Percutaneous vertebroplasty: rationale, clinical outcomes, and future directions
Section snippets
Epidemiology and economics of osteoporosis
Osteoporosis is one of the major health problems facing women and elderly persons of both genders. The World Health Organization has defined osteoporosis as a bone mineral density of more than 2.5 standard deviations below the mean in young, healthy individuals [3]. From data obtained from epidemiologic studies in Rochester, Minnesota, and extrapolated to the US white population, approximately 1.5 million fractures related to osteoporosis occur each year. These include approximately 700,000
Pathology of osteoporosis
After peak bone mass has been obtained, orderly remodeling ensures that the amount of bone resorbed by osteoclasts is balanced by the amount of new bone formed by osteoblasts. A net loss in bone mass occurs when changes in bone turnover result in increased bone resorption or decreased bone formation. With aging, a protracted slow phase of bone loss occurs in both men and women (type 2 osteoporosis) [10]. For most women entering menopause, trabecular bone loss is approximately 1% per year [10].
Clinical consequences of vertebral compression fractures
Vertebral compression fractures can be defined as the reduction in vertebral body height by 15% or more and classified by degree and type of deformity (eg, wedge, biconcavity, or compression) [14], [15], [16]. Vertebral collapse occurs when the combined axial and lateral bending stresses on the spinal column exceed the strength of the vertebral body, which is weakened by osteoporosis or by tumor infiltration [2]. The most commonly compressed levels are T8, T12, L1, and L4. The axial stress from
Conservative management of osteoporotic vertebral body fractures
Pain control and functional improvement are the immediate goals in the treatment of symptomatic patients. Symptomatic relief is limited to analgesics and muscle relaxants, immobilization through bed rest, and support devices, such as back braces. Immobilization is potentially harmful, however, leading to decubitus complications; increased bone resorption, which can worsen bone demineralization; and defunctionalization of these often frail elderly patients from loss of muscle mass. Surgical
Early clinical results
Percutaneous vertebroplasty is a minimally invasive, radiologically guided, therapeutic procedure for the treatment of pain caused by a vertebral body compression fracture, symptomatic vertebral hemangiomas, multiple myeloma, or metastases. Initially described in patients suffering from painful hemangiomas, myeloma, or metastases [29], [30], [31], percutaneous vertebroplasty has gained popularity in the treatment of fractures associated with osteoporosis [14], [32].
A review of the medical
Vertebroplasty for acute vertebral body compression fractures
Cyteval et al [33] reported on percutaneous vertebroplasty for acute osteoporotic vertebral collapse in a series of 20 patients with 23 fractures. All patients had acute pain of less than 1 month's duration that hindered ambulation and required treatment with narcotics. All patients were admitted to the hospital for pain medication and vertebroplasty. The visual analog scale (VAS) for pain was used for scoring assessment. Follow-up data were obtained at 1 and 6 months. Within the first week, 15
Vertebroplasty versus medical therapy
Despite the excellent clinical results and safety profile reported in the previously described clinical series, some physicians still have reservations regarding the effectiveness of vertebroplasty because of lack of a trial directly comparing vertebroplasty to the current standard of care, medical therapy [39], [40], [41]. A prospective randomized trial comparing percutaneous vertebroplasty with medical therapy for acute (<6 weeks) osteoporotic vertebral body compression fractures is underway
Risk of fractures of adjacent vertebrae
There are concerns that vertebroplasty may increase the risk of fracture at an adjacent level. In a study comparing a group of patients previously treated with vertebroplasty who returned with new fractures with a control group of patients who presented with multiple painful fractures, Jensen et al [14], [37] found no statistically significant difference in the rates of adjacent level fractures between the two groups. The authors postulated that these new fractures were more likely the result
History, effects, and safety of polymethylmethacrylate
Before its use in percutaneous vertebroplasty, polymethylmethacrylate (PMMA) had been used in anterior and posterior stabilization of the spine for metastatic disease in surgical series [45], [46], [47], for bone packing after curettage of giant cell tumors of the extremities [48], [49], and for the surgical treatment of vertebral hemangiomas [50].
When initially prepared for percutaneous vertebroplasty, PMMA is in a liquid state, allowing it to be injected. At approximately 30 to 40 minutes
Patient evaluation
Clinical history and physical examination are done to establish significant focal back pain (but without radicular-type pain), point tenderness on palpation, and limited mobility. All patients are required to have imaging evidence of a fracture in the immediate region of the pain. When indicated, cross-sectional imaging is obtained to exclude other causes of pain, such as intervertebral disc protrusion or extrusion, or spinal stenosis. In addition, infection or malignancy is considered a
Intraosseous venography (vertebrography)
Differences in opinion exist regarding the utility of antecedent venography in determining improved clinical outcome or decreased complications during vertebroplasty (Fig. 6). Kaufmann et al [75] conducted a retrospective review of consecutive patients treated with percutaneous vertebroplasty for vertebral body compression fractures. The first group of patients (n = 20) had antecedent venography, whereas the second group (n = 22) was treated without venography. The clinical outcomes were
Potential pitfalls
Because vertebroplasties increasingly are being performed in the United States, many by less-experienced physicians, the number of complications may increase. The complication rates will be highest in the learning phase, and adherence to a few simple rules is the best way to avoid these complications. Complications are most commonly associated with the following: inappropriate patient selection; poor visualization caused by inadequate fluoroscopic equipment; poor patient cooperation;
Research and future directions
For percutaneous vertebroplasty to be widely accepted by the medical community, scientific validation through prospective randomized clinical trials comparing percutaneous vertebroplasty with conventional medical therapy is needed. Although the published case study series are anecdotal and not randomized, they do report significant, rapid pain control, increased mobility, and decreased medication intake in high percentages of treated patients. The complication rates in these series have been
Summary
Percutaneous transpediculate vertebroplasty is an innovative and successful treatment of painful osteoporotic and pathologic compression fractures that are refractory to medical therapy. Large-scale clinical series have shown that vertebroplasty can provide significant pain relief with very low complication rates. Expectations of positive results of the ongoing randomized trials are high. With the accumulation of scientific data, technological advancements, and acceptance by the general
References (80)
- et al.
Update on primary osteoporosis
Mayo Clin Proc
(1997) - et al.
Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures
Mayo Clin Proc
(2000) The clinical consequences of vertebral compression fractures
Bone
(1992)- et al.
Percutaneous vertebroplasty with polymethylmethacrylate
Radiol Clin North Am
(1998) - et al.
Pain and disability associated with new vertebral fractures and other spinal conditions
J Clin Epidemiol
(1994) - et al.
Vertebral hemangioma: retrograde embolization-stabilization with methyl methalcrylate
Surg Neurol
(1987) - et al.
Temperature elevation caused by bone cement polymerization during vertebroplasty
Bone
(1999) - et al.
An in vitro biomechanical evaluation of bone cements used in percutaneous vertebroplasty
Bone
(1999) - et al.
Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty
Neurochirurgie
(1987) - et al.
Percutaneous vertebroplasty: a developing standard of care for vertebral compression fractures
AJNR Am J Neuroradiol
(2001)
The diagnosis of osteoporosis
J Bone Miner Res
The worldwide problem of osteoporosis: insights afforded by epidemiology
Bone
Epidemiology of spinal osteoporosis
Spine
The frequency of occurrence, impact, and cost of selected musculoskeletal conditions in the United States
Hospitalization with vertebral fracture among the aged: a national population-based study, 1986–1989
Epidemiology
Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation
J Bone Miner Res
How many women have osteoporosis?
J Bone Miner Res
Involutional osteoporosis
N Engl J Med
Preexisting fractures and bone mass predict vertebral fracture incidence in women
Ann Intern Med
Use of calcitonin in the treatment of bone pain associated with osteoporosis
Calcif Tissue Int
Percutaneous vertebroplasty in the treatment of osteoporotic compression fractures
Neuroimaging Clin N Am
Clinical consequences of vertebral fractures
Am J Med
Classification of vertebral fractures
J Bone Miner Res
Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989
J Bone Miner Res
Clinical profile of acute vertebral compression fractures in osteoporosis
Br J Rheumatol
Evaluation of adverse health outcomes associated with vertebral fractures
Osteoporos Int
Exercise and physical therapy
Magnetic resonance imaging in the evaluation of patients for percutaneous vertebroplasty
Top Magn Reson Imaging
General management of vertebral fractures
Bone
The clinical impact of vertebral fractures: quality of life in women with osteoporosis
Bone
Vertebral fractures associated with osteoporosis: patient management
Am J Med
Reduced pulmonary function in patients with spinal osteoporotic fractures
Osteoporosis International
Vertebral fractures and mortality in older women: a prospective study: study of Osteoporotic Fractures Research Group
Arch Intern Med
Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methalcrylate at clinical follow-up
Radiology
Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement
Radiology
Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects
AJNR Am J Neuroradiol
Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients
AJR Am J Roentgenol
Percutaneous vertebroplasty with acrylic cement in the treatment of osteoporotic vertebral crush fracture syndrome
Neuroradiology
Percutaneous vertebroplasty: indications, technique, and complications
Percutaneous vertebroplasty guided by a combination of CT and fluoroscopy
AJNR Am J Neuroradiol
Cited by (6)
ACR Appropriateness Criteria <sup>®</sup> Management of Vertebral Compression Fractures
2018, Journal of the American College of RadiologyCitation Excerpt :VA, in the form of VP and BK, may be offered to patients who have failed conservative therapy for 3 months [31]. Failure can be defined as pain refractory to oral medications (nonsteroidal anti-inflammatory drugs or narcotics) [66-69]. Failure can also be defined as a contraindication to such medications or a requirement for parenteral narcotics and hospital admission.
Anterior spinal artery syndrome after percutaneous vertebroplasty
2011, Spine JournalCitation Excerpt :This procedure has gained increasing popularity as therapy for painful and disabling vertebral compression fractures in the past few years. Although clinical trials have proven percutaneous vertebroplasty to be an efficient and safe procedure, its complication rates range from 1% to 10% [3]. Reported complications included transient worsening of pain, infections, bleeding (mainly in patients with coagulopathies or receiving anticoagulation medications), and injuries to the nerve roots or adjacent organs [4].
Vertebral augmentation in osteoporotic fractures
2007, InjuryAn intraatrial thrombus and pulmonary thromboembolism as a late complication of percutaneous vertebroplasty
2007, Anesthesia and AnalgesiaKyphoplasty and vertebroplasty produce the same degree of height restoration
2009, American Journal of Neuroradiology