Management of Increased Pain Post-Vertebroplasty
When a patient develops increased pain after vertebroplasty, immediately obtain cross-sectional imaging (CT or MRI) to evaluate for cement leakage and institute appropriate management rapidly. 1
Immediate Assessment and Imaging
Urgent cross-sectional imaging is mandatory when clinical deterioration occurs post-vertebroplasty, as cement leakage is the primary concern and occurs in up to 72% of cases, though most are asymptomatic. 1, 2
Key Diagnostic Steps:
Perform CT or MRI emergently to identify cement extravasation into foraminal, epidural, or dural spaces, or paravertebral veins. 1, 3
Assess neurological function systematically: Document lower limb motor and sensory examination, looking specifically for new radiculopathy or myelopathy that would indicate neural compression from cement leakage. 1, 3
Monitor vital signs closely: Check for signs of pulmonary embolism (tachycardia, hypoxia, chest pain) if cement has leaked into the venous system. 3
Common Causes of Post-Vertebroplasty Pain
1. New Adjacent Level Fracture (Most Common)
New or sudden increase in back pain after initial improvement strongly suggests a new compression fracture at an adjacent vertebral level, which is not uncommon in the post-vertebroplasty population. 1
Obtain MRI with STIR or T2-weighted fat-saturated sequences to identify acute fractures showing hyperintense bone marrow signal. 1
Management: If a new acute fracture is confirmed and pain remains refractory to conservative therapy, repeat vertebroplasty at the new level is reasonable. 1
2. Cement Leakage Complications
Moderate complications include:
- Cement extravasation into foraminal or epidural space causing radiculopathy or nerve root compression. 3
- Intradiscal cement leakage (usually asymptomatic but can cause discogenic pain). 4
Severe complications include:
- Cement embolism to lungs, heart, or cerebral circulation (rare but life-threatening). 3
- Spinal cord compression from epidural cement (requires emergency surgical decompression). 3
Management approach:
- Symptomatic foraminal/epidural cement: Consider epidural steroid injections for radicular pain; surgical decompression if progressive neurological deficit develops. 3
- Pulmonary cement embolism: Most are asymptomatic; manage supportively with anticoagulation if symptomatic. 3
3. Transient Post-Procedural Pain
Temporary increase in pain is classified as a mild complication and typically resolves within days with conservative management. 3
Manage with: Adequate analgesia (opioids if needed), bed rest for 24-48 hours, and reassurance. 1, 5
Post-Procedure Management Protocol
Immediate Post-Procedure (First 24-48 Hours):
Bed rest with regular monitoring: Assess vital signs and neurological function at regular intervals. 1
Supervised ambulation after appropriate observation period (typically same-day discharge or overnight observation). 1, 6
Pain assessment: Most patients (76%) will require continued analgesia initially, though 24% can discontinue pain medications within 24 hours. 7
Follow-Up Care:
Near-term follow-up is mandatory: Assess pain levels, mobility, and analgesic requirements. 1
Patient education: Counsel patients to immediately report sudden increase in back pain or new back pain, as this indicates possible new fracture. 1
Initiate osteoporosis treatment: Prevention of future fractures with appropriate medical therapy (bisphosphonates, denosumab, teriparatide) is particularly important given high risk of repeat fractures. 1
Red Flags Requiring Emergency Intervention
Progressive neurological deficit: New or worsening lower extremity weakness, sensory loss, or bowel/bladder dysfunction requires emergency imaging and possible surgical decompression. 1, 3
Respiratory distress: Tachypnea, hypoxia, or chest pain suggests pulmonary cement embolism. 3
Severe uncontrolled pain: Despite adequate analgesia, suggests significant complication requiring imaging. 1