Background Vertebral compression fractures (VCFs) occur in up to 20% of patients above the age of 50, mostly due to osteoporosis. Malignant VCFs are the result of osteolytic lesions from multiple myeloma or metastatic carcinoma and occur in up to 30% of patients with bone metastases. VCFs can cause significant acute and long-term pain, can compromise pulmonary function, and impair activities of daily living. Vertebroplasty (VP) and balloon Kyphoplasty (BKP) are minimally invasive surgical techniques used for treatment of both osteoporotic and malignant VCFs.
Technique VP involves percutaneous injection of cement (polymethylmethacrylate – PMMA) into a fractured vertebral body. BKP involves inserting an inflatable balloon in the vertebral body first – to attempt to elevate the vertebral end plates – with subsequent insertion of PMMA. Both are outpatient procedures, done under conscious sedation and local anesthesia, with fluoroscopic guidance. Some clinicians will augment multiple levels at once.
Patient Selection Careful correlation of a patient’s symptoms with the level of the fracture is important, as not all fractures are painful, and alternative causes of pain need to be considered. Patients with painful acute or chronic VCFs (only after neurological compromise has been ruled out) are appropriate for interventional consideration, although outcomes are slightly better in the acute setting. BKP is substantially more expensive than VP. Some practitioners empirically favor BKP in case of significant kyphosis (deformity more than 20°) or when VP is difficult due to posterior vertebral cortex involvement, which makes cement extravasation more likely. VP, on the other hand, is favored when insertion of balloon device is technically difficult due to severe vertebral collapse (> 65% reduction in vertebral height) or if the fracture is more than 3 months old, in which case elevation of the endplate is unlikely.
Relative contraindications include the presence of any neurologic damage related to the fracture, fractures with a burst component (where bone fragments extend into the spinal canal), systemic or local infection, uncorrected hypercoagulable state, and severe cardiopulmonary disease.
- Cement Extravasation is more common in VP (up to 40%, depending on the series) than in BKP (up to 13%). Cement leaks are rarely symptomatic.
- Pulmonary or neurologic emboli can occur from displaced bone marrow in <1% of cases.
- Infectious complications such as pyogenic spondylitis and osteomyelitis are very rare.
Outcomes Multiple randomized, unblinded, controlled trials have shown VP/BKP to provide better analgesia than medical management alone. RCTs have shown efficacy in pain and functional improvement for both BP and BKP vs non-surgical management in patients with osteoporotic (10, 11) and cancer-induced VCFs (12). In some of these studies the improvements lasted up to 12 months. However, two blinded, randomized, sham-procedure controlled trials showed the efficacy of VP to be similar to controls who received a sham procedure for osteoporotic VCFs (8,9). The injection of a local anaesthetic into the periosteum may explain this finding. Of note, these studies were criticized for patient selection, low pain scores, insufficient amount of cement used and other methodological issues. Pain reduction occurs in 67-100% of cases with VP and in BKP; often more than a 5 point drop (on a 0-10 scale) in the immediate postoperative period, along with significant decrease in analgesic use at 1 month. Pain relief seems to be better in patients with osteoporotic VCFs as compared to those with malignant fractures. BKP is reported to contribute to better long-term pain control (more than 2 years) than VP (73% vs. 41%, respectively); however, these data are not from a head-to-head comparison. Both BKP and VP may lead to partial vertebral height restoration in selected patients, along with reductions in depression, anxiety, drowsiness, and fatigue (13).
Summary VP and BKP are effective analgesic interventions for painful VCFs in many patients, including cancer patients, and can be particularly helpful for patients who poorly tolerate opioids and other analgesics. Although understanding of the precise mechanism of action and precise indications are still evolving, these minimally invasive procedures should be considered as a part of a multidisciplinary approach to patients with painful VCFs. The choice of the vertebral augmentation procedure for a patient with either benign or malignant VCF is still largely guided by the experience of the practitioner performing the procedure. Patients taking opioids should be evaluated carefully after VP or BKP, as they may need dose reductions.
- Diamond TH, Bryant C, Browne L, et.al.Clinical outcomes after acute osteoporotic vertebral fractures: a 2-year non-randomised trial comparing percutaneous vertebroplasty with conservative therapy. Med J Aust. 2006; 184:113–117.
- Hulme PA, Krebs J., Ferguson SJ, et al., Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine. 2006; 31:1983–2001.
- Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Spine. 2006; 31(23):2747-55.
- Pateder DB, Khanna AJ, Lieberman IH. Vertebroplasty and kyphoplasty for the management of osteoporotic vertebral compression fractures. Orthop Clin North Am. 2007; 38(3):409-18.
- Melton LJ 3rd, Kallmes DF. Epidemiology of vertebral fractures: implications for vertebral augmentation. Acad Radiol. 2006; 13(5):538-45.
- Khanna AJ, Reinhardt MK, Togawa D, Lieberman IH. Functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures. Osteoporos Int. 2006; 17(6):817-26.
- Jensen ME, McGraw JK, Cardella JF, Hirsch JA. Position statement on percutaneous vertebral augmentation: a consensus statement developed by the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of Spine Radiology. Am J Neuroradiol. 2007; 28(8):1439-43.
- Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009 Aug 6;361(6):569-79.
- Buchbinder R, Osborne RH, Ebeling PR, Wark JD,, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009 Aug 6;361(6):557-68.
- Klazen CA, Lohle PN, de Vries J, Jansen FH, et al. Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial. Lancet. 2010 Sep 25;376(9746):1085-92.
- Wardlaw D, Cummings SR, Van Meirhaeghe J, et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet. 2009 Mar 21;373(9668):1016-24.
- Berenson J, Pflugmacher R, et al; Cancer Patient Fracture Evaluation (CAFE) Investigators. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011 Mar;12(3):225-35.
- Mendoza TR, Koyyalagunta D, Burton AW, et al. Changes in pain and other symptoms in patients with painful multiple myeloma-related vertebral fracture treated with kyphoplasty or vertebroplasty. J Pain. 2012 Jun;13(6):564-70.
Authors’ Affiliations: Fox Chase Cancer Center, Philadelphia, PA (MC); University of Pittsburgh Medical Center, Pittsburgh, PA (MR).
Version History: Originally published April 2008. Updated with subsequent research publications, July 2012; copy-edited again July 2015.
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