Vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: an evidenced-based review of the literature

doi:10.1016/j.spinee.2009.01.003

The Spine Journal

Volume 9, Issue 6, June 2009, Pages 501-508

https://doi.org/10.1016/j.spinee.2009.01.003 Get rights and content

Abstract

Background

Vertebroplasty (VP) and kyphoplasty (KP) are routinely used to treat vertebral body compression fractures (VCFs) resulting from osteoporosis or vertebral body tumors in order to provide rapid pain relief. However, it remains debated whether VP or KP results in superior outcomes versus medical management alone in patients experiencing VCFs.

Purpose

To determine the level of evidence supporting VP or KP for the treatment of VCFs.

Study design

Systematic review of the literature.

Patient sample

Patients with osteoporotic or tumor-associated VCFs.

Outcome measures

Self-reported and functional measures.

Methods

We reviewed all articles published between 1980 and 2008 reporting outcomes after VP or KP for osteoporotic or tumor-associated VCFs and rated the level of evidence and grades of recommendation (per North American Spine Society [NASS] guidelines) supporting the use of VP or KP for the treatment of VCFs.

Results

Seventy-four VP studies for osteoporotic VCF (1 level I, 3 level II, 70 level IV), 35 KP studies for osteoporotic VCF (2 level II, 33 level IV), and 18 VP/KP for tumor VCFs (all level IV) were reviewed. There is good evidence (level I) that VP results in superior pain control within the first 2 weeks of intervention compared with optimal medical management for osteoporotic VCFs. There is fair evidence (level II–III) that VP results in less analgesia use, less disability, and greater improvement in general health when compared with optimal medical management within the first 3 months after intervention. There is fair evidence (level II–III) that by 2 years after intervention, VP provides a similar degree of pain control and physical function as optimal medical management. There is fair evidence (level II–III) that KP results in greater improvement in daily activity, physical function, and pain relief when compared with optimal medical management for osteoporotic VCFs by 6 months after intervention. There is poor-quality evidence that VP or KP results in greater pain relief for tumor-associated VCFs.

Conclusions

Although evidence suggests that physical disability, general health, and pain relief are better with VP and KP than those with medical management within the first 3 months after intervention, high-quality randomized trials with 2-year follow-up are needed to confirm this. Furthermore, the reported incidence of symptomatic procedure-related morbidity for both VP and KP is very low.

Introduction

VP and KP are percutaneous procedures for the treatment of medically refractory pain caused by acute or subacute VCF. VP and KP involve intraosseous injection of acrylic cement under local anesthesia and fluoroscopic guidance into vertebral bodies fractured owing to osteoporosis, tumor, or trauma. These minimally invasive techniques have become widely used by many spine surgeons, pain management specialists, and oncologists as an effective tool for rapid pain relief of osteoporotic and pathologic VCFs. The alternative to VP or KP, medical management, remains the gold standard and first line of treatment for VCFs. However, the annual cost of medical management of osteoporotic VCFs was estimated at $5–10 billion in 1995 and at $13.8 billion dollars in 2001 [1], [2]. These significant medical costs and the long-term morbidity of VCFs have shifted management paradigms in many practices toward the goal of more rapid pain relief with VP and KP. In fact, since the introduction of VP and KP in 1987 and 1998, respectively, the number of PubMed citations has risen from an average of 3/year (1997–1999) to 33/year (2005–2007). Given the growing amount of outcome data reported in the literature, we provide here a systematic review of all studies to date reporting outcome after VP or KP for VCFs and rate the level of evidence to critically analyze the justification of VP and KP in this setting.

Section snippets

Methods

To initiate an evidence-based analysis of the literature on VP or KP for the treatment of VCFs, three clinical questions were asked: 1) Is VP versus optimal medical management associated with superior outcomes in patients treated for osteoporotic VCFs?; 2) Is KP versus optimal medical management associated with superior outcomes in patients treated for osteoporotic VCFs?; and 3) Is VP or KP versus optimal medical management associated with superior outcomes in patients treated for

Vertebroplasty

There are 74 published studies to date reporting the outcomes of patients receiving VP for osteoporotic VCFs [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70],

Discussion

Over 700,000 VCFs occur per year in the United States. The prevalence of VBFs in women older than 50 years of age is estimated at 26% [106], increasing to 80% in patients older than 80 years of age [107]. Eighty-four percent of these VCFs are associated with pain [108]. In addition to acute pain, clinical consequences of VCFs include pulmonary dysfunction, loss of mobility, chronic spinal deformity, chronic pain, and depression [106]. Furthermore, epidemiological studies suggest that VCFs may

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