Figure 1

Vertebral body tumors, also known as spinal tumors, are relatively rare masses or growths of cells that occur within or surrounding the spinal cord. Spinal tumors are classified according to the specific area where they occur. When they are found inside the spinal cord they are known as intramedullary. Spinal tumors within the membranes covering the spinal cord – the meninges – are referred to as extramedullary-intradural. Extradural vertebral tumors, the most common type, refer to those tumors that occur between the bones of the spine and the meninges.
Any type of tumor may occur in the spine. The cause of vertebral body tumors is unknown, although they may be associated with genetic defects. It is estimated that 75% of vertebral body tumors are malignant, although these often can be cured.

Symptoms of vertebral body tumors will vary depending on the type of tumor, but the primary complaint is back pain. Muscle weakness and loss and abnormal sensation in the legs may also be present.

When tumors occur in this area, it is possible for them to weaken the surrounding bones, which can cause the bone to fracture and collapse. This event places pressure on the nerves or the spinal cord, and can be very painful. Spinal tumors may also grow outside the bone, causing further pressure on the nearby tissues.
Treatments for vertebral body tumors will vary depending on the type of tumor and the symptoms the patient is experiencing. When collapse of the bone has taken place, a procedure known as vertebroplasty may be recommended. In this procedure, a needle is inserted directly into the bone through the use of x-ray technology so that medical cement can be injected. This stabilizes the collapse, strengthening the bone and preventing further damage. The end result of this relatively low-risk procedure is generally rapid pain relief.

Overview of vertebroplasty
Vertebroplasty is conducted in an operating room suite. At the start of the procedure, a nurse may place a tube called a Foley catheter into the bladder to collect and monitor urine output. The procedure will take place while you are lying on your stomach. Your arms will be placed straight out, next to, and over your head in the “Superman” position. Sedatives will be administered so that you may relax during the procedure. These will be administered by an anesthesiologist intravenously. An electrocardiogram, or EKG, will monitor heart rate and rhythm as well as blood pressure and oxygen levels throughout the procedure.

During the procedure, the nurse, doctors, and other professionals in the room will explain to you the various pieces of equipment they will be using. Although you will be able to hear, it is important that you remain as still as possible in order to obtain the best results of the x-ray images and decrease the amount of time required for the procedure. If necessary, general anesthesia may be required. This will allow for total sedation during the process and will ensure that proper x-ray results are obtained.

To begin, the skin on the back immediately covering the fractured vertebrae will be washed with special soap. Sterile sheets and towels will then be draped over the area. A numbing medication will be applied and a special needle will be placed into the fractured vertebrae through the use of a fluoroscope–a special x-ray machine. As soon as the needle is confirmed to be in the appropriate location, treatment will begin.

The medical cement is mixed with a material known as a contrast which helps it show up on an x-ray. The doctors will be able to use x-ray screens to view the mixture entering into the bone. An antibiotic may also be added to the mixture to reduce the risk of infection. Once the cement and accompanying ingredients are all mixed together, it becomes liquefied. However, it will harden quickly, so the doctors need to proceed accurately and rapidly. Once they have determined (by viewing the injection on the x-ray screen) that a sufficient amount of the cement has been injected into the fracture, the needle is removed and pressure is gently applied at the insertion point to prevent bleeding. The only visible evidence that the procedure took is a band-aid; no stitches are required.

The total length of time for the procedure takes one to two hours, depending on specific circumstances. Patients who may have several affected segments of the vertebrae or who may need general anesthesia will require a longer procedure.

Following the Procedure
Once the procedure is completed, a CT scan may be performed. Following the scan, you will be transferred to a stretcher where either you will remain on your stomach or will be permitted to be placed on your back. It is necessary to remain on the stretcher for about 2 hours prior to getting up in order to ensure that the cement has completely hardened. These two hours will be sent in the Same-Day Surgery Unit of the hospital, which may also be known as Ambulatory Surgery.

Your diet following the procedure will consist of clear liquids and will gradually be returned to a normal diet.

In order to get up for the first time, you will require the assistance of a nurse. Lightheadedness may occur due to remaining flat for a long period of time, but this is normal. The medications may also leave you feeling week or tired at first, so it is wise to have support before moving around.

The majority of patients go home the same day as the procedure, some as early as 3 hours later. A friend of family member must be available to bring you home. Strenuous activity will be limited at first, but normal activities will gradually be increased. Many patients feel fine after the procedure but it is important to remember to limit activity, especially heavy lifting. A good rule of thumb is to not lift anything heavier than a purse or small bag of groceries for at least one week.

Follow-Up Care
Your doctor may recommend rehabilitation following the procedure. This may take the form of physical therapy or independent exercise. Your doctor may give you written suggestions for exercises you can do at home. Regardless of the recommendations, your doctor will want to see you about 2-3 weeks following the procedure. Most patients will eventually be able to resume normal activity and discontinue use of analgesic medication.

Many patients report feeling relief from back pain within a few days. If this is not the case, a reevaluation is warranted to determine if other causes may be contributing to the pain.

Alternatives to vertebroplasty
Not everyone is a candidate for vertebroplasty. The procedure should not be performed on people who have an active infection or coagulopathy (a condition in which the blood does clot normally).

When there is pressure on the nerves or spinal cord, surgery may be considered. However, if the tumor has a large blood supply, complication to surgery can result. In this case, a procedure known as embolization may be recommended a few days prior to surgery to maximize the chances that surgery will be successful. Very simply, this procedure involves inserting a catheter into the leg and using x-ray technology to guide the catheter to the blood vessels that supply the tumor. Materials can then be injected to block off the blood supply to the tumor.

The embolization procedure from start to finish
Prior to undergoing embolization, patients are expected to sign a consent form and will have the opportunity to have questions answered. The anesthesiologist will administer medications and fluids through the use of an intravenous line (IV) into a vein in the hand or arm. He or she will also administer general anesthesia so that the patient will be completely asleep for the procedure. Blood pressure will be monitored through an A-Line, a thin flexible tube or catheter placed in an artery in your wrist. An electrocardiogram (EKG) will monitor heart rate and rhythm as well as oxygen levels. A specific type of catheter known as a Foley will be placed in the bladder to allow urine to drain.

Once the procedure is complete, the patient will be transferred from the operating room to either the Surgical Intensive Care Unit (SICU) or the Post-Anesthesia Care Unit (PACU). Here, a heart monitor will closely monitor vital signs. This machine is very sensitive and often sounds inadvertently; this is not cause for alarm. The nursing staff will assist in changing positions, but bed rest is required. Eventually, the patient can look forward to a normal diet and transfer to a room on a surgical floor. The Foley catheter will also be removed prior to leaving the bed for the first time.

Patients are expected to keep the leg that underwent surgery straight for several hours and a tube may remain in place at the puncture sight for several days. Once it is removed, the physician will apply pressure for about 20 minutes to prevent bleeding, and a device may be used to seal the puncture.

Although embolization in conjunction with surgery can be very safe and successful in treating vertebral body tumors,2,3 surgery may not always be possible. Embolization may thus be recommended as a direct means of treating the tumor. Using x-ray guidance, the catheter may be guided directly into the tumor so that material can be injected to kill the tumor. In other cases, however, radiation therapy will be recommended as a means of treatment.