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11 Medical, Interventional, and Orthotic Management of Osteoporotic Vertebral Compression Fractures
105
they are frequently cumbersome and can be difcult to put on and off. When to apply the brace,
what type of brace to use, and how long to wear
the brace are still questions that need to be
answered formally.
In the initial 3 months following an OVCF,
there is a paucity of literature looking at the direct
effects of bracing; however, the majority of literature that discusses treatment options for OVCFs
include bracing in the algorithm. Studies looking
at three-point orthoses (3-POs) and corsets have
shown varying results as to which is the preferred
method of bracing in the acute treatment phase.
Murata et al. found that rigid external supports
are more likely to prevent deformity and nonunion compared to exible corsets, whereas
Meccariello et al. found that exible corsets in
comparison to 3-POs showed greater improvements in quality of life and function with less
complications while providing equivalent stabilization effects [38, 39]. Prospective studies looking at conservative treatment with and without
bracing are needed to better elucidate the effects
of specic orthoses.
The strongest evidence exists for the use of
bracing after the acute period. In patients who
develop kyphosis, the utility of a semirigid
backpack thoracolumbar orthosis has been
described. Two studies by Pfeifer etal. demonstrated using a thoracolumbar orthosis in the
6-month period following an OVCF resulted in
increased core strength, decreased kyphosis,
decreased pain, and improved function and
quality of life [40, 41].
Like other treatments, bracing also has its
risks. Rigid braces can result in decubitus ulcers
and infections. Although the studies above
reported increased strength following bracing,
some braces have been reported to result in weakening of the axial musculature and decreased pulmonary function. There is also the theoretical
potential for fracture at the proximal and distal
ends of the brace as there is an abrupt change in
stiffness. Therefore, when bracing is used,
patients and caregivers must be counseled on
monitoring for side effects, and the duration of
use should be limited.
As there are many brace options available, the
decision to prescribe a particular brace should be
based on patient comfort, compliance, and cost
until there is clear evidence that one brace is
superior.
Psychological Treatment
Quality of life following an OVCF has been well
studied and was shown to be negatively impacted
[42–45]. In particular, following the resolution of
pain, patients often have psychological impairment. Patients have reported anxiety and depression and, as a result of kyphosis, abdominal
protrusion, and activity limitation, can also have
diminished self-esteem [44]. Additionally, a fear
of falling, embarrassment, and frustration have
been reported [43, 46].
Orthopedic surgeons play a role in the treatment of the above conditions primarily through
recognition of the condition in follow-up, but
also in making referrals to person-centered and
other supportive interventions for continued
treatment following an OVCF.During follow-up,
the surgeon must make it a point to inquire about
patients’ quality of life and psychological issues
as many patients may not openly offer this information [43]. When abnormal moods and fear of
functional impairments are identied, consultation with a physical therapist, psychologist, or
psychiatrist may be warranted. In a study by
Olsen etal., an exercise and education program
led by a physical therapist showed a signicant
decrease in the fear of falling [47]. Gold et al.
showed that a physical therapist-led class was
able to not only teach exercises but also stress
reduction techniques, relaxation techniques, and
lifestyle modications to address psychological
symptoms [48].
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Outcomes of Non-operative Management and Vertebral Augmentation of Vertebral Compression Fractures
Robert A. McGuire Jr and Joseph M. Zavatsky
12
The primary goals of treatment for VCFs are pain
relief and restoration of vertebral body height.
There are also secondary benets of fracture
treatment– preservation of the independence of
the individual with the fracture, protection of pulmonary function, and avoidance of medical complications following the fracture. There are
several treatment options available for these
patients. Fortunately, the majority of these fractures heal uneventfully with conservative management which typically consists of rest,
short-term activity modication, bracing for
comfort, and short-term use of calcitonin [1–4].
For those patients who have unrelenting pain
or progressive collapse of the vertebral body,
cement augmentation is an option.
The concept of vertebroplasty was initiated in
France in 1987 for the treatment of symptomatic
vertebral hemangioma [5]. This consisted of
injection of a PMMA cement through a large
needle in the vertebral body performed either
unilaterally or bilaterally (Fig. 12.1).
Improvement of pain was not found to correlate
with the amount of cement injected, so this procedure could be done under local anesthesia and
at a very low cost. The concept of vertebroplasty
does not address the spinal deformity and uses
high pressure cement in a very liquid form and
therefore has a greater potential for leakage outside the vertebral body into the spinal canal and
surrounding soft tissues.
The concept of kyphoplasty, which uses a
bone tamp or balloon introduced into the vertebral body to create a cavity for implantation of
the cement [6], is more expensive to use but has
the potential to improve the kyphotic angle
through the cavity creation and placement of a
large volume of cement into the re-expanded
R. A. McGuire Jr (*)
Department of Orthopaedic Surgery, University
of Mississippi Medical Center, Jackson, MS, USA
e-mail: rmcguire@umc.edu
J. M. Zavatsky
Spine and Scoliosis Specialists, Tampa, FL, USA
© Springer Nature Switzerland AG 2020
A. E. Razi, S. H. Hershman (eds.), Vertebral Compression Fractures in Osteoporotic
and Pathologic Bone, https://doi.org/10.1007/978-3-030-33861-9_12
Fig. 12.1 This lateral radiograph reveals consistent ow
through the cancellous interstices of the vertebral body.
This is done by using cement in a very liquid consistency,
whereas the consistency of the cement is doughy in
kyphoplasty and is not likely to be extruded into the canal
109
110
R. A. McGuire Jr and J. M. Zavatsky
fractured vertebra. Additionally, the cement is
thicker in viscosity which minimizes the risk of
extrusion.
Three periods of time will be used to evaluate
the evidence available for treating these fractures
non-operatively and with cement augmentation
using the two above techniques. We will use the
available literature prior to the publication of the
AAOS guidelines, the literature used for the production of the AAOS guidelines, and then the literature published after the AAOS guideline
publication.
Pre-AAOS Guideline Evidence
Hulme etal. performed a systematic review of 69
clinical studies comparing the use of vertebroplasty and kyphoplasty [7]. Review of these clinical studies revealed no randomized or prospective
articles at that time and very few prospective
cohort studies. There were 22 kyphoplasty studies with 1288 patients, and the vertebroplasty
group consists of 44 studies with 2958 patients.
From the data analysis of this study, pain relief
was achieved in 92% of patients who were treated
with kyphoplasty, with the visual analog scale
decreasing from 7.15 to 3.4. In the vertebroplasty
group, 87% achieved some relief of their pain
with the VAS decreasing from 8.2 to 3.0. There
were a limited number of studies that involved
the physical function, but it was felt that pain
relief resulted in improvement of function in
most patients.
When evaluating height restoration, measurement techniques vary greatly from study to
study, so it is difcult to compare the two techniques directly. In the kyphoplasty group, there
was an average of 6.6 degrees of kyphosis correction, and in 34% of the studies, there was no
appreciable improvement in angular or height
restoration. In the vertebroplasty group, there
also was a 6.6 degree kyphosis correction with
39% exhibiting no appreciable improvement in
the kyphosis.
Reported complications consisted predominantly of cement leakage, which was noted 9% of
the time in the kyphoplasty group and 41% of the
time in the vertebroplasty group. Most of these
cement leakages, however, were clinically
asymptomatic in both groups. The most notable
complication in both groups was the occurrence
of fractures occurring at levels next to the treated
level. This occurred in 15% of patients in the
kyphoplasty group and 12.9% of patients in the
vertebroplasty group.
Taylor [8, 9] and Liu [10] also published studies which were consistent with the nding of the
Hulme [7] study. Liu etal. [10] recommended
vertebroplasty to be used in the treatment of VCF
based on the higher cost of the kyphoplasty. Eck
etal. [11] performed a meta-analysis of the literature comparing the two procedures; the ndings
of their study found an improvement of 4.6 points
on the visual analog scale following kyphoplasty
and 5.68 points following vertebroplasty. New
fractures were also noted in 4.1% of those
patients treated with kyphoplasty and 7.6%
treated with vertebroplasty. They also noted
cement leakage occurring in 7% of patients
treated with kyphoplasty and 19.7% with
vertebroplasty.
In conclusion, when evaluating the data from
studies comparing vertebroplasty to kyphoplasty,
pain relief was similar in both procedures, functional improvement was tied to pain relief, and
cement leakage was higher following vertebroplasty but, in most cases, was clinically irrelevant. The ability to restore height was only seen
within the rst 3–6 months and was somewhat
better with kyphoplasty.
When evaluating these techniques to conservative management, a study by Diamond etal.
[12] using a nonrandomized trial found that after
cement augmentation, there was an earlier
improvement in pain scores as well as improved
physical function in those patients treated with
vertebroplasty as compared to the control group.
The benets were usually seen within 24hours,
and patients treated with vertebroplasty seemed
to have a more rapid rehabilitation and lower
complication rate. The benets however were
only short term– after 6weeks, compared to the
control group, patients treated with vertebroplasty were noted to be fairly similar in all outcome measures.
12 Outcomes of Non-operative Management and Vertebral Augmentation of Vertebral Compression…
111
Rousing et al. [13] found that compared to
non-operative treatment, vertebroplasty was successful in improving pain early, but no difference
was found between the two groups at 3months.
Wardlaw etal. [14] published the results of a randomized trial comparing kyphoplasty to nonoperative management and found that kyphoplasty
was better than non-operative treatment with
respect to pain improvement and functional outcomes at 1month, but those improvements were
less apparent at 12 months. McGirt et al. [15]
published a systematic review using level 1 evidence and found that compared to non-operative
treatment, vertebroplasty and kyphoplasty
showed better results in the rst 2weeks after the
procedure. The level 2 and level 3 evidence
revealed that patients who underwent kyphoplasty or vertebroplasty had improved pain at
6months, but none of the studies showed overwhelming differences between conservative and
surgical management after that period of time.
From the above studies, there appears to be some
evidence that early treatment with cement augmentation results in improved pain control, but as
time progresses, these differences become
negligible.
AAOS Guidelines
benet of vertebroplasty over sham surgery at
any time point. Kallmes etal. [19] also published
a randomized, prospective, multicentered study
on patients that had failed medical treatment with
fractures less than 1 year old; the primary outcome measures were scored on the modied disability questionnaire, and patients rated their pain
during the preceding 24hours. Over 1800 patients
were screened with 431 of the patients being eligible; 70% declined participation in the study. In
the end, there were only 131 patients enrolled in
the study, and it was found that 43% of the control group crossed over to surgery by 3months
due to unrelenting pain. The ndings reported
showed a trend toward clinically meaningful
improvement in the vertebroplasty group compared to the control group (61% vs. 48%); however there was no statistical signicance
demonstrated at any point in time.
Based on the two studies in the New England
Journal of Medicine, the AAOS guidelines that
were developed recommended against vertebroplasty; this was based on the two level 1 and three
level 2 studies with a strong consensus opinion.
Strangely enough, kyphoplasty was noted to have
weak support based on two level 1 studies. When
comparing kyphoplasty to vertebroplasty, three
studies showed inconsistent results, and therefore, no recommendation could be made.
The American Academy of Orthopaedic Surgeons
convened a committee which met in 2009 and
2010 to evaluate the existing body of published
evidence in order to develop guidelines for the
treatment of osteoporotic vertebral compression
fractures. The resulting guidelines were published in 2011 [16, 17]. What was noted at that
time was the fact that there were very few level 1
studies which could be used to develop these
guidelines. Buchbinder et al. [18] performed a
multicenter, randomized, double-blind, placebocontrolled study looking at outcomes at 1week
and 1, 3, and 6 months. The primary outcome
evaluated with this study was overall pain relief
at 6 months. Seventy-eight participants were
enrolled, 38 were treated with vertebroplasty, and
40 underwent a sham procedure; 91% completed
the 6-month study. This level 1 study found no
Post-AAOS Guidelines
Since the publication of the AAOS guidelines,
there have been multiple studies comparing vertebroplasty to conservative treatment. Klazen
etal. [20] published the Vertos II study which
enrolled 431 patients; 229 patients improved
with non-operative management, and 202 were
randomized to receive cement augmentation.
Cement augmentation resulted in signicant
pain relief at 1month, and similar results were
maintained at 1 year. Farrokhi et al. [21] also
published a randomized controlled study of vertebroplasty compared to medical management
and found that after vertebroplasty there was a
signicant decrease in pain and a signicant
improvement in the quality of life at 1 week;
112
R. A. McGuire Jr and J. M. Zavatsky
this effect was sustained over 36 months.
Berenson etal. [22, 23] published a randomized,
controlled trial of cancer patients who sustained
a fracture and randomized them to either kyphoplasty or nonsurgical treatment. Patients who
underwent kyphoplasty showed a substantial
and statistically signicant improvement as
compared to the nonsurgical control group.
Eddin et al. [24] published a study evaluating
the mortality risk following VCF in Medicare
patients following operative versus non-operative treatment. They found that after 4years, the
survival rate for patients treated non-operatively
was 50% compared to the operatively treated
group which was 60.8%. When comparing vertebroplasty and kyphoplasty, there was a 57.3%
survival rate in patients treated with vertebroplasty and 62.8% in patients treated with
kyphoplasty.
Anderson etal. [25] published a meta-analysis of eight prospective randomized trials comparing vertebral augmentation to conservative
treatment. The meta-analysis revealed greater
pain relief, functional recovery, and quality of
life with cement augmentation as compared to
conservative treatment. Similar results were
noted by Yang etal. [26], after they followed 107
patients for 1 year. Wang et al. [27] looked at
studies comparing vertebroplasty to kyphoplasty
for single- level compression fractures. They
evaluated 8 studies involving 845 patients and
found that there were no differences in long-term
VAS scores, ODI scores, and short- or long-term
SF 36 scores, or differences in adjacent segment
fracture rates with either of these procedures.
The study did however show kyphoplasty to be
superior in correcting the kyphotic angle and
vertebral body height as compared to
vertebroplasty.
In summary, recent studies have shown that
vertebroplasty and kyphoplasty can be used for
the treatment of patients with osteoporotic compression fractures in patients who fail to improve
with medical management. Determining who
will benet from cement augmentation versus
conservative treatment is an ongoing issue and
warrants further research.
Conclusion
Some patients with VCFs can benet from
cement augmentation. Studies show that the
greatest benet following cement augmentation
is usually within the rst 3months following a
fracture. Controversies exist in the literature with
no study providing denitive evidence as to
which patients will benet most from cement
augmentation. Patients who are immobilized due
to chronic pain from their fracture should be
offered the option of cement augmentation.
Patients with pain from myeloma and lymphoma
are also good candidates for treatment with
cement augmentation. The use of kyphoplasty
within 3months of a VCF has the possibility of
reducing kyphosis that resulted from the fracture.
After 3months, both vertebroplasty and kyphoplasty have a low likelihood of kyphosis
correction.
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Vertebroplasty Cement Augmentation Technique
A.OrlandoOrtiz
13
Key Points
1. Careful patient selection is a prerequisite to performing a safe and effective
vertebroplasty procedure.
2. Accurate needle placement whether
unilateral or bilateral can be achieved
with oblique “down-the-barrel” uoroscopic imaging or with traditional frontal pedicle-targeting techniques.
3. Cement injection should be performed
with meticulous imaging surveillance in
order to avoid cement extravasation into
the spinal canal, paraspinal veins, or
intervertebral disk.
4. Complications in vertebroplasty, though
uncommon, can be further reduced by
attention to specic procedure details
including use of proper uoroscopic
techniques, consistent needle insertion
maneuvers with an active appreciation
of all osseous landmarks during the procedure, and exquisite attention to the
cement injection process.
A. O. Ortiz (*)
Department of Radiology, Jacobi Medical Center,
Bronx, NY, USA
e-mail: ortizo@nychhc.org
Introduction
It is now four decades since the rst imageguided vertebroplasty procedure was performed
in 1984 by Galibert and Deramond [1]. As compared to the standard vertebroplasty procedure
which is most often performed percutaneously in
the thoracic or lumbar spine to treat an osteoporotic vertebral compression fracture, this rst
image-guided vertebroplasty procedure was performed transorally in the upper cervical spine for
a painful C2 hemangioma. Indeed, vertebroplasty
is a percutaneous procedure in which a bone needle is advanced using image guidance into a vertebral body that has been fractured as a result of
osteoporosis or, less commonly, neoplastic inltration [2]. Acrylic bone cement, usually polymethyl methacrylate that is impregnated with
barium for radiopacity, is injected through the
bone needle into the vertebral body under direct
imaging guidance [3]. The term vertebral augmentation is now used as the acrylic bone cement
is considered an implant that augments the
strength of the damaged vertebra.
The rst image-guided vertebroplasty procedures that were performed in the United States
commencing in 1993 were reported in 1997 [2].
Due to its early and dramatic success with respect
to patient outcomes, this procedure was quickly
adopted by those operators who perform percutaneous image-guided procedures. A review of the
Medicare database from 2005 to 2008 showed
© Springer Nature Switzerland AG 2020
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and Pathologic Bone, https://doi.org/10.1007/978-3-030-33861-9_13
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