Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy

Safety and efficacy of vertebroplasty in the treatment of osteoporotic vertebral compression fractures: a prospective multicenter international randomized controlled study

BACKGROUND

Vertebral compression fractures (VCFs) treated non-operatively can diminish function and quality of life, and lead to chronic health effects. The short-term safety and effectiveness of vertebroplasty for symptomatic VCFs are well-documented, but long-term follow-up is needed.

PURPOSE

The aim of this paper was to analyse a multicenter international experience of 200 compression fractures treated with percutaneous vertebroplasty (VP) and compare the results of this procedure with the result of 200 patients treated conservatively. To estimate cost-effectiveness of VP compared to conservative care in terms of: pain reduction, quality of life, complications, secondary fractures and mortality.

MATERIALS AND METHODS

400 patients have been enrolled in a prospective randomized controlled study with painful VCFs with bone edema on MR imaging, local back pain for 6 weeks or less, osteoporosis and aged 55 years or older; after obtaining informed consent patients are included and randomized for VP or conservative care. Before treatment and at follow-up with regular intervals during 1-year period were administered to patients standard questionnaires addressing: clinical symptoms, pain medication, Visual Analogue Scale (VAS) score for pain, Oswestry Disability Index (ODI) score to evaluate functional activity.

RESULTS

200 patients treated with PV compared with 200 patients treated conservatively had significantly better VAS and used less analgesics 1 day after treatment. Twenty-four hours after VP, there was a reduction in pain scores and an improvement in physical functions, whereas remain unchanged in the patients treated conservatively.

CONCLUSIONS

Pain relief and improvement of mobility and function after PV is immediate and significantly better in the short term compared with non-surgical care treatment.

Predicting delayed union in osteoporotic vertebral fractures with consecutive magnetic resonance imaging in the acute phase: a multicenter cohort study

This study demonstrated the predictive values of radiological findings for delayed union after osteoporotic vertebral fractures (OVFs). High-signal changes on T2WI were useful findings.

INTRODUCTION

The purpose of the present study is to determine predictive radiological findings for delayed union by magnetic resonance imaging (MRI) and plain X-rays at two time points in the acute phase of OVFs.

METHODS

This multicenter cohort study was performed from 2012 to 2015. A total of 218 consecutive patients with OVFs ≤2 weeks old were enrolled. MRIs and plain X-rays were performed at the time of enrollment and at 1- and 6-month follow-ups. Signal changes on T1-weighted imaging (T1WI) were classified as diffuse low-, confined low-, or no-signal change; those on T2WI were classified as high (similar to the intensity of cerebrospinal fluid), confined low-, diffuse low-, or no-signal change. The angular motion of the fractured vertebral body was measured with X-rays.

RESULTS

A total of 153 patients completed the 6-month follow-up. A high-signal change on T2WI was most useful in predicting delayed union. Sensitivity, specificity, and positive predictive values were 53.3, 87.8, and 51.6 % at enrollment and 65.5, 84.8, and 51.4 % at the 1-month follow-up, respectively. The positive predictive value increased to 62.5 % with observation of high- or diffuse low-signal changes at both enrollment and the 1-month follow-up. The cutoff value of vertebral motion was 5 degrees. Sensitivity and specificity at enrollment were 52.4 and 74.1 %, respectively.

CONCLUSIONS

This study demonstrated the radiological factors predicting delayed union after an OVF. T2 high-signal changes showed the strongest association with delayed union. Consecutive MRIs were particularly useful as a differential tool to predict delayed union following OVFs.

Increased sagittal vertical axis is associated with less effective control of acute pain following vertebroplasty

OBJECTIVES

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.

PATIENTS AND METHODS

Patients with single-level acute osteoporotic vertebral compression fracture at thoracolumbar junction (T10 to L2) were followed. If the patients were not satisfied with acute pain reduction after a three-week conservative treatment, vertebroplasty was recommended. Pain assessment was carried out at the time of diagnosis, as well as three, four, six, and 12 weeks after the diagnosis. The effect of vertebroplasty, compared with conservative treatment, on back pain (visual analogue score, VAS) was analysed with the use of analysis-of-covariance models that adjusted for pre-operative VAS scores.

RESULTS

A total of 342 patients finished the 12-week follow-up, and 120 patients underwent vertebroplasty (35.1%). The effect of vertebroplasty over conservative treatment was significant regardless of age, body mass index, medical comorbidity, previous fracture, pain duration, bone mineral density, degree of vertebral body compression, and canal encroachment. However, the effect of vertebroplasty was not significant at all time points in patients with increased sagittal vertical axis.

CONCLUSIONS

For single-level acute osteoporotic vertebral compression fractures, the effect of vertebroplasty was less favourable in patients with increased sagittal vertical axis (> 5 cm) possible due to aggravation of kyphotic stress from walking imbalance.Cite this article: Y-C. Kim, D. H. Bok, H-G. Chang, S. W. Kim, M. S. Park, J. K. Oh, J. Kim, T-H. Kim. Increased sagittal vertical axis is associated with less effective control of acute pain following vertebroplasty. Bone Joint Res 2016;5:544-551. DOI: 10.1302/2046-3758.511.BJR-2016-0135.R1.

Application of digital volume correlation to study the efficacy of prophylactic vertebral augmentation

BACKGROUND

Prophylactic augmentation is meant to reinforce the vertebral body, but in some cases it is suspected to actually weaken it. Past studies only investigated structural failure and the surface strain distribution. To elucidate the failure mechanism of the augmented vertebra, more information is needed about the internal strain distribution. This study aims to measure, for the first time, the full-field three-dimensional strain distribution inside augmented vertebrae in the elastic regime and to failure.

METHODS

Eight porcine vertebrae were prophylactically-augmented using two augmentation materials. They were scanned with a micro-computed tomography scanner (38.8μm voxel resolution) while undeformed, and loaded at 5%, 10%, and 15% compressions. Internal strains (axial, antero-posterior and lateral-lateral components) were computed using digital volume correlation.

FINDINGS

For both augmentation materials, the highest strains were measured in the regions adjacent to the injected cement mass, whereas the cement-interdigitated-bone was less strained. While this was already visible in the elastic regime (5%), it was a predictor of the localization of failure, which became visible at higher degrees of compression (10% and 15%), when failure propagated across the trabecular bone. Localization of high strains and failure was consistent between specimens, but different between the cement types.

INTERPRETATION

This study indicated the potential of digital volume correlation in measuring the internal strain (elastic regime) and failure in augmented vertebrae. While the cement-interdigitated region becomes stiffer (less strained), the adjacent non-augmented trabecular bone is affected by the stress concentration induced by the cement mass. This approach can help establish better criteria to improve vertebroplasty.

Vertebroplasty and balloon kyphoplasty versus conservative treatment for osteoporotic vertebral compression fractures: A meta-analysis

OBJECTIVE

Although the majority of available evidence suggests that vertebroplasty and kyphoplasty can relieve pain associated with vertebral compression fractures (VCFs) and improve function, some studies have suggested results are similar to those of placebo. The purpose of this meta-analysis was to compare the outcomes of vertebroplasty and kyphoplasty with conservative treatment in patients with osteoporotic VCFs.

METHODS

Medline, Cochrane, and Embase databases were searched until January 31, 2015 using the keywords: vertebroplasty, kyphoplasty, compression fracture, osteoporotic, and osteoporosis. Inclusion criteria were randomized controlled trials (RCTs) in which patients with osteoporosis, and VCFs were treated with vertebroplasty/kyphoplasty or conservative management. Outcome measures were pain, function, and quality of life. Standardized differences in means were calculated as a measure of effect size.

MAIN RESULTS

Ten RCTs were included. The total number of patients in the treatment and control groups was 626 and 628, respectively, the mean patient age ranged from 64 to 80 years, and the majority was female. Vertebroplasty/kyphoplasty was associated with greater pain relief (pooled standardized difference in means = 0.82, 95% confidence interval [CI]: 0.374-1.266, P < 0.001) and a significant improvement in daily function (pooled standardized difference in means = 1.273, 95% CI: 1.028-1.518, P < 0.001) as compared with conservative treatment. The pooled estimate indicated vertebroplasty/kyphoplasty was associated with higher quality of life (pooled standardized difference in means = 1.545, 95% CI: 1.293-1.798, P < 0.001). Subgroup analysis of 8 vertebroplasty studies and 2 kyphoplasty studies that reported pain data, however, indicated that vertebroplasty provided greater pain relief than conservative treatment but kyphoplasty did not.

CONCLUSION

Vertebroplasty may provide better pain relief than balloon kyphoplasty in patients with osteoporotic VCFs, both may improve function, and their effect on quality of life is less clear.

Percutaneous Vertebroplasty Versus Conservative Treatment in Aged Patients With Acute Osteoporotic Vertebral Compression Fractures: A Prospective Randomized Controlled Clinical Study

STUDY DESIGN

A prospective randomized clinical trial.

OBJECTIVE

In this study, we determine whether percutaneous vertebroplasty (PVP) offers extra benefits to aged patients with acute osteoporotic vertebral compression fractures (OVCFs) over conservative therapy (CV).

SUMMARY OF BACKGROUND DATA

OVCFs are common in the aged population with osteoporosis. While the optimal treatment of aged patients with acute OVCFs remains controversial, PVP, a minimally invasive procedure, is a treatment option to be considered.

METHODS

Patients aged at 70 years or above with acute OVCF and severe pain from minor or mild trauma were assigned randomly to PVP and CV groups. The primary outcome was pain relief as measured by VAS score in 1-year follow-up period. The second outcome was quality of life assessed with ODI and Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Patient satisfaction surveys were also recorded.

RESULTS

A total of 135 patients were enrolled, and 107 (56 in PVP group; 51 in CV group) completed 1-year follow-up. In PVP group, the vertebroplasty procedure was performed at a mean of 8.4 ± 4.6 days (range, 2-21 days) after onset. Vertebroplasty resulted in much greater pain relief than did conservative treatment at postoperative day 1 (P < 0.0001). At every time point of follow-up, pain relief and quality of life were significantly improved in PVP group than in CV group at 1 week, 1 month, 3 months, 6 months, and 1 year (all P < 0.0001). The final follow-up surveys indicated that patients in PVP group were significantly more satisfied with given treatment (P < 0.0001). In addition, lower rate of complications was observed in PVP group (P < 0.0001).

CONCLUSION

In aged patients with acute OVCF and severe pain, early vertebroplasty yielded faster, better pain relief and improved functional outcomes, which were maintained for 1 year. Furthermore, it showed fewer complications than conservative treatment.

LEVEL OF EVIDENCE

2.

An evaluation of the functional and radiological results of percutaneous vertebroplasty versus conservative treatment for acute symptomatic osteoporotic spinal fractures

PURPOSE

This study aimed to compare the results of the two different treatment regimens (percutaneous vertebroplasty (PV) and conservative treatment (CT)) regarding to efficacy, quality of life, functional and radiological results in patients with acute osteoporotic vertebral compression fractures (OVF).

METHODS

The study comprised 83 patients who presented with complaints of OVF associated with osteoporosis and were treated with CT (37) or PV (46). All patients were evaluated according to preoperative and postoperative visual analogue scale (VAS), Oswestry disability index (ODI) and plain radiographs.

RESULTS

All patients in VP group reported a significant decrease in pain at 1st day postoperative. While Pain relief and functional outcomes were significantly better in PV group than CT at 1st and 3rd months according to VAS and ODI scores, there were no statistically significant differences between the groups at 6th months follow-up. The mean preoperative local sagittal Cobb angle (LSCA) and the mean vertebra corpus mid-level height (MVCH) were 42.3° and 14.6 mm in the PV group, while they were measured as 39.8° and 15.7 mm in CT group, respectively. 15.6° decreasing the LSCA and 10.2 mm increasing MVCH were noted in the PV group at the 6th month follow-up. While LSCA increased 19.1° and MVCH decreased 7.6mm in CT group at same time period (p<0.001).

CONCLUSIONS

Compared to the CT group, PV provides a rapid decrease of pain and an early return to daily life activities. Although improvement was observed on the radiological findings following treatment in the PV group, PV may not enhance the quality of life in patients with acute OVF at 6th months follow up.

Conservative Management of Osteoporotic Vertebral Fractures: A Prospective Study of Thirty Patients

Introduction

Osteoporotic vertebral fractures relate to poorer quality of life and higher long-term mortality. In a resource-poor setup, conservative management assumes great importance as primary means of treatment. We assess the clinico-pathological epidemiology of osteoporotic vertebral fractures and prospectively evaluate the effectiveness of conservative management in their treatment.

Materials & Methods   

Thirty consecutive patients, diagnosed with osteoporotic vertebral fracture, underwent the predetermined protocol of conservative treatment (bed rest, titrated analgesia, antiosteoporosis pharmacotherapy, bracing, and supervised physical therapy) after assessment of basic demographic data and clinical examination. They were evaluated every three months for nine months, using visual analog scale (VAS) for backpain, Oswestry Disability Index (ODI), and radiological and hematological parameters.

Results 

The mean age of the patients was 66.9 +/-7.6 years and the female: male ratio was 14:1. All (100%) women were postmenopausal and the mean time since menopause was 16.75 +/- 8.12 years. The presenting complaints were backpain (100%) and deformity (53.33%). Neurodeficit was noted in one (3.33%) patient. Higher age was correlated to greater vertebral collapse (p=0.001) and higher kyphotic angle (p=0.002). At nine months after treatment, there was a significant decrease in the VAS score (p<0.0001) and the ODI score (p<0.0001), with the final VAS score improving by 49.25% and the ODI score improving by 47.23% from the baseline. There was progressive increase in vertebral collapse (p=0.0474) with no change in kyphotic or scoliotic angles. With treatment there was a consistent increase in serum calcium (p<0.0001), phosphorous (p<0.0001), and vitamin D3 (p<0.0001) levels, and decrease in parathyroid hormone levels (p<0.0001).

Conclusions 

A multidisciplinary conservative treatment is effective as the primary treatment for patients with osteoporotic vertebral fractures. It alleviates pain, decreases disability, reduces morbidity, and is effective in preventing further progression of the disease process clinically, radiologically, and hematologically.

A prospective randomized controlled study comparing the pain relief in patients with osteoporotic vertebral compression fractures with the use of vertebroplasty or facet blocking

PURPOSE

To compare the clinical and radiological outcomes of patients undergoing percutaneous vertebroplasty (PVP) versus those undergoing facet blocking (FB) for severe pain due to osteoporotic vertebral compression fractures (OVCFs).

METHODS

Two hundred and six patients who had OVCFs on spine radiography and intractable back pain for ≤8 weeks were recruited between January 2009 and January 2013 (165 females and 41 males, age ≥55 years). Patients were randomly assigned to the PVP group (100 patients) or the FB group (106 patients). VAS, ODI, Roland Morris disability (RMD) scores, scores on the Standardized Physical Component of the SF-36 form (SPC) and scores on the Standardized Mental Component of the SF-36 form (SMC) were determined preoperatively and at each follow-up time (1 day, 1 week, 1, 3, 6, and 12 months). In addition, plain radiographs were obtained at 3, 6, and 12 months postoperatively to detect new fractures.

RESULTS

Significantly lower VAS, ODI, and RMD scores for patients in the PVP group compared to those in the FB group were observed at follow-up of 1 day and 1 week (p < 0.05). However, differences in the VAS, ODI, RMD and SPC/MCS (SF-36) scores between the two groups at follow-ups of more than 1 month were statistically insignificant (p > 0.05). Difference in numbers of new fractures in the two groups at the follow-up of 12 months was also statistically insignificant.

CONCLUSIONS

PVP produced better pain relief than FB in the short term (≤1 week). However, the difference in pain-relief between these two techniques was insignificant in the long term (follow-up between 1 month and 12 months).

Percutaneous Vertebroplasty: A New Serial Injection Technique to Minimize Cement Leak

Study Design

This is a prospective cohort study.

Purpose

This study discusses a new technique for injecting cement in the affected vertebrae.

Overview of Literature

Since introduction of vertebroplasty to clinical practice, the cement leak is considered the most frequent and hazardous complication. In literature, the cement extravasation occurred in 26%-97% of the cases.

Methods

A hundred and twenty-three patients underwent vertebroplasty using the serial injection technique. The package of the cement powder and the solvent was divided into five equal parts. Each part of the powder and the solvent was mixed as a single dose and injected to the affected vertebra. The duration between subsequent injections was 10 minutes. Each injection consisted of 1-1.5 mL of cement.

Results

This new technique gives the surgeon enough time to make multiple separate injections using the same package. The time interval between injections hardens the cement just enough so that it does not get displaced by the next cement injection. This technique gives time to the preceding injected cement to seal off the cracks and cavities in the vertebra, and subsequently leads to a significant decrease in cement leak (p<0.001), as compared to literature.

Conclusions

This study demonstrates a previously unreported technique for vertebroplasty that adds more safety to the procedure by significantly decreasing cement leak. It also makes the surgeon more relaxed due to time intervals, giving him more self-confidence whilst performing the procedure.

Treating the Aging Spine

Demographic trends make it incumbent on orthopaedic spine surgeons to recognize the special challenges involved in caring for older patients with spine pathology. Unique pathologies, such as osteoporosis and degenerative deformities, must be recognized and dealt with. Recent treatment options and recommendations for the medical optimization of bone health include vitamin D and calcium supplementation, diphosphonates, and teriparatide. Optimizing spinal fixation in elderly patients with osteoporosis is critical; cement augmentation of pedicle screws is promising. In the management of geriatric odontoid fractures, nonsurgical support with a collar may be considered for the low-demand patient, whereas surgical fixation is favored for high-demand patients. Management of degenerative deformity must address sagittal plane balance, including consideration of pelvic incidence. Various osteotomies may prove helpful in this setting.

Vertebroplasty and kyphoplasty: national outcomes and trends in utilization from 2005 through 2010

BACKGROUND CONTEXT

Vertebral compression fractures secondary to low bone mass are responsible for almost 130,000 inpatient admissions and 133,500 emergency department visits annually, totaling over $5 billion of direct inpatient costs. Although most vertebral compression fractures heal within a few months with conservative therapy, a significant portion fail to improve with conservative treatment and require long-term care, conservative treatment, or both. Fractures that fail conservative therapy are treated with vertebral augmentation procedures (VAPs) such as vertebroplasty (VP) and kyphoplasty (KP). Two large randomized clinical trials published in 2009 questioned the efficacy of VP in treatment of VAPs.

PURPOSE

This study aimed to investigate trends in utilization of VP and KP between 2005 and 2010 to capture the impact of the 2009 literature on utilization of VAPs. The study also compares patient characteristics and perioperative outcomes between VP and KP to further delineate the risks of each procedure.

STUDY DESIGN

Retrospective analysis of national utilization rates, clinical outcomes, patient demographics, and patient comorbidities using a large national inpatient database.

PATIENT SAMPLE

A total of 63,459 inpatient admissions from 46 states and more than 1,000 different hospitals were included in the analysis.

OUTCOME MEASURES

Length of stay (LOS), total direct cost, mortality, postoperative complications.

METHODS

Data were obtained from the National Inpatient Sample database for the period between 2005 and 2010. National Inpatient Sample is the largest publicly available all payer inpatient database in the United States. Patients undergoing VP and KP were identified via corresponding the International Classification of Diseases, 9th Revision procedure codes. National utilization trends were estimated using weights supplied as part of the National Inpatient Sample dataset. Information on patient comorbidities and demographics was collected. A series of univariate and multivarariate analyses were used to identify statistically significant differences in patient characteristics, clinical outcomes, as well as cost and LOS between patients undergoing VP versus KP.

RESULTS

A total of 307,050 inpatient VAPs were performed in the United States between 2005 and 2010. Of those procedures, 225,259 were KP and 81,790 were VP. Kyphoplasty utilization showed an increasing trend between 2005 and 2007, increasing from 27 to 33 procedures per 100,000 capita older than 40 years. During the same time period, VP utilization remained constant at approximately nine procedures per 100,000 capita older than 40 years. After 2007, utilization of both VP and KP decreased. The most precipitous decrease in VAP utilization occurred in 2009. Patients undergoing VP were on average older (76.7 vs. 77.8, p<.0001), more frequently women (74.48% vs. 73.15%, p=.00083), and black (1.77% vs. 1.55%, p=.004059). Patients undergoing VP had on average more comorbidities then those undergoing KP. Patients undergoing VP had a higher rate of postoperative anemia secondary to acute bleeding and higher rate of venous thromboembolic events. Those undergoing KP had a greater rate of cardiac complications; however, this difference was not statistically significant when taking into account patient age and comorbidity burden. Vertebroplasty was associated with higher mortality (0.93% vs. 0.60%, p<.001), longer LOS (6.78 vs. 5.05 days, p<.0001), and lower total cost ($42,154 vs. $46,101, p<.0001).

CONCLUSIONS

Overall, KP was associated with lower complication rates, shorter LOS, and a higher total direct cost compared with VP. Utilization rates showed a significant decrease since 2009 in both VP and KP, suggesting that both procedures were impacted by the two randomized controlled trials published in 2009 that suggested poor efficacy of VP.

The relationship between the spinopelvic balance and the incidence of adjacent vertebral fractures following percutaneous vertebroplasty

We evaluated the relationship between sagittal spinopelvic parameters and the occurrence of adjacent vertebral fractures (AVF) and determined the possible risk factor. The most important factors for AVFs are the degree of osteoporosis and altered biomechanics due to the spinopelvic imbalance in the fractured area of the spine.

INTRODUCTION

We intend to evaluate the relationship between sagittal spinopelvic parameters and the occurrence of adjacent vertebral fractures following the initial compression fracture and to determine the possible dominant risk factor associated with new compression fractures.

METHODS

From March 2010 to May 2012, 240 consecutive patients with painful vertebral compression fractures (VCFs) were enrolled in a retrospective study. Ninety-one patients with VCFs underwent percutaneous vertebroplasty (VP) at 112 levels. The sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and segmental kyphotic angle on sagittal standing radiographs were used to evaluate radiologic outcomes.

RESULTS

In 2 years, 15 out of 134 patients (11.1%) treated with conservative treatment, and 12 out of 91 patients (13.1%) treated with VP sustained adjacent level fracture. More patients with the BMD higher or equal to 3.0 experienced a new fracture than those with a BMD less than 3.0 (p = 0.019), and the risk for adjacent level fractures decreased significantly when segmental kyphotic angle was less than 11° (p = 0.001), SVA was less than 6 cm (p = 0.001), SS was higher or equal to 25° (p = 0.004), and LL was higher or equal to 25° (p = 0.020).

CONCLUSIONS

The most important factors for new VCFs after the initial compression fractures are the degree of osteoporosis and altered biomechanics due to the spinopelvic imbalance in the fractured area of the spine. Regarding the spinopelvic alignment to investigate the relationship with a subsequent AVF, segmental kyphotic angle, SS, LL, and SVA may be a potential predictor.

Critique of the analysis of UpToDate.com on the treatment of painful vertebral compression fractures: time to update UpToDate

The treatment of painful vertebral compression fractures has changed substantially since the introduction of vertebroplasty in the mid-1980s and balloon kyphoplasty in the late 1990s. Both procedures were widely accepted with the vertebral fractures treated reaching 150,000 per annum in 2009 prior to the publication of 2 randomized controlled trials comparing vertebroplasty with a sham treatment published in the New England Journal of Medicine in August 2009. Since then, there has been a flood of information on vertebral augmentation and balloon kyphoplasty. It is worth evaluating this information especially because it relates to current recommendations that are often followed blindly by medical and administrative groups unfamiliar with either the procedure or the high level of evidence surrounding vertebral augmentation. To streamline the evaluation of some current recommendations, we limited the analysis to the recommendations found on UpToDate.com. This Web site is an evidence-based, peer-reviewed source of information available for patients, doctors, health insurance companies, and population-based medical decision-making.

Is kyphoplasty better than vertebroplasty at restoring form and function after severe vertebral wedge fractures?

BACKGROUND CONTEXT

The vertebral augmentation procedures, vertebroplasty and kyphoplasty, can relieve pain and facilitate mobilization of patients with osteoporotic vertebral fractures. Kyphoplasty also aims to restore vertebral body height before cement injection and so may be advantageous for more severe fractures.

PURPOSE

The purpose of this study was to compare the ability of vertebroplasty and kyphoplasty to restore vertebral height, shape, and mechanical function after severe vertebral wedge fractures.

STUDY DESIGN/SETTING

This is a biomechanical and radiographic study using human cadaveric spines.

METHODS

Seventeen pairs of thoracolumbar "motion segments" from cadavers aged 70-98 years were injured, in a two-stage process involving flexion and compression, to create severe anterior wedge fractures. One of each pair underwent vertebroplasty and the other kyphoplasty. Specimens were then compressed at 1 kN for 1 hour to allow consolidation. Radiographs were taken before and after injury, after treatment, and after consolidation. At these same time points, motion segment compressive stiffness was assessed, and intervertebral disc "stress profiles" were obtained to characterize the distribution of compressive stress on the vertebral body and neural arch.

RESULTS

On average, injury reduced anterior vertebral body height by 34%, increased its anterior wedge angle from 5.0° to 11.4°, reduced intradiscal (nucleus) pressure and motion segment stiffness by 96% and 44%, respectively, and increased neural arch load bearing by 57%. Kyphoplasty caused 97% of the anterior height loss to be regained immediately, although this reduced to 79% after consolidation. Equivalent gains after vertebroplasty were significantly lower: 59% and 47%, respectively (p<.001). Kyphoplasty reduced vertebral wedging more than vertebroplasty (p<.02). Intradiscal pressure, neural arch load bearing, and motion segment compressive stiffness were restored significantly toward prefracture values after both augmentation procedures, even after consolidation, but these mechanical effects were similar for kyphoplasty and vertebroplasty.

CONCLUSIONS

After severe vertebral wedge fractures, vertebroplasty and kyphoplasty were equally effective in restoring mechanical function. However, kyphoplasty was better able to restore vertebral height and reverse wedge deformity.

Is thoracolumbar fascia injury the cause of residual back pain after percutaneous vertebroplasty? A prospective cohort study

Some patients with osteoporotic vertebral compression fractures still suffer from back pain after percutaneous vertebroplasty. We have found that osteoporotic vertebral compression fractures with thoracolumbar fascia injury are common and that thoracolumbar fascia injury may account for the residual pain after percutaneous vertebroplasty.

PURPOSE

Osteoporotic vertebral compression fractures are successfully treated with percutaneous vertebroplasty (PVP). However, some patients still suffer from back pain after the procedure. We hypothesized that there is a relationship between thoracolumbar (TL) fascia injury and residual postoperative pain.

METHODS

This prospective study included 133 elderly patients (age range 55 - 92 years) with osteoporotic vertebral compression fractures treated with PVP from February 2010 to March 2012 in our hospital. The patients were divided into two groups based on the presence of TL fascia injury. A visual analog scale (VAS) and the Chinese modified Oswestry Disability Index were used to evaluate the pain before and after PVP.

RESULTS

The mean VAS score and the Chinese modified Oswestry Disability Index in the patients with TL fascia injury were reduced from 9.11 ± 0.76 to 6.4 ± 1.1 and 73.93 ± 1.46% to 44.6 ± 3.1%, respectively, and in the patients without TL fascia injury from 9.26 ± 0.82 to 8.0 ± 1.3 and 73.96 ± 1.38% to 51.7 ± 1.8%, respectively. Pain and disability were reduced more in patients without TL fascia injury than in those with TL fascia injury (both p < 0.05).

CONCLUSIONS

There may be a relationship between TL fascia injury and residual back pain after PVP.

Clinical outcome after the use of a new craniocaudal expandable implant for vertebral compression fracture treatment: one year results from a prospective multicentric study

The purpose of this prospective multicentric observational study was to confirm the safety and clinical performance of a craniocaudal expandable implant used in combination with high viscosity PMMA bone cement for the treatment of vertebral compression fractures. Thirty-nine VCFs in 32 patients were treated using the SpineJack minimally invasive surgery protocol. Outcome was determined by using the Visual Analogue Scale for measuring pain, the Oswestry Disability Index for scoring functional capacity, and the self-reporting European Quality of Life scores for the quality of life. Safety was evaluated by reporting all adverse events. The occurrence of cement leakages was assessed by either radiographs or CT scan or both. Statistically significant improvements were found regarding pain, function, and quality of life. The global pain score reduction at 1 year was 80.9% compared to the preoperative situation and the result of the Oswestry Disability Index showed a decrease from 65.0% at baseline to 10.5% at 12 months postoperatively. The cement leakage rate was 30.8%. No device- or surgery-related complications were found. This observational study demonstrates promising and persistent results consisting of immediate and sustained pain relief and durable clinical improvement after the procedure and throughout the 1-year follow-up period.

Is vertebroplasty a risk factor for subsequent vertebral fracture, meta-analysis of published evidence?

In our paper, we systemically retrieved the eligible study evaluating whether increased incidence of subsequent vertebral fracture is associated with vertebroplasty. Main effect sizes were vertebral fracture rates reported in terms of hazard ratio (HR) for time-to-event data or relative risk (RR) for dichotomous outcome. Our results do not support the hypothesis that vertebroplasty contributes to increased risk of subsequent vertebral fracture, neither adjacent nor total vertebral fracture.

INTRODUCTION

Vertebroplasty has been implicated in significant changes in vertebral strength, vertebral shape, and consequently increased risk for subsequent vertebral fracture, especially the adjacent level. Here, we further tested the hypothesis whether new-onset vertebral fracture is a natural result of osteoporosis or consequence of cement augmentation.

METHODS

Relevant literatures were retrieved using PubMed, Web of Knowledge, and Cochrane Central Register of Controlled Trials (CENTRAL), supplemented by a hand-search of the reference lists of selected articles. Eligible studies assessed whether increased morbidity of subsequent vertebral fracture is associated with vertebroplasty. Main effect sizes were vertebral fracture rates reported in terms of hazard ratio (HR) for time-to-event data or relative risk (RR) for dichotomous outcome. Random-effects model was used to account for clinical or methodological heterogeneity across studies.

RESULTS

Thirteen studies with a number of 2,551 individuals (1,631 in vertebroplasty group and 920 in control group) were suitable for this meta-analysis. In trials that reported adjacent vertebral fracture as time-to-event data (two trials, n = 328), we found a similar incidence of vertebral fracture in percutaneous vertebroplasty (PVP) group compared to conservative therapy (HR 0.60, 95% confidence interval 0.29 to 1.26; P = 0.18). In trials that reported overall vertebral fracture as time-to-event data (three trials, n = 704), vertebroplasty was associated with a slightly increased but non-significant risk for vertebral fracture (HR 1.14, 95% confidence interval 0.65 to 2.00; P = 0.65). The outcome was further confirmed in the secondary meta-analysis of studies that reported vertebral fracture as dichotomous data. Subgroup analysis according to study design revealed no difference either.

CONCLUSIONS

Our results do not support the hypothesis that vertebroplasty contributes to increased risk of subsequent vertebral fracture, neither adjacent nor total vertebral fracture. However, adequately designed randomized controlled trials are warranted to confirm the present findings.

Lumbar Nerve Root Compression due to Leakage of Bone Cement after Vertebroplasty

We experienced a 73-year-old male with lumbar nerve root compression due to leakage of bone cement after vertebroplasty. He was underwent vertebroplasty for acute osteoporotic L4 compression fracture at our hospital. After vertebroplasty, his back pain was improved but right leg pain was newly developed. Lumbar computed tomography scanning showed that bone cements were leaked along the L4 nerve root. The leaked cements around L4 nerve root were removed carefully via paraspinal muscle-splitting approach. After operation, severe right leg radiating pain was improved. We recommend proper entry point, high viscosity of polymethylmethacrylate and constant monitoring can reduce complication.

Real-life results of balloon kyphoplasty for vertebral compression fractures from the SWISSspine registry

BACKGROUND CONTEXT

The Swiss Federal Office of Public Health mandated a nationwide health technology assessment-registry for balloon kyphoplasty (BKP) for decision making on reimbursement of these interventions. The early results of the registry led to a permanent coverage of BKP by basic health insurance. The documentation was continued for further evidence generation.

PURPOSE

This analysis reports on the 1 year results of patients after BKP treatment.

STUDY DESIGN

Prospective multicenter observational case series.

PATIENT SAMPLE

The data on 625 cases with 819 treated vertebrae were documented from March 2005 to May 2012.

OUTCOME MEASURES

Surgeon-administered outcome instruments were primary intervention form for BKP and the follow-up form; patient self-reported measures were EuroQol-5D questionnaire, North American Spine Society outcome instrument /Core Outcome Measures Index (including visual analog scale), and a comorbidity questionnaire. Outcome measures were back pain, medication, quality of life (QoL), cement extrusions, and new fractures within the first postoperative year.

METHODS

Data were recorded preoperatively and at 3 to 6-month and 1-year follow-ups. Wilcoxon signed-rank test was used for comparison of pre- with postoperative measurements. Multivariate logistic regression was used to identify factors with a significant influence on the outcome.

RESULTS

Seventy percent of patients were women with mean age of 71 years (range, 18-91 years); mean age of men was 65 years (range, 15-93 years). Significant and clinically relevant reduction of back pain, improvement of QoL, and reduction of pain killer consumption was seen within the first postoperative year. Preoperative back pain decreased from 69.3 to 29.0 at 3 to 6-month and remained unchanged at 1-year follow-ups. Consequently, QoL improved from 0.23 to 0.71 and 0.75 at the same follow-up intervals. The overall vertebra-based cement extrusion rates with and without extrusions into intervertebral discs were 22.1% and 15.3%, respectively. Symptomatic cement extrusions with radiculopathy were five (0.8%). A new vertebral fracture within a year from the BKP surgery was observed in 18.4% of the patients.

CONCLUSIONS

The results of the largest observational study for BKP so far are consistent with published randomized trials and systematic reviews. In this routine health care setting, BKP is safe and effective in reducing pain, improving QoL, and lowering pain_killer consumption and has an acceptable rate of cement extrusions. Postoperative outcome results show clear and significant clinical improvement at early follow-up that remain stable during the first postoperative year.

Prospective quantitative assessment of spinal range of motion before and after minimally invasive surgical treatment of vertebral body fractures

INTRODUCTION

Randomized clinical trials have generated doubts regarding the therapeutic effectiveness of spinal kyphoplasty to reduce pain and improve quality of life in patients with vertebral fractures. There is a paucity of data on the influence of kyphoplasty on spinal range of motion. To quantify early postoperative changes following kyphoplasty in spinal motion, a noninvasive, radiation-free measurement method was used and results related to clinical and radiological parameters.

METHODS

The study group included 30 patients with an overall number of 54 symptomatic pathological vertebral compression fractures. All patients were treated with balloon kyphoplasty. Clinical results were recorded using the visual analog scale, SF 36, Roland Morris Score and the Oswestry Disability Index, at three time points; preoperative, 2 days postoperative, and at 12 weeks postoperative. The kyphosis angle/sagittal index were determined with biplanar X-rays. Amplitude/velocity of motion in extension/flexion was measured at each time point by use of the EpionicsSPINE(©) system (Epionics Medical GmbH; Potsdam, Germany) using two external sensor strips.

RESULTS

Preoperative magnetic resonance imaging scans showed bone marrow edema in all vertebral bodies indicative of a recent, non-consolidated fracture. Pain and quality of life was significantly improved by kyphoplasty, both for the immediate postoperative period, as well as at 12 weeks postoperative. Radiological parameters also showed significant improvement following surgery. Total ROM did not significantly change 2 days after kyphoplasty, but amplitude and velocity were found to be increased 12 weeks postoperatively. Significant positive correlations were observed between increased range of motion and improved clinical/radiological scores.

CONCLUSION

Significant clinical and radiological improvement following kyphoplasty supports the rational for cement augmentation in patients with pathological vertebral body fractures. To the knowledge of the authors, no prior study has assessed the influence of preservation and improvement of spinal range of motion on clinical outcome following kyphoplasty.

Two-year results of a randomized placebo-controlled trial of vertebroplasty for acute osteoporotic vertebral fractures

We previously reported the results of a randomized controlled trial that found no benefit of vertebroplasty over a sham procedure for acute osteoporotic vertebral fractures up to 6 months. We report here the 12-month and 24-month clinical outcomes of this trial. Eligible participants (n = 78) were randomly assigned to receive either vertebroplasty (n = 38) or a sham procedure (n = 40). Randomization was stratified by treatment center, sex, and symptom duration (<6 weeks or ≥6 weeks). Participants, investigators (except the treating radiologists), and outcome assessors were blinded to group assignments. Enrolment occurred between April 2004 and October 2008 with follow-up completed October 2010. The primary outcome was overall pain measured on a scale of 0 (no pain) to 10 (maximal imaginable pain). Secondary outcomes included pain at rest and at night, disability, quality of life, perceived recovery, and adverse events, including incident clinically apparent vertebral fractures. At 12 and 24 months, complete data were available for 67 (86%) and 57 (73%) participants, respectively. At 12 months participants in the active group improved by 2.4 ± 2.7 (mean ± SD) units in overall pain compared with 1.9 ± 2.8 units in the sham group, adjusted between-group mean difference (MD) 0.3 (95% confidence interval [CI], –0.9 to 1.5), whereas at 24 months participants in the active group had improved by 3.0 ± 3.1 units compared with 1.9 ± 3.0 units in the sham group, MD 1.1 (95% CI, –0.3 to 2.4). No significant between-group differences were observed for any of the secondary efficacy outcomes at 12 or 24 months. There were no between-group differences in incident clinical vertebral fractures up to 24 months (active: n = 14, sham: n = 13), although the study had inadequate power for this outcome. These results provide further evidence that the use of this treatment in routine care is unsupported.

Biomechanical effects of vertebroplasty on thoracolumbar burst fracture with transpedicular fixation: a finite element model analysis

OBJECTIVE

To investigate the biomechanical effects of augmentation of the fractured vertebrae after posterior instrumentation.

METHODS

By simulating internal fixation plus augmentation with cement, eight tridimensional, anatomically detailed finite element models of the T11-L1 functional spinal junction were developed. Two kinds of models for mimicking different severity of the fracture were established according to the Denis' classification. Augmentation with cement was conducted after reduction with posterior fixation using a universal spine system. These models assumed a three-column loading configuration as follows: compression, anteflexion, extension, lateroflexion and axial rotation. Stress of the implants and spine was evaluated.

RESULTS

Data showed that for severely fractured models, augmentation apparently decreased the von Mises stresses by 50% for the rods and 40% for the screws, about 40% for the inferior endplate of T11, and 50% for the superior endplate of L1 in vertical compression and other load situations.

CONCLUSION

We should only apply vertebroplasty to prevent correction loss and implants failure based on the fact that it could significantly decrease stress of the instrumentations and spine when the vertebrae are severely fractured.

LEVEL OF EVIDENCE

Level IV, biomechanical study.

Risks and benefits of percutaneous vertebroplasty or kyphoplasty in the management of osteoporotic vertebral fractures

Vertebral fracture (VF) is the most common osteoporotic fracture and is associated with high morbidity and mortality. Conservative treatment combining antalgic agents and rest is usually recommended for symptomatic VFs. The aim of this paper is to review the randomized controlled trials comparing the efficacy and safety of percutaneous vertebroplasty (VP) and percutaneous balloon kyphoplasty (KP) versus conservative treatment. VP and KP procedures are associated with an acceptable general safety. Although the case series investigating VP/KP have all shown an outstanding analgesic benefit, randomized controlled studies are rare and have yielded contradictory results. In several of these studies, a short-term analgesic benefit was observed, except in the prospective randomized sham-controlled studies. A long-term analgesic and functional benefit has rarely been noted. Several recent studies have shown that both VP and KP are associated with an increased risk of new VFs. These fractures are mostly VFs adjacent to the procedure, and they occur within a shorter time period than VFs in other locations. The main risk factors include the number of preexisting VFs, the number of VPs/KPs performed, age, decreased bone mineral density, and intradiscal cement leakage. It is therefore important to involve the patients to whom VP/KP is being proposed in the decision-making process. It is also essential to rapidly initiate a specific osteoporosis therapy when a VF occurs (ideally a bone anabolic treatment) so as to reduce the risk of fracture. Randomized controlled studies are necessary in order to better define the profile of patients who likely benefit the most from VP/KP.

Transpedicular vertebroplasty after intravertebral cavity formation versus conservative treatment for osteoporotic burst fractures

BACKGROUND CONTEXT

There has been no study regarding the comparison between vertebroplasty and conservative treatment for osteoporotic burst fracture.

PURPOSE

To compare the results of vertebroplasty after intravertebral cavity formation with that of conservative treatment alone.

STUDY DESIGN

A case-control study.

METHODS

The vertebroplasty group included 40 consecutive patients with primary osteoporotic burst fracture who underwent vertebroplasty using calcium phosphate cement, and the control group was made up of 40 patients given conservative treatment alone who were matched for age, gender, the injury level, and the type of fracture. Two groups of patients who had no neural deficit were prospectively examined. Clinical and radiological outcomes of these two groups were compared blindly. The authors do not report any conflict of interest in this study.

OUTCOME MEASURES

Outcome measures included visual analog scale (VAS) of the back pain, analgesic requirements, and mobility; in a lateral radiograph, the deformity index was measured and expressed as the ratio of the vertebral body (VB) height (sum of measurements at anterior, middle, and posterior regions of VB) to the longitudinal diameter of VB. Anteroposterior height comparison was expressed as the percentage of VB height at the anterior region compared with the height at the posterior region. Each recovery rate was calculated as a percentage by the formula: (value at the examination-value before treatment)/value before treatment × 100.

RESULTS

The duration of follow-up was more than 12 months (mean; 22.5 months). The mean VAS at 12 months after injury was 2.17 cm in the conservative group and 0.61 cm in the vertebroplasty group (p=.0002). The mean duration of analgesic medication required was 157.2 days in the conservative group and 21.3 days in the vertebroplasty group (p=.0048). The mean deformity index at 12 months after injury was 1.66 in the vertebroplasty group and 1.38 in the control group, and the mean recovery rate was +7.3% and -18.4%, respectively (p<.0001). Anteroposterior height comparison at 12 months after injury was 49.1% in the conservative group and 71.2% in the vertebroplasty group, and the mean recovery rate was -26.4% and +30.1%, respectively (p<.0001). One fracture in the vertebroplasty group showed delayed union until 6 months after injury. In the control group, there were six delayed union including four pseudoarthroses at over 6 months after injury that caused leg pain and were treated by conservative therapy.

CONCLUSIONS

We conclude that vertebroplasty after intravertebral cavity formation provided a better clinical and radiological result than conservative treatment for osteoporotic burst fracture.

Vertebroplasty increases compression of adjacent IVDs and vertebrae in osteoporotic spines

BACKGROUND CONTEXT

Approximately 25% of vertebroplasty patients experience subsequent fractures within 1 year of treatment, and vertebrae adjacent to the cemented level are up to three times more likely to fracture than those further away. The increased risk of adjacent fractures postaugmentation raises concerns that treatment of osteoporotic compression fractures with vertebroplasty may negatively impact spine biomechanics.

PURPOSE

To quantify the biomechanical effects of vertebroplasty on adjacent intervertebral discs (IVDs) and vertebral bodies (VBs).

STUDY DESIGN

A biomechanics study was conducted using cadaveric thoracolumbar spinal columns from elderly women (age range, 51-98 years).

METHODS

Five level motion segments (T11-L3) were assigned to a vertebroplasty treated or untreated control group (n=10/group) such that bone mineral density (BMD), trabecular architecture, and age were similar between groups. Compression fractures were created in the L1 vertebra of all specimens, and polymethylmethacrylate bone cement was injected into the fractured vertebra of vertebroplasty specimens. All spine segments underwent cyclic axial compression for 115,000 cycles. Microcomputed tomography imaging was performed before and after cyclic loading to quantify compression in adjacent VBs and IVDs.

RESULTS

Cyclic loading increased strains 3% on average in the vertebroplasty group when compared with controls after 115,000 cycles. This global strain manifested locally as approximately fourfold more compression in the superior VB (T12) and two- to fourfold higher axial and circumferential deformations in the superior IVD (T12-L1) of vertebroplasty-treated specimens when compared with untreated controls. Low BMD and high cement fill were significant factors that explained the increased strain in the vertebroplasty-treated group.

CONCLUSIONS

These data indicate that vertebroplasty alters spine biomechanics resulting in increased compression of adjacent VB and IVD in severely osteoporotic women and may be the basis for clinical reports of adjacent fractures after vertebroplasty.

Current status of percutaneous vertebroplasty and percutaneous kyphoplasty--a review

Percutaneous vertebroplasty (PV) and kyphoplasty (PK) are the 2vertebral augmentation procedures that have emerged as minimally invasive surgical options to treat painful vertebral compression fractures (VCF) during the last 2 decades. VCF may either be osteoporotic or tumor-associated. Two hundred million women are affected by osteoporosis globally. Vertebral fracture may result in acute pain around the fracture site, loss of vertebral height due to vertebral collapse, spinal instability, and kyphotic deformity. The main goal of the PV and PK procedures is to give immediate pain relief to patients and restore the vertebral height lost due to fracture. In percutaneous vertebroplasty, bone cement is injected through a minimal incision into the fractured site. Kyphoplasty involves insertion of a balloon into the fractured site, followed by inflation-deflation to create a cavity into which the filler material is injected, and the balloon is taken out prior to cement injection. This literature review presents a qualitative overview on the current status of vertebral augmentation procedures,especially PV and PK, and compares the efficacy and safety of these 2 procedures. The review consists of a brief history of the development of these 2 techniques, a discussion on the current research on the bone cement, clinical outcome of the 2 procedures, and it also sheds light on ongoing and future research to maximize the efficacy and safety of vertebral augmentation procedures.

Guidance on the management of pain in older people

This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

Risk factors for new vertebral fractures after percutaneous vertebroplasty in patients with osteoporosis: a prospective study

PURPOSE

To determine the risk factors for new vertebral compression fractures (VCFs) following percutaneous vertebroplasty (PV) in patients with osteoporosis.

MATERIALS AND METHODS

This prospective study included 132 consecutive patients with osteoporosis treated with PV in a single institution over 46 months from March 2005 to December 2008. Multivariable logistic regression and univariate analysis were employed to identify risk factors for new VCFs after PV, including patient demographic data, parameters of the initial and new fractured vertebrae, procedure-related information, and follow-up data.

RESULTS

During the follow-up period (22.4 months ± 12.1), 80 new vertebral fractures occurred in 36 (27.3%) patients. Multivariate analysis showed that number of VCFs per time frame, computed tomography (CT) value of nonfractured vertebrae (T11-L2), activity level after discharge, duration of follow-up, and cement distribution in the inferior part of the vertebral body or close to the endplate were statistically correlated with new fractures (odds ratios, 2.63, 0.96, 3.59, 1.00, 0.30, and 0.05; P = .006, P = .001, P = .007, P = .004, P = .021 and P = .029). Univariate analysis showed preexisting old VCFs were correlated with new VCFs (P = .045). Subsequent compression fractures in adjacent vertebrae (45 of 80) occurred more frequently and sooner than nonadjacent vertebral fractures (both P < .05).

CONCLUSIONS

The incidence of new VCFs after PV is relatively high and affected by several risk factors that are related to both the PV procedure and the natural course of osteoporosis.

Clinical Effects and Radiological Results of Vertebroplasty: Over a 2-year Follow-Up Period

Objective

We investigated the association between clinical and radiological results and assessed the radiological changes according to the distribution pattern and amount of injected cement after vertebroplasty.

Methods

Two hundred and one patients underwent vertebroplasty; of these, 15 were follow up for more than 2 years. For radiological analysis, we grouped the patients according to cement distribution as follows: group 1, unilateral, unilateral distribution of cement; group 2, bilateral-uneven, bilateral distribution of cement but separated mass; and group 3, bilateral-even, bilateral single mass of cement. To compare radiologic with clinical results, we assessed the visual analogue scale (VAS) score, amount of injected cement, bone mineral density (BMD), postoperative and follow-up vertebral body compression ratios, and postoperative and follow-up kyphotic angles.

Results

There were 4 (26.7%) patients in group 1, 6 (40.0%) in group 2, and 5 (33.3%) in group 3. The mean VAS score was 5.2 preoperatively, 1.8 postoperatively, and 3.2 at 2-year follow-up. The 2-year follow-up compression ratio was better in patients with even distribution of injected cement (group 2 and 3) than group 1. However, it was not statistically insignificant (p>0.05). The follow-up kyphotic angle was more aggravated in the group 1 than in the other groups (p<0.05).

Conclusion

Our study showed that vertebroplasty had a beneficial effect on pain relief, particularly in the immediate postoperative stage. The augmented spine tended to be more stable in the cases with increased amount and more even distribution of injected cement.

[The end of vertebroplasties]

In 2009, two clinical trials that questioned the usefulness of vertebroplasty for the treatment of osteoporotic fractures compared with conservative treatment were reported in the New England Journal of Medicine, leading to wide debate in the literature. In this article, we provide a critical review of the scientific evidence in this field and discuss our own experience with this technique.

Comparative analysis of clinical outcomes in patients with osteoporotic vertebral compression fractures (OVCFs): conservative treatment versus balloon kyphoplasty

BACKGROUND CONTEXT

Most osteoporotic vertebral compression fractures (OVCFs) can be treated conservatively. Recently, kyphoplasty has become a common treatment for painful osteoporotic compression fractures and has shown numerous benefits, such as early pain control and height restoration of the collapsed vertebral body. In spite of being a simple procedure, numerous complications related to kyphoplasty have been reported. Moreover, there is limited evidence to support its superiority.

PURPOSE

To compare the clinical outcomes of patients with OVCF according to different treatment modalities and identify clinical risk factors related to failure of conservative treatment of OVCF.

STUDY DESIGN

A prospective study consisting of a review of case report forms. PATIENTS SAMPLE: We prospectively enrolled 259 patients who had one or two acute painful OVCFs confirmed by magnetic resonance imaging. All patients were treated conservatively in the initial 3 weeks. Kyphoplasty was performed in 91 patients who complained of sustained back pain and disability in spite of conservative treatment for the initial 3 weeks.

OUTCOME MEASURES

Pain score using visual analog scale (VAS) and the Oswestry Disability Index (ODI).

METHODS

Participants were stratified according to age, sex, level and number of fractures, bone mineral density, body mass index (BMI), collapse rates, and history of spine fractures. Pain scores using VASs were assessed at 1 week and at 1, 3, 6, and 12 months.

RESULTS

A total of 259 patients were enrolled, and 231 patients (82 of 91 patients in the kyphoplasty group [KP] and 149 of 168 patients in the conservative treatment group) completed the 1-year follow-up. About 65% of patients were treated successfully with conservative treatment. Risk factors for failure of 3 weeks of conservative treatment were older age (older than 78.5 years), severe osteoporosis (t score less than -2.95), overweight (BMI more than 25.5), and larger collapse rates (more than 28.5%). There were significant reductions in VAS and ODI scores in both groups at each follow-up assessment. At the first month, better clinical results were observed in KP. However, there were no significant differences in outcome measures between the two groups at 3, 6, or 12 months. Thirteen subsequent compression fractures (five in KP and eight in the conservative treatment group) occurred during the 1-year follow-up period.

CONCLUSION

Both treatments of OVCF showed successful clinical results at the end of the 1-year follow-up period. Kyphoplasty showed better outcomes in the first month only. Given these results, prompt kyphoplasty should not be indicated in the case of a patient with OVCF that has no risk factors for failure with conservative treatment. Rather, a trial of conservative, 3-week treatment would be beneficial.

Is there really no benefit of vertebroplasty for osteoporotic vertebral fractures? A meta-analysis

BACKGROUND

Osteoporotic vertebral compressed fractures (VCFs) are the most common osteoporotic fractures. Although percutaneous vertebroplasty (PVP) reportedly relieves pain and improves function, a recent pooled analysis from two multicenter randomized controlled trials concluded the improvement in pain and disability treated with PVP was similar to those with sham surgery.

QUESTIONS/PURPOSE

Using meta-analysis we therefore asked whether compared with either nonoperative therapy or a sham injection for patients with VCF, PVP would (1) better relieve pain, (2) provide greater improvement in pain-related disability, and (3) increase the recurrence of vertebral fractures.

METHODS

We searched PubMed, EMBASE, Medline, and the Cochrane library using the keywords "vertebroplasty AND osteoporosis OR fracture". We included nine of the 469 articles identified. Using a random effects model, we calculated the weighted mean differences to evaluate the pain reduction at different times as the primary outcome. Pain-related disability was assessed by a quality of life (QOL) measure. Improvement of QOL and recurrence of vertebral fractures were the secondary outcomes. We used subgroup analysis to reinvestigate pain relief and function improvement of PVP based on two different controls: nonoperative therapy and sham injection. The total number of patients was 886.

RESULTS

Pain scoring was similar between the PVP group and the sham injection group at 1 to 29 days and 90 days. However, compared with nonoperative therapy, PVP reduced pain at all times studied. QOL in the PVP group was improved or tended to be improved compared with QOL for both control groups. The risk of new fractures was similar between the PVP groups and both control groups.

CONCLUSIONS

Different control groups may have accounted for the different conclusions in the literature regarding the ability of PVP to relieve pain and restore function recovery. Compared with nonoperative treatment PVP relieved pain better and improved QOL. PVP did not increase the risk of new fractures.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A review of vertebroplasty for osteoporotic and malignant vertebral compression fractures

Vertebral compression fractures are a common clinical problem and the incidence of them will increase with the ageing population. Traditionally management has been conservative; however, there has been a growing trend towards vertebroplasty as an alternative therapy in patients with persisting severe pain. NICE produced guidance in 2003 recommending the procedure after 4 weeks of conservative management. Recent high-quality studies have been contradictory and there is currently a debate surrounding the role of the procedure with no agreement in the literature. We examine the evidence in both osteoporotic and malignant vertebral compression fractures; we also describe the benefits and side effects, alternative treatment options and the cost of the procedure. Finally, we recommend when vertebroplasty is most appropriately used based on the best available evidence.

Percutaneous vertebroplasty for pathological vertebral compression fractures secondary to multiple myeloma

BACKGROUND

Vertebral compression fractures are common in multiple myeloma. Percutaneous vertebroplasty is used to stabilize vertebral collapse and treat the pain. The major technical drawbacks of percutaneous vertebroplasty are the potential for neural comprise and pulmonary embolism of cement from leakage of polymethylmethacrylate into epidural space and perivertebral veins. We have retrospectively evaluated the safety and complication of percutaneous vertebroplasty in the vertebral compression fractures resulting from multiple myeloma.

METHODS

From August 2003 to July 2008, we describe 24 patients with multiple myeloma who were treated for vertebral compression fractures with percutaneous vertebroplasty to a total of 36 vertebrae. There were 4 male and 20 female patients with an average age of 67 (range 54–81 years). The pain symptoms were measured on a visual analog pain scale and quality of life as measured by the physical component summary scale of the Short Form- 36 before operation and at 24 h, at 3 months and at 1 year following vertebroplasty. Radiography was reviewed for evidence of cement leakage and pulmonary complication.

RESULTS

The mean visual analog pain scale decreased from a preoperative value of 9.0–3.8 at 24 h following operation and SF-36 score improved from 22.1 to 41.8. Of the twenty-four patients, four had cement leakage (2 leak through inferior endplate into disc, 2 leak into perivertebral vessels). There were no intra-postoperative neurologic or pulmonary complications. Eight patients died 2–18 months post-operatively due to multiple myeloma-related organ failure.

CONCLUSIONS

In this study, vertebroplasty significantly improved pain scores and function and, thereby, the quality of life. There were no major procedure-related complications in this study. Direct cytotoxic effect, polymerization and biomechanical microfractures stabilizer of polymethylmethacrylate play multiple roles in pain relief. In multiple myeloma, when pathological spinal compression fractures cause intractable pain and are unresponsive to conservative treatment, vertebroplasty remains the best option for pain relief and is effective in increasing quality of life.

The effect of vertebroplasty on costal pain related to osteoporotic thoracic compression fractures in elderly patients

Objective

To analyze the effect of vertebroplasty on costal pain which develops following osteoporotic thoracic compression fractures (OTCFs).

Methods

The authors reviewed the medical records of 35 patients who underwent vertebral augmentation for the treatment of OTCFs over a five year period. The patients were divided into two groups: the costalgia group included patientswho had costal pain after a vertebral fracture and the non-costalgia group included patients without costalgia. To evaluate the effect of vertebroplasty on costal pain and factors related to costal pain, several factors including: vertebral body fracture type, pedicle injury, bone mineral density, the fracture level and clinical outcome were confirmed with magnetic resonance imaging and chart reviews.

Results

Among 35 patients, ten patients (28.6%) complained of costal pain with back pain. Only five of the ten patients (50%) had improved costal pain after a vertebroplasty. In the remaining 5 patients, the costal pain was improved through the use of medication including pain killers or a costal block during the follow-up period. Although the incidence of wedge deformity in the costal group was low(10%), there was no significant relationship to the incidence of costal pain statistically. Pedicle injury, bone mineral density and the fracture level had no significant relation to costal pain.

Conclusion

The patients with wedge type, OTCFs may have a low incidence of costal pain as compared to those patients with bi-concave and crush deformities. The vertebroplasty effect on costal pain may not be effective. Therefore, before doing vertebroplasty, the surgeon should advise patients of this potential outcome in those treated for OTCFs.

FINITE ELEMENT ANALYSIS OF A MODEL OF SIMULATED VERTEBRAL CEMENT AUGMENTATION: INFLUENCE OF THE REPRESENTATION OF THE SHAPE OF THE CEMENT DOMAIN ON BIOMECHANICAL PARAMETERS

Vertebral cement augmentation is rapidly becoming the modality of choice for treating patients who are experiencing severe and persistent pain because of osteoporosis-induced vertebral compression fracture(s). The resulting cement domain (the part of the vertebral body (VB) filled with the cement) has an irregular or complicated shape. In literature reports of finite element analysis (FEA) of models of simulated vertebral cement augmentation, a variety of representations of the shape of the cement domain have been used. In the literature, only very limited attention has been given to the issue of the influence of cement domain shape representation on biomechanical parameters for a given combination of model and loading. This issue is the subject of the present work, with the model being of the L1-L3 motion segments. Augmentation of an unfractured L2 (prophylactic augmentation) was simulated, three cement domain shapes were considered — namely, solid cylinder, with rounded edges; two prolate spheroids; and oblate spheroid — and the applied loading comprised a simultaneous application of a uniform compressive pressure of 0.53 MPa (equivalent to an 800-N compression load) and a counter-clockwise-acting axial rotation moment of 1 Nm to the superior surface of L1. It was found that (1) while the cement domain shape representation has a marked influence on the mean von Mises stress (σAVM), the maximum von Mises stress (σMVM), and the strain energy density (MSED) distribution in the cement domain, its influence on each of these parameters in each of the biological tissues in the model as well as on the total segmental range of motion is minimal and (2) for σAVM and σMVM, the lowest value of each of these parameters was obtained when the oblate spheroid model was used. From both clinical and computational perspectives, these findings are significant. For example, the latter finding suggests that there is scope for researching the combination of key process variables used, such as the cement chemistry, the cement delivery system, and the augmentation technique/approach, that would ensure that the final cement domain shape in cement-augmented VBs of patients be oblate spheroid on a consistent and predictable basis.

Conservative management of patients with an osteoporotic vertebral fracture

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.