Treatment Of Painful Vertebral Fractures Research Articles

Results of treatment of painful vertebral fractures by kyphoplasty or conservative symptomatic management

Purpose: This nonrandomised study analyzed the results of treatment of painful vertebral fractures in patients with primary osteoporosis with balloon kyphoplasty and compared them with conventional management (control group).
 Methods: Consecutive patients were enrolled from an outpatient orthopaedic department over a four month period. Eight patients were treated with balloon kyphoplasty and eight with a symptomatic approach (analgesics, bed rest, thoracolumbosacral orthosis). Outcome measures included back pain severity measured on a visual analog scale (VAS), activity level measured on a VAS, bed rest, the SF-36 medical outcomes survey, subject satisfaction, and radiomorphology.
 Results: Patients reported severe back pain interfering with daily activities before treatment. Physical functioning and quality of life were also markedly impaired. Statistically significant (P < 0.05) improvements in pain and functional outcomes occurred after treatment in the kyphoplasty group. Minor improvements were noted in the control group. Clinical outcomes were significantly different between the groups (P < 0.05). Kyphoplasty increased the midline vertebral height of the treated vertebral bodies, whereas in the control group vertebral height decreased.
 Conclusion: A positive effect of kyphoplasty over conventional treatment was observed on vertebral morphology and patient satisfaction, pain, level of activity, and overall health perception.

Vertebroplasty and kyphoplasty; evidence based treatment of painful vertebral fractures?

Vertebroplasty and kyphoplasty; evidence based treatment of painful vertebral fractures?

SP0092 Osteoporosis. Whom, When and How to Treat

The evaluation and treatment of osteoporosis differ depending on several conditions such as the associated risk factors for the development of osteoporosis and fragility fractures, gender, age and menopausal status...

Current Treatment and Management of Dystrophinopathies

• Duchenne muscular dystrophy (DMD), the most common and severe type of dystrophinopathy, is a progressive disease affecting primordially skeletal and cardiac muscle. A coordinated multidisciplinary approach is required to address its multisystemic manifestations and secondary problems.• Treatment with glucocorticosteroids (GCS) is accepted as standard of care in ambulant DMD. Daily and intermittent administrations are both in common use with different efficacy and different side effect profile.• There are no established guidelines for age/stage at initiation and treatment duration of GCS. Common practice is initiation of GCS before the child is starting to decline (between age 3 and 6years) and continuation of monitored treatment after loss of ambulation, aiming at delaying cardiac and respiratory manifestations and preventing the development of scoliosis.• Prevention, monitoring, and treatment of the side effects of long-term chronic GCS use, such as excessive weight gain, hypertension, osteoporosis, impairment of glucose metabolism, delayed puberty, and cataract, should be integrated in the standards of care.• Noninvasive ventilatory support associated with cough assisting techniques has significantly improved the longevity in DMD.• Pharmacologic treatment for cardiac manifestations includes the standard treatments of dilated cardiomyopathy and arrhythmia such as the use of angiotensin converting enzyme (ACE) inhibitors, beta-blockers and diuretics. The lack of robust controlled data hampers clear recommendations about preventive treatment with ACE inhibitors.• DMD is associated with low bone mineral content, which is aggravated by the use of corticosteroids. The use of biphosphonates can be considered in the treatment of painful vertebral fractures. The use of biphosphonates as a preventive treatment should be investigated in randomized controlled studies.• DMD has evolved from a pediatric disease to an adult condition. This underscores the need to prepare adult neurologists for the optimal surveillance and management of patients with a severe chronic disease that have outgrown the pediatric care and that may develop new disease manifestations with improved longevity.

Bone Cement Pulmonary Embolism after Percutaneous Vertebroplasty

Percutaneous vertebroplasty (PVP) is a common procedure for treatment of painful vertebral fractures. Although PVP is considered minimally invasive, complications may occur during the procedure. Bone cement pulmonary embolism (CPE) is a severe and potentially life-threatening complication following vertebroplasty (VP). CPE commonly occurs after performing VP, but hemodynamically it has little clinical impact. Treatment strategies of CPE is still unclear.

Late onset of pulmonary cement embolism after a regular vertebroplasy. A clinical documentation

Abstract Vertebroplasty is a new minimal-invasive procedure for the treatment of painful vertebral fractures. The risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. However, data about the incidence and treatment strategies of pulmonary cement embolisms (PCE) are limited. We report a case of a patient with symptomatic pulmonary cement embolism after the vertebroplasty. The diagnosis was confirmed by means of CT- scan. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up. In our case of symptomatic embolisms, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy.

Bisphosphonate treatment of painful vertebral fractures due to osteoporosis in five boys with Duchenne muscular dystrophy

Bisphosphonate treatment of painful vertebral fractures due to osteoporosis in five boys with Duchenne muscular dystrophy

Kiva® VCF Treatment System – klinische Studie zur Wirksamkeit und Patientensicherheit mit einem neuen System zur Augmentation von vertebralen Kompressionsfrakturen

As a further alternative to previously used vertebral augmentation methods, the Kiva VCF Treatment System® was clinically investigated. The pilot study included 24 patients (mean age 74 years, 34 vertebrae). During an operation period of 16.6 minutes on average 2.2 ± 1 mL of PMMA cement were injected. 87 % of patients were satisfied or very satisfied with this treatment. In 2 cases leakage of cement has been registered. The pain intensity was already reduced after 7 days to 69.5 mm (VAS scale 0-100). After 30 days, the difference from baseline was 76 mm. Significant improvements have also been shown in the Oswestry Score (functional ability), physical performance and mental well-being. On the basis of these results, the new augmentation can be described as being effective in the treatment of painful vertebral fractures.

The use of intravenous bisphosphonate therapy to treat vertebral fractures due to osteoporosis among boys with Duchenne muscular dystrophy

The impact of intravenous bisphosphonate treatment to treat painful vertebral fractures in boys with DMD has not been documented. In this retrospective observational study of seven boys, 2 years of intravenous bisphosphonate therapy was associated with back pain improvement and stabilization or increases in the height ratios of fractured vertebrae. Boys with Duchenne muscular dystrophy (DMD) are at risk for vertebral fractures. We studied the impact of intravenous bisphosphonate therapy for the treatment of painful vertebral fractures in DMD. This was a retrospective observational study in seven boys with DMD (median 11.6 years, range 8.5 to 14.3) treated with intravenous pamidronate (9 mg/kg/year) or zoledronic acid (0.1 mg/kg/year) for painful vertebral fractures. At baseline, 27 vertebral fractures were evident in the seven boys. After 2 years of bisphosphonate therapy, 17 of the fractures had an increase in the most severely affected vertebral height ratio, 10 vertebrae stabilized, and none showed a decrease in height ratio. Back pain resolved completely (N = 3) or improved (N = 4). The median change in lumbar spine volumetric bone mineral density Z-score was 0.5 standard deviations (interquartile range, -0.3 to 1.7). Two boys had three incident vertebral fractures in previously normal vertebral bodies that developed over the observation period. There was a decline in the trabecular bone formation rate on trans-iliac bone biopsy but no evidence of osteomalacia. First-dose side effects included fever and malaise (N = 4), hypocalcemia (N = 2), and vomiting (N = 1); there were no side effects with subsequent infusions. Intravenous bisphosphonate therapy was associated with improvements in back pain and stabilization to improvement in vertebral height ratios of previously fractured vertebral bodies. At the same time, such therapy does not appear to completely prevent the development of new vertebral fractures in this context.

Comparison of percutaneous vertebroplasty and kyphoplasty in the treatment of osteoporotic vertebral compression fractures

Objective To investigate and compare the efficacy, safety, and cost effectiveness in the treatment of painful osteoporotic vertebral compression fractures ( OVCFs ) with percutaneous vertebroplasty (PVP) and kyphoplasty(PKP). Methods Seventy-two patients (96 vertebrae) with painful OVCFs were treated by PVP (n ＝34) or PKP (n ＝38) under radiological monitoring. After bone biopsy needle into the compressed vertebra, bone cement (polymethylmethacrylate) was injected in PVP group, and that was inserted followed by the inflation of vertebra to create cavities in PKP group. The fluoroscopy time, total amount of bone cement injected, and cost were recollected respectively. The score of visual analogue scale point( VAS, 10-point scale)was determined at before the procedures, and 24 hours, one week, and one month after the procedures. Pain relief and complications were observed. The Cobb angle and vertebral heights of the anterior, middle, and posterior border were measured pre-and post-operative. Results The two procedures were technically successful in all patients. The follow-up ranged from 1. 0 to 34. 0 months [mean time, (8. 9 ±3.2) months]. The Mean fluoroscopy time of treating per vertebra in PVP group was ( 11. 1 ± 10. 6 ) min, which was significant shorter than that ( 23.5 ± 13. 0) min in PKP group( P ＜0. 05 ).The mean total cost per patient was (5127. 2 ± 502.3 ) yuan in PVP group, which were strikingly lower than that(32 301.4 ±3204. 6) yuan in PKP group (P ＜0. 05). (3)There was no significant difference( P ＞0. 05 ) in average cement volumes in PVP group [ (4. 9 ± 1.1 ) ml]and PKP group [ (5.4 ± 1.7 ) ml]. Pain relief of was observed in 94. 1％ (32/34) of PVP group and in 92. 1％ (35/38) of PKP group. The score of VAS at pre-operation was (8. 3 ±0. 4 vs 7.9 ±0. 8) ,and at post-operative 24 h (2. 9 ±0. 9 vs 2. 8 ± 1. 2),1 week (2.6 ± 0. 9 vs 2.6 ± 1. 1 ), and 1 month (2.6 ± 0. 9 vs 2. 5 ± 1.3 ) were no difference at PKP and PVP group(P ＜0.05). There was significant difference between pre- and post-operative time point in each group. The Cobb angle, anterior and middle height of vertebra was corrected in both PVP and PKP group. In PVP group, the preoperative Cobb angle, anterior and middle height of vertebra was (24. 2 ± 3.8 )°,( 19. 1 ± 1.4) mm, (25. 2 ± 1.0) mm, which was significant different ( P ＜ 0. 05 ) from that of ( 19.4 ±3.9)°, (21.0 ± 1.5) mm, (27.0 ± 1.2) mm at pre-operation. In PKP group,there was significant difference (P ＜ 0. 05 ) in the preoperative Cobb angle, anterior and middle height of vertebra [(25. 1 ±5.0)°vs(10.7 ±2.8)°, (19.5 ± 1.5) mm vs (24.3 ± 1.9) mm, (25.4 ± 1.1) mm vs (29.7 ±1.3) mm, respectively]. As to the above index, the overall correcting effect in PKP was much better than that in PVP( P ＜0. 05 ). Cement leakage occurred in 9 cases in PVP group and 3 cases in PKP group ( P ＜0. 05 ) but no symptoms. There were no major complications during operation in the two groups. Conclusion PVP and PKP are effective and safe in the treatment of painful OVCFs but PVP is more cost effective than PKP. Key words: Percutaneous vertebroplasty; Spine; Osteoporosis; Fracture,compression

Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature

Balloon kyphoplasty and percutaneous vertebroplasty are relatively recent procedures in the treatment of painful vertebral fractures. There are, however, still some uncertainties about the incidence and treatment strategies of pulmonary cement embolisms (PCE). In order to work out a treatment strategy for the management of this complication, we performed a review of the literature. The results show that there is no clear diagnostic or treatment standard for PCE. The literature research revealed that the risk of a pulmonary embolism ranges from 3.5 to 23% for osteoporotic fractures. In cases of asymptomatic patients with peripheral PCE we recommend no treatment besides clinical follow-up; in cases of symptomatic or central embolisms, however, we recommend to proceed according to the guidelines regarding the treatment of thrombotic pulmonary embolisms, which includes initial heparinization and a following 6-month coumarin therapy. In order to avoid any types of embolisms, both procedures should only be performed by experienced surgeons after critical determination of the indications.

Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial

Balloon kyphoplasty is a minimally invasive procedure for the treatment of painful vertebral fractures, which is intended to reduce pain and improve quality of life. We assessed the efficacy and safety of the procedure. Adults with one to three acute vertebral fractures were eligible for enrolment in this randomised controlled trial at 21 sites in eight countries. We randomly assigned 300 patients by a computer-generated sequence to receive kyphoplasty treatment (n=149) or non-surgical care (n=151). The primary outcome was the difference in change from baseline to 1 month in the short-form (SF)-36 physical component summary (PCS) score (scale 0-100) between the kyphoplasty and control groups. Quality of life and other efficacy measurements and safety were assessed up to 12 months. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00211211. 138 participants in the kyphoplasty group and 128 controls completed follow-up at 1 month. By use of repeated measures mixed effects modelling, all 300 randomised participants were included in the analysis. Mean SF-36 PCS score improved by 7.2 points (95% CI 5.7-8.8), from 26.0 at baseline to 33.4 at 1 month, in the kyphoplasty group, and by 2.0 points (0.4-3.6), from 25.5 to 27.4, in the non-surgical group (difference between groups 5.2 points, 2.9-7.4; p<0.0001). The frequency of adverse events did not differ between groups. There were two serious adverse events related to kyphoplasty (haematoma and urinary tract infection); other serious adverse events (such as myocardial infarction and pulmonary embolism) did not occur perioperatively and were not related to procedure. Our findings suggest that balloon kyphoplasty is an effective and safe procedure for patients with acute vertebral fractures and will help to inform decisions regarding its use as an early treatment option.

Aortic aneurysm complicated with pyogenic spondylitis following vertebroplasty

Percutaneous vertebroplasty is a commonly used procedure for the treatment of painful vertebral fractures induced by osteoporosis or metastatic disease. It is generally considered to be safe and effective. However, infectious complications can be serious. We present a patient in whom pyogenic spondylitis developed 3 months after vertebroplasty. During the debridement, profuse bleeding was encountered from injury to the aorta and the patient was managed with primary closure. Two months after the initial surgery, an aortic aneurysm was detected. A wide resection of all infected tissue, including the bony lesion and aortic aneurysm was performed, and the descending thoracic aorta was replaced with a vascular graft. A titanium mesh cage filled with bone graft was employed for anterior reconstruction. Our patient illustrates that a life-threatening aortic aneurysm can indeed occur as an infectious complication of this minimally invasive procedure due to the proximity of the aorta to the thoracolumbar vertebra. The spine surgeon should be aware of the possibility of aortic wall erosion caused by long-standing spondylitis, and be prepared to manage an inadvertent injury to the aorta during surgical debridement.

Treatment of chronic and painful vertebral compressive fractures with vertebroplasty in senior patients

To evaluate the efficiency of treatment of chronic and painful compressive fractures of vertebral bodies with vertebroplasty in senior patients. 98 patients of chronic and painful compressive fractures of vertebral bodies suffering from severely back pain and activity of daily living, 33 males and 65 females, aged 71 +/- 12, with the average medical history of 12 months, underwent vertebroplasty. Follow-up was conducted for 3 - 40 months. Six-point Behavioral Rating Scale and Activity of Daily Living (ADL) Scale were used to evaluate the efficacy. 123 affected compressive vertebral bodies in the 98 cases were treated with vertebroplasty. After 3.5 - 7 ml of bone cement was injected into the lesions, complete relief was got in 20 cases, obvious relief was achieved in 59 cases, improvement was made in 14 cases, and no progress was seen in 5 case. The score of 6-point Behavioral Rating Scale decreased from 4.2 +/- 1.1 before vertebroplasty to 1.2 +/- 0.9 (P < 0.01). The ADL score decreased from 4.2 +/- 1.1 before vertebroplasty to 1.9 +/- 0.6 (P < 0.01). Vertebroplasty significantly improves the painful symptoms and ability of daily life in senior patients with chronic painful vertebral compressive fractures.

Percutaneous vertebroplasty in the therapy of osteoporotic vertebral compression fractures: a critical review

Percutaneous vertebroplasty has become an efficient technique for the treatment of painful vertebral fractures. Osteoporotic vertebral compression fractures are characterized by severe back pain and immobilization causing other complications like thrombosis or pneumonia. Vertebral cement augmentation provides increased strength of the vertebral body and an obvious pain relief. Between 1989 and 2004, 30 studies and a total of 2,086 treated patients have been published in literature. A review of these studies has been performed. The number and age of the patients, number of treated vertebrae, pre- and postoperative outcome of pain and complications of the different studies were assessed and analyzed. Percutaneous vertebroplasty is an efficient technique with low complication rates and a significant reduction in pain. It rapidly improves the mobility and quality of life of patients with vertebral compression fractures. With an increasing number of treated patients, experience with this interventional technique has become excellent. But still there are no randomized controlled trials available, showing that percutaneous vertebroplasty has a significantly better outcome than other treatment options, especially after a long-term follow-up.

Treatment of Painful Vertebral Fractures by Kyphoplasty in Patients With Primary Osteoporosis: A Prospective Nonrandomized Controlled Study

This study investigates the effects of kyphoplasty on pain and mobility in patients with osteoporosis and painful vertebral fractures compared with conventional medical management. Pharmacological treatment of patients with primary osteoporosis does not prevent pain and impaired activity of patients with painful vertebral fractures. Therefore, we evaluated the clinical outcome after kyphoplasty in patients with vertebral fractures and associated chronic pain for >12 months. Sixty patients with primary osteoporosis and painful vertebral fractures presenting for >12 months were included in this prospective, nonrandomized controlled study. Twenty-four hours before performing kyphoplasty, the patients self-determined their inclusion into the kyphoplasty or control group so that 40 patients were treated with kyphoplasty, whereas 20 served as controls. This study assessed changes in radiomorphology, pain visual analog scale (VAS) score, daily activities (European Vertebral Osteoporosis Study [EVOS] score), number of new vertebral fractures, and health care use. Outcomes were assessed before treatment and at 3 and 6 months of follow-up. All patients received standard medical treatment (1g calcium, 1000 IE vitamin D(3), standard dose of oral aminobisphosphonate, pain medication, physical therapy). Kyphoplasty increased midline vertebral height of the treated vertebral bodies by 12.1%, whereas in the control group, vertebral height decreased by 8.2% (p = 0.001). Augmentation and internal stabilization by kyphoplasty resulted in a reduction of back pain. VAS pain scores improved in the kyphoplasty group from 26.2 +/- 2 to 44.2 +/- 3.3 (SD; p = 0.007) and in the control group from 33.6 +/- 4.1 to 35.6 +/- 4.1 (not significant), whereas the EVOS score increased in the kyphoplasty group from 43.8 +/- 2.4 to 54.5 +/- 2.7 (p = 0.031) and in the control group from 39.8 +/- 4.5 to 43.8 +/- 4.6 (not significant). The number of back pain-related doctor visits within the 6-month follow-up period decreased significantly after kyphoplasty compared with controls: mean of 3.3 visits/patient in the kyphoplasty group and a mean of 8.6 visits/patient in the control group (p = 0.0147). The results of this study show significantly increased vertebral height, reduced pain, and improved mobility in patients after kyphoplasty. Kyphoplasty performed in appropriately selected osteoporotic patients with painful vertebral fractures is a promising addition to current medical treatment.

Clinical Measurements of Cement Injection Pressure During Vertebroplasty

Clinical study of injection pressure during vertebroplasty. To investigate the range of injection pressures during conventional vertebroplasty interventions and to study the influence of syringe design and cement polymerization time on injection pressure. Vertebroplasty is an efficient procedure for the treatment of painful vertebral fractures. However, cement leakage is a potentially serious complication. Although injection pressure has been suggested as a factor for extravasation risk, to date, there are only anecdotal reports of pressure data for cement augmentation in the clinic. Using a syringe holder instrumented with load and displacement transducers, injection pressure and volume were recorded in vivo during conventional cement augmentation. Wide (3 mm opening) and normal (1.8 mm opening) syringes were alternated such that each type was evaluated for early (300-500 seconds postmixing) and late (>500 seconds postmixing) cement polymerization time. The influence of syringe type and polymerization time on injection pressure was evaluated using a multifactorial analysis of variance followed by Scheffe post hoc comparison. The maximum peak injection pressure measured was 3215 kPa. The average pressure peaks for normal and wide syringes were 1693 +/- 653 kPa and 1727 +/- 597 kPa, respectively. No statistically significant differences were found between injection pressures with wide and normal syringes. Higher injection pressures were observed later in the polymerization process. High injection pressures approaching 20 atmospheres are reached during conventional vertebroplasty. Widening the syringe tip diameter did not significantly change injection pressures, whereas elapsed time did. Further research is needed to improve injection equipment and materials for vertebroplasty.

Bone substitutes in vertebroplasty.

Vertebroplasty--percutaneous cement augmentation of vertebral bodies--is an efficient procedure for the treatment of painful vertebral fractures in osteoporosis. At the present time, polymethylmethacrylate (PMMA) is the only available cement with reports of clinical application and experience. The material is easy to handle, the radiopacity can be adapted by adding contrast dye, and it is mechanically efficient. Composite cements (acrylic cements in conjunction with ceramics) are bioactive, highly radiopaque, and feature excellent mechanical properties. One such cement, Cortoss, is currently undergoing clinical trials for vertebroplasty and has so far been shown to be a potentially valuable alternative to PMMA. Several in vitro studies with injectable calcium phosphate (CaP) cements show their feasibility and mechanical effectiveness. Animal studies confirm their biocompatibility and osteoconductivity. However, handling problems and the limited radiopacity of these cements currently preclude their clinical use.

Percutaneous transpedicular vertebroplasty with PMMA: operative technique and early results. A prospective study for the treatment of osteoporotic compression fractures.

Vertebroplasty-percutaneous cement augmentation of osteoporotic vertebrae is an efficient procedure for the treatment of painful vertebral fractures. From a prospectively monitored series of 70 patients with 193 augmented vertebrae for osteoporotic and metastatic lesions, we analysed a group of 17 patients suffering from back pain due to osteoporotic fractures. The reinforcement of 45 vertebral bodies in these patients led to a significant and lasting pain reduction (P < 0.01 ). The presented technique is useful, as, in one session, at least four injections can be performed when required, allowing the prophylactic reinforcement of adjacent vertebrae as well. The use of a low-viscosity polymethyl methacrylate (PMMA) in combination with a non-ionic liquid contrast dye provides a reliable and safe procedure. Extraosseous cement leakage was seen in 20% of the interventions; however, none of them had clinical sequelae.