Percutaneous Vertebroplasty: A New Option In The Treatment
of Osteoporotic Compression Fractures

By Jon K. Kostelic, M.D.

Osteoporotic compression fractures represent a significant source of disability in the elderly population. Approximately 700,000 vertebral body fractures occur annually in the United States. The lifetime risk of a symptomatic vertebral fracture for women is 16%. The high incidence and prevalence of these fractures result in significant cost. The annual cost related to osteoporosis is approximately $10 billion per year in the United States. For vertebral osteoporosis alone, there is a direct identifiable cost of over $600 million. In addition, there is significant morbidity associated with these fractures.

Of clinically detected fractures, 84% are associated with pain. The pain typically lasts 4 to 6 weeks, with greater degrees of deformity resulting in a greater likelihood of pain or disability. This pain may also result in reduced exercise tolerance, weight loss, difficulty with self-care, depression, and sleep disorders. Furthermore, the likelihood of developing life-threatening deep venous thrombosis or pneumonia is accelerated in those individuals with symptomatic vertebral compression fractures. Current therapy involves symptomatic relief with analgesics, immobilization, external bracing, and, rarely, surgery. Preventative measures such as hormone replacement therapy and calcitonin are also used. Clearly, osteoporotic compression fractures represent a significant source of morbidity and mortality in the elderly population.

Percutaneous vertebroplasty offers an option for treatment of acutely symptomatic or refractory osteoporotic compression fractures. The procedure involves placing an 11-gauge trocar into the affected vertebral body under imaging guidance, usually fluoroscopy or CT. With positioning of the needle confirmed, a vertebral venogram is performed to assess the venous drainage from the vertebra. Once satisfactory positioning of the trocar has been achieved, an opacified methyl methacrylate is injected into the vertebrae under careful direct flouroscopic visualization. The methyl methacrylate injection is continued until the trabecular spaces have been filled with the cement material. The cement hardens in 15 to 20 minutes after which time the vertebra has been stabilized. The theorized effect of the methyl methacrylate on the vertebral body fractures is to immobilize microfractures which reduces any motion at the fracture level and associated irritation of the adjacent periosteum. In addition, the methyl methacrylate reduces stress on the remaining bone, and may cause thermal necrosis of any nerve endings. Post-procedure care consists of a 2-hour observation period after which time the patient can be discharged home with follow-up on the post-procedure day.

Potential complications which can result from this procedure include venous extravasation of the opacified cement, embolization of the cement into the draining veins, vertebral or rib fracture, or, rarely, infection and bleeding. The vertebral venogram is an essential part of the procedure. It is at this time that any potential direct communication of the vertebral veins with the epidural venous plexus or inferior vena cava can be identified and potential inadvertent injection of cement into the epidural venous plexus or cement pulmonary emboli can be avoided. Fortunately, these complications are rare.

Results have been quite favorable. At present, a large multicenter trial is under way to prospectively evaluate the procedure in a large number of patients. However, a group of 84 patients treated at the University of Virginia, Tampa General Hospital, and John Hopkins Hospital between 1994 and 1997 demonstrated pain improvement within 48 hours in 79 of the patients. Furthermore, patientís analgesic use scale scores and mobility scale scores significantly improved such that most patients no longer required narcotic pain medications and were able to become ambulatory.

Potential candidates for this procedure should be seen and evaluated by a spine surgeon. In addition, pre-procedure imaging evaluation should include plain films, an MRI (to exclude disc extrusion or other potential soft tissue cause for pain), and a bone scan (to precisely localize a symptomatic level).

Percutaneous vertebroplasty has been used in the treatment of several other disorders including metastatic disease, symptomatic hemangiomas, and presurgical stabilization of partially compressed vertebrae. The risk of hemorrhagic complications is somewhat increased with the treatment of metastases and hemangiomas.

In conclusion, percutaneous vertebroplasty represents a promising new therapy for the treatment of symptomatic osteoporotic compression fractures as well as other lesions of the vertebrae in patients who otherwise have few therapeutic options.

 

Figures 1-2. Posteroanterior and lateral projections of T7 after right side injection,
confirming placement of needle prior to left side injection.

 

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