Spine Specialists On-Call: Osteoporotic Vertebral Compression Fractures -- Restoring Spinal Stability and Quality of Life

In this presentation, Dr. Lieberman explains the differences between traditional forms of treatment and vertebroplasty and kyphoplasty. It is an interesting analysis!

Incidence and Cause: Osteoporosis
There are an estimated 700,000 pathological vertebral body compression fractures in the United States each year of which over 1/3 become chronically painful. The majority of these fractures (about 85%) are the result of primary osteoporosis, the remainder due to secondary osteoporosis or osteolytic spinal metastases (e.g. bone cancer).

These compression fractures lead to progressive deformity and changes in spinal biomechanics, and are believed to contribute to an increased risk of further fracture. Whether the fracture is painful or not, spinal deformity caused by two or more fractures dramatically impacts health, daily living, medical costs, loss of lung capacity, reduced mobility, chronic pain, loss of appetite and/or clinical depression.

With each osteoporotic vertebral compression fracture, there has been shown to be a 9% loss in predicted forced vital capacity (a measure of lung function) and a 15% age-adjusted increase in mortality.

Traditional Treatment
Traditionally, vertebral body compression fractures were treated with medical and rarely with surgical modalities. Unfortunately, the medical management of painful fractures (bed rest, hospitalization, narcotic analgesics, and bracing) does nothing to restore spinal alignment and does compound the problems associated with osteoporosis.

Surgical treatment of vertebral body compression fractures has been limited to cases where there is concurrent spinal instability or neurologic deficit. This limitation is due to surgery's inherent risks, invasive nature, and the poor quality of osteoporotic bone.

Vertebroplasty
In response to the limited results of medical and surgical modalities, to stabilize and strengthen the collapsed vertebral bodies, interventional neuroradiologists, first in France and now the United States, have begun percutaneous (through a small skin puncture) bone cement injections.

Direct cement injection, or vertebroplasty, has been shown to reduce or eliminate fracture pain. This is of significant benefit, as it allows a rapid return to mobility, preventing the known bone loss caused by bed rest.

While vertebroplasty can reduce or eliminate fracture pain, it does not address the spinal deformity or secondary problems of the deformity (i.e. the loss of lung function, the protuberant abdomen). Also, this technique requires cement injection under high pressure using low viscosity cement thus increasing the risk of cement leaks. In four recent studies, cement leaks were observed in 30%-80% of procedures. The majority of these leaks had no clinical consequences; however, cement leaks are always a clinical concern.

Kyphoplasty
Kyphoplasty is a newer technique having evolved from the vertebroplasty experience combined with the balloon catheter technology developed for angioplasty (used in cardiac procedures).

Kyphoplasty has a number of potential advantages over vertebroplasty. It involves inserting a cannula (tube) into the vertebral body under fluoroscopic x-ray guidance, followed by insertion of an inflatable bone tamp. Once inflated, the tamp restores the vertebral body back toward its original height, while creating a cavity to be filled with bone cement. The cement injection is done under relatively low pressure in an attempt to reduce the risk of leakage.

Figure 1. Vertebral compression fracture	Figure 2. Insertion of inflatable bone tamp
Figure 3. Balloon inflation	Figure 4. Cavity is filled with bone cement
Figure 5. Bone tamp is removed	Figure 6. Bone tamp and inflatable balloon

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