Percutaneous Vertebroplasty: Rapid Pain Relief for Vertebral Compression Fractures

The following article is meant to provide doctors of chiropractic with more [i]or[/i] less information that will enable them to knowledgeably discuss other available therapies with patients.

INTRODUCTION

Percutaneous vertebroplasty (PV) was conceived and first performed in France by the agency of the interventional neuroradiologist Herve Deramond in 19841 Deramond treated a destructive hemangioma at C2 by dint of injecting bone cement into the affected bone This caused almost immediate pain relief. PV was subsequently base to also relieve pain in vertebral compression fractures caused by dint of osteoporosis.1,2 Dion and colleagues (Jensen DeNardo, and Mathis) introduced the technique into the United States in 1993 at the University of Virginia. These investigators focused their work primarily upon osteoporotic compression fractures and subsequently provided the first clinical series using PV in the United States.3 They fix significant pain relief in 85 to 90% of patients treated for painful osteoporotic compression fractures. This was similar to early reports about PV from Europe Since that time, the practice has grown in acceptance around the world and is becoming the standard of care for the treatment of pain associated with vertebral compression fractures (VCF)

Demographics of Vertebral Compression Fractures

VCF be met with when the combined axial and bending loads upon the spine exceed the power of the vertebral body.4 Reduction in the individual vertebral material part strength may result from infiltrative processe created by the agency of benign or malignant tumors or, more commonly from bone mineral los precipitated by means of osteoporosis.57 Osteoporosis, which may be age-related (primary) or owed to steroid use (secondary), is the greatest in quantity common cause of VCF in the United States.8

The osteoporotic population in the United States at risk of fracture is immense: between 700000 and 1200000 vertebral compression fractures meet the eye annually.8 Osteoporosis is greatest in somewhat old Caucasian females and is increasing yearly in the number of affected individuals.' In addition, significant numbers of fractures are occurring in patients receiving steroids for conditions like as cancer, collagen vascular disease, transplant therapy, and austere allergy or asthma.

Neoplastic disease, granting less common than osteoporosis, is a well-known cause of painful VCF These fractures are commonly associated with metastatic cancer, myeloma, and with aggressive benign tumors of the like kind as bone hemangiomas. If the determination of the etiology of the fracture is uncertain, biopsy can introduce or accompany the PV. PV will not impair other therapeutic measures of that kind as chemotherapy or radiotherapy. Because the vertebra is frequently partially destroyed by malignant lesions, the risk of mortar leaks during PV is greater than during treatment for osteoporosis. PV however, is known to provide profitable pain relief in selected individuals with metastatic vertebral destruction and may be a useful alternative for treatment since pain relief is abundant faster than with radiation or chemotherapy.

Patient Selection for Vertenroplasty

Patients prefered for PV should have a painful vertebral compression fracture.3,10-23 Without PV chronic pain in these individuals may typically last from 2 weeks to 3 months24 The time between fracture and therapy may be protracted by failed attempts at conservative management or delayed referral. granting there are no absolute exclusionary criteria based upon the time between fracture and PV elderly fractures (>3 months) are les likely to have beneficial arises from PV unless one can display signs of nonunion or signs of intermittent fracture. Nonunion is indicated by dint of persistent motion noted on fluoroscopy and can signify osteonecrosis (Kummell's disease). Other spinal entities, of the like kind as herniated nucleus pulposus, facet arthropathy, and spinal stenosis may be not absent and complicate the evaluation. For this reason, imaging that provides physiologic information about the fracture is normally used to help pick patients for PV. The preferr imaging rule is magnetic resonance (MR), on the other hand nuclear medicine can also be used when MR is preclud (as in patients with pacemakers) or not available. The typical MR imaging finding in VCF is los of signal upon the TI weighted image and bright signal upon inversion recovery (IR) images. (Fig. 1) These signal changes are to be paid to marrow edema resulting from the compression fracture and are not seen in advanced in years or healed compression injuries. This difference allows single to exclude old fractures from consideration for PV

Bone scans may also be helpful to assess problematic VCF(s) when used as a secondary screening tool. Nevertheless, MR imaging is preferr whenever possible because of the anatomic detail and information about other abnormalities (such as spinal stenosis, disk herniation, or tumor extension in the epidural space) that impacts decisions about the use of PV Bone scans are sensitive in detecting VCF and a negative bone scan, like a negative MR image, indicates a depressed likelihood of pain relief after PV therapy. Bone scans, however, can be positive drawn out after substantial healing of a VCF has occurr This fact, coupl with the more restricted anatomic information (as compared with MR imaging), makes bone scans preferable alone when MR imaging cannot be performed.