Vertebroplasty

Common use

Area of application

Contrast

Description

This procedure is contraindicated for

• high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
• high alert Patients with conditions associated with adverse reactions to vertebroplasty cement.
• high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. 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.
• high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
• high alert Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure.
• high alert Patients with bleeding disorders receiving an arterial or venous puncture because the site may not stop bleeding.
• high alert Patients with pain that is primarily radicular in nature.
• high alert Patients with pain that is improving or that has been present and unchanged for years.
• high alert Patients who have undergone imaging procedures that suggest no fracture is present or that the fracture is remote from the patient’s pain.

Indications

• Assist in the detection of nonmalignant tumors before surgical resection.
• Repair of compression spinal fractures of varying ages. Fractures older than 6 mo will respond but at a slower rate. Fractures less than 4 wk old should be given a chance to heal without intervention unless they are associated with disabling pain or hospitalization.
• Repair of spinal problems due to tumors.

Potential diagnosis

Normal findings

• Improvement in the ability to ambulate without pain
• Relief of back pain

Abnormal findings related to

• Failure to reduce the patient’s pain
• Failure to improve the patient’s mobility

Critical findings

N/A

Interfering factors

• Factors that may impair clear imaging

  • 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.

• Other considerations

  • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
  • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status, may interfere with the test results.
  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
  • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
  • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.

Nursing Implications and Procedure

Pretest

• Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
• Patient Teaching: Inform the patient this procedure can assist in improving spinal cord function.
• Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, vertebroplasty cement, or sedatives.
• Note any recent procedures that can interfere with test results, including examinations using barium- or iodine-based contrast medium.
• Obtain a history of the patient’s musculoskeletal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
• Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
• Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
• Note that if iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
• Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Explain that contrast medium, if ordered, may be used to verify placement of the vertebroplasty cement. Inform the patient that the procedure is usually performed in the radiology department by an HCP, with support staff, and takes approximately 30 to 90 min.
• Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
• Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected, by catheter, at a separate site from the IV line.
• Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
• Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Protocols may vary among facilities.
• Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
• Note that this procedure may be terminated if chest pain or severe cardiac arrhythmias occur.

Intratest

• Potential complications:

• Injection of the contrast through IV tubing into a blood vessel is an invasive procedure. Complications are rare but do include risk for allergic reaction related to cement or contrast reaction, cardiac arrhythmias, hematoma related to blood leakage into the tissue following insertion of the IV needle, or infection that might occur if bacteria from the skin surface is introduced at the IV needle insertion site. Other 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 standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
• Ensure the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
• Ensure the patient has removed all external metallic objects from the area to be examined.
• Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug. Use nonionic contrast medium for the procedure.
• Have emergency equipment readily available.
• Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided. Geriatric Considerations Elderly 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. Elderly patients are often chronically dehydrated; anticipating the effects of hypovolemia and orthostasis can also help prevent falls.
• Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still throughout the procedure because movement produces unreliable results.
• Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
• Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
• Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative to a child or to an uncooperative adult, as ordered.
• Place electrocardiographic electrodes on the patient for cardiac monitoring. Establish baseline rhythm; determine if the patient has ventricular arrhythmias.
• Place the patient in the prone position on an examination table. Cleanse the selected area, and cover with a sterile drape.
• A local anesthetic is injected at the site, and a small incision is made or a needle inserted under fluoroscopy.
• Orthopedic cement is injected through the needle into the fracture.
• Ask the patient to inhale deeply and hold his or her breath while the images are taken, and then to exhale.
• Instruct the patient to take slow, deep breaths if nausea occurs during the procedure.
• Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
• The needle or catheter is removed, and a pressure dressing is applied over the puncture site.
• Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.

Post-Test

• Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
• Instruct the patient to resume diet, fluids, and medications, as directed by the HCP. Renal function should be assessed before metformin is resumed.
• Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
• Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
• Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
• Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
• Instruct the patient in the care and assessment of the site.
• Instruct the patient to apply cold compresses to the puncture site as needed to reduce discomfort or edema.
• Instruct the patient to maintain bed rest for 4 to 6 hr after the procedure or as ordered.
• Recognize anxiety related to test results, and be supportive of perceived loss of independent function. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate.
• Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
• Depending on the results of this procedure, additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

• Related tests include bone mineral densitometry, bone scan, CT spine, EMG, and MRI musculoskeletal.
• Refer to the Musculoskeletal System table at the end of the book for related tests by body system.