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INTRODUCTION

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KEY POINTS

  1. Vertebral compression fractures are a common cause of pain and loss of independence in middle-aged and elderly adults.

  2. Vertebroplasty and kyphoplasty are minimally invasive, image-guided vertebral augmentation procedures that involve the injection of cement into a fractured vertebral body. The primary goal of augmentation is pain relief and enhanced functional status with the secondary goals of vertebral body stabilization in cases of fracture.

  3. Although two recent high-profile trials in the New England Journal of Medicine (NEJM) found no benefit to vertebroplasty, more recent randomized controlled trials of vertebral augmentation versus conservative therapy for both osteoporotic and malignant fractures have demonstrated significant improvements in back pain, reduction in disability, and improvement in quality of life in favor of vertebral augmentation.

  4. Complications are rare and generally result from unrecognized extraosseous leakage of the injected cement. These include radiculopathy, paralysis, and pulmonary embolism. These risks can be minimized and vertebral augmentation safely performed by experienced operators using high-quality imaging, preferably with biplane fluoroscopy.

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CLINICAL RELEVANCE

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Osteoporosis is a prevalent disease that affects 200 million women worldwide.1 Approximately one in two women and one in four men older than the age of 45 years will experience an osteoporotic fracture. Most of these are asymptomatic or have tolerable symptoms, with only one-third of new fractures resulting in medical attention.2 In the vast majority, acute back pain symptoms subside over a period of 6 to 8 weeks as the fracture heals.3 Vertebroplasty and kyphoplasty are minimally invasive, image-guided procedures that involve the injection of cement into a vertebral body. The majority of these vertebral augmentation procedures are performed for a small subset of these patients with symptomatic osteoporotic compression fractures that are refractory to conventional medical therapy. The primary goals of augmentation are pain relief and enhanced functional status with the secondary goal of vertebral body stabilization.

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Augmentation for neoplastic fractures, in particular from multiple myeloma or osteolytic metastasis or symptomatic neoplasm or vascular tumor, is also common. The spine is affected by osteopenic or osteolytic bone disease in 70% of those with multiple myeloma.4 Sixty-five percent of patients experience a fracture during the course of the disease,5 with 30% of patients sustaining a vertebral compression fracture.6 The vertebral column is the most common site for bone metastasis.7 Osteolytic metastases weaken bony integrity and are at higher risk of compression fracture compared with osteoblastic lesions. Although up to 70% of the patients who die of cancer have spinal metastases at autopsy, only 14% have symptomatic lesions during their illness.8 Vertebral augmentation is used in a small cohort with symptomatic vertebral involvement or pathological fractures that are refractory to conventional medical therapy.

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MEDICAL MANAGEMENT

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The goals of conservative therapy are pain reduction (with analgesics, bed rest, or both), improvement in functional status (with orthotic devices and physical therapy), and prevention of future ...

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