Opinion: The start-up and running of a vertebroplasty (spinal augmentation) programme

By Professor Peter Munk, MD and Anthony Ryan, MD

Most interventional radiologists are well aware that spinal augmentation has taken on an increasingly important role in the practice of interventional radiology. Over the last ten years, something which was done by only a few radiologists in small numbers has now become widespread throughout North America.  Although well established in the US, vertebroplasty is only beginning to make significant inroads into Canada, and many Canadian interventional radiologists are asking the same questions that radiologists in other jurisdictions asked themselves a few years ago: once you’ve got the appropriate training, how do you get referrals? How do you clinically assess and follow-up the patients that have been referred to you? The answers to these questions will, of course, be specific to the individual practice, and dependent on the practice pattern and interests locally. What follows is an outline of how we found ourselves answering these two questions.

In our own jurisdiction, I (Professor Munk) was amongst the first radiologists to aggressively pursue the establishment of a programme. Having trained at Johns Hopkins Hospital with Dr Kieran Murphy, I found myself back at home wondering how I would go about setting up a referral pattern to send appropriate patients for this procedure.  In jurisdictions where vertebroplasty or other spinal augmentation procedures have not previously been performed, the first task is to educate referring clinicians as to what these procedures are, when they may be indicated, how they are done, and how to send a patient for evaluation. From experience I found that amongst the most receptive group of physicians for referring patients are those in general and family practice. These physicians see a large number of patients complaining of back pain, particularly amongst elderly patients. These patients return on a recurring basis and can be very difficult to treat.

By agreeing to assess these patients and organise an appropriate imaging work-up, you are doing a really important service to general and family practice physicians. Patients may be candidates for spinal augmentation (vertebroplasty, kyphoplasty, skyphoplasty), or may benefit more from facet injections, epidural injections or other therapy which we can also usually arrange. In order to contact these physicians, I find myself frequently going to Continuing Medical Education courses, hospital rounds, and also volunteering at drug sponsored dinners, typically put on by companies manufacturing drugs for the treatment of osteoporosis. I also published an article in the local medical association journal, and was invited to appear briefly on a local television programme featuring advances in medicine. Although the level of knowledge in the medical community has certainly improved over the last five years, I find myself still astonished by the unfamiliarity of a very large number of physicians with vertebroplasty and its potential benefits in properly selected patients.

Other groups of physicians who I have found highly responsive to the potential application of vertebroplasty in their patient population are rheumatologists, endocrinologists, oncologists and geriatricians. I have received few referrals from surgeons.

Once the referral occurs, the question then comes: now what do I do? This again will depend significantly on the inclination of the interventional radiologist and what sort of resources he or she may have at their disposal. In our own institution we do not have clinic facilities, find it very difficult to find time to examine patients, and are certainly not well remunerated for doing so. Other institutions may find that these activities are much more practical to undertake. For this reason I work closely with a rheumatologist with a particular interest in spine medicine. My colleague sees the patient in this clinic and assesses them thoroughly with a history, physical examination and function and pain score scales. We then have joint rounds approximately once every two weeks. We review the imaging in conjunction with the clinical assessment, and then determine whether patients are appropriate candidates for vertebroplasty, or if they might benefit from a different type of therapy. We find that approximately 50% of candidates are rejected. A written file is kept for each patient containing: the referral letter/requisition, the clinical assessment consultation, copies of all pertinent imaging reports, and the final decision as to what procedure (if any) is to be performed. Follow-up clinic notes also form part of this record. Copies of these files are kept in a separate filing facility in the booking office of the department of radiology. A move to convert these to an electronic format is under way. The patient is then subsequently scheduled for a spinal augmentation procedure, and is seen in follow-up three to four weeks post procedure by my clinical colleague. Any additional therapy that might be needed is then organised.

I strongly recommend that anyone embarking on the development of a spinal augmentation programme either have the ability to perform other types of spinal injection (epidural, facet, nerve root, etc) or have colleagues in their practice who do in order to provide a full service to patients who are being referred.

The clinical colleague you may choose to partner with does not necessarily have to be a specialist, but certainly has to be a physician interested in spinal medicine who has strong clinical skills in spinal assessment. From the patient’s point of view, this provides a second opinion (which in this case is certainly better than mine in terms of physical examination). It also protects me bias or from being accused of performing procedures on inappropriately selected candidates.

I have found this to be a fruitful and successful way to run a spinal augmentation programme which has been adopted by a number of other centres in my Province. Both patients and referring physicians are for the most part pleased with a system that provides for comprehensive spinal diagnosis and treatment with a single referral.

“Republished with permission of the Society of Interventional Radiology 2004, 2008, www.SIRweb.org. All rights reserved.”