The Pain of Vertebral Compression Fractures Can Arise in the Posterior Elements

Paravertebral Nerve Block for Procedural Pain in Percutaneous Vertebroplasty

OBJECTIVES

This study aimed to unidimensionally measure procedural pain at each percutaneous vertebroplasty (PVP) stage and evaluate the effectiveness of paravertebral nerve block (PVNB) in reducing procedural pain.

METHODS

A retrospective study of prospectively collected data was conducted on 66 patients who underwent PVP for osteoporotic vertebral compression fractures. The patients were divided into 2 groups: group A (fluoroscopic-guided PVNB; 5 cm 3 of 0.75% ropivacaine on each side) and group B (local anesthesia). To investigate procedural pain associated with PVP, the visual analog scale score was assessed at each surgical stage: before the incision (stage 1), transpedicular approach (stage 2), and polymethylmethacrylate cement injection (stage 3). After the procedure, patients were asked about their surgical experience and satisfaction using the Iowa Satisfaction with Anesthesia Scale. Periprocedural complications were also recorded.

RESULTS

A total of 63 patients (78.65 y of age) were finally enrolled: 30 from group A and 33 from group B. In both groups, a significant ≥2-point increase in procedural pain was observed during PVP compared with that during stage 1 ( P < 0.001). In stages 2 and 3, the pain intensity was significantly lower in group A ( P < 0.001). Upon discharge, the visual analog scale score improved in all groups; however, the Iowa Satisfaction with Anesthesia Scale score was significantly higher in group A ( P < 0.001). There was no difference in periprocedural complications between the two groups ( P = 0.743).

CONCLUSION

PVP causes significant procedural pain, and PVNB is a potentially effective modality for enhancing patient satisfaction and reducing procedural pain.

[Lumbar Facet Joint Injection: A Review of Efficacy and Safety]

Facet joint arthrosis is a progressive degenerative disease that is frequently associated with other spinal degenerative disorders such as degenerative disc disease or spinal stenosis. Lumbar facet joint arthrosis can induce pain in the proximal lower extremities. However, symptoms and imaging findings of "facet joint syndrome" are not specific as they mimic the pain from herniated discs or nerve root compression. Currently, evidence for therapeutic intra-articular lumbar facet joint injections is still considered low, with a weak recommendation strength. Nevertheless, some studies have reported therapeutic effectiveness of facet joint injections. Moreover, the use of therapeutic facet joint injections in clinical practice has increased. This review article includes opinions based on the authors' experience with facet joint injections. This review primarily aimed to investigate the efficacy of lumbar facet joint injections and consider their associated safety aspects.

The Invasive Management of Pain: Diagnosis and New Treatment Options

Both the diagnosis and treatment of pain are evolving, especially in interventional approaches. Diagnosis of low back pain combines old and new methodologies, in particular, it involves an expanded role for ultrasound. While low back pain is a common complaint, there are many etiologies to the condition which must be explored before a final diagnosis can be made and treatment planned. Tumors and infections are rarely involved in low back pain but should be ruled out in the initial phase itself since failing to address them early can have devastating consequences. Some invasive treatments seem promising in the management of low back pain. Treating musculoskeletal pain with regenerative medicine, such as platelet-rich plasma, holds great promise. Autologous blood products are safe and may help stimulate the body's own responses for regeneration. The so-called "orthobiologics" play a role in sports medicine and the treatment of musculoskeletal pain. Neuromodulation, especially spinal cord stimulation, is undergoing a renaissance with new waveforms, devices, and a greater albeit incomplete understanding of its mechanisms of action. Spinal cord stimulation is not a first-line therapy and not all patients or all back problems respond to this treatment. Nevertheless, the therapy can be safe, effective, and cost-effective with appropriate patient selection. Radiofrequency ablation of nerves in the form of neurotomy can be effective in reducing the pain of osteoarthritis. These procedures, including the newer cooled radiofrequency neurotomy, can restore function, reduce pain, and may potentially have an opioid-sparing effect. Technical expertise in nerve and anatomy is needed for the use of this technique. This review article aims to provide updated information on some invasive intervention techniques in pain management.

Vertebroplasty combined with facet joint block vs. vertebroplasty alone in relieving acute pain of osteoporotic vertebral compression fracture: a randomized controlled clinical trial

Objective

The study objective was to compare the efficacy and safety of percutaneous vertebroplasty (PVP) combined with facet joint block (FB) and vertebroplasty alone in relieving acute pain on osteoporotic vertebral compression fractures (OVCFs).

Methods

A prospective, randomized controlled study was conducted. One hundred ninety-eight patients of OVCFs undergoing surgery were randomly divided into two groups: Group P (PVP, n = 97), Group PF (PVP + FB, n = 101). The Visual analogue scale (VAS) and Oswestry disability index (ODI) were measured during pre-operation, 1 day, 1, 3, 6 and 12 months after the operation, respectively. The hospitalization time, operation time, complications, recurrence, the mean amount of cement injected and the number of patients who applied Cox-2 inhibitors within 3 days after operation were compared in the two groups.

Results

The VAS and ODI scores at each observation point of the post-operation were significantly decreased than that at the pre-operation in both groups (P < 0.05). The VAS and ODI scores in Group PF were significantly lower than that in Group P 1 day and 1 month after the operation (P < 0.05). The number of patients who applied Cox-2 inhibitors within 3 days after operation in group PF was significantly lower that in Group P (P < 0.001). There was no significant difference in hospitalization time, operation time, the mean amount of cement injected, complication rate, VAS and ODI scores at the pre-operation (P > 0.05).

Conclusion

Both PVP combined with FB and PVP alone are effective treatment methods for OVCFs. But PVP combined with FB showed better back pain relief than PVP alone in the short term after the operation for OVCFs.

Can facet joint block be a complementary or alternative therapeutic option for patients with osteoporotic vertebral fractures: a meta-analysis

Background

Recently facet joint block has been increasingly used to relief the residual pain after vertebral augmentation, but whether it can be a complementary or alternative to vertebral augmentation remain largely unknown. Thus, we conducted this meta-analysis to determine the effect of facet joint block in the treatment of osteoporotic vertebral compression fractures (OVCF).

Methods

Following PRISMA statement, a comprehensive literature search through Embase, PubMed, Web of Science, Wanfang Data, China National Knowledge Infrastructure and Chinese BioMedical Literature Database was performed to identify relevant studies. Studies comparing vertebral augmentation combined with facet joint block (combined therapy) with vertebral augmentation, and studies comparing facet joint block with vertebral augmentation were analyzed, respectively.

Results

A total of 10 studies were included. There were seven studies comparing combined therapy with vertebral augmentation, the results showed combined therapy was associated with significantly lower visual analog scale (VAS) scores on postoperative day 1, 7, month 1, 3, and lower oswestry disability index (ODI) scores on postoperative day 1, 7, and month 3. There were three studies comparing facet joint block with vertebral augmentation, the results demonstrated vertebral augmentation only provided better analgesia in month 1 after surgery, but it was associated with a higher incidence of refracture.

Conclusions

Current evidence suggested facet joint block might be considered as a complementary to vertebral augmentation in the treatment of OVCF, but it might not be effectively used as an alternative therapy.

Left Lower Abdominal Pain as an Initial Symptom of Multiple Myeloma

Multiple myeloma can present with various general symptoms such as fever, fatigue, and night sweats. Bone pain can occur in the pelvic and vertebral bones. However, there are a few reports of abdominal pain as an initial symptom of multiple myeloma. Here, we report the case of a 73-year-old male patient with a chief complaint of acute left lower abdominal pain. The abdominal physical findings were unremarkable. The pain was considered as referred pain, but there was no pain in response to a knock on the back. Further investigation using enhanced abdominal CT revealed a lesion in the left vertebral arch of the 10th thoracic vertebra. Bone marrow biopsy led to a diagnosis of IgA-type multiple myeloma. This case shows that abdominal pain could indicate vertebral lesions, and even without back pain, the condition of the vertebral arches should be investigated.

Percutaneous Vertebroplasty and Facet Blocking for Treating Back Pain Caused by Osteoporotic Vertebral Compression Fracture

Methods

Clinical and radiological data of 204 patients were reviewed. The patients were divided into Group A (PVP alone) and Group B (PVP and FB combined therapy) according to treatments. Back pain was evaluated with Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). The operation, fluoroscopic exposure time, and bone cement leakage were recorded. The χ² test, Student's t-test, and repeated measures analysis of variance were used to compare the differences between the two groups.

Results

There were 125 patients in Group A and 79 patients in Group B. Their baseline characteristics were similar (P > 0.05). The mean VAS scores of Group A and Group B were 7.03 and 7.21 at admission, 4.7 and 3.2 at 1 day after operation, 4.0 and 3.0 at 3 months, and 2.2 and 2.2 at 12 months after operation, respectively. The mean ODI scores of Group A and Group B were 30.9 and 29.8 at admission, 17.6 and 17.7 at 3 months, and 10.5 and 10.9 at 12 months after operation, respectively. The mean operation time and fluoroscopic exposure time of Group A (35.6 minutes and 7.2 seconds, respectively) was significantly shorter than that of Group B (45.7 minutes and 11.7 seconds, respectively, P < 0.01). The incidence of bone cement leakage and new fractures after operation did not have statistically significant difference between groups.

Conclusion

PVP and FB combined therapy could provide better pain relief than PVP alone in short term after operation in patients with OVCFs associated back pains.

The evidentiary basis of vertebral augmentation: a 2019 update

No aspect of neurointerventional practice has been associated with as longstanding contention and debate as to its effectiveness as has vertebroplasty (VP). Four blinded randomized controlled trials published since 2009 have demonstrated conflicting results regarding a conferred benefit in pain reduction and functional improvement for patients who undergo VP for osteoporotic vertebral compression fractures. Significant heterogeneity exists between each of these trials, which has resulted in difficulty for interventionalists and surgeons to translate the trial findings into routine clinical practice. In addition, patients and their families are ever more enlightened and enabled via the internet and social media to review both medical literature and websites. Without the proper background and context, their decisions may be lacking appropriate and necessary scientific discussion. This review article summarizes the randomized controlled trial data to date, with particular focus on the aforementioned four blinded studies. We will also evaluate the profound impact of the decrease in vertebral augmentation utilization on short- and long-term patient morbidity and mortality using available national and administrative datasets from both within the USA and internationally. We also consider future trial design to help evaluate this procedure and determine its role in modern neurointerventional practice.

Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection

PURPOSE

To analyze the causes of pain, imaging characteristics, and therapeutic effect of spinal injection in patients with extreme low back pain or sciatica.

METHODS

We analyzed 381 consecutive patients with extreme low back pain or sciatica visiting our spinal intervention center between January and December 2017. Clinical and imaging characteristics were analyzed. The treatment response, defined as a numerical pain rating scale decrease of ≥ 30%, was measured. Fisher's exact test was performed to identify the association between the injection response and subsequent lumbar surgery rate.

RESULTS

The most frequent cause of pain was spinal stenosis, followed by herniated intervertebral disc, facet osteoarthritis, and osteoporotic compression fracture. A herniated intervertebral disc was the most common disorder in patients < 50 years of age, while spinal stenosis was the most common in patients ≥ 50 years of age. Women comprised 66.4% of the study population. The majority of lumbar pathologies occurred below L3/4. Spinal injection was found to be effective in 44.2% of cases. Those who responded to the injection showed a significantly lower rate of lumbar surgery within 6 months (P = 0.004).

CONCLUSIONS

Those with extreme low back pain or sciatica had clinical and imaging characteristics similar to those with typical low back pain referred for spinal injection. Spinal injection could be an effective method of pain control for patients with extreme low back pain or sciatica.

Network meta-analysis of percutaneous vertebroplasty, percutaneous kyphoplasty, nerve block, and conservative treatment for nonsurgery options of acute/subacute and chronic osteoporotic vertebral compression fractures (OVCFs) in short-term and long-term effects

BACKGROUND

Osteoporotic vertebral compression fractures (OVCFs) commonly afflicts most aged people resulting back pain, substantial vertebral deformity, functional disability, decreased quality of life, and increased adjacent spinal fractures and mortality. Percutaneous vertebral augmentation (PVA) included percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP), nerve block (NB), and conservative treatment (CT) are used for the nonsurgery treatment strategy of OVCFs, however, current evaluation of their efficacy remains controversial.

METHODS AND ANALYSIS

A systematic literature search was carried out in PubMed, EMBASE, Web of Knowledge, and the Cochrane Central Register of Controlled Trials up to October 31, 2017. Randomized controlled trials (RCTs) were compared PVP, PKP, NB, or CT for treating OVCFs. The risk of bias for each trial was rated according to the Cochrane Handbook. Mean differences (MDs) with 95% confidence intervals (CIs) were utilized to express VAS (visual analog scale) outcomes. The network meta-analysis (NMA) of the comparative efficacy measured by change of VAS on acute/subacute and chronic OVCFs was conducted for a short-term (<4 weeks) and long-term (≥6-12months) follow-up with the ADDIS software.

RESULTS

A total of 18 trials among 1994 patients were included in the NMA. The PVA (PVP and PKP) had better efficacy than CT. PKP was first option in alleviating pain in the case of the acute/subacute OVCFs for long term, and chronic OVCFs for short term and long term, while PVP had the most superiority in the case of the acute/subacute OVCFs for short term. NB ranks higher probability than PKP and PVP on acute/subacute OVCFs in short and long-term, respectively.

CONCLUSIONS

The present results suggest that PVA (PVP/PKP) had better performance than CT in alleviating acute/subacute and chronic OVCFs pain for short and long-term. NB may be used as an alternative or before PVA, as far as pain relief is concerned. Various nonsurgery treatments including CT, PVA (PVP/PKP), NB, or a combination of these treatments are performed with the goal of reducing pain, stabilizing the vertebrae, and restoring mobility.

Medial branch nerve block and ablation as a novel approach to pain related to vertebral compression fracture

PURPOSE OF REVIEW

This review offers a critical examination of the biomechanical model that posits the posterior elements as a substantial contributor to pain in vertebral fracture. Further, the review assesses the treatment of posterior-element-associated pain in the setting of vertebral compression fracture in relation to vertebral augmentation.

RECENT FINDINGS

In 2015, the only prospective randomized trial comparing percutaneous vertebroplasty with facet blockade was published in which authors found that percutaneous vertebroplasty produced better pain relief and function based on Oswestry Disability Index, Roland Morris Disability Questionnaire, and visual analog scale in the short term (≤1 week). However, differences in pain relief at 1 month and 12 months were not statistically significant.

SUMMARY

The posterior elements may play a significant role in the pain generated after vertebral compression fractures. Treatment of the posterior element pain through medial branch radiofrequency ablation or facet injections may be another tool in providing analgesia in those with pain after vertebral compression fractures.

Osteoporosis and fragility fractures: Vertebral fractures

The incidence of vertebral fragility fractures and deformity increase steeply with age. Every sixth woman and every twelfth man will sustain a symptomatic vertebral fracture. Vertebral fractures result in pain, functional disability and decreased quality of life, which may last for several years, and may also affect mortality. The patient with an acute fracture should be examined with radiology for diagnosis. In case of a low-energy fracture, osteoporosis should be suspected and investigated. If the pain management fails, vertebroplasty or kyphoplasty could be considered. Braces may be used, but evidence for its effect is lacking. In the rare event of neurological compromise, or unstable fractures, surgical treatment should be considered. After vertebral fragility fractures, the risk for new fractures is high and secondary preventive measures advocated. The best evidence for secondary prevention is currently on medical treatment of osteoporosis.

Progressive kyphosis after vertebroplasty in osteoporotic vertebral compression fracture

STUDY DESIGN

A single-center retrospective study.

OBJECTIVE

To identify the relevant incidence and risk factors of delayed vertebral collapse and progressive kyphosis with spinal canal encroachment after percutaneous vertebroplasty (PVP) for vertebral compression fracture (VCF).

SUMMARY OF BACKGROUND DATA

Delayed vertebral collapse and progressive kyphosis with spinal canal encroachment are complications after PVP for VCF.

METHODS

Between December 2002 and February 2011, 843 patients underwent PVP for VCFs for at least 2 years of minimum follow-up term in a tertiary referral center. All imaging measurements were obtained digitally, with comparisons of the Cobb angle and spinal canal stenosis on fractured vertebral level at 3 different time points of pre- and postvertebroplasty, and before revision surgery.

RESULTS

Thirteen patients (14 fractures) who underwent PVP had delayed vertebral collapse and progressive kyphosis on the level of the fractured vertebra, 3 were male and 10 female, with a median age of 75 years (range, 66-89 yr). One had 2-level VCFs. All were treated with revision surgery of decompressive laminectomy for spinal canal stenosis with neurological complications. Twelve patients had additional instrument fixation. The involved vertebras were concentrated at the thoracolumbar junction region (T11-L2). The mean Cobb angles were measured at 23.67° before PVP, 15.90° after PVP, and 30.92° before revision surgery. The ratio of spinal canal stenosis was 35.45% and 49.48% before PVP and revision surgery, respectively. The occurrence rate of delayed complications was about 1.5% (13/843).

CONCLUSION

Conservative treatment and minimal invasive vertebral augmentation surgery can be selected from patients with stable VCFs. Close follow-up is warrant to monitor the occurrence of late collapse with neurological complications.

LEVEL OF EVIDENCE

N/A.

Facet joint signal change on MRI at levels of acute/subacute lumbar compression fractures

BACKGROUND AND PURPOSE

The prevalence of facet joint signal change in acute/subacute lumbar vertebral body compression fractures is unknown. We hypothesized that facet joint signal change on MR imaging is more common in facet joints associated with an acute/subacute lumbar compression fracture than those associated with normal vertebral bodies or ones that have a chronic compression fracture.

MATERIALS AND METHODS

Three neuroradiologists and a neuroradiology fellow retrospectively graded facet joint inflammatory change on MR imaging in 900 facet joints in 75 patients with at least 1 painful osteoporotic lumbar compression fracture. Facet joint signal change was assessed on T2-weighted images with chemical fat-saturation, STIR images, and/or gadolinium-enhanced T1-weighted images with chemical fat-saturation. Each facet joint from the T12/L1 to L5/S1 level was assessed individually. An overall facet joint signal-change score, which is a composite measure of the grade of signal change for all 4 facet joints associated with a given lumbar vertebral level, was devised, and statistical significance was assessed via Wilcoxon rank sum tests.

RESULTS

The overall facet joint signal-change scores were significantly higher at vertebral body levels affected by an acute/subacute compression fracture compared with control levels, which were associated with either normal bodies or chronic compression fractures.

CONCLUSIONS

Our findings suggest an association between facet joint signal change on MR imaging and acute/subacute lumbar vertebral body compression fractures.

Meta-analysis of vertebral augmentation compared with conservative treatment for osteoporotic spinal fractures

Cement augmentation is a controversial treatment for painful vertebral compression fractures (VCF). Our research questions for the meta-analysis were: Is there a clinical and statistical difference in pain relief, functional improvement, and quality of life between conservative care and cement augmentation for VCF and, if so, are they maintained at longer time points? We conducted a search of MEDLINE from January 1980 to July 2011 using PubMed, Cochrane Database of Systematic Reviews and Controlled Trials, CINAHL, and EMBASE. Searches were performed from medical subject headings. Terms "vertebroplasty" and "compression fracture" were used. The outcome variables of pain, functional measures, health-related quality of life (HRQOL), and new fracture risk were analyzed. A random effects model was chosen. Continuous variables were calculated using the standardized mean difference comparing improvement from baseline of the experimental group with the control group. New vertebral fracture risk was calculated using log odds ratio. Six studies met the criteria. The pain visual analog scale (VAS) mean difference was 0.73 (confidence interval [CI] 0.35, 1.10) for early (<12 weeks) and 0.58 (CI 0.19, 0.97) for late time points (6 to 12 months), favoring vertebroplasty (p < 0.001). The functional outcomes at early and late time points were statistically significant with 1.08 (CI 0.33, 1.82) and 1.16 (CI 0.14, 2.18), respectively. The HRQOL showed superior results of vertebroplasty compared with conservative care at early and late time points of 0.39 (CI 0.16, 0.62) and 0.33 (CI 0.16, 0.51), respectively. Secondary fractures were not statistically different between the groups, 0.065 (CI -0.57, 0.70). This meta-analysis showed greater pain relief, functional recovery, and health-related quality of life with cement augmentation compared with controls. Cement augmentation results were significant in the early (<12 weeks) and the late time points (6 to 12 months). This meta-analysis provides strong evidence in favor of cement augmentation in the treatment of symptomatic VCF fractures.

Vertebroplasty and kyphoplasty: new evidence adds heat to the debate

PURPOSE OF REVIEW

Cement bone augmentation has become very popular worldwide in treating painful noncomplicated spine fractures. Controversy about the effectiveness was raised by two randomized trials in 2009. Recent new evidence contradicts those findings giving credit to vertebroplasty/kyphoplasty.

RECENT FINDINGS

Well designed prospective clinical trials in cancer and noncancer vertebral fractures as well as an excellent meta-analysis showed that painful vertebral compression fractures have better and faster pain relief, better functional outcomes, and with low complication rate when treated with percutaneous cement than conservatively.

SUMMARY

The saga is unfinished. The treatment of vertebral compression fractures with cement augmentation is still in its infancy. The potential for development with new materials and the injection of biologic and active bone cements or anticancer products, in metastatic disease, will revolutionize the treatment of this condition.