The Journal of Bone and Joint Surgery

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Commentary & Perspective

Commentary & Perspective on
"Quality of Life Following Vertebroplasty"
by Fergus McKiernan, MD, et al.

Commentary & Perspective by
Alexander R. Vaccaro, MD*,
The Rothman Institute, Philadelphia, Pennsylvania

The technique of percutaneous cement augmentation of symptomatic compression fractures has evolved over the last several years^1-3. It is clear that cement permeation of a structurally compromised osteoporotic vertebral body fracture can lead to early and substantial pain relief^2,4,5. However, at this time many questions remain: what is the appropriate timing of surgical intervention; which vertebral proprietary cement augmentation devices best decrease the potential for cement leakage; what are the effects on the stiffness and biomechanics of adjacent spinal segments; and what are the long-term effects of methylmethacrylate exposure to native trabecular bone and contiguous intervertebral disks?

The study by McKiernan et al. is a well-designed, noncontrolled, prospective evaluation of a cohort of patients who underwent percutaneous vertebroplasty for the treatment of a symptomatic compression fracture after failure of nonoperative treatment for approximately 2.5 months. The authors should be congratulated for stressing the importance of attempting to exhaust reasonable nonoperative measures before proceeding with vertebroplasty. They duly note the rare but important complications of its use, such as cement extravasation. The patients were noted to have a dramatic improvement in visual analog scores and an improvement in score on the quality-of-life questionnaire, a validated thirty-item, five-domain, seven-point response instrument that has been validated in female patients with osteopenia and symptomatic compression fractures. The authors also demonstrated that pain relief was sustained over a period of six months, contrary to the conclusions drawn in other reports^2,5. Unfortunately, they did not discuss the learning curve that is needed to perform this procedure accurately.

It is clear that a symptomatic thoracolumbar vertebral osteoporotic compression fracture can adversely affect the quality of life of these patients by decreasing mobility and appetite and increasing the requirements for mood-altering narcotics.

The financial cost of performing a percutaneous cement augmentation procedure may be mitigated by the cost savings that would result from an earlier return to work and from improved function. The authors attempted to compare the results of vertebroplasty with kyphoplasty. The theoretical benefit of kyphoplasty, which is decreased cement leakage, was contrasted to the inconsequential rate of cement leakage that was reported in this study, which compared favorably to the results in other published reports. The authors also voiced concern about the changes in modulus that occur following cement injection during kyphoplasty, which may lead to excessive stresses in the adjacent disks or the potential for thermal injury. The authors reported an incident fracture of 6.5% following vertebroplasty, which compared favorably to a recent report of a 25% new symptomatic fracture rate in patients following a kyphoplasty procedure³.

Recently, the United States Food and Drug Administration has approved a particular brand of methylmethacrylate for use in the spine. It is still unclear what the long-term consequences of cement contact will be on the long-term viability of trabecular bone. The introduction of new cement polymers that are biocompatible, resorbable, or readily replaceable with native bone are presently in development. The stiffness of these biomaterials will ultimately determine their early success and long-term effectiveness.

In summary, percutaneous cement augmentation of a symptomatic vertebral body compression fracture appears to be a safe and effective method of improving the quality of life of affected patients. At this time, no one proprietary vertebral augmentation device appears to be safer than others. The quality of the methodology of this paper serves as a guide to evaluate how the benefits of percutaneous cement augmentation procedures can impact the patient's quality of life, both for the short and long term. The use of validated specific functional outcome measurements along with visual analog scores will allow an accurate assessment of the utility of vertebral body cement augmentation in specific patient populations. To truly demonstrate the long-term value of vertebroplasty, further studies must be performed, comparing the benefit of these procedures with the outcome of a control population that is treated with standard, nonoperative measures.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Diamond TH, Champion B, Clark WA. Management of acute osteoporotic vertebral fractures: a nonrandomized trial comparing percutaneous vertebroplasty with conservative therapy. Am J Med. 2003;114:257-65.
2. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285:320-3.
3. Rhyne A 3rd, Banit D, Laxer E, Odum S, Nussman D. Kyphoplasty: report of eight-two thoracolumbar osteoporotic vertebral fractures. J. Orthop Trauma. 2004;18:294-9.
4. Evans AJ, Jensen ME, Kip KE, DeNardo AJ, Lawler GJ, Negin GA, Remley KB, Boutin SM, Dunnagan SA. Vertebral compression fractures: pain reduction and improvement in functional mobility after percutaneous polymethylmethacrylate vertebroplasty retrospective report of 245 cases. Radiology. 2003;226:366-72.
5. Cortet B, Cotten A, Boutry N, Flipo RM, Duquesnoy B, Chastanet P, Delcambre B. Percutaneous vertebroplasty in the treatment of osteoporotic vertebral compression fractures: an open prospective study. J. Rheumatol. 1999;26:2222-8.