As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body. PVP is an established interventional technique in which bone cement is injected under local anaesthesia via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines, increased mobility with improved quality of life and early return to work in days.

In this era of minimally access surgery replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression fracture spine.

Morbidity & consequences of spinal fracture:

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory & GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc element
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Results / Outcome

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral.
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Percutaneous Vertebroplasty (PVP) is an emerging interventional technique in which surgical polymethyl methacrylate bone cement is injected under local anaesthesia via a large bore needle into a vertebral body (VB) under imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work. Started in 1984 by Galibert PVP is done in host of indications.

Senile osteoporotic compression remains the commonest Indication. Other indications are Metastatic VB, Multiple myeloma VB, VB haemangioma, Vertebral osteonecrosis & for strengthening VB before major spinal surgery. The benefit has been extended to the traumatic stable uncomplicated VB compression (VCF) which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

Discovering the fact that VB is the commonest of body, its incidence >the hip, it becomes imperative to take it more seriously. With increasing life-span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and post menopausal osteoporosis. Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest.

Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression.

Morbidity & consequenses of spinal 

Traumatic VB is a painful condition requiring bed rest restricting daily activities markedly.
Left untreated it can cause DVT, increase osteoporosis, loss of VB height, respiratory &
GI disturbances, emotional & social problems secondary to unremitting pain, loss of independence with high cost of rehabilitation.
High risk of primary or consequential damage to neural, bony or disc elements.
Increased wedging, deformity & increase incidence of adjacent VB
Chronic pain of altered spine mechanics.
Uncomfortable braces & sleep disturbance because of pain & discomfort with its sequels.
Morbidity and complication of spinal surgery 

Cost of surgery and hospital treatment
Cost of implants
Phobia of surgery
Prolonged recovery period & Extensive rehabilitation
Changed spinal mechanics & transition syndrome
Major surgery & anesthesia with its own complications
Preparation & Procedure:
X-ray spine in a/p & lat view. CT is more informative of bone & morphology. MRI is good for soft tissue injuries. Ask for pedicle size in all dimensions and construct a 3D image aiming needle placement and cement filling in scan room itself as rehearsal of PVP. This reduces operative time & gives better results. Conventionally PVP is done by hammering the vertebroplasty needle through the bone. Here we use light weight drill to bore through the vertebra. It is important to set the needle at exact entry site & side with right trajectory aiming the defects.

In lateral view needle should go through middle of the pedicle going up to anterior 1/3 of VB. In P/A view the needle can be in midline or paramedian depending upon & if uni/bipedicular approach is planned. Approach varies as per location of vertebra, anterolateral in cervical, costotransverse/parapedicular in thoracic & transpedicular in lumbar vertebra.

Do bone biopsy if there is any doubt about lession. Do dye test (vertebral venography). Make cement more radiopaque by adding barium /or tungsten. Inject cement with 1or2 ml luerlock syringes strictly under fluoroscope in lateral view & cross checking in P/A view. Stop injecting either there is adequate filling or at the first sight of ectopic cement leak. Keep sample cement to see for hardening. Remove needle with rotational movement before cement hardens.

Pain relief is by virtue of different mechanisms postulated :

Cementing of fragments.
Thermal neurolysis of VB nerve ending due to heat of polymerization.
Washing away of nociceptor chemicals.
Neurolytic action of liquid monomer.
By allowing early ambulation decreasing pains of immobility & bed rest.
Complications 

PVP is generally safe with low risk.
Ectopic cement leak is frequent but generally inconsequential.
Outcome 

PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
Different studies show an immediate pain relief in (85   90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
PVP does augment height of VB but ideal would be kyphoplasty.
Patient is either off medicine or on reduced doses.
Patient feels so well that he almost forgets if he had VB

Vertebroplasty (PVP) / Kyphoplasty - Approach To Management Of Vertebral Body Fractures!

Breaking a bone no matter how small is painful. This pain is caused both by the actual break in the bone and the damage to surrounding muscles, ligaments, nerves and other soft tissue. There are three stages of pain caused by a fracture:

Acute Pain: Pain that occurs immediately after a bone is fractured
Sub-Acute Pain: Pain experienced while the one and soft tissues heal
Chronic Pain: Pain experienced after the fracture has healed
Any kind of fracture can cause these types of pain. However, it is not essential for everyone who has had a fracture to experience all the three kinds of pain. Many people experience pain only when the fracture occurs but in few cases, a person may break a bone and not realize it. Each type of pain needs to be dealt with in a different way.

Acute Pain: Acute pain reduces as the fracture heals. For this, the fractured bone must be reset in place and held together with a splint, brace or cast so as to immobilize it. In some cases, surgery may also be needed. Over the counter pain medication is often prescribed to help deal with this type of pain. The patient is also advised to rest the broken bone and avoid certain types of movement that could worsen the break. A broken bone takes a minimum of 6 to 8 weeks to heal. However, in cases of other conditions such as osteoporosis, this time period could be much longer.
Sub-Acute Pain: As the injury heals, the sub-acute pain experienced reduces. Immobilizing a broken bone to help it heal causes the muscles and soft tissues around it to stiffen and weaken thus triggering this type of pain. Physical therapy can be very helpful in dealing with this type of pain. Along with strengthening the muscles and reducing stiffness, physical therapy also helps reduce inflammation and scar tissue. Physical therapy can be provided in many ways including exercises, electrical stimulation, ultrasounds, massage etc. It is important to remember that at this stage of treatment, the more the affected limb is used, the faster it will heal. However, it is advisable to avoid putting too much pressure on the bone.
Chronic Pain: Some people may experience pain for several months and even years after a fracture has healed. This is usually caused by nerve damage or the development of scar tissue. Underlying conditions such as arthritis could also trigger this type of pain. Management of chronic pain varies from individual to individual. Treatment usually takes the form of medication, exercises and physical therapy. It is important not to avoid this type of pain and consult a doctor to ensure that it is not being caused by any other condition.

Fracture Pain - How To Deal With It?

If you have been facing back problems in the form of pain and discomfort for a long time despite undergoing treatment and medications, then you must be wondering whether you should go for a spine surgery. With the advancement in technology in the field of medical surgery, spine surgery has gained popularity owing to its effectiveness and high success rate. However, there are plenty of misconceptions regarding spine surgery, which need to be busted so that people do not make decisions based on these false beliefs.

Here are five myths about spine surgery debunked-

  Myth: Surgery is a must if you have damaged discs.
Fact: Many people live with a herniated disc. It is a fairly common spinal condition. The common belief is that you need to undergo a surgery to fix the problem. However, it is not true. In fact, many people have found relief from back pain following non-surgical methods such as physiotherapy and low-key exercises. These are the initial course of the treatment and usually, the patient sees positive results after the completion of the course.

  Myth: Surgery can relieve you from back pain completely.
Fact: Spine surgery is meant to correct spinal problems by restoring the functioning of your spine and reducing back pain. However, a surgery cannot relieve you from the pain completely. In other words, it cannot fix the problem entirely. There are certain parameters, which you need to correct on your own. These include maintaining a healthy body weight, living a healthy and active life, eating a balanced diet etc. Nevertheless, if the spine problem/injury is diagnosed early, the chances of a successful spine surgery increase.

  Myth: Spine surgery has serious repercussions, and it is not worth a try.
Fact: Like all other types of surgery, spine surgery too has a few risks or side effects associated with it. The most common types include blood clots, infection, weakness, and bleeding. However, these are not as serious as it sounds like. Since most of the surgeries are minimally invasive today, the minor side effects do not last more than a week and recovery takes place sooner. The side effects can also be managed with pain management medications well so the patient need not worry.

  Myth: Visiting a spine surgeon means you will definitely need a surgery.
Fact: Your orthopaedic may advise you to see a spine surgeon if the symptoms of your spine injury/problem become severe. This does not necessarily mean you will have to undergo a surgery. Sometimes, the doctor may schedule an appointment with the surgeon to have a unique perspective of the condition. Surgery is prescribed only as the last resort.

  Myth: Undergoing a surgery once means you will need another one soon.
Fact: If you have gone under the knife once, it does not necessarily mean you will need another surgery soon. Multiple surgical procedures are required only if the patient has sustained complex trauma to the spine. Such cases are rare. Usually, the patient undergoes spine surgery once, following which he/she is provided with a post-operative guideline. The guideline suggests engaging in mild exercises and making vital lifestyle changes to ensure fast recovery.

If you have been suffering from persistent, recurring pain in the back or neck that has altered or affected your quality of life in a negative way, its time you should consult a doctor. Do not hesitate if you need to undergo e a spine surgery urgently. The facts stated above will help clear your mind and eliminate any false belief that you had been holding in.

Spine Surgery - Busting The Myths Around It!

At some point in life most people experience acute pain in their lower back which is extremely painful. Pain in the spine causes a lot of discomfort and disruption in the life of an individual and hence, it is always better to get it checked on time. There are patients who even wonder when they should consult a neurosurgeon or a spine surgeon for their back pain. It is advisable that a physical examination is done by a primary care physician for low back pain before consulting a spine surgeon.

Why consult a Physical care Physician First?
The main reason to consult a primary care physician at first is that he would prescribe medications for severe lower back pain. The medications could include non-narcotic pain medications such as Ultram or non-steroidal anti-inflammatory drugs such as Motrin. The physician can even refer you to a chiropractor or for physical therapy to get relief from the back pain. Mechanical means are made use of by a chiropractor mainly to alleviate the back pain of the patient.

If the patient feels better with the physical therapy or the medications prescribed by the family doctor and is able to resume normal activities, then there is no need to see a spine surgeon. It is often recommended to take good care of the back and to exercise. A combination of ergonomics, regular stretching and improved everyday posture is beneficial as it reduces the chance of causing pain in the lower back. Exercise plays a very important role and it provides the possibility of reducing the pain.

Conservative Care for Treating Lower back Pain
It is best for patients to consult a conservative care specialist if after consulting a chiropractor they do not find any reduction in their pain and they do not want to undergo spine surgery. The conservative care specialists are well-trained in rehabilitation of musculoskeletal disorders and specialize in spine care. The role of the conservative care specialist is similar to a cardiologist who specializes in treating neurological disorders.

The specialist for spine care works along with the surgeon in a spine center to treat the lower back pain. The specialist is trained in diagnostic techniques and is capable of making use of a combination of diagnostic tests as well as injection techniques such as epidural steroid injections to diagnose the source of the lower back pain in a patient. They can even advise patients whether it is appropriate to consult a spine surgeon for surgery. Surgery is done to correct the anatomical conditions and it is performed only when non-surgical treatments are not successful in alleviating the pain of the patient.

When Is The Right Time To See A Spine Surgeon?

Endoscopy refers to inserting microscopic cameras into the body through tiny incisions which throw up pictures of the inside of the body onto a screen. Endoscopy has been used for diagnostic purposes since the 1970s. Endoscopy for surgery has become popular from the 1990s.

Endoscopic spine surgery is a state-of-the-art surgery technique which involves micro incisions and minute tubes that cause almost no damage to surrounding tissues and muscles. It is a minimally invasive surgery and it is also called a pinhole surgery.

What are the advantages of endoscopic pinhole spine surgery?

There are a lot of reasons why doctors opt for an endoscopic surgery-

  It is also called Minimally Invasive Spine Surgery (MISS) because it causes little blood loss
  Recovery is almost immediate. A person can resume everyday activities within a week
  Very little pain around the surgery region so minimum pain medication is needed.
  No muscle or bone is removed.
  Since screws and rods are not used, full mobility of the spine can be restored
  The wounds are minute and do not usually require stitches and thus no ugly scars are left after the wounds heal.

What are the characteristics of an endoscopic spine surgery?

  The surgery is performed under local anaesthesia
  The person is discharged within 24 hours of the surgery
  The incisions that are made are microscopic

What are the different types of endoscopic surgery?

Endoscopic discectomy:
It is the least invasive of all spinal surgeries. It is used for treating herniated discs. Endoscopy reveals images of the spine. Through the same tunnel, surgery tools are inserted and the bulging or herniated disc is pulled out with a grasper. The wound does not always require stitches to close it.

Endoscopic Laminotomy:
This a substitute for open laminotomy. The camera helps locate exactly where the target area is. Then an incision is made below and above the lamina to relieve the pressure compressing the nerve.

Endoscopic facet rhizotomy:
With microscopic cameras, the nerves causing pain are identified and then the laser is used to numb these nerves which relieve pain. This type of surgery can also remedy a previously botched spinal surgery, facet joint arthritis or facet joint pain

Endoscopic foraminotomy:
This type of surgery again uses microscopic surgical tools guided by a tiny camera to enlarge a narrowed neuro of spinal nerve root canal to give it more room to move about without being compressed.

Endoscopic Spine Surgery & Pinhole Technique!

A bone fracture is often abbreviated as FX or # and is a painful medical condition that causes damage in the continuity of the bone. A dictionary meaning of fracture is a separation of an object or a material into two or more pieces under the action of stress.


A bone fracture could be due to a high force impact or stress, an injury from trauma or sports or even certain medical conditions that weaken the bones, such as osteoporosis, bone cancer or osteogenesis imperfecta.


However, a significant number of fractures occur due to high force impact or stress. A fracture could be simple where the skin is not exposed or compound where skin gets exposed. A fracture could be complete where the bone breaks up in two pieces or could be incomplete with a crack in the bone.


Treatment of bone fracture depends on the type of fracture. In a large number of cases, the bone is aligned through a cast or splint. However, a very crucial part in the recovery of the treatment is physiotherapy. Physiotherapy is a comprehensive care plan designed for the patient for optimal and complete recovery. Yet most patients do not understand its effectiveness. In layman's terms physiotherapy is understood as few exercises or messages designed to aid the patient's treatment. However, Physiotherapy not only aids the recovery, it effectively promotes healing, reduces pain and stiffness and gradually helps the patient to return back to his/her normal daily activities of life.


Physiotherapy is a complete preventive and rehabilitative approach to treatment and must begin as early as possible and continue post fracture. Physiotherapy has been proven to be effective in preventing post fracture stiffness and weakness that occurs in adjacent joints and muscles generally during the first six weeks of the healing process. If the X-ray shows poor healing, physiotherapy is a medium used to help the patient regain muscle strength and speed up recovery.


Irregular movements can lead the bones to further damage the surrounding tissues and muscles. Damage may also lead to infection, especially in compound fractures where the skin is exposed. Thus, physiotherapy regulates the movements, supports healing and prevents further damage. Physiotherapy not only involves messages or exercises. It includes a range of interventions designed for prevention and rehabilitation of patients. These interventions include pain management, education and awareness on safety and prevention of injury, strength building and flexibility exercises and in some cases taping, bracing and electrotherapy.


To add to its benefits, physiotherapy procedures are also completely safe and are supported by medical science. These procedures also do not have any side effects. Always remember to consult your orthopedic doctor as he can guide you towards the best physiotherapy treatment.


Stay fit and healthy!"

Physiotherapy - Why it is Critical for Recovery from Fracture?

Don't wait any longer, manage your Column Traumatology online with a Lybrate doctor today

Consult for Column Traumatology - Online and Easy!

FilterClear All

COMMON SPECIALITIES

COMMON ISSUES