What are the contraindications to vertebroplasty?

Contraindications to Vertebroplasty

Absolute contraindications to vertebroplasty include severe coagulation disorders, general infection, infection at the puncture site, and neurological compression. 1

Absolute Contraindications

• Coagulopathy: Severe coagulation disorders present a significant risk of bleeding complications during the procedure
• Infection:
  • Active systemic infection
  • Local infection at the puncture site
  • Vertebral osteomyelitis
• Neurological compression: Spinal cord or nerve root compression requiring decompression
• Unstable fractures: Fractures with significant posterior wall involvement requiring surgical stabilization

Relative Contraindications

• Posterior wall involvement: Extensive involvement of the posterior wall of the vertebral body is not an absolute contraindication but requires an experienced team and should be systematically combined with radiation therapy 1
• Vertebral body collapse >70%: Severe vertebral collapse may limit the technical feasibility of the procedure
• Asymptomatic fractures: Vertebroplasty should not be performed in asymptomatic patients with less than 70% carotid stenosis that has remained stable over time 1
• Radiculopathy: Patients with radicular symptoms require careful evaluation before proceeding with vertebroplasty 2

Technical Considerations

• Proximity to neural structures: Nerve or spinal cord proximity is not strictly a contraindication as innovative techniques have been developed to protect these structures:

  • Hydro-dissection
  • Gas dissection
  • Balloon interposition 1

• Burst fractures: While traditionally considered a contraindication, recent evidence suggests vertebroplasty can be performed safely in osteoporotic burst fractures without neurologic deficit 3

Procedural Risks to Consider

1. Cement leakage: The most feared complication of vertebroplasty

   • Can result in metastatic epidural spinal cord compression (MESCC)
   • Nerve root compression
   • Pulmonary cement embolism (though symptomatic leakage is rare, <2%) 1

2. Acetabular procedures: Leakage of cement into the hip joint may result in significant functional impairment 1

3. Transient post-procedural pain: Can occur in some cases and should be anticipated 1

Special Patient Populations

• Cancer patients: While some contraindications have been challenged in cancer patients with severe pain unresponsive to other therapies, complication rates are significantly higher (39% vs 11%) when vertebroplasty is performed in contraindicated cases 4

• Patients on anticoagulants: Careful management of hemorrhagic risk is essential, and pre-operative embolization could be considered 1

• Osteoporotic patients: Most patients with osteoporotic vertebral compression fractures experience spontaneous resolution of pain within 6-8 weeks even without intervention 5

Alternative Approaches

When vertebroplasty is contraindicated, consider:

• Conservative management: Including physical therapy, education, exercise, and pain relief 5
• Radiation therapy: For metastatic lesions, especially those with neurological compromise 1
• Surgical decompression: For cases with significant neurological compression 1
• Alternative interventional techniques: Such as radiofrequency ablation, cryoablation, or electrochemotherapy for certain tumor types 1

Remember that vertebroplasty should only be considered if the patient has failed conservative therapy for 3 months, has refractory pain, and significant functional limitations persist 5.