Is Intraosseous Venography a Significant Safety Measure in Performance of Vertebroplasty?

Abstract

AS percutaneous vertebroplasty becomes more widespread, controversies surrounding this technique arise. A growing controversy centers around the use of intraosseous venography. Is it helpful? Is it representative of the flow pattern of polymethylmethacrylate? Is it essential for safety? When vertebroplasty first started in Europe, operators did not include or depend on this as part of the procedure. Even today, most operators in Europe still do not perform intraosseous venography as part of the procedure. Yet their complication rates are no higher than their American counterparts (1–4). Intraosseous venography was popularized in the United States. In the original U.S. article on vertebroplasty by Jensen et al (5), the authors advocated intraosseous venography as a means of predicting dangerous venous runoffs and potential leaks along fracture lines. As a result, many if not most American operators perform intraosseous venography before application of polymethylmethacrylate. However, an increasing number of more experienced vertebroplasty operators have been excluding intraosseous venography. They have found that they see no difference in complication rates with versus without intraosseous venography. They may also argue that intraosseous venography adds cost, increases radiation, and may obscure cement during its application if the contrast material pools in a cavity or disc space. In addition, reimbursement for venography is now not recoverable. Some have claimed that the difference in flow pattern between polymethylmethacrylate and iodine contrast material has poor correlation. However, the study by McGraw et al (6) in this issue of JVIR reports a high predictive value of intraosseous venography to cement application in their cases, particularly when the stasis pattern is excluded. However, the important issue is not whether intraosseous venography correlates with cement application, but whether intraosseous venography is essential for safety. A study by Gailloud et al (7) showed no significant complications caused by adverse cement venous runoff or leakage through fracture lines in 112 consecutive vertebroplasty procedures without intraosseous venography. The authors of this commentary together have performed more than 1,500 vertebroplasty procedures without vertebral venography and have seen no significant complications caused by cement leakage or adverse venous runoff. How could venography improve on these numbers? Perhaps safety issues in vertebroplasty lie beyond intraosseous venography, and these should be reviewed. Vertebroplasty, in experienced hands, carries a low complication rate of less than 2% (1–4), and the rate is much lower among many operators. Nevertheless, complications can be catastrophic, including pulmonary emboli, paralysis, and even death. Complications usually arise from improper needle placement, uncontrolled cement application, or improper patient selection.