It used to be that if an elderly patient developed a vertebral compression fracture, his life was effectively over. He'd have to spend months in bed on pain medications as he recovered from the injury. During his convalescence, he'd get weaker and more dependent on others for daily care. The end result would likely have been a reduced lifespan.

Thanks to vertebroplasty and kyphoplasty, however, we can spare our patients this fate. With an injection that takes only a little more training and equipment than what's usually offered in orthopedic operating rooms, you can dramatically improve the quality of life of patients with VCF in a matter of moments. So whether you're interested in helping a large patient population or considering adding new procedures to your facility's repertoire, here's what you should know about vertebroplasty and kyphoplasty.

Target population
The ideal candidate for vertebroplasty and kyphoplasty is someone with osteoporosis who has suffered a recent VCF. That population includes about 700,000 patients a year. VCFs can result from trauma but can also occur in the osteoporotic spine from bending, lifting or no apparent cause. This injury is associated with pain and disability and, after two or three fractures, significant loss of vital (respiratory) capacity and a significant increase in mortality compared to age-matched controls without fractures.

Younger patients can be treated with reduced activity or an external lumbar support (back brace), and after about six weeks of rest they're ready for rehabilitation. In the elderly patient, however, the pain and disability from an osteoporotic VCF can last for six months or longer. Orthopedists and neurosurgeons are reluctant to instrument the osteoporotic spine because pedicle screws may not hold in the spine's soft bones.

Vertebroplasty and kyphoplasty patients are therefore typically older with osteoporosis and a VCF between the third thoracic and fifth lumbar vertebrae, where both procedures have been proven to be safe and effective techniques. The only relative contraindication is cord impingement, where a fracture fragment is pushed back toward the spinal cord. Because of the potential for cord injury if the fragment is pushed back further by the treatment, we generally don't consider such patients to be appropriate candidates for either procedure. Fortunately, this contraindication exists only in a minority of patients. In addition, vertebroplasty and kyphoplasty aren't indicated for use in non-osteoporotic bone.

To perform vertebroplasty, we use two needles to inject methyl methacrylate cement, the substance used to hold artificial joints, into the collapsed vertebra. The procedure alleviates the pain associated with the fracture within minutes to hours post-op and lets patients resume their former level of activity and independence. Kyphoplasty involves the placement of balloon catheters through the cannulas in the vertebral body to create a cavity in the bone. The cement is injected into the cavity when the balloon is deflated and removed.

The procedures are simple enough to be done in a surgery center with the equipment to offer injections for orthopedic procedures. With some specialized training and competency with fluoroscopic guidance, an orthopedist, neurosurgeon, interventional radiologist, anesthesiologist or pain management specialist who offers epidural injections can easily learn the techniques.

The equipment for the procedures is available in kits from manufacturers for around $3,500. The big startup expense comes from the imaging equipment. You can't do these cases with a single, simple C-arm. You need equipment that will give you both vertical and horizontal views of the procedure so you can track the exact position of the needles as they enter the spinal column. To accomplish this, you can either set up two portable C-arms or use the dedicated rotating C-arms found in most interventional radiology suites.

Some of the companies that manufacture kits for the procedures offer staff training. One manufacturer goes further by providing cadaver and laboratory training and technical assistance during cases. As for the rest of the staff, the operator will need a scrubbed assistant and a circulator trained in the preparation of the methyl methacrylate cement.

Having excellent fluoroscopic imaging is essential to a successful performance of these procedures, especially when you consider the potential complications. Not only must we have certainty the needle is appropriately positioned, but good visualization of the cement is crucial to avoiding misplacement since we're injecting the methyl methacrylate into the vertebral body. Inadvertent extravasation of cement into the adjacent disk space, the venous plexus or even into the spinal canal has been reported. Inform prospective patients of the risk of neurologic injury, including paralysis from the procedure, even though this risk is less than one percent.

You can perform these procedures with conscious sedation in the majority of patients. Treatment of a single vertebral body fracture takes 30 to 45 minutes. We treat up to three fractures at a time, which could take up to an hour and a half. About 5 percent of patients will require endotracheal intubation and general anesthesia because of respiratory compromise occurring when they lie prone. These cases usually involve patients with severe chronic obstructive lung disease.

We keep our patients for about two to three hours post-procedure and ambulate them when their conscious sedation wears off. Patients usually report a marked decrease in their back pain before they leave our facility. In follow-up visits, most patients report a significant decrease in their requirement for narcotics for post-op pain control.

No reason not to
From a clinical perspective, there's no reason not to be offering vertebroplasty if you already have the imaging equipment at your center. But from a business perspective, keep in mind that the market has already taken off. Many facilities currently offer this procedure, so unless there's a large underserved population in your area, there's not much of a competitive edge in hosting vertebroplasty. Kyphoplasty, in contrast, is still novel enough to make your center attractive (see "The Advantages of Kyphoplasty" on page 32).

Exactly how much you'll be reimbursed for these procedures varies widely by Medicare reimbursement rates in your area and the contracts you have with vendors and other services. But with the right arrangements they can be profitable. As a physician, I've always found it rewarding when I encounter a patient after the procedure and they tell me how vertebroplasty or kyphoplasty has let them get back to their previous level of activity and function without pain.