Anesthesiology

Percutaneous vertebroplasty

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What the Anesthesiologist Should Know before the Operative Procedure

Vertebroplasty is a percutaneous vertebral augmentation procedure that has grown over the last decade as an effective treatment for painful vertebral compression fractures (VCFs), often in the setting of advanced osteoporosis or metastatic tumor spread.

  • Reduces pain from VCF

  • Improves function and quality of life

  • May restore vertebral body height and correction of deformity

  • Low complication rate

  • Approximately 700,000 new VCFs occur in the United States each year.

    • Women are affected three times as often as men (15% versus 5% lifetime incidence)

    • Women: 25% of women age 75 and 50% of women age 80 have at least 1 vertebral compression fracture

  • It should be noted that 2/3 of vertebral compression fractures are asymptomatic.

  • Pain is the most common symptom of osteoporotic vertebral compression fractures (VCF).

    • Symptomatic patients often present with variable pain symptoms, but often with radiating thoracic pain consistent with the level of injury.

    • There is often no inciting event or history of trauma.

  • Diagnosis is made radiographically, with concordant pain.

    • The most common sites of fracture are at the thoracolumbar junction.

  • Back pain after a new VCF usually decreases in several months and can be treated conservatively with analgesics, rest and bracing.

  • Vertebral augmentation procedures (vertebroplasty and kyphoplasty) are indicated when there is evidence of an acute (>4-6 weeks) or subacute (< 6 months) vertebral body compression fracture with associated pain that does not respond to these conservative measures.

    • The fractures are most often due to osteoporosis or tumor involvement.

  • Vertebroplasty is a minimally invasive outpatient procedure in which the compression fractures are stabilized by the injection of bone cement, typically polymethyl methacrylate (PMMA).

    • Access to the vertebral body is typically achieved by passing a specialized needle under fluoroscopic guidance through the pedicles bilaterally

  • Balloon Kyphoplasty (BK) is a variation where orthopedic balloons are used to gently elevate the fractured vertebra in an attempt to return it to the correct position and to create a cavity that is subsequently filled with the bone cement.

    • Absolute contra-indications to vertebroplasty and kyphoplasty include asymptomatic stable fractures, clinically effective medical therapy, osteomyelitis or other local infection of target vertebra, uncorrected coagulation disorders, allergy to any required component, and local or systemic infection.

    • Relative contra-indications include radicular pain or radiculopathy caused by a compressive syndrome unrelated to vertebral body collapse, a retropulsed fragment with >20% spinal canal compromise, tumor extension into epidural space, severe vertebral body collapse (vertebra plana) and poor visualization with fluoroscopy.

  • Both vertebroplasty and kyphoplasty have consistently shown a significant improvement in post-procedure pain scores.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Because vertebroplasty is a procedure performed for improvement in pain, there is no defined urgency to the surgery.

However, should the symptomatic patient have neurologic compromise secondary to the compression fracture, a neurosurgical evaluation should be sought in a more urgent manner, depending on the degree of deficit.

In this setting, a more invasive decompression and internal stabilization procedure may be indicated.

Because vertebroplasty is an elective procedure for the management of pain, there is little risk in delaying the procedure for an adequate preoperative evaluation.

Because VCFs are most often secondary to advanced osteoporosis or malignancy, these patients often have comorbidities that warrant a thorough preoperative evaluation.

Symptoms can be managed in a conservative fashion with analgesics until the workup is completed.

However, a relative urgency for treatment often exists for alleviation of the painful symptoms, especially in the setting of metastatic cancer.

2. Preoperative evaluation

Because verterboplasty is often performed in patients with metastatic disease involving the spine, a thorough history should be taken to delineate the underlying cancer diagnosis, including systemic involvement and degree of compromise, as well as prior cancer treatments

Painful osteoporotic vertebral compression fractures occurs often in patients of advanced age, so that attention should be paid to history of age-related comorbidities, especially cardiopulmonary status.

Patients with advanced osteoporosis may also have scoliotic or kyphotic deformities, which could potentially compromise pulmonary function. One thoracic VCF may lead to enough sagittal kyphosis to reduce forced vital capacity by 9%.

Medically unstable conditions warranting further evaluation include:

  1. Malignancy affecting end-organ function

  2. Unstable coronary disease

  3. Uncontrolled hypertension

  4. Advanced pulmonary disease - obstructive or restrictive

  5. Coagulopathy

Delaying surgery may be indicated if:

  1. Malignancy is not well-defined or has significant end-organ involvement compromising function

  2. Underlying medical conditions are not controlled (uncorrected coagulopathy)

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation

Patients with vertebral compression fractures should be evaluated with a careful history and physical exam, in conjunction with radiographic studies. Because compression fractures can be asymptomatic, care should be taken to ensure the patient’s symptoms are concordant with the level of fracture.

A careful neurologic examination should be performed to diagnose any new or document underlying neurologic compromise.

Medication history should be reviewed especially in regards to opioid pain medications, anticoagulants and anti-platelet medications.

  • Review of patient’s comorbidities, with particular attention given to cardiopulmonary status and cancer history

  • Routine lab work – CBC with platelets, chemistry, coagulation studies

  • EKG – elderly patients or those with underlying cardiac risk factors

  • For patients with advanced scoliosis or kyphosis and secondary pulmonary disease, pulmonary function tests may be indicated if there is significant functional compromise

Perioperative Risk Reduction Strategies

Beta-blockers are generally continued throughout the perioperative period. Anticoagulants are generally held due to bleeding concerns; however sequential compression devices (SCDs) can be utilized throughout the procedure. (See discussion of NSAIDs and other medications below.) Antibiotics are administered preoperatively per the most recent Surgical Care Improvement Program (SCIP) guidelines.

b. Cardiovascular system

Acute/unstable conditions: Vertebroplasty is an elective procedure and should be delayed in the setting of an acute coronary syndrome or unstable cardiac condition.

Baseline coronary artery disease or cardiac dysfunction - Goals of management: Once assessed and determined to be optimized, care must be taken to maintain blood pressure and heart rate within 10-15% of the baseline ensuring that euvolemia is maintained.

  • Prone position may lead to pooling of blood in extremities and compression of the abdomen may decrease preload, cardiac output and blood pressure.

  • Patient may also be at risk of systemic cement or fatty embolism, potentially leading to hypotension, arrhythmia and cardiovascular collapse.

c. Pulmonary

COPD: The prone position may result in compression of the thorax and abdomen thereby decreasing total lung compliance and increasing work of breathing.

Reactive airway disease (Asthma): Care must be taken to ensure hypoxia and hypercube are avoided. If the procedure is performed under general anesthesia, the goal is to depress airway reflexes with anesthetic drugs during induction and maintenance.

d. Renal-GI:

Preoperative renal dysfunction should be noted to avoid fluid overload and medications that are eliminated by renal clearance.

e. Neurologic:

If patient has new neurological symptoms, then further neurological work-up should be performed to ensure that an urgent open procedure is not needed. Patients may have metastatic lesions to their brain and spine and intracranial pressure (ICP) and cerebral blood flow (CBF) should be maintained.

Acute issues: The procedure should be delayed for any acute neurological issues.

Chronic disease: Maintain ICP and CBF.

f. Endocrine:

Patients with cancer may have adrenal suppression due to chronic corticosteroid administration. Additionally, patients on chronic corticosteroids for other medical conditions may have osteoporosis and be at increased risk for VCF. Patients should be instructed to continue their basal regimen and/or supplemental corticosteroid should be administered when indicated.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. Musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Patients may have abnormal blood counts (anemia, leukopenia/leukocytosis, thrombocytopenia) due to their underlying disease and associated treatments.

Patients also may have coagulopathies due to nutritional deficiency, their underlying disease, or associated iatrogenic causes (anticoagulant medications).

Oncology patients and also those that have had limited ambulation secondary to pain, may be at increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE).

4. What are the patient's medications and how should they be managed in the perioperative period?

Many patients may be taking oral opioid pain medications.

Generally, at least 50% of the normal morning dose should be taken, especially if they are on around-the-clock dosing regimens and / or long-acting opioids.

Anticoagulant and antiplatelet medications (Clopidogrel) are generally held as per ASRA guidelines for neuraxial anesthesia.

Additionally, many practitioners will hold aspirin for 7 days and non-steroidal anti-inflammatory drugs (NSAIDS) for 2-3 days prior to the procedure.

Herbal medications that interfere with platelet aggregation or coagulation should generally be held (Vitamin E, fish oil, Garlic, Gingko-Biloba).

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Many patients will be taking opioid medications for their pain.

Given the generally advanced age and/or medical co-morbidities in the patients undergoing the procedure, they may be more sensitive and less tolerant to the side effects of these medications.

Also, patients often have significant pain relief shortly after the procedure and with less nociceptive input and may be more prone to the side effects if their medications are continued.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Antiplatelet and anticoagulant medications are generally held for the procedure to reduce the incidence of sequelae related to neuraxial bleeding and epidural hematoma. If these medications are indicated because of recent insertion of a drug-eluting coronary stent, then consultation with the patient's cardiologist is needed to determine the optimum perioperative management.

Pulmonary: patients should continue their chronic pulmonary medications.

Renal: continue

Neurologic: continue

Anti-platelet: generally held

Psychiatric: continue.

j. How To modify care for patients with known allergies -

Known allergies should be avoided. Generally, this most commonly would involve allergies to antibiotics, contrast dye and/or latex.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Latex-free conditions in the operating room should be ensured at all times in both the anesthesia delivery and in the surgical field.

l. Does the patient have any antibiotic allergies? (Common antibiotic allergies and alternative antibiotics)

Primary: Cefazolin 1 gram IV (2gram if >80kg)

Secondary (If allergic to penicillin or cephalosporin)

Clindamycin 600mg or Vancomycin 1 gram

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia:

  • Documented- avoid all trigger agents such as succinylcholine and inhalational agents:

  • Proposed general anesthetic plan: consider performing under regional and/or local with sedation.

  • Insure MH cart available:

  • [- MH protocol]

  • Family history or risk factors for MH: Avoid potential triggers.

  • Local anesthetics/ muscle relaxants: Muscle relaxants are not required for surgical conditions and can be avoided.

5. What laboratory tests should be obtained and has everything been reviewed?

CBC with platelets, PT/PTT/INR, basic metabolic profile and other laboratory tests as indicated based on underlying medical co-morbidities.

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Hemoglobin levels: May be low due to cancer and/or chemotherapy, or possibly high due to cancer and/or bone marrow stimulating agents

Electrolytes: Should be checked and corrected as indicated.

Coagulation panel: Generally want INR<1.5.

Imaging: MRI and/or CT to better visualize the affected levels.

Other tests: Assessing patient symptoms and underlying medical diagnosis as indicated.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Anesthetic options include local anesthesia, local anesthesia plus sedation, regional anesthesia (intrathecal) or general anesthesia. Often, the number of compression fractures being treated, the expected length of the procedure, the surgeon’s level of experience, and the patient’s status and comorbidities determine the choice of anesthetic.

  • An uncomplicated, single-level vertebral compression fracture can usually be treated in less than one hour, and may be very amenable to local anesthesia and sedation.

  • However, multilevel treatments can be prolonged, and may necessitate general anesthesia.

  • Additionally, balloon kyphoplasty typically involves placement of a larger trochar and additional pain assisted with the balloon inflation, often necessitating general anesthesia although successful treatment with both subarachnoid bupivacaine and local anesthesia and sedation have been reported.

Positioning:

  • For the procedure, patients are placed prone with the arms above the shoulders.

  • The OR table is generally not turned (head of patient towards anesthesiologist).

  • In cases where the compression fracture is in the thoracolumbar region, padding is placed under the chest and pelvis to optimize extension.

  • Biplanar fluoroscopy (or 2 c-arms) is often utilized further limiting visualization and access to the body of the patient.

a. Regional anesthesia

Generally, the procedure is performed with local anesthetic combined with monitored anesthetic care (MAC) or general anesthesia. There has been a case series reporting successful treatment under subarachnoid bupivacaine anesthesia, but often requiring supplemental IV sedation.

Neuraxial

  • Benefits-Avoidance of sedation/general anesthesia in the prone patient.

  • Drawbacks-May be challenging to monitor for neuraxial complications (from the vertebral augmentation procedure) post-procedurally and may not eliminate the need for sedation.

b. General Anesthesia

Benefits: GA is a good option when the procedure is expected to be prolonged, for example when multiple compression fractures will be treated. Advantages include possible improvement in optimal patient positioning, immobility, and control of the airway.

Drawbacks: Inherent risks of general anesthesia, particularly in patients with cardiopulmonary disease.

Other issues: Also, should complications occur, such as cement leak, patient’s neurologic status cannot be easily assessed.

Airway concerns: Because of prone positioning, there is a necessity for endotracheal intubation, and particular attention should be given to securing the endotracheal tube.

c. Monitored Anesthesia Care (MAC)

Benefits: MAC is an option for when the procedure is expected to be of shorter duration, for example in treatment of single-level compression fractures. Advantages include a faster recovery time, no need for endotracheal intubation or mechanical ventilation, and the ability to communicate with the patient, particularly in the event of a complication.

Drawbacks include patient discomfort in the prone position, the potential for patient movement during critical portions of the procedure, and less control over the airway.

Other issues: If airway difficulties arise, the procedure may need to be aborted due to difficulties achieving airway access in the prone position.

6. What is the author's preferred method of anesthesia technique and why?

Vertebroplasty: 1-Level, 1 hour or less or significant medical comorbidities (especially cardiopulmonary)

Local anesthesia with MAC. Generally the procedure is well tolerated and the patient can tolerate the trochar placement after localization of the planned tract. Supplemental IV analgesia is often required as the trochar enters through the periosteum and into the vertebral body. There is generally not a great amount of post-procedural discomfort and many patients are already seeing decreased pain at the time of discharge.

Vertebroplasty > 1 level, Kyphoplasty, > 1 hour, or patient unable to tolerate prone position

General anesthesia. There is additional pain associated with multi-level procedures and with kyphoplasty. There may also be pain associated with prolonged prone positioning especially in patients with metastatic cancer.

a. What prophylactic antibiotics should be administered?

  • Primary: Cefazolin 1 g (2gm if >80kg)

  • Secondary (penicillin/cephalosporin allergy or MRSA)

    • Clindamycin 600 mg

    • Vancomycin 1 g

    • Vancomycin 1 g + clindamycin 600 mg

b. The anesthesiologist should discuss with the surgeon the planned complexity of the case to gauge the estimated time and whether MAC or general anesthesia may be a better option for the patient.

c. Intraoperatively, the anesthesiologist should ensure that the spine of the patient doesn't move, especially during key portions such as trochar placement and augmentation (balloon inflation if applicable and injection of cement).

d. The most common intraoperative complications include ventilatory difficulties, hypotension, and allergic reaction.

Surgical complications include local cement leakage (23%-41% by CT scan with vertebroplasty; less with kyphoplasty), but only symptomatic in 4% of patients.

  • Other local complications include fractures to the pedicle or transverse process and also distant complications such as fractures of the ribs and sternum.

  • Intravenous cement leakage and subsequent pulmonary cement embolism is the most dangerous and potentially fatal complication.

    • In most cases, embolism was asymptomatic and noted on postoperative radiograph; however it has also been reported to cause immediate or delayed cardiorespiratory symptoms, cardiac arrest/acute respiratory distress syndrome (ARDS) and death.

  • One patient with a patent foramen ovale (PFO) experience paradoxical embolization into the middle cerebral artery resulting in persistent hemiparesis.

Procedure Technique

  • Position the patient prone with gel rolls to support torso and head rest on the fluoroscopy suitable OR table with partial extension. Use sequential images to localize the planned needle tract with a 22G spinal needle and then use sequential (bi-planar) images to direct an 11-gauge bone marrow biopsy needle into the vertebral body

    • Continue to advance with biplanar fluoroscopic images until the needle is in the anterior half of the vertebral body

  • Inject contrast under live fluoroscopy to ensure that the needle tip does not have a direct anastamosis with the epidural or central veins that could allow embolization.

  • Allow the cement mixture to polymerize until it has a paste-like consistency (~9minutes) necessary for controlled injection

  • Inject the cement

    • Continue fluoroscopic monitoring to prevent overfilling or extension into the spinal canal or neuroforamen

      • If central venous filling is noted, stop the injection for 60 seconds and slowly resume

      • If cement is observed within the posterior one-third of the vertebral body, or if epidural spread is suspected, stop the injection immediately.

  • Because significant cross-filling occurs in more than one-half of the vertebrae injected, often it is necessary to inject only one side of the vertebra.

  • Most patients can be discharged after an appropriate monitoring period.

  • Cardiac complications-Hypotension leading to arrhythmia, ischemia, heart failure or cardiacarrest. This may uncommonly be related to intravenous cement leakage andsubsequent pulmonary cement embolism

  • Pulmonary-Pulmonaryembolism resulting in bronchospasm, ARDS and death is a rare, butdreaded complication associated with vertebral augmentation procedures.

  • Neurologic:Intraoperative visual complications, nerve root/spinal cord injury fromlocal extravasation of cement, spine fracture from trochar placementand augmentation.

  • Uniqueto procedure: Intravenous cement leakage resulting in pulmonary embolismand potential for cardiopulmonary collapse and death.

a. Neurologic:

Unique to procedure: Local spread of cement damaging neuraxial structures or intravenous spread resulting in potential cardiopulmonary collapse and/or paradoxical brain embolism if patient has a PFO.

b. If the patient is intubated, are there any special criteria for extubation?

No. Standard extubation criteria are warranted.

c. Postoperative management

What analgesic modalities can I implement?

  • Generally opioids are the first line for treatment of post-procedural pain and discomfort.

  • Ice may be helpful over the area of the procedure, but heat should generally be avoided over the first 24 hours.

  • Anti-inflammatory medications such as acetaminophen and ibuprofen (or other NSAIDs) may be of some benefit.

  • For patients who are intolerant of the opioid medications, tramadol may be another therapeutic option.

What level bed acuity is appropriate?

  • Patients are generally discharged home or back to their current location from the PACU following the procedure.

What are common postoperative complications, and ways to prevent and treat them?

  • The procedure is not associated with common postoperative complications. The most common side effect of the procedure is post-procedurally pain that is often responsive to analgesic medications as outlined above.

What's the Evidence?

Cagli, S, Isik, HS, Zileli, M. "Vertebroplasty and kyphoplasty under local anesthesia: review of 91 patients". Turkish Neurosurgery. vol. 20. 2010. pp. 464-469.

Luginbuhl, M. "Percutaneous vertebroplasty, kyphoplasty and lordoplasty: implications for the anesthesiologist". Curr Opin Anaesthesiol. vol. 21. 2008. pp. 504-513.

Mohr, M, Pillich, D, Kirsch, M. "Percutaneous balloon kyphoplasty with the patient under intravenous analgesia and sedation: a feasibility study". Am J Neuroradiol. vol. 32. 2011. pp. 649-53.

Souvatzis, X, Katonis, P, Licoudis, S. "Subarachnoid anesthesia for kyphoplasty: is anesthesia adequate?". Anesth-Analg. vol. 111. 2010. pp. 238-240.

Fourney, DR, Schomer, DF, Nader, R. "Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients". J Neurosurg. vol. 98. 2003. pp. 21-30.

Klazen, CA, Lohle, PN, de Vries, J. "Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (VERTOS II): an open-label randomized trial". Lancet. vol. 376. 2010. pp. 1085-1092.

Taylor, RS, Taylor, RJ, Fritzell, P. "Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety". Spine. vol. 31. 2006. pp. 2747-55.

Wardlaw, D, Cummings, SR, Van Meirhaeghe, J. "Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): A randomized controlled trial". Lancet. vol. 373. 2009. pp. 1016-1024.

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