Percutaneous vertebroplasty in osteoporotic vertebral compression fractures

Abstract

Percutaneous vertebroplasty (PV) literary means augmentation of the vertebral body through the skin. The main goal is partial or complete pain relief. Nowadays, the most frequent indication for treatment is a painful invalidating osteoporotic vertebral compression fracture (VCF), not responding to conservative treatment. In PV the collapsed vertebral body is stabilized by the injection of bone cement. In patients with painful, invalidating osteoporotic VCF, PV is the first therapy that is directly aimed at the source of pain: the vertebral fracture.

The technical aspects of the procedure have been scientifically investigated and are optimized during the last 25 years. The complication risk of the procedure is low and depends mainly on experience of the operator, the used inclusion criteria, optimal fluoroscopy and the materials used. Less studied is the clinical outcome of PV.

In this thesis the literature was reviewed on prospective studies to determine the effectiveness and safety of PV in patients with painful osteoporotic VCF treated with PV. Immediate pain relief was seen in 60-100% of patients and improved to 78-100% long term (maximum 4 years). Complications were related to cementleakage's and were mostly of no clinical consequence. Serious complications were rare. Long term, PV was associated with an increased risk of fractures in adjacent vertebrae. A prospective randomized clinical intervention study was not published.

Our longitudinal prospective study in 112 patients with 168 osteoporotic VCF demonstrated significant immediate and long lasting pain reduction in nearly all treated patients. A randomized prospective study assessed the short-term clinical outcome of patients with painful osteoporotic VCF treated with PV compared to optimal pain medication (OPM). Pain relief and improvement of mobility, function and spinal stature after PV was immediate and significantly better on short term compared to OPM treatment.

In the preprocedural workup of patients selected for PV, the clinical relevance of bone marrow edema (BME) in osteoporotic VCF detected by MRI is unknown. Our study showed that pain decrease after PV in patients with VCF was more frequently observed when full BME was present on preprocedural MRI. Since 71% of patients with osteoporotic VCF with absent BME responded favorably on pain, PV should not be withheld based on absence of BME alone. Postprocedural, a gradual decrease of BME in osteoporotic VCF treated with PV was apparent during 12 months MRI follow-up. Decrease of BME was unrelated to pain relief.

This thesis demonstrates that during one year follow-up after PV, 24% of patients developed new VCF at untreated levels. Most new VCF occurred within three months of PV. Half of new VCF appeared in levels adjacent to treated levels and half were symptomatic. More than two pre-existing VCF was the only independent risk factor for the development of new VCF.

Finally, a future interventional application had been investigated. Navigation on 3DRX image data is feasible in transpedicular percutaneous needle introduction, and has two advantages over fluoroscopic guidance: it poses less strict requirements on the expertise of the operator and it reduces the radiation exposure to the operator.