When is vertebroplasty (injection of bone cement, usually polymethylmethacrylate) used to treat fractured vertebrae?

When Vertebroplasty is Used to Treat Fractured Vertebrae

Vertebroplasty is indicated for painful osteoporotic vertebral compression fractures that have failed conservative medical management for at least 3 months, or earlier (within 6 weeks) in patients with severe, debilitating pain that significantly impairs mobility and quality of life. 1

Primary Indications

Failed Conservative Management

• Patients who have not achieved sufficient pain relief after 3 months of conservative treatment (analgesics, bracing, physical therapy) are appropriate candidates for vertebroplasty. 1
• The VERTOS II trial demonstrated that most patients who respond to medical management achieve relief by 3 months, making this a reasonable threshold for intervention. 1
• Conservative therapy includes analgesics, bed rest, external bracing, and physical therapy, but some patients experience protracted or ongoing pain despite these measures. 2

Acute Severe Pain

• Vertebroplasty is superior to placebo for pain reduction in patients with acute osteoporotic fractures of less than 6 weeks duration. 1
• Patients with severe, debilitating pain (typically VAS ≥4) and significant functional impairment may benefit from earlier intervention. 1, 3
• The procedure provides immediate and substantial improvement in pain and patient mobility compared to continued conservative management. 1

Clinical Selection Criteria

Essential Requirements

• Pain must be localized to the level of the vertebral fracture on physical examination. 3
• Imaging (MRI preferred) must confirm the fracture is the source of pain, typically showing bone marrow edema on fluid-sensitive sequences. 3
• Other causes of pain must be ruled out through appropriate imaging and clinical evaluation. 3
• The vertebral body must have an intact posterior cortex without epidural involvement to minimize risk. 1

Fracture Age Considerations

• The age of the fracture does not independently contraindicate vertebroplasty—patients with fractures older than 12 weeks show equivalent benefit to those with newer fractures. 1, 3
• Both subacute and chronic painful compression fractures can be treated effectively. 1
• Acute fractures (≤6 weeks) may gain the most benefit as healed fractures are less amenable to cement injection. 4

Clinical Benefits Supporting Use

Pain and Functional Outcomes

• Meta-analysis shows pain VAS standardized mean difference of 0.73 (95% CI 0.35-1.10) at early time points (<12 weeks) and 0.58 (95% CI 0.19-0.97) at late time points (6-12 months) favoring vertebroplasty over conservative treatment. 1
• Vertebroplasty results in significantly greater pain relief than conservative medical treatment at all time points, with mean VAS difference of -2.06 (95% CI -3.39 to -0.74) between 1-29 days. 1
• Significant reductions in disability (RDQ/Oswestry scores) and improvements in quality of life occur within 30 days. 1

Prevention of Secondary Complications

• Vertebroplasty helps prevent secondary sequelae of vertebral fractures including decreased bone mineral density, muscle strength loss from immobility, increased DVT risk, and cardiovascular/respiratory deconditioning. 1
• The procedure improves pulmonary function in patients with vertebral compression fractures through improved alignment and decreased pain. 1
• Early mobilization reduces the risk of prolonged bed rest complications. 1

Specific Clinical Scenarios

Osteoporotic Compression Fractures

• This is the primary indication for vertebroplasty in patients with age-related osteoporosis and pathological fractures. 1, 3
• Patients with persistent localized pain, significant functional impairment, and documented osteoporosis are ideal candidates. 3

Malignancy-Related Fractures

• Vertebroplasty can be used for pathologic fractures from metastatic disease or myeloma causing pain or neurologic compromise. 5
• A systematic review of vertebroplasty in malignancy settings showed 0.5% mortality and 2% severe complication rates. 1

Contraindications and Cautions

Absolute Contraindications

• Active spinal infection or osteomyelitis. 5
• Fractures with posterior wall disruption or epidural extension that would increase risk of cement leakage into the spinal canal. 1
• Presence of neurologic deficits or spinal cord compression requiring surgical decompression. 6

Relative Contraindications

• Coagulopathy or inability to safely discontinue anticoagulation. 7
• Allergy to bone cement components. 5
• Fractures with complete vertebral body collapse where cement injection is not technically feasible. 5

Important Clinical Pitfalls

Patient Selection Errors

• Do not perform vertebroplasty in patients who have not been given an adequate trial of conservative therapy (minimum 3 months), unless pain is severe and debilitating. 1
• Always confirm with MRI that the fracture shows active bone marrow edema—chronic healed fractures without edema are less likely to benefit. 3
• Multiple vertebral fractures should raise suspicion for underlying malignancy rather than simple osteoporosis. 6

Technical Considerations

• Careful fluoroscopic guidance is essential to prevent cement leakage, which occurs commonly but is usually asymptomatic. 7
• Cement leakage into the venous system can rarely cause pulmonary embolism. 7
• The procedure should be performed by experienced operators to minimize complications. 8

Comparison with Kyphoplasty

• Both vertebroplasty and kyphoplasty are equally effective for pain relief and disability reduction. 1
• Kyphoplasty may offer superior benefits for improving spinal deformity, extending kyphotic angle, increasing vertebral body height, and potentially better functional recovery. 1
• Kyphoplasty costs approximately 2.5 times more than vertebroplasty due to additional equipment and anesthesia requirements. 7
• No head-to-head studies definitively prove superiority of one technique over the other. 7

Expected Outcomes

Short-term Results

• Vertebroplasty provides prompt pain relief within 24 hours, with 53% reduction in pain scores and 29% improvement in physical functioning. 8
• Approximately 24% of patients can cease all analgesia within 24 hours after the procedure. 8
• Rapid rehabilitation and early mobilization are typical. 8

Long-term Results

• Clinical outcomes at 6 weeks to 12 months show sustained benefit compared to baseline. 8
• By 2 years, outcomes may be similar to optimal medical management, but vertebroplasty provides earlier relief and prevents complications of prolonged immobility. 9