Kyphoplasty and Vertebroplasty for the Treatment of Osteoporotic Vertebral Compression Fractures
Karen Beattie, BSc, PhD Candidate and Dr. A. Papaioannou, MSc, MD, FRCP(C), Associate Professor of Medicine; Department of Geriatrics, McMaster University, Hamilton, ON.
Dr. P. Boulos, MD, FRCP(C) and Dr. J.D. Adachi, MD, FRCP(C), Professors of Medicine; Department of Rheumatology, McMaster University, Hamilton, ON.
Osteoporosis is a major health concern in Canada, affecting 25% of women and 12% of men. Vertebral compression fractures, the most common of all osteoporotic fractures, are clinically diagnosed only 30% of the time. Treatment for such fractures is primarily pharmacological. However, newer, non-invasive methods of treatment, namely vertebroplasty and kyphoplasty, stabilize compression fractures, provide pain relief and even improve posture and functional ability. While vertebroplasty involves the injection of a cement product into one or more compressed vertebrae, kyphoplasty adds another step of inserting a balloon into the vertebra to re-establish original vertebral height. Clinical studies of these procedures suggest kyphoplasty provides better symptomatic relief and is associated with fewer complications than vertebroplasty. However, further randomized, controlled evidence comparing these procedures is required.
Key words: kyphoplasty, vertebroplasty, osteoporosis, vertebral fracture, compression fracture.
Introduction
It is estimated that 25% of Canadian women and 12% of Canadian men have osteoporosis.1 With approximately one-quarter of the population reaching 65 years of age and older in the next 35 to 40 years, the prevalence of osteoporosis will only continue to significantly increase.2 It has been said that vertebral body compression fractures are the most commonly experienced consequence of osteoporosis.3 However, because the diagnosis of vertebral compression fractures relies on patients reporting back pain severe enough to elicit a radiograph, it is estimated that only 30% of compression fractures are actually clinically diagnosed.4 Of those presenting with a clinical vertebral fracture, approximately 75% suffer from chronic pain.5,6 Between the ages of 50 and 54 years, the prevalence of radiographically-identified vertebral deformities is approximately 5%, increasing to 50% in individuals between 80 and 84 years of age.7 Canadian data suggest that the prevalence of vertebral deformity in men is approximately one in five, while in women it is nearly one in four.8 The treatment regimen of vertebral compression fractures traditionally has involved the management of the clinical consequences of fractures in addition to the provision of physical rehabilitation and prevention of subsequent fractures. However, newly developed, minimally invasive techniques referred to as vertebroplasty and kyphoplasty not only stabilize compressed vertebra, but also provide significant pain relief and improve the functional abilities of people with these painful, debilitating fractures. This paper will review these procedures, as well as the results and complications of these treatments observed in clinical studies.
Management of Vertebral Fractures
Osteoporotic vertebral compression fractures can be a significant burden to both patients and their families in terms of direct physical pain and disability and associated complications (Table 1). In addition to relieving the symptoms of these fractures, acute therapy usually involves initiation of medication for osteoporosis and physiotherapy. Chronic pain, depression, loss of sleep and loss of independence can result directly from vertebral compression fractures, and medications associated with these consequences may lead to further mood or mental alterations that can exacerbate the underlying problem.9 Evidence from randomized controlled trials suggests that future fracture risk can be reduced by 40-50% with the use of pharmacological treatments.10 However, such medications are usually geared towards the long-term management of osteoporosis and often can take up to one year to achieve efficacy, during which time other fractures can occur.11 In addition, these agents do not deal with symptoms associated with vertebral fractures. This suggests there is an important place for the treatment of vertebral compression fractures that provides patients