Pain relief following vertebroplasty in patients with and without localizing tenderness on palpation

Pain location is associated with fracture type in acute osteoporotic thoracolumbar vertebral fracture: a prospective observation study

OBJECTIVE

This study investigated the relationship between pain location and fracture type in the patients with acute osteoporotic vertebral fracture (OVF).

DESIGN

A prospective observation study.

SUBJECT

A total of 306 patients with acute OVF were included.

METHODS

The site of pain of each patient was recorded, and the patients were divided into pain at fracture site group (group 1) and pain at non-fracture site group (group 2). The fracture type was classified into four types: type I, upper endplate type; type II, central type; type III, lower endplate type; type IV, burst type.

RESULTS

There were 146 patients in the group 1, of which 20.55% (30/146) were type I, 33.56% (49/146) were type II, 15.75% (23/146) were type III, and 30.14% (44/146) were type IV. There were 227 patients in the group 2, of which 57.27% (130/227) were type I, 5.29% (12/227) were type II, 35.24% (80/227) were type III, and 2.20% (5/227) were type IV. There was a statistical difference in the fracture type distribution between the two groups (P < 0.05). The VAS in the group 1 was higher than that in the group 2 at the initial diagnosis (P < 0.05).

CONCLUSIONS

For patients with acute OVF, the site of pain is related to the type of fracture. The pain at the fracture site is more often observed in the central type and burst type of fractures, while pain at the non-fracture site is more often observed in the upper and lower endplate type of fractures. Additionally, when OVF are suspected, radiological assessment of thoracic and lumbar spine is recommended to better detect fractures that could cause pain distal to the site of the fracture.

Vertebral augmentation

Vertebral augmentation, including vertebroplasty and kyphoplasty, is a minimally invasive, image-guided procedure in which cement (typically polymethylmethacrylate (PMMA)) is injected into a vertebral body to treat painful fractures. The majority of vertebroplasty and kyphoplasty procedures are performed to treat symptomatic osteoporotic compression fractures refractory to conservative medical therapy; however, there is also evidence to suggest the benefits of augmentation in patients with refractory pain in the acute compression setting. The primary goal of augmentation is decreasing pain and improving a patient's functional status. The secondary goal of augmentation is vertebral body stabilization. This chapter outlines the indications, contraindications, techniques, and literature behind vertebral augmentation.

Back pain from painful osteoporotic vertebral fractures: discrepancy between the actual fracture location and the location suggested by patient-reported pain or physical examination findings

Caution is necessary when using symptom or physical examination findings to localize the osteoporotic vertebral fractures (VFs) attributable to the discrepant colocalized relationship.

INTRODUCTION

Whether the location of symptoms or physical examination findings delineates the appropriate spinal range for imaging has not been thoroughly investigated for VFs. The present study aims to analyze the consistency between the fractural vertebrae location and the location suggested by patient-reported pain or physical examination findings.

METHODS

This observational study, following a prospective design, enrolled 358 patients with VFs. The locations of two symptoms (patient-reported back pain [P-RBP], radiating pain [RP]) and findings from two physical examinations (spinal palpation tenderness [SPT], axial spinal percussion pain [ASPP]) were used to locate the VF segments identified using whole-spine magnetic resonance imaging (MRI). The percentage of agreements and kappa coefficient were calculated.

RESULTS

In 20.7% (74/358), the P-RBP site and VF segments were in the same location (kappa = 0.153); 21.2% (76/358) presented with concomitant RP in 93.4% (71/76) of whom the RP dermatome was colocalized with the VF segments (kappa = 0.924); 55.0% (197/358) and 23.2% (83/358) of patients presented with positive SPT and ASPP, respectively; and in 49.2% (97/197) and 96.4% (80/83) of patients with positive SPT (kappa = 0.435) and ASPP (kappa = 0.963), the positive finding and the VF segments were consistently colocalized.

CONCLUSIONS

The positive finding of RP or ASPP is useful in determining the spinal range for imaging tests, while an MRI scan covering the whole thoracic and lumbar spine is necessary in VF-suspected patients with P-RBP or positive SPT, indicating that caution is necessary when using symptoms or physical examination findings to localize VFs.

Percutaneous kyphoplasty for the treatment of distal lumbosacral pain caused by osteoporotic thoracolumbar vertebral fracture

Background Kyphoplasty has been demonstrated to be minimally invasive and effective in treating osteoporotic vertebral fracture patients with back pain over the level of the fractured vertebrae. Rare studies have reported on thoracolumbar vertebral fracture patients presenting with distal lumbosacral pain (DLP). Whether kyphoplasty had a favorable therapeutic benefit for these patients remains unclear. Purpose To evaluate the therapeutic efficacy of kyphoplasty in treating osteoporotic thoracolumbar vertebral fracture (OTVF) patients with DLP and assess the clinical significance of focal tenderness to palpation in these patients. Material and Methods Thirty-two OTVF patients who only complained of DLP were treated by kyphoplasty. The vertebral heights, local kyphotic angle, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) scores were assessed preoperatively, one day after surgery, and at last follow-up. All patients were evaluated regarding their degree of satisfaction with kyphoplasty. In addition, we compared the therapeutic efficacy of kyphoplasty in patients with and without focal tenderness to palpation. Results All patients successfully underwent kyphoplasty without complications. The vertebral heights, local kyphotic angles, VAS, and ODI scores were all significantly improved after kyphoplasty and maintained at last follow-up in our patients ( P < 0.001). At last follow-up, all patients expressed satisfaction with kyphoplasty. No significant differences in these parameters were detected between patients with and without focal tenderness. Conclusion The possibility of thoracolumbar vertebral fractures in elderly patients complaining of DLP should not be neglected. Kyphoplasty presents a superior benefit in treating OTVF patients with DLP. The absence of focal tenderness does not influence the clinical efficacy in these patients.

Effect of Systemic Therapies on Outcomes following Vertebroplasty among Patients with Multiple Myeloma

BACKGROUND AND PURPOSE

The role of vertebroplasty in patients with myeloma remains relatively undefined. Accordingly, we sought to better define the efficacy of vertebroplasty for myeloma-associated fractures and determine the effect of procedure timing relative to the initiation of systemic therapy on outcomes and complication rates.

MATERIALS AND METHODS

Clinical, laboratory, and medication data were retrieved for 172 patients with multiple myeloma treated with vertebroplasty since October 2000. Quantitative outcome data (Roland-Morris Disability Questionnaire [scale, 0-24] and the Numeric Rating Scale [0-10] for pain at rest and with activity) were collected immediately pre- and postoperatively and at 1 week, 1 month, 6 months, and 1 year following vertebroplasty. Patients with ≥50% improvement on the Numeric Rating Scale and ≥40% improvement on the Roland-Morris Disability Questionnaire were classified as "responders." Peri- and postoperative complications were also collected.

RESULTS

Significant median improvement in the Roland-Morris Disability and rest and activity Numeric Rating Scale scores (15, 2, and 6 points, respectively; P < .0001) persisted at 1 year without significant change from the immediate postoperative scores (P > .36). Patients on systemic therapy at the time of vertebroplasty were more likely to achieve "responder status," compared with patients not on systemic therapy, for the Numeric Rating Scale pain at rest score (P < .01) and the Roland-Morris Disability Questionnaire score (P < .003), with no difference in complication rates (χ² = 0.17, P = .68).

CONCLUSIONS

Vertebroplasty is an effective therapy for patients with myeloma with symptomatic compression fractures. Favorable outcomes are more likely to be achieved when spinal augmentation is performed after systemic therapy is initiated. Complication rates were not affected by the timing of systemic therapy.

Vertebroplasty

Percutaneous vertebroplasty has become widely accepted as a safe and effective minimally invasive procedure for the treatment of painful vertebral body compression fractures refractory to medical therapy. In this article, the authors review the indications and contraindications for vertebroplasty, principles of appropriate patient selection, useful techniques to achieve optimal outcomes, and the potential risks and complications of the procedure.

Is severe pain immediately after spinal augmentation a predictor of long-term outcomes?

BACKGROUND AND PURPOSE

Severe, immediate postprocedural pain and the need for analgesics after vertebroplasty can be a discouraging experience for patients and caregivers. The goal of this study was to investigate whether the presence of severe pain immediately after vertebroplasty predicts short- and long-term pain relief.

MATERIALS AND METHODS

A chart review was performed to categorize patients regarding pain severity and analgesic usage immediately after vertebroplasty (< 4 h). "Severe" pain was defined as at least 8 of 10 with the 10-point VAS. Outcomes were pain severity and pain medication score and usage at 1 month and 1 year after vertebroplasty. Outcomes and clinical characteristics were compared between groups by using the Wilcoxon signed-rank test and the Fisher exact test.

RESULTS

Of the 429 vertebroplasty procedures identified, 69 (16%) were associated with severe pain, and 133 (31%) were associated with analgesic administration immediately after the procedure. The group experiencing severe pain had higher preprocedure median VAS rest pain scores (5 [IQR, 2-7]) and activity pain scores (10 [IQR, 8-10]) compared with patients who did not experience severe pain (3 [IQR, 1-6]; P = .0208, and 8 [IQR, 7-10]; P = .0263, respectively). At 1 month postprocedure, VAS rest and activity pain scores were similar between the severe pain group and the nonsevere pain group (P = .16 and P = .25, respectively) and between the group receiving pain medication and the group not receiving pain medication (P = .25 and P = .67, respectively). This similarity continued for 1 year after the procedure. Analgesic usage was similar among all groups at 1 year postprocedure.

CONCLUSIONS

Patients with severe pain immediately after vertebroplasty have similar long-term outcomes compared with patients without severe pain.

Neither subendplate cement deposition nor cement leakage into the disk space during vertebroplasty significantly affects patient outcomes

PURPOSE

To determine the impact of cement placement immediately adjacent to and through the endplate during percutaneous vertebroplasty on postprocedural pain and subsequent fracture rate.

MATERIALS AND METHODS

Institutional review board approval with waived consent was obtained. Medical records of 424 patients undergoing first-time, single-level vertebroplasty for osteoporotic or traumatic compression fractures were examined. Data regarding pain at rest and with activity before the procedure, along with timing and level of subsequent fractures over a 24-month period, were collected. Group 1 (n=64) included patients with no cement extension to the endplate(s), group 2 (n=216) included those with cement extension to the endplate(s) but no leakage into the disk space(s), and group 3 (n=144) included those with cement extension to the endplate(s) and cement leakage into the disk space(s). Analysis of variance and Fisher test were used to analyze the data, with significance set at P<.05.

RESULTS

Baseline characteristics and demographics were similar among the groups. At 1 month, for groups 1, 2, and 3, the respective mean postprocedural pain numeric scores at rest were 1.4±2.7, 1.4±2.4, and 1.6±2.5 (P=.51), while the respective pain scores with activity were 4.3±2.9, 3.8±3.1, and 3.9±3.3 (P=.50). Total subsequent fractures were noted in five (8%), 26 (12%), and 15 (10%) patients in group 1, 2, and 3, respectively (P=.77).

CONCLUSION

Neither extension of cement to the endplate nor cement leakage into the disk space has significant impact on postprocedural pain or subsequent fracture rate at 2 years.

Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty

BACKGROUND AND PURPOSE

Cement PE represents a potentially serious complication following vertebroplasty. To determine the frequency and extent of cement PE during percutaneous vertebroplasty, we performed a retrospective review of chest CT scans obtained in patients who had previously undergone ≥1 vertebroplasty procedure.

MATERIALS AND METHODS

After approval by our local institutional review board, we retrospectively evaluated 244 patients who had undergone vertebroplasty at 465 levels and subsequently underwent chest CT. A thoracic radiologist evaluated the presence, number, size, and location of discrete cement PEs. We catalogued the following data: age, sex, number of treated vertebrae, cement volume per vertebra, operator, presence of cement leakage noted by the operator during the procedure, and clinical presentation at postvertebroplasty CT.

RESULTS

At least 1 cement PE was detected in 23 (9.4%; 95% CI, 6%-13%) of 244 patients; 1 patient was symptomatic from a cement PE. The mean number of discrete cement PEs was 3.2 ± 3.4 (median, 2; range, 1-12). There was no correlation among the total number of treatment sessions, number of levels treated per session, cement volume per level, operator, or time between vertebroplasty and chest CT in the detection of cement PE. Those with PE were significantly younger (P=.0229) and had significantly more total levels treated (P=.0260). Cement PE was recognized by the operator during the vertebroplasty in 2 (8.7%) of 23 patients found to have it on CT.

CONCLUSIONS

Small asymptomatic cement PEs are common during vertebroplasty and usually are not recognized by the operator during the procedure.

Low-energy osteoporotic pelvic fractures

The vast majority of pelvic fractures in geriatric patients are classified as stable injuries. The current treatment strategies of these fractures involve pain management and mobilization. Pain-related immobility may pose a serious hazard to patients with severe preexisting comorbidities. There is paucity of literature on the outcome and mortality after osteoporotic pelvic fractures in the elderly. This review aims to provide an overview of epidemiology, injury mechanism, fracture patterns, management and outcome after osteoporotic pelvic fractures.

Fractures of the pubic rami: a retrospective review of 534 cases

INTRODUCTION

Fractures of the pubic rami are typically classified as stable injuries. The current treatment strategies involve pain management and mobilization. However, pain-dependent immobilization may pose a serious hazard to patients with severe preexisting co-morbidities. There is paucity of literature on the outcome and mortality of these patients.

METHODS

We retrospectively analysed 534 patients with these injuries. The following parameters were examined: gender, age, mechanism of injury, fracture pattern, length of hospital stay, care after discharge, number of outpatient follow-ups, and 1-year mortality. Multiple logistic regression analysis was performed for the assessment of factors influencing 1-year mortality.

RESULTS

The observed 1-year mortality in the patients group was further compared to a virtual control group with the same age and gender distribution. Women were older and more frequently injured as a result of a simple fall. Age was the only factor to be predictive of 1-year mortality. Mortality increased with higher age in both the patient and the control group, but mortality was higher in the patients group in all age groups. This difference was significant for patients > or =90 years of age. Pubic rami fractures are a heterogeneous cohort of injuries and might not be as benign as thought in patients with severe preexisting co-morbidities.

CONCLUSION

Prospective studies are needed to better gauge the outcome after pubic rami fractures.

Efficacy of percutaneous vertebroplasty for multiple synchronous and metachronous vertebral compression fractures

BACKGROUND AND PURPOSE

Limited data exists regarding the efficacy of percutaneous vertebroplasty for multiple synchronous and metachronous vertebral compression fractures. The purpose of this study was to evaluate whether the number of vertebral levels treated during percutaneous vertebroplasty procedures or the number of separate vertebroplasty procedures performed on a given patient affect clinical outcomes.

MATERIALS AND METHODS

We defined 3 patient populations in our retrospective study. Group 1 included 328 patients who underwent 1 single-level vertebroplasty procedure. Group 2 included 226 patients who underwent a single procedure in which 2 or more vertebral levels were treated. Group 3 included 101 patients who underwent 2 or more separate vertebroplasty procedures. Follow-up was performed between 1 week and 2 years postoperatively. Clinical outcomes were assessed through analysis of quantitative measurements of pre- and postoperative levels of pain with and without activity (0-10) as well as mobility improvement. The Kruskal-Wallis rank sum test was used to evaluate the differences among groups. Univariate and chi(2) analyses were performed to show the proportion of underlying diseases in each group.

RESULTS

Mean pain improvement with/without activity at 2-year follow-up was 5.8/3, 4.9/3.7, and 5.4/3.1 in groups 1, 2, and 3, respectively; and mean mobility improvement in 2-year follow-up was 0.67, 0.63, and 0.65 for groups 1, 2, and 3, respectively.

CONCLUSIONS

There was no significant difference in pain relief and mobility improvement in patients treated for multiple synchronous or metachronous vertebral compression fractures in comparison with those treated for solitary isolated fractures.

Clinical outcomes with hemivertebral filling during percutaneous vertebroplasty

BACKGROUND AND PURPOSE

Vertebroplasty has been commonly used for the treatment of vertebral compression fractures. Practitioners usually attempt to maximize filling of the vertebral body with polymethylmethacrylate (PMMA), either by using a bipediculate approach with separate infusions in both hemivertebrae or by using a unipediculate approach with central needle placement that allows bilateral hemivertebral filling. This study serves to investigate the clinical efficacy of a unipediculate approach in which the cement injected does not cross the midline, with resultant "hemivertebroplasty."

MATERIALS AND METHODS

A retrospective review of 917 vertebroplasty procedures was performed. A radiologic review of each vertebroplasty in the data base was performed to extract the vertebroplasties in which there was filling of only 1 side of the hemivertebra, which we term "hemivertebroplasty." Pre- and postoperative evaluations (1-week to 2-year postprocedure) included a Visual Analog Scale (VAS) for pain, the Roland-Morris Disability Questionnaire (RDQ) scores, and information regarding new fractures and retreatment of augmented fractures.

RESULTS

No significant difference was found between the hemivertebroplasty cases and the bilaterally filled vertebroplasty group in reducing VAS or RDQ scores. Moreover, survival analysis showed no significant difference in the risk of incident fracture between groups (hazard ratio = 0.81; 95% confidence interval, 0.33-2.65).

CONCLUSIONS

On the basis of our results, unilateral "hemivertebroplasty" is as effective in reducing pain with activity and at rest and decreasing the RDQ scores as bilateral vertebral filling. Additionally, vertebrae undergoing unilateral filling were at no greater risk of refracture or fracture of adjacent vertebrae than bilaterally filled vertebrae.

Vertebroplasty for the treatment of traumatic nonosteoporotic compression fractures

BACKGROUND AND PURPOSE

Vertebroplasty is commonly used for osteoporotic and neoplastic compression fractures, yet little evidence exists for its use in traumatic nonosteoporotic compression fractures. The purpose of this study was to evaluate the safety and efficacy of percutaneous vertebroplasty for patients with traumatic nonosteoporotic compression fractures.

MATERIALS AND METHODS

We performed a retrospective review of 819 patients (982 procedures) who underwent percutaneous vertebroplasty, to identify patients who had normal bone mineral densitometry scores or had no previous diagnosis of osteoporosis, multiple myeloma, or history of long-term steroid use. Follow-up evaluations included pain at rest and with activity (assessed with the visual analog scale [VAS]), medication use, and mobility. Roland-Morris Disability Questionnaire (RDQ) scores were also collected. Statistical analysis included a 2-tailed t test comparing postprocedure outcomes with baseline values.

RESULTS

Fifteen patients (53% women) were included. Mean age and t-score were 60 years and -0.35, respectively. We found significant improvements in the VAS scores, both at rest and with activity, and in the RDQ scores, starting at the 2-hour follow-up. Additionally, we found marked decreases in medication use and improvements in mobility. The complication rate was low and characterized by asymptomatic extravasation of cement.

CONCLUSIONS

From our study, we have shown that vertebroplasty can be successfully and safely used in patients with traumatic nonosteoporotic compression fractures. Vertebroplasty in these patients should be used after failure of conservative treatments and may be used in place of more invasive spinal reconstruction techniques.

Urinary tract infections in the potential vertebroplasty patient: incidence, significance, and management

SUMMARY

Percutaneous vertebroplasty has been deferred due to potential complications from urinary tract infections (UTIs). Our aim was to help sort out the types of treatment needed for percutaneous vertebroplasty patients and the length delay for performing the procedure. We searched for information regarding the ramifications of infection from the literature and devised a plan of treatment for the various infectious problems that may occur in patients undergoing percutaneous vertebroplasty. We devised a plan of action for the screening, testing, diagnosis and treatment of patients with a potential UTI who are presenting for a percutaneous vertebroplasty.