Synonym/Acronym
None.
Rationale
A minimally invasive procedure to treat the spine for disorders such as tumor, lesions, osteoporosis, and vertebral compression.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 8 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org.
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Improvement in the ability to ambulate without pain
- Relief of back pain
Study type: X-ray, plain; related body system: Musculoskeletal system.
Vertebroplasty involves the injection of an orthopedic cement mixture through a needle into a fracture site. The cement hardens, stabilizes the bone preventing further collapse, and reduces the pain caused by bone rubbing against bone. The injection is visualized with guidance from radiological imaging or fluoroscopy; a small amount of contrast (with or without iodine) may be used to provide imaged guidance for the injection of the cement. Vertebroplasty may be the preferred procedure when patients are older adults or too frail to tolerate open spinal surgery or if bones are too weak for surgical repair. Patients with a malignant tumor may benefit from vertebroplasty. Other possible applications include in younger patients whose osteoporosis is caused by long-term steroid use or a metabolic disorder. This procedure is recommended after basic treatments such as bed rest and orthopedic braces have failed or when pain medication has been ineffective or caused the patient medical problems, including stomach ulcers.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Patients with conditions associated with adverse reactions to vertebroplasty cement.
Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with bleeding disorders receiving an arterial or venous puncture, because the site may not stop bleeding.
Patients with pain that is primarily radicular in nature.
Patients with pain that is improving or that has been present and unchanged for years.
Patients who have undergone imaging procedures that suggest no fracture is present or that the fracture is remote from the patient’s pain.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
- Failure to reduce the patient’s pain
- Failure to improve the patient’s mobility
Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist in improving spinal cord function.
- Explain that the procedure takes about 30 to 90 min and is usually performed in the radiology department.
- Review the procedure with the patient.
- Explain that pregnancy testing may be required.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing).
- Discuss how there may be moments of discomfort or pain when the IV line is inserted, allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain that contrast medium, if ordered, may be used to verify placement of the vertebroplasty cement and will be mixed with the cement prior to placement.
Procedural Information
- Baseline vital signs are recorded and monitored throughout the procedure.
- Positioning for the procedure is in the prone position on an examination table with the selected area cleansed and covered with a sterile drape.
- Electrocardiographic electrodes are placed for cardiac monitoring and to establish a baseline rhythm and determine the presence of ventricular dysrhythmias.
- A local anesthetic is injected at the site, and a small incision made or a needle inserted under fluoroscopy.
- Orthopedic cement is injected through the needle into the fracture.
- The patient is instructed to inhale deeply, hold the breath while the x-ray images are taken, and then exhale.
- The patient is advised to take slow, deep breaths if nausea occurs during the procedure.
- An ordered antiemetic drug is administered, as needed. An emesis basin is available for use, as needed.
- Once the study is completed, the needle is removed, and a pressure dressing is applied over the puncture site.
- Older Adult Considerations
- Older adult patients present with a variety of concerns when undergoing diagnostic procedures.
- Level of cooperation and fall risk may be complicated by underlying problems such as visual and hearing impairment, joint and muscle stiffness, physical weakness, mental confusion, and the effects of medications.
- A fall injury can be avoided by providing assistance getting on and off the x-ray table.
- Older adult patients are often chronically dehydrated; anticipating the effects of hypovolemia and orthostasis can also help prevent falls.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Explain the importance of immediately reporting symptoms such as difficulty breathing, chest pain, fever, hyperpnea, hypertension, nausea, palpitations, pruritus, rash, tachycardia, urticaria, or vomiting.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated With Diagnostic Procedures.
- Additional complications related to the use of the cement include soft tissue damage and nerve impingement (related to extravasation of cement), embolism to the lungs (related to a blood clot or cement leakage), and respiratory and cardiac failure. Risk for complications increases when more than one vertebra is treated at the same time.
- Observe/assess the needle insertion site for bleeding, inflammation, or hematoma formation.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
Treatment Considerations
- Follow postprocedure vital sign and assessment protocol.
- Resume diet, fluids, and medications, as directed by the health-care provider.
- Instruct the patient to maintain bed rest for 4 to 6 hr after the procedure or as ordered.
- Provide instruction on the care and assessment of the procedure site.
- Explain the value of applying cold compresses to the puncture site as needed to reduce discomfort or edema.
Clinical Judgement
- Consider how to overcome body image and self-esteem disturbances associated with spinal dysfunction.
Follow-Up and Desired Outcomes
- Understands that depending on the results of this procedure, additional testing may be needed to monitor disease progression and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Acknowledges contact information provided for the National Osteoporosis Foundation (www.nof.org), National Institutes of Health (www.nih.gov), and Centers for Disease Control and Prevention (www.cdc.gov).