Treating Vertebral Compression Fractures

Summarized by Robert W. Griffith, MD
May 31, 2007

Summary

Percutaneous vertebroplasty is an effective and safe treatment for osteoporosis-related vertebral compression fractures in the elderly; pain and analgesic use is significantly reduced for at least 2 weeks compared with optimal pain medication, and long-term results show a high success rate with a low complication rate.

Introduction

A vertebral compression fracture (VCF) may occur in people with severe osteoporosis; the vertebral body breaks and is compressed, allowing pressure to develop on nerves, producing considerable pain. The chief cause is osteoporosis, but trauma or cancer invading the bone can also be responsible. Almost 10 years ago a treatment called percutaneous polymethylmethacrylate vertebroplasty was introduced, which has become a valuable therapy for relieving pain in patients who don't respond to analgesic medication.

The procedure consists of injecting bone cement to stabilize the fracture site; it's been shown to result in pain relief in about 90% of patients. Researchers from the Netherlands have reported the results of a controlled clinical study published in the American Journal of Neuroradiology, which compares vertebroplasty with pain medication in patients with painful osteoporotic vertebral compression fractures.

What was done

Patients with painful osteoporotic VCFs that were unresponsive to medical therapy for at least 6 weeks were enrolled. They had to be over 50, and in good cardiovascular and respiratory health. Participants were then randomly assigned to treatment by percutaneous vertebroplasty or so-called 'optimal pain medication'. Both groups were to be followed for 1 year, with MRI (magnetic resonance imaging) scans and symptom questionnaires after 1 day, 2 weeks, and 3, 6, and 12 months. Pain (which was scored on a 10-point scale), disability rating, and painkiller use were recorded, along with results of a special Quality-of-Life questionnaire for osteoporosis.

After 2 weeks patients in the pain medication group could change over to the vertebroplasty group if they wished; in that case, their results 2 weeks after their vertebroplasty were compared with their results 2 weeks after starting the pain medication treatment.

Vertebroplasty was done under local anesthesia. Continuous fluoroscopy was used to monitor the injection of polymethylmethacrylate bone cement; immediately after the injection, computerized tomography (CT) was done to confirm correct placement of the cement and whether there was any leakage.

The pain medications used were optimized for the individual patient's requirements. Starting with acetaminophen (Tylenol®), there was progression to non-steroid anti-inflammatory (NSAID) agents such as ibuprophen (Advil®), and opiate derivatives, as necessary. Medications and their dosage were adjusted daily by the physicians.

What was found

Thirty-four patients qualified for inclusion in the study; 18 were randomly assigned to vertebroplasty and 16 to optimal pain medication. Their average age was 73 years and 28 of them (82%) were women.

One day after starting treatment - vertebroplasty or optimal medication - the pain scores and use of painkillers were significantly lower in the vertebroplasty patients. After 2 weeks the pain scores were still lower in the vertebroplasty patients, but no longer statistically significant; however, the difference favoring less analgesic use by the vertebroplasty group remained statistically significant.

Also at 2 weeks, the Quality-of-Life scores and the disability showed greater improvements over baseline with the vertebroplasty patients than those given optimal medication; in the 'pain' subsection of the Quality-of-Life questionnaire, the difference was significant.

The 'cross-over' patients

After 2 weeks of optimal pain medication, 14 of the 16 patients requested vertebroplasty because of continued pain. One day after vertebroplasty, their pain scales and analgesic use were significantly better than they had been compared with one day after starting their medication. At 2 weeks after vertebroplasty their pain scale, analgesic use, Quality-of-Life and disability scores all showed significant improvement.

Adverse events

One vertebroplasty patient had a complication of the procedure - a small spur of cement broke off during manipulation of the injection needle, but caused no neurological symptoms or signs apart from some local pain that was relieved by local anesthesia.

Two patients given vertebroplasty experienced their highest pain scores at 2 weeks after the procedure; their MRIs showed new VCFs in adjacent vertebral bodies, and they were both treated several weeks later with a second vertebroplasty.

Conclusions

This study shows quite conclusively that percutaneous vertebroplasty is an effective and safe treatment for osteoporosis-related VCF in the elderly; pain and analgesic use is reduced for at least 2 weeks, compared to optimal pain medication.

Unfortunately, comparative results beyond 2 weeks in this study were not available, as most of the medication group elected to cross-over to have the injections. However, the first vertebroplasty for osteoporotic VF was done in 1989, and since then numerous clinical studies have been reported that document long-term benefits.

In an article in the same journal, Mayo Clinic radiologists have reported on the first 1,000 VCF patients they have treated by vertebroplasty.¹ Improvements in pain, mobility, analgesic use, and disability were noted immediately after the procedure and persisted through the 2-year follow-up. Complications of the treatment were rare - 1.8% of the patients. They were mostly rib fractures, related to lying prone on the fluoroscopy table for the procedure (something quite likely to occur in a few patients with severe osteoporosis). Only one in 1,000 procedures resulted in a clinically significant cement pulmonary embolus (where the cement enters a vein and travels to the lung); this patient made a full recovery.

We can conclude that vertebroplasty has been well-tested by physicians and is a safe and effective treatment for the pain of vertebral compression fractures resulting from osteoporosis. At present it's customary in many centers to treat such fractures conservatively - analgesics, braces, immobilization, and physical therapy - but the results summarized here indicate that vertebroplasty can probably be used earlier, i.e. using a shorter trial period for conservative treatment. This should become clearer when the results of additional clinical studies now running are available.

Source

• Percutaneous vertebroplasty compared with optimal pain medication treatment: Short-term clinical outcomes of patients with subacute or chronic painful osteoporotic vertebral compression fractures. MHJ Voormolen, WPTM Mali, PNM Lohle,  et al., Am J Neuroradiol , 2007, vol. 28, pp. 555--560

Footnotes
1. . Vertebroplasty, first 1000 levels of a single center: Evaluation of the outcomes and complications. KF Layton, KR  Thielen,  et al., Am J Neurolradiol, 2007, vol. 28, pp. 683--689

Related Links
Vertebroplasty at Mayo Clinic
Family Doctor: Vertebroplasty
Vertebroplasty Procedure Animation Video

Please take a moment to give us your comments. For questions about Health matters you may check our "Questions & Answers" Portal and Service.