Regarding the Surgical Management of Vertebral Compression Fractures

Abstract

I read the recent overview of diagnosis and management of vertebral compression fractures with great interest by Alsoof et al.1Alsoof D, Anderson G, McDonald CL, et al. Diagnosis and management of vertebral compression fracture [e-pub ahead of print]. Am J Med. doi: 10.1016/j.amjmed.2022.02.035, May 1, 2022.Google Scholar As they mentioned, determining when to refer a patient for surgical treatment remains a challenge when confirming a reduction in the height of the individual vertebral by 20% or 4 mm. According to guidelines,2Tsoumakidou G Too CW Koch G et al.CIRSE guidelines on percutaneous vertebral augmentation.Cardiovasc Intervent Radiol. 2017; 40: 331-342https://doi.org/10.1007/s00270-017-1574-8Crossref PubMed Scopus (91) Google Scholar specific indications must include pain refractory to medical management for 3 weeks or achievement of adequate pain relief with intolerable side effects. It is always essential to evaluate adverse events; an interesting metanalysis by Guo et al3Guo JB Zhu Y Chen BL et al.Surgical versus non-surgical treatment for vertebral compression fracture with osteopenia: a systematic review and meta-analysis.PLoS One. 2015; 10e0127145https://doi.org/10.1371/journal.pone.0127145Crossref Scopus (25) Google Scholar found no significant difference between surgical and conservative treatments. Nonsurgical management is not free of complications, and follow-up must be offered, emphasizing associated neurological symptoms. The most feared complication in vertebral augmentation is cement leakage, especially to the epidural and foraminal space, and massive pulmonary embolization in the postoperative period. However, a usually forgotten complication is the augmented risk of new vertebral fractures reported up to 30% at 1 year.4Rocha Romero A Hernández-Porras BC Plancarte-Sanchez R et al.Risk of new fractures in vertebroplasty for multiple myeloma. a retrospective study.Pain Med. 2020; 21: 3018-3023https://doi.org/10.1093/pm/pnaa018Crossref Google Scholar This demands a close follow-up, emphasizing low thoracic and lumbar levels. Medial branch nerve intervention is a safer option to treat pain. In a prospective randomized controlled trial,5Wang B Guo H Yuan L et al.A prospective randomized controlled study comparing the pain relief in patients with osteoporotic vertebral compression fractures with the use of vertebroplasty or facet blocking.Eur Spine J. 2016; 25: 3486-3494https://doi.org/10.1007/s00586-016-4425-4Crossref Scopus (37) Google Scholar the difference in pain relief between these 2 techniques was insignificant in the long term. The disadvantage is that it does not provide stability to the fracture, but the fracture heals, and pain remains in the posterior column of Denis. Another option that must be mentioned in cases of cancer-related bone pain is a single 8-Gy radiotherapy dose. It must be offered as early as possible for palliative, analgesic, or decompressive purposes and to prevent severe bone events, even for those with poor survival prognosis.6Gottumukkala S Srivastava U Brocklehurst S et al.Fundamentals of radiation oncology for treatment of vertebral metastases.Radiographics. 2021; 41: 2136-2156https://doi.org/10.1148/rg.2021210052Crossref Google Scholar Finally, a recent metanalysis7Mattie R, Brar N, Tram JT, et al. Vertebral augmentation of cancer-related spinal compression fractures: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2021;46(24):1729–37. doi: 10.1097/BRS.0000000000004093Google Scholar demonstrated an overall positive and statistically significant effect of vertebral augmentation, especially when compared with nonsurgical management. So, this procedure must always be considered in the multimodal management of pain in this scenario.