John M Mathis

Vertebroplasty is a term that describes a surgical therapy that has been performed as an open operative procedure for decades, using bone graft, cement, or metal implants to modify or reconstruct damaged or destroyed vertebra.1-12 In these procedures, polymethylmethacrylate (PMMA) has been the cement most often used for reconstruction and augmentation of bone damaged by trauma or tumor invasion.1,3,11,12 Shortly after Galibert and Deramond13 performed the first percutaneous vertebroplasty (PV) in 1984 (by injecting PMMA into a C2 vertebra that had been destroyed by an aggressive hemangioma), Dusquenel adapted the procedure to treat the pain resulting from the compression fractures associated with osteoporosis and malignancy; this was reported by Lapras et al. in 1989.14 A small series followed in 1991 by Debussche-Depriester et al. that reported good pain relief in five osteoporotic compression fractures treated with PV.15 Even though the procedure was known to be useful in osteoporotic compression fractures, its early use in Europe focused on the treatment for pain resulting from tumor invasion of the spine.

In 1993, PV was introduced into the United States at the University of Virginia by Dion and colleagues (Jensen, DeNardo, and Mathis). These investigators focused their work primarily on osteoporotic compression fractures and subsequently provided the first clinical series from the United States in which PV was used.16 Their report noted significant pain relief in 85 to 90% of patients treated for painful osteo-porotic compression fractures. This was similar to the early reports about PV from Europe. Since that time, the procedure has grown in popularity and is now becoming the standard of care for pain produced by osteoporotic compression fractures of the spine.17

The osteoporotic population at risk of fracture is huge, with between 700,000 and 1,200,000 vertebral compression fractures a year in the United States resulting from osteoporosis alone.18 The incidence of compression fracture exceeds that for hip fracture, and the direct costs of fractures yearly in the United States due to osteoporosis is in excess of $15 billion.18-20 Osteoporosis is greatest in elderly Caucasian females, and the number of affected individuals is growing yearly.20 Additionally, significant numbers of fractures occur in males and in patients receiving steroids for conditions such as cancer, collagen vascular disease, transplant therapy, and severe allergy or asthma.

Percutaneous vertebroplasty is indicated in patients who exhibit pain resulting from vertebral compression fractures (VCFs) that are due to the weakening associated with bone mineral loss secondary to osteoporosis and who are not effectively treated by medical or conservative therapy (i.e., analgesics, bed rest, external bracing, etc.).16,17,21-33 Without PV, chronic pain in these individuals typically lasts from 2 weeks to 3 months.34 The chronic debilitation, limitation of activity, and decline in quality of life resulting from these fractures has been shown to result in depression, loss of self-esteem, and physical impairment. Recent data reveal that vertebral compression fractures are associated with an increased mortality of 25 to 30% compared with age-matched controls.35

Though less common than osteoporosis, neoplastic disease is well known as a cause of painful VCFs. These fractures can be associated with primary malignant or metastatic lesions, myeloma, and with aggressive benign tumors such as hemangiomas. Painful compression fractures may have a clinical picture similar to that of the osteoporotic variety. If the etiology is in question, biopsy should precede or accompany the PV, which will not alter or impair other therapeutic measures such as chemotherapy or radiotherapy. The risk of cement leak is higher with a tumor etiology for VCF than with osteoporosis, generally because the vertebra is less intact. The risk of significant cement leak (or tumor extrusion by the cement) is increased with destruction of the posterior wall of the vertebra. With tumor extension into the spinal canal (even without symptoms), PV will have a high risk of creating or exacerbating neural compression and should generally be avoided.

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