What is the role of vertebroplasty in treating vertebral fractures?

Role of Vertebroplasty in Treating Vertebral Fractures

Vertebroplasty and kyphoplasty are reasonable therapeutic options for selected patients with severe back pain from vertebral fractures that are refractory to conservative medical therapy, particularly in osteoporotic and cancer-related fractures. 1

Indications for Vertebroplasty

• Vertebroplasty should be limited to selected patients who fail conservative medical management, typically after at least 3-4 weeks of treatment 1, 2
• Most appropriate for patients with:
  • Severe back pain (VAS score ≥5) from a vertebral fracture 1
  • Pain that is refractory to conservative medical therapy 1
  • Focal tenderness at the fracture level 1
  • MRI evidence of bone edema indicating acute/subacute fracture 1

Efficacy Based on Fracture Type

• Cancer-related vertebral fractures:

  • Kyphoplasty has demonstrated superior efficacy to conservative therapy in reducing pain, disability, and improving quality of life and performance status (AHA Class IIA, Level of Evidence B) 1
  • Both vertebroplasty and kyphoplasty are reasonable options for patients with cancer and severe back pain from vertebral fractures 1

• Osteoporotic vertebral fractures:

  • Evidence is more conflicting but generally supports vertebral augmentation 1
  • The VERTOS II trial showed significantly greater pain relief with vertebroplasty compared to conservative treatment at 1 month (mean VAS reduction 2.6 points greater) and 1 year (mean VAS reduction 2.0 points greater) 1
  • Patients experience earlier significant pain relief with vertebroplasty (30 days) compared to conservative treatment (116 days) 1

Factors Associated with Better Outcomes

• Younger age (under 60 years) 3
• End-plate fractures (versus burst or retropulsed fractures) 3
• Thoracolumbar fractures (T10-L2) 3
• Segmental kyphosis less than 20 degrees 3
• Cement volume greater than 5 ml 3
• Acute fractures (≤6 weeks old) may benefit most as healed fractures are less amenable to cement injection 4

Procedure Considerations

• Can be performed using local anesthesia with moderate sedation 1
• Having the patient awake is preferable to allow feedback about pain or neurologic symptoms that might indicate complications 1
• Post-procedure care includes:
  • Period of bed rest and observation tailored to clinical circumstances 1
  • Regular assessment of vital signs and lower limb neurological function 1
  • Supervised ambulation after appropriate observation period 1
  • Most patients can be discharged same day or after overnight observation 1

Potential Complications and Monitoring

• Cement leakage is a potential complication that requires monitoring 5
• Cross-sectional imaging should be performed if clinical deterioration occurs 1
• Post-procedure follow-up should assess:
  • Pain levels 1
  • Mobility 1
  • Requirement for analgesia 1
  • Patients should be counseled to report sudden increases in back pain that may indicate new fractures 1, 2

Long-term Considerations

• Repeat fractures in the treatment cohort are not uncommon 1
• Prevention of future fractures with appropriate medical therapy is particularly important 1
• Vertebroplasty may be more effective than balloon kyphoplasty for pain relief in patients with osteoporotic vertebral compression fractures 6

Cost-Effectiveness

• The VERTOS II trial found that vertebroplasty provided an average of 120 pain-free days gained in the 12 months after the procedure 1
• The cost difference between vertebroplasty and conservative treatment at 1 year was approximately the cost of the vertebroplasty procedure itself (€2463) 1

Limitations of Current Evidence

• Some randomized controlled trials have shown conflicting results 1
• The lack of blinding in some studies (like VERTOS II) may overestimate treatment benefit 1
• Further randomized controlled trials in both osteoporotic and malignant disease are needed to improve the strength of available evidence 1