Vertebroplasty for Compression Fractures

By Deborah Pate, DC, DACBR

It is estimated that approximately 50 million people in the United States alone have osteoporosis. Associated with this disorder are compression fractures, which cause significant pain and immobility that can persist throughout life.

Traditional treatments for painful compression fractures have included bed rest, oral or parenteral analgesics, muscle relaxants, external back-bracing, and physical therapy. Calcitonin also has been found to be effective as an analgesic in the treatment of osteoporotic compression fractures. The majority of patients respond to conservative therapy, but some patients suffer from prolonged pain and immobility, which worsen the effects of osteoporosis.

The list of complications from compression fractures is long. Some of the more common complications include deep venous thrombosis, acceleration of osteoporosis, loss of height, respiratory or gastrointestinal disturbances and emotional and social problems secondary to unremitting pain and loss of independence. Any therapy or procedure that will shorten recovery time and eliminate the need for extended nursing and/or rehabilitative care should be employed to avoid any unnecessary expenses, both economic and emotional. It is for this reason that I would like to add vertebroplasty to the therapies we should consider reasonable for acute compression fractures, particularly among the elderly.

Presently, I am not aware of any controlled studies comparing percutaneous vertebroplasty with conservative therapy for the treatment of osteoporotic vertebral fractures. There have been multiple case studies and series that have demonstrated positive outcomes.

Compressions fractures caused by age-related or steroid-induced osteoporosis seem to respond best to vertebroplasty, with around 90 percent relief of symptoms. Even patients with compression fractures due to multiple myeloma and metastasis respond well to this treatment.^1-3

This procedure is not indicated for patients with healed compression fractures, or for chronic back pain caused by degenerative disc or facet disease, or disc herniation. This also includes compression fractures with greater than 80 percent to 90 percent vertebral body collapse. It also is contraindicated in patients with discitis/osteomyelitis or sepsis and untreated coagulopathy.

Vertebroplasty is most commonly performed by an intervental radiologist with the aide of high-quality fluoroscopy. Midazolam (Versed), fentanyl (Duragesic) or other medications may be administered to provide moderate sedation. Patients in severe pain may require general anesthesia to tolerate the prone positioning required for this procedure. Under fluoroscopic guidance, an 11-gauge needle is advanced into the vertebral body via a transpedicular or parapedicular approach. The semisolid mixture of polymethylmethacrylate (PMMA), an acrylic cement and sterile barium or tungsten powder opacifier is slowly injected into the vertebral body, diffusing throughout the intertrabecular marrow space. The procedure is repeated through the contralateral pedicle unless there is adequate cross-filling of the vertebral body by the initial injection. The cement sets in less than one hour and should stabilize the vertebra by forming a hard internal "cast" that prevents further collapse of the vertebrae. The patient is kept in the supine position for approximately one hour after the procedure to make certain the cement has stabilized. Usually the patient is about to stand and walk with marked reduction in symptoms.

Although rare, complications of the procedure include hemorrhage, rib or vertebral posterior-element fracture, transient fever, and worsening of pain for several hours following the procedure, caused by the heat generated by cement polymerization. Other very rare complications can include nerve-root irritation, cement embolization to the lungs, pneumothorax for thoracic lesions, and infection. Permanent complications, including those requiring decompressive surgery to remove extruded cement or repair a fractured pedicle, occur at a rate of less than 1 percent.⁴

The first vertebroplasty was performed in 1984 by French radiologists; since the mid-1980s, the procedure has been used in France. Since the mid-1990s in the United States, radiologists have been successfully treating pathologic vertebral fractures secondary to osteoporosis, painful vertebral metastasis, and multiple myeloma with verebroplasty. Percutaneous vertebroplasty stabilizes and strengthens the vertebral body, but does not restore the height or shape of a compressed or wedged vertebra.

A modification of the vertebroplasty procedure, termed kyphoplasty, is presently being developed and evaluated. This procedure involves the inflation of a high-pressure balloon that is introduced through an 11-gauge needle into the vertebral centrum to restore the height and shape of the vertebral body. The resultant cavity is then filled with cement.

So, why should a chiropractor know about this procedure? The answer is simple: We all want to give our patients the best care possible and to alleviate painful symptoms. We need to know what types of treatments are available for the disorders we generally manage, and stable compression fractures is one such entity. I am not recommending vertebroplasty for all compressions fractures. This procedure should be considered only for those patients who do not respond to conservative treatment, and in cases in which there is concern for further loss in vertebral body height that might endanger the integrity of the cord.

For those of you with a statistical bent, as I stated earlier, the first vertebroplasty was performed in 1984 by a French radiologist. Since the mid-1980s, this procedure has been done in France for painful compression fractures. The procedure has been performed in the United States since the mid-1990s, so this is a relatively well-tested procedure, with more than 20 years of data. It has been successful in managing the symptoms caused by pathologic vertebral fractures secondary to osteoporosis, painful vertebral metastasis, and multiple myeloma.

In addition to the references cited in this article, I have included a list of resources below for more information regarding studies done on vertebroplasty.

References

1. Jensen ME, Evans AJ, Mathis Jim Kallmes DF, Cloft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997;18:1897-904.
2. Corted B, Cotten A, Boutry N, Flipo RM, Duquesnoy B, Chastanet P, et al. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J Rheumatol 1999;26: 2222-8.
3. Cotten A, Dewatre F, Cortet B, Assaker R, Leblond D, Duquesnoy B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filing and the leakage of methyl methacrylate at clinical followup. Radiology 1996;200:525-30.
4. Jensen ME. Percutaneous vertebroplasty: a new therapy for the treatment of painful vertebral body compression fractures. Applied Radiology; 29:7-11.

Other Resources

1. Melton LJ 3d. Epidemiology of spinal osteoporosis. Spine 1997;22:2S-11S.
2. Tamayo-Orozco J, Arzac-Palumbo P, Peon-Vidales H, Mota-Bolfeta R, Fuentes F. Vertebral fractures associated with osteoporosis: patient management. Am J Med 1997;103:44S-50S.
3. Pun KK, Chan LW. Analgesic effect of intranasal salmon calcitonin in the treatment of osteoporotic vertebral fractures. Clin Ther 1989;11:205-9.
4. Chrischilles E, Shireman T, Wallace R. Costs and health effects of osteoporotic fractures. Bone 1994;15:377-86.
5. Tohmeh AG, Mathis JM, Fenton DC, Levine AM, Belkoff SM. Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine 1999;24:1772-6.
6. Convery FR, Gunn DR, Hughes JD, Martin WE. "The Relative Safety of Polymethylmethacrylate: A Controlled Clinical Study of Randomly Selected Patients Treated With Charnley and Ring Total Hip Replacements." Paper presented at combined meeting of the Orthopaedic Research Society and The American Academy of Orthopaedic Surgeons, Feb. 1, 1973, Las Vegas.
7. Bai B, Jazrawi LM, Kummer FJ, Spivak JM. The use of an injectable, biodegradable calcium phosphate bone substitute for the prophylactic augmentation of osteoporotic vertebrae and the management of vertebral compression fractures. Spine 1999;24:1521-6.
8. Bostrom MP, Lane JM. Future directions. Augmentation of osteoporotic vertebral bodies. Spine 1997;22:38S-42S.
9. Galibert P, Deramond H, Rosat P, LeGars D. Preliminary note on the treatment of vertebral angioma by percutaneous acrylic vertebroplasty [in French]. Neurochirurgie 1987;33:166-8.
10. Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results. Radiol Clin North Am 1998;36:533-46.
11. Gangi A, Dietemann JL, Guth S, Steib JP, Roy C. Computed tomography (CT) and flouroscopy-guided vertebroplasty: results and complications in 187 patients. Seminars in Interventional Radiology 1999;16:137-42.
12. Weill A, Chiras J, Simon JM, Rose M, Sola-Martinez T, Enkaoua E. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996;199:241-7.
13. San Millan Ruiz D, Burkhardt K, Jean B, Muster M, Martin JB, Bouvier J, et al. Pathology findings with acrylic implants. Bone 1999;25:85S-90S.
14. Chiras J, Deramond H. Complications des Vertebroplasties. In: Saillant G, Laville C, eds. Echecs et Complications de la Chirurgie du Rachis: Chirurgie de Reprise. Paris, France: Sauramps Medical, 1996;149-53.
15. Padovani B, Kasriel O, Brunner P, Peretti-Viton P. Pulmonary embolism caused by acrylic cement: a rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol 1999;20:375-7.

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