d. Images in a 50-year-old woman being treated with high-dose steroids who presented with worsening back pain. (a) Lateral radiograph shows multiple thoracic and lumbar compression fractures of indeterminate age. Sagittal (b) T1-weighted (750/12) and (c) turbo spin-echo T2-weighted (4,500/112) MR images show no evidence of edema to indicate a new fracture; however, (d) posteroanterior bone scan demonstrates intense radionuclide uptake at L3 (arrow). (e) Fluoroscopic spot image. After injection of polymethylmethacrylate (PMMA) (arrows), the patient noted marked relief of her pain.

View larger version (139K): [in a new window]   Figure 2e. Images in a 50-year-old woman being treated with high-dose steroids who presented with worsening back pain. (a) Lateral radiograph shows multiple thoracic and lumbar compression fractures of indeterminate age. Sagittal (b) T1-weighted (750/12) and (c) turbo spin-echo T2-weighted (4,500/112) MR images show no evidence of edema to indicate a new fracture; however, (d) posteroanterior bone scan demonstrates intense radionuclide uptake at L3 (arrow). (e) Fluoroscopic spot image. After injection of polymethylmethacrylate (PMMA) (arrows), the patient noted marked relief of her pain.

View larger version (105K): [in a new window]   Figure 3a. Lateral radiographs in an elderly woman with acute low back pain. (a) Severe anterior wedge deformity of L2 during weight bearing is demonstrated, but restoration of height and pain relief occurred in the recumbent position. T2-weighted MR image (not shown) depicted a large intravertebral cavity, consistent with Kummell osteonecrosis. (b) After vertebroplasty, height restoration and vertebral stability are shown, with resolution of symptoms.

View larger version (115K): [in a new window]   Figure 3b. Lateral radiographs in an elderly woman with acute low back pain. (a) Severe anterior wedge deformity of L2 during weight bearing is demonstrated, but restoration of height and pain relief occurred in the recumbent position. T2-weighted MR image (not shown) depicted a large intravertebral cavity, consistent with Kummell osteonecrosis. (b) After vertebroplasty, height restoration and vertebral stability are shown, with resolution of symptoms.

View larger version (46K): [in a new window]   Figure 4. Needles suitable for vertebroplasty are supplied with a variety of stylets: A, single bevel; B, multibevel point; C, diamond point; D, threaded stylet. (Image courtesy of Parallax Medical.)

View larger version (75K): [in a new window]   Figure 5a. (a) Lateral radiograph shows initial trajectory (arrow) of the needle, which places the tip anteriorly at the midportion of the vertebral body. However, use of a beveled stylet, with bevel face pointing upward, deflects the tip downward. (b) Lateral radiograph shows that final position of the cannula approximates the anterior inferior corner of the vertebral body (arrow).

View larger version (80K): [in a new window]   Figure 5b. (a) Lateral radiograph shows initial trajectory (arrow) of the needle, which places the tip anteriorly at the midportion of the vertebral body. However, use of a beveled stylet, with bevel face pointing upward, deflects the tip downward. (b) Lateral radiograph shows that final position of the cannula approximates the anterior inferior corner of the vertebral body (arrow).

View larger version (155K): [in a new window]   Figure 6. Lateral radiograph shows curved stylet, which allows the operator to deposit PMMA precisely at superior (arrowheads) and inferior (arrows) endplates. The referring physician specifically requested that reinforcement of these locations be performed prior to a surgical procedure.

View larger version (127K): [in a new window]   Figure 7a. Prone intraosseous venograms obtained during (a) anteroposterior and (b) lateral injections of contrast material prior to vertebroplasty shows rapid filling of intraosseous venous complex followed by egress into paravertebral veins (PVV) and basivertebral plexus (BVP). Filling of inferior vena cava (IVC) demonstrates how cement migration into the venous system may result in pulmonary embolization.

View larger version (139K): [in a new window]   Figure 7b. Prone intraosseous venograms obtained during (a) anteroposterior and (b) lateral injections of contrast material prior to vertebroplasty shows rapid filling of intraosseous venous complex followed by egress into paravertebral veins (PVV) and basivertebral plexus (BVP). Filling of inferior vena cava (IVC) demonstrates how cement migration into the venous system may result in pulmonary embolization.

View larger version (111K): [in a new window]   Figure 8a. Multilevel vertebroplasty in a 60-year-old woman with steroid-dependent chronic obstructive pulmonary disease, who presented with severe midthoracic back pain unresponsive to narcotic analgesia. (a) Sagittal T1-weighted (750/12) MR image shows three adjacent thoracic compression fractures at T7, T8, and T9. (b) Lateral radiograph shows vertebroplasty of thoracic vertebrae. Patient’s pain resolved after vertebroplasty of all three levels. She returned 1 month later with new lumbar pain, and a new L4 fracture was treated. (c) Patient returned 1 month later with new fractures of L1 and L2, identified on sagittal T1-weighted (750/12) MR image, which were injected. Ultimately, she went on to fracture three more vertebral bodies.

View larger version (75K): [in a new window]   Figure 8b. Multilevel vertebroplasty in a 60-year-old woman with steroid-dependent chronic obstructive pulmonary disease, who presented with severe midthoracic back pain unresponsive to narcotic analgesia. (a) Sagittal T1-weighted (750/12) MR image shows three adjacent thoracic compression fractures at T7, T8, and T9. (b) Lateral radiograph shows vertebroplasty of thoracic vertebrae. Patient’s pain resolved after vertebroplasty of all three levels. She returned 1 month later with new lumbar pain, and a new L4 fracture was treated. (c) Patient returned 1 month later with new fractures of L1 and L2, identified on sagittal T1-weighted (750/12) MR image, which were injected. Ultimately, she went on to fracture three more vertebral bodies.

View larger version (97K): [in a new window]   Figure 8c. Multilevel vertebroplasty in a 60-year-old woman with steroid-dependent chronic obstructive pulmonary disease, who presented with severe midthoracic back pain unresponsive to narcotic analgesia. (a) Sagittal T1-weighted (750/12) MR image shows three adjacent thoracic compression fractures at T7, T8, and T9. (b) Lateral radiograph shows vertebroplasty of thoracic vertebrae. Patient’s pain resolved after vertebroplasty of all three levels. She returned 1 month later with new lumbar pain, and a new L4 fracture was treated. (c) Patient returned 1 month later with new fractures of L1 and L2, identified on sagittal T1-weighted (750/12) MR image, which were injected. Ultimately, she went on to fracture three more vertebral bodies.

View larger version (83K): [in a new window]   Figure 9a. Lateral radiographs in 35-year-old, obese, steroid-dependent woman with asthma who presented with severe lumbar pain. (a) Acute compression fractures of the superior endplate of L1 (upper arrows) and inferior endplate of L4 (lower arrows) are shown. After vertebroplasty, the patient returned to full activity, with relief of her pain; 2 weeks later, however, she was admitted for recurrent back pain. (b) Repeat radiograph shows new superior endplate fractures of L2 and L3 (arrowheads).

View larger version (78K): [in a new window]   Figure 9b. Lateral radiographs in 35-year-old, obese, steroid-dependent woman with asthma who presented with severe lumbar pain. (a) Acute compression fractures of the superior endplate of L1 (upper arrows) and inferior endplate of L4 (lower arrows) are shown. After vertebroplasty, the patient returned to full activity, with relief of her pain; 2 weeks later, however, she was admitted for recurrent back pain. (b) Repeat radiograph shows new superior endplate fractures of L2 and L3 (arrowheads).