Kyphoplasty and Vertebroplasty in vertebral fractures
Kyphoplasty and Vertebroplasty
• Epidemiology of osteoporotic fractures• Natural history• Morbidity and mortality• Conservative treatment• Vertebroplasty/Kyphoplasty• How its done• Selection of patients and imaging
Kyphoplasty and Vertebroplasty
• Results• Vertebroplasty v Kyphoplasty• Acute v Chronic fractures• Controversies• Other indications• Future developments
EpidemiologyRadiographic
• 25 % in post menopausal females
• 40% in women > 80yrs• Age group 65 yrs+ are
fastest growing segment of the population
• Less common in men• Melton et al. Epidemiology of vertebral
fractures in women. Am J Epidemiol 1989; 129:1000-11.
Consequences of vertebral fractures
• Sentinel sign of failing health
• 35-40% increase in cancer deaths
• 23-34% increase in mortality rates
• 5yr survival 61% cf. 76%• Cooper C et al. Population based study of
survival after osteoporotic fractures. Am J Epidemiol 1993:137;1001-5.
Clinical incidence
• Majority are asymptomatic
• Loss of height and stooped posture
• 23-33% are painful• Over ⅔rds become
manageable or asymptomatic in 6-12 weeks
• Cooper C et al. The epidemiology of vertebral fractures. Bone 1993-14.611-5
Predictors of fracture
• Age• Sex• Osteoporosis• Inactivity• Smoking• 20-30% are multiple• Previous fracture
Predictors of fracture
Predictors of fracture 19.2% of females with a
confirmed incidental fracture had a second fracture within one year.
24% of females with two or more fractures developed a further fracture within a year.
Lindsay et al. JAMA 2001; 285: 320-3.
Evaluation• Severe back pain• Often no history of
trauma• Pain is worse upright• Thoracic kyphosis• Pain reproduced by
pressure over spinous process
• Very rare neurological deficit
• Exclude other causes
Evaluation
Think twice!
• Fractures above T6• Less than 55 yrs without
history of trauma• Patients with known
malignancy
Radiographic evaluationof age of fracture
• Plain films• MRI Low signal T1 High signal T2 High signal STIRBest indicator of age is the
history.
Bone Scan
• Not as commonly used as MRI
• Been show to have a 93% predictive value in vertebroplasty!
• May be abnormal when MRI is normal
• Maynard et al. Value of bone scan imaging in predicting pain relief in vertebroplasty. AJNR 2000;21:1807-12.
Treatment
• Pain relief• Exercise• Diet• Osteoporosis• Brace?
Vertebroplasty / KyphoplastyWhat is it?
Vertebroplasty Kyphoplasty
How does it work?
• Structural support – but no good correlation with amount of cement injected
• Thermal properties• Decompression• Placebo
How is it done?
• Usually performed under general anaesthetic
• Can be performed under local
• Day case procedure• Minimal invasive
How is it done?
How is it done?
How is it done?
Vertebroplasty Kyphoplasty
How is it done?
Indications for vertebroplasty/kyphoplasty
• Only needed in a small subset of patients
• High signal on STIR.• Pain on percussion• Increased activity on
bone scan• T5 and below-
kyphoplasty• Timing?
Contraindications
• Infection• Uncorrectable
coagulopathy• Anaesthetic Risk• Neurology• Middle column
compromise is NOT.
Complications
• Very few cliniccal relevant complications.• Cement extravasation 70%+• Pulmonary embolus 70%+
Results
Vertebroplasty• Significant better pain and
functional improvement than conservative treatment at 3 months.
• No difference at twelve months.
• Vertebroplasty patients had significantly more pain than the conservative group.
• Hulme PA et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine 2006:31;1983-2001.
Kyphoplasty• FREE trial.• 300 patients randomised.• Assessed at one year• SF 36 PCS 0-100.• Kyphoplasty 26 33.4• Conservative 25.5 27.4 p<0.0001 Wardlaw D et al Lancet 2009;21:1016-24
ControversiesNo Benefit
• A Randomized Trial of Vertebroplasty for painful Osteoporotic Vertebral Fractures
• Buckbinder R et al. NEJM 2009;361:557-568.
• A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures
• Kalmes DF et al. NEJM 2009;361: 569-579.
• No improvement against sham procedure at 1 week, or at 1,3 or 6 months.
Controversies No Benefit
• Previous studies – lack of blinding, lack of true sham control. Couldn’t exclude a placebo effect.
• NEJM studies- randomised, blinded and a sham procedure. Buckbinder needle against lamina. Kalmes – local anaesthetic around the facet joint.
ProblemsFracture acuity
Buckbinder: bone marrow oedema indicates an acute fracture but a detectable fracture line sufficed for inclusion.
Kalmes only used MRI or Bone scan in which fracture age was uncertain.
• Both groups had to have a fracture less than a year old- most groups would use 6 weeks as an acute fracture definition.
ProblemsEnrollment
• Kalmes: 1812 patients initially screened,only 131 entered into study. Most common reason – patient refusal.
• Buckbinder: Needed 4.5 years in 4 high volume centres to accrue 78 patients- 141 declined randomisation.
• Pain severity of groups who refused not reported.
ProblemsControl Group
• Is injection of local anaesthetic around the facet joint a sham procedure?
Vertos II Study
• Prospective randomised trial vertebroplasty v conservative treatment. 202 patients.
• Results Vertebroplasty had better pain relief at one year.
• All fractures less than six weeks old.• Klazen C et al Lancet 2010:376;1085-1092.
Timing
• The best evidence is that the best results are achieved within 6 weeks of onset!
• Rarely achievable in the UK• 50% + get better within 6 weeks
conservatively treated.• Philosophical when to treat.• Most fractures treated in UK > 3 months old.
TimingOlder fractures
• No randomised control trials for efficacy of treatment of old fractures.
• There are trials suggesting similar success rates to acute fractures of 80% success in fractures a year or older.
• Brown et al. Treatment of Chronic symptomatic vertebral compression fractures with percutaneous vertebroplasty . AJN 2004;182:319-312.
My protocol
• Fractures less than 6 weeks old who need to be hospitilised.
• Failure of conservative treatment after 3 months
• Vertebroplasty for all except where middle column is involved – Kyphoplasty,
• Bone scan +ve
Vertebroplasty v Kyphoplasty
Vertebroplasty• Cheaper• Quicker
Kyphoplasty• Expensive• Takes longer• Restoration of vertebral
height?• Less adjacent fractures• Less cement leakage• Quality of life
Vertebroplasty v Kyphoplasty
A review of 168 studies.Vertebroplasty• Mean change in VAS 5.68
• New fracture 17.9%
• Cement leak 19.7%
Kyphoplasty• Mean change in VAS 4.60
p<0.001• New fracture 14.1%
p<0.01• Cement leak 7.0%
p<0.001
• Comparison of vertebroplasty and kyphoplasty in vertebral compression fractures: a meta-analysis of the literature. Spine J 2008;8:488-97.
Other Uses
• Tumours• Trauma• Myeloma
Other uses
• Sacroplasty• Sacral insufficiency
fractures• Best performed under
CT guidance.
Developments
• Calcium phosphate in young patients with traumatic fractures
• Prophylaxis• Adding chemotherapy
agents or radioactive isotopes to the cement in tumour
Conclusions
• Vertebroplasty/Kyphoplasty is useful in the treatment of vertebral osteoporotic fractures although some controversy still exists.
• Low morbidity• Should be considered in painful fractures over
6 weeks old.