Vertebroplasty and Kyphoplasty

Osteoporotic vertebral compression fractures are the leading cause of disability and morbidity in the elderly.73-75 The consequences of these fractures may include pain, and in many cases vertebral collapse and kyphosis. Traditionally, these fractures have been treated nonsurgi-cally, except in cases of fractures associated with neurological compromise. Obviously, surgical reconstruction in the patient with osteoporosis is challenging. From a surgical point of view, orthopedic fracture care emphasizes the restoration of anatomy, correction of deformity, and subsequent preservation of function. These goals have not been met in the conservative care of patients with vertebral compression fractures. The ideal treatment should address both the fracture-related pain and the mechanical compromise related to kyphosis.

Percutaneous vertebroplasty was described in 1987.76 In this procedure, whereby polymethylmethacrylate is injected into a compressed segment, immediate stability is obtained, but deformity is not corrected. Suggested indications included stabilization of painful osteoporotic fractures, painful fractures due to myeloma, and painful hemangiomata. Reports on clinical outcome for vertebroplasty have been encouraging, with most patients experiencing partial or complete pain relief within 72 hours.77-82 Complication rates have been low, with the most significant complications resulting from extravertebral cement leakage causing spinal cord or nerve root compression, or pulmonary embolism.77,78,80,82-84 Additionally, a higher rate of extravasation has been noted in patients with metastatic disease versus patients with osteoporosis.85,86

Overall, vertebroplasty appears to be a reasonable method by which to treat a symptomatic vertebral compression fracture that has failed to respond to time-limited conservative care. Certainly, in a patient with multiple levels and significant debility, this may be the procedure of choice. However, a potential theoretical limitation of vertebroplasty is its inability to address the aspect of persistent deformity, which is accompanied by a theoretical increased risk of adjacent segment degeneration, or possible fracture, as well as chronic pain related not to the fracture per se but, rather, to the postural concerns raised by deformity.

Kyphoplasty claims to reduce a fracture via an inflatable bone tamp placed percutaneously into the vertebral body.86-90 Indications for kyphoplasty include painful osteoporotic compression fractures with induced kyphotic deformity. Kyphoplasty has not been investigated in the treatment of nonosteoporotic spinal metastatic disease. Initial reports of pain relief with kyphoplasty are comparable to those for ver-tebroplasty. In a study by Garfin et al.,91 90% of patients reported significant pain relief in the first 2 weeks of the procedure. In the initial series of these investigators, there were four major complications in 340 patients. Overall, serious adverse events occurred in 1.2% of patients.88 Wong et al.86 reported one presumed cement embolus to the lung, although this was attributed predominantly to technical issues associated with the use of a less viscous cement. Lieberman et al.89 had one major and two minor complications while achieving an average of only 2.9 mm height restoration. In addition, Phillips et al.90 reported improvement in local kyphosis by a mean of 14°. Kyphosis reduction may also be seen with vertebroplasty simply as a result of pain relief, so the effect with kyphoplasty may be less significant as an indicator of a procedural advantage.

The obvious theoretical advantage of kyphoplasty—namely, an attempt to restore normal anatomy—requires further follow-up and investigation. Certainly, if fracture reduction can be demonstrated to result in a decreased risk of adjacent segment failure, either by a painful degenerative change or subsequent fracture, then the advantages of kyphoplasty would be apparent. However, height restoration, to date, has been meager (89), and the cost and complication rates remain a disadvantage when the bone tamp procedure is compared with vertebroplasty.

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