Percutaneous Vertebroplasty: Rapid Pain Relief for Vertebral Compression Fractures

Journal of the American Chiropractic Association,  Dec 2004  by Kim, Jon S,  Mathis, John M

• E-mail
• Print
• Link

The following article is meant to provide doctors of chiropractic with some information that will enable them to knowledgeably discuss other available therapies with patients.

INTRODUCTION

Percutaneous vertebroplasty (PV) was conceived and first performed in France by the interventional neuroradiologist Herve Deramond in 1984.1 Deramond treated a destructive hemangioma at C2 by injecting bone cement into the affected bone. This caused almost immediate pain relief. PV was subsequently found to also relieve pain in vertebral compression fractures caused by osteoporosis.1,2 Dion and colleagues (Jensen, DeNardo, and Mathis) introduced the technique into the United States in 1993 at the University of Virginia. These investigators focused their work primarily on osteoporotic compression fractures and subsequently provided the first clinical series using PV in the United States.3 They found significant pain relief in 85 to 90% of patients treated for painful osteoporotic compression fractures. This was similar to early reports about PV from Europe. Since that time, the procedure has grown in acceptance around the world and is becoming the standard of care for the treatment of pain associated with vertebral compression fractures (VCF).

Demographics of Vertebral Compression Fractures

VCFs occur when the combined axial and bending loads on the spine exceed the strength of the vertebral body.4 Reduction in the individual vertebral body strength may result from infiltrative processes created by benign or malignant tumors or, more commonly, from bone mineral loss precipitated by osteoporosis.57 Osteoporosis, which may be age-related (primary) or due to steroid use (secondary), is the most common cause of VCF in the United States.8

The osteoporotic population in the United States at risk of fracture is immense: between 700,000 and 1,200,000 vertebral compression fractures occur annually.8 Osteoporosis is greatest in elderly Caucasian females and is increasing yearly in the number of affected individuals.' In addition, significant numbers of fractures are occurring in patients receiving steroids for conditions such as cancer, collagen vascular disease, transplant therapy, and severe allergy or asthma.

Neoplastic disease, though less common than osteoporosis, is a well-known cause of painful VCFs. These fractures are commonly associated with metastatic cancer, myeloma, and with aggressive benign tumors such as bone hemangiomas. If the determination of the etiology of the fracture is uncertain, biopsy can precede or accompany the PV. PV will not impair other therapeutic measures such as chemotherapy or radiotherapy. Because the vertebra is often partially destroyed by malignant lesions, the risk of cement leaks during PV is greater than during treatment for osteoporosis. PV, however, is known to provide good pain relief in selected individuals with metastatic vertebral destruction and may be a good alternative for treatment since pain relief is much faster than with radiation or chemotherapy.

Patient Selection for Vertenroplasty

Patients selected for PV should have a painful vertebral compression fracture.3,10-23 Without PV, chronic pain in these individuals may typically last from 2 weeks to 3 months.24 The time between fracture and therapy may be prolonged by failed attempts at conservative management or delayed referral. Though there are no absolute exclusionary criteria based on the time between fracture and PV, old fractures (>3 months) are less likely to have beneficial results from PV unless one can show signs of nonunion or signs of recurrent fracture. Nonunion is indicated by persistent motion noted on fluoroscopy and can signify osteonecrosis (Kummell's disease). Other spinal entities, such as herniated nucleus pulposus, facet arthropathy, and spinal stenosis may be present and complicate the evaluation. For this reason, imaging that provides physiologic information about the fracture is normally used to help select patients for PV. The preferred imaging method is magnetic resonance (MR), but nuclear medicine can also be used when MR is precluded (as in patients with pacemakers) or not available. The typical MR imaging finding in VCF is loss of signal on the TI weighted image and bright signal on inversion recovery (IR) images. (Fig. 1) These signal changes are due to marrow edema resulting from the compression fracture and are not seen in old or healed compression injuries. This difference allows one to exclude old fractures from consideration for PV.

Bone scans may also be helpful to assess problematic VCF(s) when used as a secondary screening tool. Nevertheless, MR imaging is preferred whenever possible because of the anatomic detail and information about other abnormalities (such as spinal stenosis, disk herniation, or tumor extension in the epidural space) that impacts decisions about the use of PV. Bone scans are sensitive in detecting VCFs, and a negative bone scan, like a negative MR image, indicates a low likelihood of pain relief after PV therapy. Bone scans, however, can be positive long after substantial healing of a VCF has occurred. This fact, coupled with the more restricted anatomic information (as compared with MR imaging), makes bone scans preferable only when MR imaging cannot be performed.