Can vertebroplasty be repeated at the same vertebral level for another compression fracture?

Repeat Vertebroplasty at the Same Vertebral Level

Yes, vertebroplasty can be repeated at the same vertebral level for recurrent or unrelieved pain, and clinical evidence demonstrates it is effective for this indication. 1, 2

Clinical Scenarios for Repeat Vertebroplasty

Immediate Failure (Unrelieved Pain)

• Repeat vertebroplasty is indicated when initial pain relief is not achieved within 4-32 days after the first procedure. 1
• Approximately 5-22% of patients experience no pain improvement after initial vertebroplasty, making them candidates for repeat intervention. 1
• The primary technical reason for initial failure is absent or inadequate cement filling in the unstable fractured areas of the vertebral body. 1, 3

Delayed Recurrence (Recurrent Pain)

• Recurrent pain at a previously treated level can develop months to years after initially successful vertebroplasty due to progression of the original fracture. 2, 3
• The presence of an intravertebral cleft sign (fluid-filled cavity) on pre-procedure imaging is the most important indicator that repeat vertebroplasty will be beneficial. 2, 3
• All patients with recurrent pain at previously treated levels demonstrated cleft signs on imaging before repeat procedure, even if not present initially. 2

Clinical Outcomes of Repeat Vertebroplasty

Pain Relief Efficacy

• Complete or partial pain relief is achieved in 100% of appropriately selected patients undergoing repeat vertebroplasty. 1, 2
• Mean pain reduction of 6.93 points on visual analog scale (from 8.6 to 1.67) within the first month after repeat procedure. 1
• At 3-month follow-up, mean pain scores remain low at 2.8 points with sustained improvement in mobility. 2

Technical Considerations

• Larger cement volumes are typically required during repeat vertebroplasty compared to initial procedures (mean 6.8 mL vs 4.2 mL, statistically significant difference). 2
• The mean cement volume in repeat procedures ranges from 4.0-6.8 mL per vertebra. 1, 2
• Successful repeat vertebroplasty correlates with disappearance of the cleft sign on post-procedure imaging. 2

Mechanisms of Failure Requiring Repeat Intervention

Technical Failures During Initial Procedure

• Incomplete filling of the fracture site is the most common technical cause of persistent pain. 3
• Cement missing the actual fracture location allows continued osteoporotic compression. 3
• Persistent or worsened intravertebral fluid-filled clefts indicate inadequate initial treatment. 3
• Development of fluid at the bone-cement interface after initial procedure signals progressive fracture. 3

Safety Profile

Complication Rates

• No serious complications occurred in published series of repeat vertebroplasty. 1, 2
• Asymptomatic cement leakage around vertebrae occurred in 13-22% of cases on imaging but remained clinically insignificant. 1
• The safety profile of repeat vertebroplasty mirrors that of initial procedures, with major complications occurring in less than 1% of osteoporotic fracture treatments. 4

Patient Selection Criteria

Imaging Requirements Before Repeat Procedure

• MRI is essential to identify intravertebral cleft signs and assess fracture acuity at the previously treated level. 4, 2
• The presence of bone marrow edema on MRI (T1 hypointensity and T2 hyperintensity) confirms acute or subacute fracture activity. 4
• CT or radiographs should demonstrate inadequate cement distribution from the initial procedure. 1, 3

Clinical Requirements

• Point tenderness at the spinous process of the previously treated vertebra must be documented. 4
• Pain should be refractory to conservative medical therapy for a minimum of 6 weeks (unless immediate failure is evident). 4
• Baseline neurological examination should be performed to facilitate rapid assessment of any post-procedural changes. 4

Important Caveats

Distinguishing Recurrent vs Adjacent Fractures

• 58.8-63.8% of new compression fractures after vertebroplasty occur at adjacent levels rather than the treated level. 5
• Adjacent-level fractures occur much sooner than non-adjacent fractures (mean 72 days vs 287 days). 5
• Careful imaging correlation is essential to distinguish true recurrence at the treated level from new adjacent fractures. 5

Risk Factors for Multiple Fractures

• Older age, lower baseline bone mineral density, and more pre-existing vertebral fractures increase risk of repeated compression fractures. 6, 5
• The 1-year fracture-free rate after initial vertebroplasty is 92.2%, meaning 7.8% will develop new symptomatic fractures within the first year. 6

Post-Procedure Management

• Patients should be counseled to report any sudden increase in back pain or new back pain as it may indicate a new fracture. 4
• Prevention of future fractures with appropriate medical therapy (bisphosphonates, calcium, vitamin D) is particularly important after repeat procedures. 4, 7
• Follow-up should assess pain levels, mobility, and analgesic requirements in the near term. 4