Vertebral compression fractures: When is surgery indicated?

Frank M. Phillips, MD, gives his views on uses of vertebroplasty, kyphoplasty for treatment of these osteoporotic fractures.

Issue: December 2004

ByFrank M. Phillips, MD

ByDouglas W. Jackson, MD

Frank M. Phillips, MD [photo]
Frank M. Phillips, MD,
Associate Professor of Orthopedic Surgery, Rush University Medical Center Chicago, Illinois

As orthopedic surgeons, we come in contact with the impact of osteoporosis of the spine in our patients. Even though we may not elect to treat them ourselves, we should all be aware of the recent advances in treatment available.

This month, I have asked Dr. Frank Phillips to share his answers about this topic with Orthopedics Today.

Douglas W. Jackson, MD: What is the incidence of vertebral compression fractures and the consequences in the United States?

Frank M. Phillips, MD: The National Osteoporosis Foundation estimates that more than 100 million people worldwide and nearly 30 million in the United States are at risk for developing fragility fractures secondary to osteoporosis.

In the United States there are an estimated 700,000 pathological vertebral body compression fractures each year, of which more than one-third become chronically painful. Vertebral compression fractures account for a significant portion of the more than $17 billion of annual direct costs associated with osteoporotic fractures in the United States.

Osteoporotic vertebral compression fractures (VCF) are a leading cause of disability and morbidity in the elderly. Consequences of these fractures include pain and, in many cases, progressive vertebral collapse with resultant spinal kyphosis. Whether the fracture is painful or not, the spinal deformity impacts health and medical costs.

Spinal kyphosis because of osteoporotic VCF has been shown to adversely affect quality of life, physical function, mental health and survival. These effects are related to the severity of the spinal deformity and are, in part, independent of pain.

Jackson: What are the current indications for surgical intervention?

Phillips: Surgical intervention in patients with osteoporotic VCFs has traditionally been reserved for those patients with neurologic sequelae. Open surgery is, however, complicated by the medical comorbidities often present in this elderly patient population, as well as by difficulties in instrumenting osteoporotic bone.

“The ideal surgical treatment of osteoporotic vertebral compression fractures should address both the fracture-related pain and the kyphotic deformity.”
— Frank M. Phillips

The ideal surgical treatment of osteoporotic VCFs should address both the fracture-related pain and the kyphotic deformity. This should be accomplished in a minimally invasive fashion without subjecting the patient to unacceptable risks or excessive surgical trauma.

Over the past decade, percutaneous vertebroplasty involving the injection of polymethylmethacrylate (PMMA) into a fractured vertebral body in an attempt to alleviate pain has been popularized. Although effective at relieving vertebral fracture pain, vertebroplasty is not designed to address the associated sagittal plane deformity.

Kyphoplasty involves the penetration of the vertebral body with a trochar, followed by insertion of an inflatable balloon tamp (IBT). Inflation of the balloon tamp will restore the vertebral body back toward its original height while creating a cavity to be filled with bone void filler. This technique was first performed in 1998.

The primary indications for vertebral augmentation procedures are painful or progressive osteoporotic or osteolytic vertebral compression fractures. Contraindications include systemic pathologies such as sepsis, prolonged bleeding times or cardiopulmonary conditions that would preclude the safe completion of the procedures. In certain vertebra plana fracture configurations, vertebral augmentation may be technically difficult.

Patients with true burst fractures or fractures associated with neurologic findings are not candidates for percutaneous vertebral augmentation procedures. Generally, we do not advocate cementing more than three vertebral levels in one procedure because of the potential for deleterious cardiopulmonary effects related to pulmonary embolization (fat or cement) or to cement monomer.

The optimal timing of kyphoplasty after sustaining a VCF is uncertain. In a patient with an acute VCF and relatively minor vertebral collapse, I will attempt a trial of conservation care during which serial radiographs are obtained. Kyphoplasty is recommended if there is progressive collapse of the vertebral body, if the pain attributed to the VCF is incapacitating or if the pain attributed to the VCF does not respond to a reasonable period of conservative care.

With advanced kyphosis at the time of presentation after a VCF, immediate kyphoplasty treatment may be considered to improve sagital alignment.

Jackson: What are the clinical results and benefits for patients?

Phillips: Both vertebroplasty and kyphoplasty have been reported to result in partial or complete pain relief within 72 hours of the procedure. Overall, 60% to 100% of patients reported in the literature noted dramatically decreased pain after vertebral augmentation.

In addition to decreased pain, improved functional levels and reduced analgesic medical requirements have been reported. Kyphoplasty has also been shown to reduce days in bed and improve ambulatory status in patients with VCFs. In addition to pain relief, kyphoplasty also will restore vertebral body height and improve spinal sagittal balance. We have published on a series of 39 patients in whom kyphoplasty improved local kyphosis by 14º in reducible VCFs.

Jackson: What are the complications and the incidence of their occurrence?

Phillips: Complications of vertebral augmentation largely related to extravertebral cement extravasation during the procedure. During vertebroplasty, “runny” bone cement is injected directly into the fractured vertebral body and cement may leak out of the vertebral body directly through deficiencies in the vertebral body cortex or via the venous system. Extravertebral cement leak rates of up to 65% have been reported with vertebroplasty.

In addition, cases of cement pulmonary embolism have been reported. Despite this high leak rate, the incidence of clinically significant complications with vertebroplasty has been reported at less than 5%. With kyphoplasty, placement of partially cured cement into the intravertebral cavity created by IBT inflation has led to a lower extravertebral cement leak rate of less than 10%.