Vertebroplasty is a surgical procedure that involves the injection of synthetic cement (e.g., polymethylmethacrylate [PMMA], bis-glycidal dimethacrylate [Cortoss]) into a fractured vertebra. It has been suggested that vertebroplasty may provide an analgesic effect through mechanical stabilization of a fractured or otherwise weakened vertebral body. However, other mechanisms of effect have been postulated, including thermal damage to intraosseous nerve fibers.
Sacroplasty evolved from the treatment of insufficiency fractures in the thoracic and lumbar vertebrae with vertebroplasty. The procedure, essentially identical to vertebroplasty, entails guided injection of PMMA through a needle inserted into the fracture zone. While first described in 2000 as a treatment for symptomatic sacral metastatic lesions, it is most often described as a minimally invasive alternative to conservative management for SIFs.
Percutaneous vertebroplasty may be considered medically necessary for:
Percutaneous vertebroplasty is considered investigational for all other indications, including use in acute vertebral fractures due to osteoporosis or trauma
Percutaneous sacroplasty is considered investigational for all indications, including use in sacral insufficiency fractures due to osteoporosis and spinal lesions due to metastatic malignancies or multiple myeloma
Practice Guidelines and Position Statements
American College of Radiology
The American College of Radiology (2018) revised its ACR Appropriateness Criteria for the use of percutaneous vertebral augmentation in the management of vertebral compression fractures. Table 15 shows the appropriateness categories for each variant.
Table 15. ACR Appropriateness Criteria for the use of Percutaneous Vertebral Augmentation for the Management of Vertebral Compression Fractures
|“New symptomatic compression fracture identified on radiographs or CT. No known malignancy.”||May Be Appropriate|
|“Osteoporotic compression fracture, with or without edema on MRI and no ‘red flags.’ With or without spinal deformity, worsening symptoms, or pulmonary dysfunction.”||Usually Appropriate|
|“Asymptomatic pathologic spinal fracture with or without edema on MRI.”||May Be Appropriate|
|“Pathologic spinal fracture with severe and worsening pain.”||Usually Appropriate|
|“Pathologic spinal fracture with spinal deformity or pulmonary dysfunction.”||Usually Appropriate|
CT: computed tomography; MRI: magnetic resonance imaging; ACR: American College of Radiology.
American College of Radiology et al
The American College of Radiology (2014) and 4 other medical specialty associations updated a 2012 joint position statement on percutaneous vertebral augmentation. The statement indicated that percutaneous vertebral augmentation with the use of vertebroplasty or kyphoplasty is a safe, efficacious, and durable procedure in appropriate individuals with symptomatic osteoporotic and neoplastic fractures, when performed in accordance with public standards. The document also stated that these procedures are offered only when nonoperative medical therapy has not provided adequate pain relief, or pain is significantly altering individuals’ quality of life.
Society for Interventional Radiology
The Society of Interventional Radiology (2014) issued a joint position statement with 7 other societies on percutaneous vertebral augmentation noting that “percutaneous vertebral augmentation (PVA) with the use of vertebroplasty and kyphoplasty is a safe, efficacious, and durable procedure in appropriate individuals with symptomatic osteoporotic and neoplastic fractures, when performed in a manner in accordance with published standards.” The society states that percutaneous vertebral augmentation should be “offered only when nonoperative medical therapy has not provided adequate pain relief or pain is significantly altering the individuals’s quality of life.” Finally, the society notes that “the benefits of PVA outweigh its risk and the risks of non-operative medical therapy, and the success rate in appropriately selected individuals is consistently high.”
In a quality improvement guideline from the Society for Interventional Radiology (2014), failure of medical therapy was defined as follows:
American Academy of Orthopaedic Surgeons
The AAOS (2010) approved practice guidelines on the treatment of osteoporotic spinal compression fractures. The AAOS approved a strong recommendation against the use of vertebroplasty for individuals who “present with an osteoporotic spinal compression fracture on imaging with correlating clinical signs and symptoms and who are neurologically intact.” With this recommendation, the AAOS expressed its confidence that future evidence is unlikely to overturn the existing evidence.
National Institute for Health and Care Excellence
The NICE (2003) concluded in its guidance on percutaneous vertebroplasty that the current evidence on the safety and efficacy of vertebroplasty for vertebral compression fractures appeared “adequate to support the use of this procedure” to “provide pain relief for people with severe painful osteoporosis with loss of height and/or compression fractures of the vertebral body….” The guidance also recommended that the procedure be limited to individuals whose pain is refractory to more conservative treatment. A NICE (2013) guidance indicated that percutaneous vertebroplasty and percutaneous balloon kyphoplasty “are recommended as options for treating osteoporotic vertebral compression fractures” in persons having “severe, ongoing pain after a recent, unhealed vertebral fracture despite optimal pain management” and whose “pain has been confirmed to be at the level of the fracture by physical examination and imaging.”
The NICE (2008) issued guidance on the diagnosis and management of adults with metastatic spinal cord compression. This guidance indicated that vertebroplasty or kyphoplasty should be considered for “individuals who have vertebral metastases and no evidence of MSCC [metastatic spinal cord compression] or spinal instability if they have: mechanical pain resistant to conventional pain management, or vertebral body collapse.”