Vertebroplasty and Kyphoplasty: How Are They Holding Up?

It's time. It's been 20 years since surgeons started using vertebroplasty (VP) to treat vertebral compression fractures and 10 years since kyphoplasty (KP) was developed. It's time to take a look back and see how well these treatments are working. In this article, researchers from The Johns Hopkins Department of Neurosurgery review all the published articles on VP and KP. They summarize the level evidence (fair to good) for both of these minimally invasive procedures.

Patients with osteoporosis, spinal tumors, or trauma can develop compression fractures in the spine bones, or vertebrae. The front of a vertebra cracks under pressure, causing it to collapse in height. These fractures often cause poor back posture, debilitating pain, and difficulty completing routine activities. Vertebroplasty restores the strength of the fractured bone, thereby reducing pain. More than 80 percent of patients get immediate relief of pain with this procedure.

A vertebroplasty is done by making a small incision in the skin on each side of the spinal column. A long needle is inserted through each opening. The surgeon slides the needles through the back of the spinal column into the fractured vertebral body.

A fluoroscope is used to guide the needles. This is a special X-ray television camera adjusted above the patient's back that lets the surgeon see the patient's spine on a screen. Metal objects show up clearly on X-rays. The needles are easy for the surgeon to see on the fluoroscope screen. This helps the surgeon confirm that the needles reach the correct spot.

Once the needle is in place, special acrylic bone cement is injected through the needle into the fractured vertebra. A chemical reaction in the cement causes it to harden in about 15 minutes. This fixes the bone so it can heal. Bandages are placed over the small openings where the needles were inserted.

A kyphoplasty is done with the same minimally invasive technique. But instead of a needle injecting cement into the bone, a hollow tube with a deflated balloon on the end is slid into holes drilled in the vertebrae. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis (hunchback) deformity that can occur with vertebral compression fractures. Then surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. Once the cement hardens, the bone is held in its corrected height and position.

These procedures provide rapid pain relief, but is the final outcome of treatment any different or better than standard medical care? Can the cost of these procedures be justified? That's what these authors tried to find out by doing a systematic review of all available literature. They looked at the treatment of vertebral compression fractures for three separate conditions: osteoporosis, trauma, and tumors.

They found that in the short-term (within the first two weeks to three months) patients experienced significant improvement in pain, mobility, and quality of life. No wonder because they could stand up, sleep, sit, get dressed, go shopping, take a bath and participate in their usual activities once again. But when compared with standard medical care, the results weren't any different in the long-run (two years later).

Looking at the comparisons a little closer, there were some other benefits of VP and KP. Patients could use less pain medication, their general health improved in the first three months, and there were very few complications with the treatment. Patients with tumor-related compression fractures did not respond as well as patients with osteoporosis or trauma-induced fractures.

Vertebral compression fractures are painful enough that many people in the studies crossed over from standard medical care to the surgical procedure despite being assigned to the standard care group as part of the study. Seeing immediate pain relief and greater improvement in physical functioning in other patients after only 24 hours was the reason some patients insisted on crossing over.

Given those results, telling patients that standard care will have the same results as VP or KP in 12 to 24 months loses some of its punch. Although the evidence isn't always consistently high-level, the results of this systematic review support the use of VP and KP. Rapid pain relief, earlier mobilization, fewer and shorter hospitalizations all add up to improved care at a reduced cost.

The authors suggest further study is needed now. First, to confirm with a high-level of evidence (not just fair-to-good evidence) the positive findings so far. Second, to evaluate the risk of treatment failure over time. For example, are patients able to maintain the restored vertebral height? Is there a transfer of load to adjacent levels that causes problems above or below the fractured level?

Since almost one million vertebral compression fractures occur every year in the United States, better, faster treatment would be appreciated by everyone affected. The fact that many spine surgeons are now using minimally invasive procedures such as VP and KP also means more studies are already being published each year to show the benefits of this management approach.

Matthew J. McGirt, MD, et al. Vertebroplasty and Kyphoplasty for the Treatment of Vertebral Compression Fractures: An Evidence-Based Review of the Literature. In The Spine Journal. June 2009. Vol. 9. No. 6. Pp. 501-508.

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