Non-Surgical Treatment of Compression Fractures
Osteoporosis affects more than 30 million Americans. Compression fractures occur in more than 500,000 patients per year in the US, are more frequent than hip fractures, and often result in prolonged disability. Current preventative measures include calcium and vitamin D supplementation, exercise, smoking cessation, and medications such as biphosphonates.
Management includes pain control with acetaminophen (Tylenol), non-steroidals (Motrin), narcotics (Percocet), and bracing. Unfortunately, the compression fractures often progress and develop at other levels resulting in loss of height, disability, and secondary complications from immobilization including pneumonia and pulmonary embolism.
Percutaneous Vertebroplasty has recently been introduced into the US as an effective therapeutic and preventative treatment for the pain and progressive loss of height in compression fractures.
An alternate treatment is Kyphoplasty.
Frequently Asked Questions:
1. What is Vertebroplasty?
Vertebroplasty literally means fixing the vertebral body. A metal needle is passed into the vertebral body and a cement mixture containing polymethylmethacrylate (PMMA), barium powder, and a solvent are injected under imaging guidance by the physician. The PMMA glue/cement hardens rapidly and buttresses the weakened bone. The barium makes the cement visible on x-ray. The procedure was originally developed in France in 1984 and has been further refined and used in the US since 1995. Many thousands of vertebroplasties have been performed in the US since, and it is one of the fastest growing medical procedures in the US.
2. How is it performed?
The procedure is performed in an interventional radiology suite with special x-ray equipment (dual overhead and C-arm fluoroscopy) with nurses and technologists to help sedate the patient and operate the equipment. The patient is placed prone on the x-ray table and made as comfortable as possible. Sedation usually includes a narcotic (fentanyl) and a benzodiazopine (versed), which are short acting and can be reversed if necessary.
The skin and underlying tissues are anesthetized with lidocaine and a special bone needle is passed slowly through the pedicle into the vertebral body using a slightly angled posterior approach.
When the needle is in appropriate position, the cement mixture is slowly injected during constant x-ray monitoring. When the potential spaces within the vertebral body are filled, the needle is slowly removed and the other half of the vertebral body is then filled with the cement.
3. How long does it take?
It usually takes approximately 45-60 minutes to perform one level. More than one level can be performed if necessary during a single session. After the procedure, the patient is allowed to carefully ambulate and can usually go home within several hours. Most patients experience significant pain relief within the first 1-2 days. Many patients progressively decrease and sometimes stop their pain medications.
4. What are the risks involved?
1) Paralysis secondary to leakage of cement
2) Leakage of cement into veins and or lungs
3) Worsened pain
4) Rib or Pedicle fracture
It should be noted that there have been very few reports of serious complications form this procedure in the US.
5. What are indications for Vertebroplasty?
1) Painful compression fracture secondary to osteoporosis
2) Painful compression fracture secondary to tumor which does not respond to conventional therapy
3) Prevent further compression fractures
4) Buttress weakened bone for spine fusions
6) Are there any Relative Contraindications?
1) Young patient – the long term effects of the cement mixture are unknown
2) Vertebral bodies above the T5 level – the procedure is riskier and more difficult
3) Patients with prior unsuccessful spine surgery
7. Do I have any alternatives to Vertebroplasty?
At this point there are no surgical alternatives. Conservative therapy which emphasizes pain management over weeks to months could be considered an alternative.
8. Which tests do I need to undertake to see if I would be a candidate for Vertebroplasty?
Recent xrays and MRI are needed for appropriate imaging assessment. If a patient cannot have an MRI examination, a radionuclide Bone Scan and CT of the spine could be used as an alternative.
9. What kind of Follow Up Care do I need?
No specific follow up care is needed following a Vertebroplasty procedure. The following medications may be useful in certain patients check with your physician if they are appropriate for you.
1) Pain medications – usually tapered over several days after procedure
2) Muscle relaxants
3) Adjust osteoporosis therapy medications to prevent further mineral loss
10. What causes back pain?
There are many causes of back pain, such as muscle spasm, disc disease, joint disease, infections, tumors and fractures. The fractures typically are caused by osteoporosis, but occasionally fractures due to trauma and tumors such as metastases, multiple myeloma and hemangiomas can be treated to reduce the associated pain. The most common cause of vertebral compression fracture is osteoporosis. Each year about 200,000 people suffer from vertebral compression fractures due to osteoporosis. Osteoporosis can be a primary disorder of bone, but may also result from the long term use of certain medications for other disorders, such as long term steroid or heparin therapy.
11. What treatments are available?
Until recently, treatment options for these fractures were limited to management with pain medications, reduced activity, bracing or invasive back surgery. But now, vertebroplasty is available. As with all of these therapies, it is important that there be continued medical management of the underlying cause of the fracture, eg; osteoporosis or tumor etc.
12. Is Vertebroplasty for everyone?
No. Vertebroplasty is intended to treat the pain of compression fractures. Old fractures that are no longer painful would not benefit from vertebroplasty. This procedure is NOT intended for those patients who suffer from the pain associated with degenerative disc disease or degenerative joint disease of the spine.
13. Will my insurance cover it?
Most major insurance companies cover the procedure.
Belkoff SM, Mathis JM, Fenton DC, et al: An ex vivo biomechanical evaluation of an inflatable bone tamp used in the treatment of compression fracture. Spine 2001 Jan 15; 26(2): 151-6[Medline].
Belkoff SM, Maroney M, Fenton DC: An in vitro biomechanical evaluation of bone cements used in percutaneous vertebroplasty. Bone 1999 Aug; 25(2 Suppl): 23S-26S[Medline].
Belkoff SM, Mathis JM, Jasper LE: The biomechanics of vertebroplasty the effect of cement volume on mechanical behavior. Spine 2001 Jul 15; 26(14): 1537-41[Medline].
Deramond H, Depriester C, Galibert P, Le Gars D: Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results Radiol Clin North Am 1998 May; 36(3): 533-46[Medline].
Jensen ME, Evans AJ, Mathis JM, et al: Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol 1997 Nov-Dec; 18(10): 1897-904[Medline].
Jensen ME, Dion JE: Percutaneous vertebroplasty in the treatment of osteoporotic compression fractures. Neuroimaging Clin N Am 2000 Aug; 10(3): 547-68[Medline].
Mathis JM, Petri M, Naff N: Percutaneous vertebroplasty treatment of steroid-induced osteoporotic compression fractures. Arthritis Rheum 1998 Jan; 41(1): 171-5[Medline].
Mathis JM, Barr JD, Belkoff SM: Percutaneous vertebroplasty: a developing standard of care for vertebral compression fractures. AJNR Am J Neuroradiol 2001 Feb; 22(2): 373-81[Medline].
Tohmeh AG, Mathis JM, Fenton DC: Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine 1999 Sep 1; 24(17): 1772-6[Medline].
Weill A, Chiras J, Simon JM, et al: Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996 Apr; 199(1): 241-7[Medline].
Wong W, Reiley MA, Garfin S: Vertebroplasty/kyphoplasty. J Womens Imaging 2000 Aug; 2(3): 117-24