Vertebroplasty Reduces Pain Following Spine Fractures
Joshua M. Hirsch, MD comments on a research study about vertebroplasty performed to treat painful spinal fractures
Spine fractures are common and disabling in people with osteoporosis. Standard treatment for these fractures includes rest, pain medication, physical therapy, and bracing. New findings suggest that injecting a special type of bone cement into a spine fracture—a procedure called vertebroplasty—markedly reduces pain compared with standard treatment.
The study, published in the October 1 issue of The Lancet, included 120 people with osteoporosis who had a recent spine fracture (within the past 6 weeks). The subjects were randomly assigned to vertebroplasty or a procedure in which a short needle is placed into the tissue immediately beneath the skin avoiding the spine. In that way, vertebroplasty was compared with something like a placebo.
Vertebroplasty involves the injection of bone cement called polymethylmethacrylate (PMMA) through a needle directly into the fractured bone. The goal is to stabilize the vertebrae and reduce pain. In the placebo procedure, a short needle is placed immediately beneath the skin (not into the spine), and the surgeons talked about mixing and injecting the PMMA (but didn’t actually inject anything into the patient).
At 14 days after the procedure, 44% people who received vertebroplasty showed marked in improvement in pain scores (from ≥7 to <4 on a 10-point pain scale) compared with 21% of people in the placebo group. The benefits of vertebroplasty over placebo were still found 6 months later. In addition, among people who were hospitalized, vertebroplasty appeared to reduce hospital stays by 5.5 days. These were felt to be important differences between the two groups.
Two people who underwent vertebroplasty had serious adverse events: one patient had a respiratory arrest after a sedative was given before the procedure (this patient was resuscitated and underwent the procedure 2 days later), and one patient’s arm was fractured when being transferred onto a table before the procedure.
“It is important to note that patients who were not treated with vertebroplasty, the placebo group, arguably had worse adverse events, including the dreaded neurological dysfunction as the bone fracture worsened over the ensuing time period,” said Joshua A. Hirsch, MD, Past President of the Society of NeuroInterventional Surgery and coauthor of a companion commentary in The Lancet.
Previous Studies Showed Mixed Findings
Use of vertebroplasty for spinal fracture is somewhat controversial because earlier studies have shown conflicting findings on whether this procedure is effective. However, the present study different from previous trials in many respects, including earlier treatment of fractures, selection of patients with severe pain, and use of a placebo that was closer to a true sham procedure than in past studies, noted Drs. Hirsch, MD, and Ronil V. Chandra in the commentary that accompanied the article.
“Overall, the implications from VAPOUR as a standalone trial are clear: patients with severe pain from a recent osteoporotic fracture appear to benefit from vertebroplasty,” the experts commented.
While vertebroplasty is not without risk, neither is standard nonsurgical management, the experts noted. In fact, as noted above two people group developed spinal cord compression from further collapse and bursting of the fractured bone into the spinal canal.
“These findings are important because, for the first time, vertebroplasty has been demonstrated to reduce pain more effectively than a sham intervention,” said Dr. Hirsch, who also is President of the American Society of Spine Radiology. “Moreover, the trial suggests that conservative therapy including narcotics, bedrest and back braces, are themselves not risk-free.”