Threat of Subsequent Fracture Risk Haunts Vertebroplasty

WASHINGTON — Percutaneous vertebroplasty, while effective for relieving pain, has not been shown to prevent new fractures, Dr. Gregg H. Zoarski said in a state of the art review at a symposium sponsored by the Society of Interventional Radiology.

The procedure works in 85%–95% of patients who have pain localized to one or two nonsclerotic vertebrae and osteoporotic fractures that have occurred within less than 2–3 months. When pain is not localized and there are no observable deformities on imaging or fractures have been present for over 1 year, patients seldom respond well to vertebroplasty, Dr. Zoarski said.

Vertebroplasty also can be used to relieve pain caused by soft tumors in the vertebrae, including myelomas. For patients with neoplastic fractures, pain relief ranges from 60% to 90%, said Dr. Zoarski, professor of diagnostic radiology at the University of Maryland, Baltimore, and director of diagnostic and interventional radiology at the University of Maryland Hospital.

In addition, vertebroplasty and kyphoplasty are “tremendously safe procedures,” according to Dr. Zoarski. “Minor complications should be less than 3% and major complications should be well less than 1%,” he stated. Less clear is whether vertebroplasty, like surgical intervention, actually increases the risk of adjacent vertebral fractures.

In small follow-up studies, there was no statistically significant increase in adjacent fractures with vertebroplasty. A retrospective study of 177 patients, however, found a significantly higher rate of adjacent fractures within 30 days of the procedure, and 67% of new fractures occurred adjacent to treated vertebrae, he said.

The natural history of osteoporosis and nonuniform stress within the spine may create a “hot spot” where subsequent fractures are likely to occur, irrespective of intervention. Biomechanical studies are uneven in terms of predicting fracture location.

With regard to both vertebroplasty and kyphoplasty, “I think we have to conclude that there is mixed data on this and we cannot clearly state whether the procedure is going to prevent or cause adjacent fractures,” Dr. Zoarski said. The need for vertebroplasty or other interventional treatments is relatively high, especially because surgery isn't an option for many patients with poor bony substrate or comorbidities.

Noninterventional alternatives have their own complications. Bed rest can exacerbate bone deterioration and decrease patient strength. Bracing has compliance problems, and removal of the brace causes patients “to regress to the same level of deformity that they would have [had] without the brace.” Medications for pain can interact with other drugs as well as directly contribute to morbidity. Dr. Zoarski stated that he had no financial relationships to disclose in regard to percutaneous vertebroplasty.

WASHINGTON — Percutaneous vertebroplasty, while effective for relieving pain, has not been shown to prevent new fractures, Dr. Gregg H. Zoarski said in a state of the art review at a symposium sponsored by the Society of Interventional Radiology.

The procedure works in 85%–95% of patients who have pain localized to one or two nonsclerotic vertebrae and osteoporotic fractures that have occurred within less than 2–3 months. When pain is not localized and there are no observable deformities on imaging or fractures have been present for over 1 year, patients seldom respond well to vertebroplasty, Dr. Zoarski said.

Vertebroplasty also can be used to relieve pain caused by soft tumors in the vertebrae, including myelomas. For patients with neoplastic fractures, pain relief ranges from 60% to 90%, said Dr. Zoarski, professor of diagnostic radiology at the University of Maryland, Baltimore, and director of diagnostic and interventional radiology at the University of Maryland Hospital.

In addition, vertebroplasty and kyphoplasty are “tremendously safe procedures,” according to Dr. Zoarski. “Minor complications should be less than 3% and major complications should be well less than 1%,” he stated. Less clear is whether vertebroplasty, like surgical intervention, actually increases the risk of adjacent vertebral fractures.

In small follow-up studies, there was no statistically significant increase in adjacent fractures with vertebroplasty. A retrospective study of 177 patients, however, found a significantly higher rate of adjacent fractures within 30 days of the procedure, and 67% of new fractures occurred adjacent to treated vertebrae, he said.

The natural history of osteoporosis and nonuniform stress within the spine may create a “hot spot” where subsequent fractures are likely to occur, irrespective of intervention. Biomechanical studies are uneven in terms of predicting fracture location.

With regard to both vertebroplasty and kyphoplasty, “I think we have to conclude that there is mixed data on this and we cannot clearly state whether the procedure is going to prevent or cause adjacent fractures,” Dr. Zoarski said. The need for vertebroplasty or other interventional treatments is relatively high, especially because surgery isn't an option for many patients with poor bony substrate or comorbidities.

Noninterventional alternatives have their own complications. Bed rest can exacerbate bone deterioration and decrease patient strength. Bracing has compliance problems, and removal of the brace causes patients “to regress to the same level of deformity that they would have [had] without the brace.” Medications for pain can interact with other drugs as well as directly contribute to morbidity. Dr. Zoarski stated that he had no financial relationships to disclose in regard to percutaneous vertebroplasty.

WASHINGTON — Percutaneous vertebroplasty, while effective for relieving pain, has not been shown to prevent new fractures, Dr. Gregg H. Zoarski said in a state of the art review at a symposium sponsored by the Society of Interventional Radiology.

The procedure works in 85%–95% of patients who have pain localized to one or two nonsclerotic vertebrae and osteoporotic fractures that have occurred within less than 2–3 months. When pain is not localized and there are no observable deformities on imaging or fractures have been present for over 1 year, patients seldom respond well to vertebroplasty, Dr. Zoarski said.

Vertebroplasty also can be used to relieve pain caused by soft tumors in the vertebrae, including myelomas. For patients with neoplastic fractures, pain relief ranges from 60% to 90%, said Dr. Zoarski, professor of diagnostic radiology at the University of Maryland, Baltimore, and director of diagnostic and interventional radiology at the University of Maryland Hospital.

In addition, vertebroplasty and kyphoplasty are “tremendously safe procedures,” according to Dr. Zoarski. “Minor complications should be less than 3% and major complications should be well less than 1%,” he stated. Less clear is whether vertebroplasty, like surgical intervention, actually increases the risk of adjacent vertebral fractures.

In small follow-up studies, there was no statistically significant increase in adjacent fractures with vertebroplasty. A retrospective study of 177 patients, however, found a significantly higher rate of adjacent fractures within 30 days of the procedure, and 67% of new fractures occurred adjacent to treated vertebrae, he said.

The natural history of osteoporosis and nonuniform stress within the spine may create a “hot spot” where subsequent fractures are likely to occur, irrespective of intervention. Biomechanical studies are uneven in terms of predicting fracture location.

With regard to both vertebroplasty and kyphoplasty, “I think we have to conclude that there is mixed data on this and we cannot clearly state whether the procedure is going to prevent or cause adjacent fractures,” Dr. Zoarski said. The need for vertebroplasty or other interventional treatments is relatively high, especially because surgery isn't an option for many patients with poor bony substrate or comorbidities.

Noninterventional alternatives have their own complications. Bed rest can exacerbate bone deterioration and decrease patient strength. Bracing has compliance problems, and removal of the brace causes patients “to regress to the same level of deformity that they would have [had] without the brace.” Medications for pain can interact with other drugs as well as directly contribute to morbidity. Dr. Zoarski stated that he had no financial relationships to disclose in regard to percutaneous vertebroplasty.