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Clinical Medicine & Research Jun 2022Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying... (Review)
Review
Physicians involved in treating spine fractures secondary to osteopenia and osteoporosis should know the pathogenesis and current guidelines on managing the underlying diminished bone mineral density, as worldwide fracture prevention campaigns are trailing behind in meeting their goals. This is a narrative review exploring the various imaging and laboratory tests used to diagnose osteoporotic fractures and a comprehensive compilation of contemporary medical and surgical management. We have incorporated salient recommendations from the Endocrine Society, the American Association of Clinical Endocrinology (AACE), and the American Society for Bone and Mineral Research (ASBMR). The use of modern scoring systems such as Fracture Risk Assessment Tool (FRAX®) for evaluating fracture risk in osteoporosis with a 10-year probability of hip fracture and major fractures in the spine, forearm, hip, or shoulder is highlighted. This osteoporosis risk assessment tool can be easily incorporated into the preoperative bone health optimization strategies, especially before elective spine surgery in osteoporotic patients. The role of primary surgical intervention for vertebral compression fracture and secondary fracture prevention with pharmacological therapy is described, with randomized clinical trial-based wisdom on its timing and dosage, drug holiday, adverse effects, and relevant evidence-based literature. We also aim to present an evidence-based clinical management algorithm for treating osteoporotic vertebral body compression fractures, tumor-induced osteoporosis, or hardware stabilization in elderly trauma patients in the setting of their impaired bone health. The recent guidelines and recommendations on surgical intervention by various medical societies are covered, along with outcome studies that reveal the efficacy of cement augmentation of vertebral compression fractures via vertebroplasty and balloon kyphoplasty versus conservative medical management in the elderly population.
Topics: Aged; Fractures, Compression; Humans; Kyphoplasty; Osteoporosis; Osteoporotic Fractures; Randomized Controlled Trials as Topic; Spinal Fractures; Treatment Outcome; Vertebroplasty
PubMed: 35478096
DOI: 10.3121/cmr.2021.1612 -
The Cochrane Database of Systematic... Apr 2018Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Percutaneous vertebroplasty remains widely used to treat osteoporotic vertebral fractures although our 2015 Cochrane review did not support its role in routine practice.
OBJECTIVES
To update the available evidence of the benefits and harms of vertebroplasty for treatment of osteoporotic vertebral fractures.
SEARCH METHODS
We updated the search of CENTRAL, MEDLINE and Embase and trial registries to 15 November 2017.
SELECTION CRITERIA
We included randomised and quasi-randomised controlled trials (RCTs) of adults with painful osteoporotic vertebral fractures, comparing vertebroplasty with placebo (sham), usual care, or another intervention. As it is least prone to bias, vertebroplasty compared with placebo was the primary comparison. Major outcomes were mean overall pain, disability, disease-specific and overall health-related quality of life, patient-reported treatment success, new symptomatic vertebral fractures and number of other serious adverse events.
DATA COLLECTION AND ANALYSIS
We used standard methodologic procedures expected by Cochrane.
MAIN RESULTS
Twenty-one trials were included: five compared vertebroplasty with placebo (541 randomised participants), eight with usual care (1136 randomised participants), seven with kyphoplasty (968 randomised participants) and one compared vertebroplasty with facet joint glucocorticoid injection (217 randomised participants). Trial size varied from 46 to 404 participants, most participants were female, mean age ranged between 62.6 and 81 years, and mean symptom duration varied from a week to more than six months.Three placebo-controlled trials were at low risk of bias and two were possibly susceptible to performance and detection bias. Other trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding.Compared with placebo, high- to moderate-quality evidence from five trials (one with incomplete data reported) indicates that vertebroplasty provides no clinically important benefits with respect to pain, disability, disease-specific or overall quality of life or treatment success at one month. Evidence for quality of life and treatment success was downgraded due to possible imprecision. Evidence was not downgraded for potential publication bias as only one placebo-controlled trial remains unreported. Mean pain (on a scale zero to 10, higher scores indicate more pain) was five points with placebo and 0.6 points better (0.2 better to 1 better) with vertebroplasty, an absolute pain reduction of 6% (2% better to 10% better, minimal clinical important difference is 15%) and relative reduction of 9% (3% better to14% better) (five trials, 535 participants). Mean disability measured by the Roland-Morris Disability Questionnaire (scale range zero to 23, higher scores indicate worse disability) was 14.2 points in the placebo group and 1.7 points better (0.3 better to 3.1 better) in the vertebroplasty group, absolute improvement 7% (1% to 14% better), relative improvement 10% better (3% to 18% better) (three trials, 296 participants).Disease-specific quality of life measured by the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) (scale zero to 100, higher scores indicating worse quality of life) was 62 points in the placebo group and 2.75 points (3.53 worse to 9.02 better) in the vertebroplasty group, absolute change: 3% better (4% worse to 9% better), relative change: 5% better (6% worse to 15% better (two trials, 175 participants). Overall quality of life (European Quality of Life (EQ5D), zero = death to 1 = perfect health, higher scores indicate greater quality of life) was 0.38 points in the placebo group and 0.05 points better (0.01 better to 0.09 better) in the vertebroplasty group, absolute improvement: 5% (1% to 9% better), relative improvement: 18% (4% to 32% better) (three trials, 285 participants). In one trial (78 participants), 9/40 (or 225 per 1000) people perceived that treatment was successful in the placebo group compared with 12/38 (or 315 per 1000; 95% CI 150 to 664) in the vertebroplasty group, RR 1.40 (95% CI 0.67 to 2.95), absolute difference: 9% more reported success (11% fewer to 29% more); relative change: 40% more reported success (33% fewer to 195% more).Moderate-quality evidence (low number of events) from seven trials (four placebo, three usual care, 1020 participants), up to 24 months follow-up, indicates we are uncertain whether vertebroplasty increases the risk of new symptomatic vertebral fractures (70/509 (or 130 per 1000; range 60 to 247) observed in the vertebroplasty group compared with 59/511 (120 per 1000) in the control group; RR 1.08 (95% CI 0.62 to 1.87)).Similarly, moderate-quality evidence (low number of events) from five trials (three placebo, two usual care, 821 participants), indicates uncertainty around the risk of other serious adverse events (18/408 or 76 per 1000, range 6 to 156) in the vertebroplasty group compared with 26/413 (or 106 per 1000) in the control group; RR 0.64 (95% CI 0.36 to 1.12). Notably, serious adverse events reported with vertebroplasty included osteomyelitis, cord compression, thecal sac injury and respiratory failure.Our subgroup analyses indicate that the effects did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks. Including data from the eight trials that compared vertebroplasty with usual care in a sensitivity analyses altered the primary results, with all combined analyses displaying considerable heterogeneity.
AUTHORS' CONCLUSIONS
Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and subgroup analyses indicated that the results did not differ according to duration of pain ≤ 6 weeks versus > 6 weeks.Sensitivity analyses confirmed that open trials comparing vertebroplasty with usual care are likely to have overestimated any benefit of vertebroplasty. Correcting for these biases would likely drive any benefits observed with vertebroplasty towards the null, in keeping with findings from the placebo-controlled trials.Numerous serious adverse events have been observed following vertebroplasty. However due to the small number of events, we cannot be certain about whether or not vertebroplasty results in a clinically important increased risk of new symptomatic vertebral fractures and/or other serious adverse events. Patients should be informed about both the high- to moderate-quality evidence that shows no important benefit of vertebroplasty and its potential for harm.
Topics: Aged; Aged, 80 and over; Bone Cements; Female; Fractures, Compression; Glucocorticoids; Humans; Male; Middle Aged; Osteoporotic Fractures; Pain Measurement; Pain, Postoperative; Quality of Life; Randomized Controlled Trials as Topic; Spinal Fractures; Vertebroplasty
PubMed: 29618171
DOI: 10.1002/14651858.CD006349.pub3 -
Journal of Orthopaedic Surgery and... Mar 2022Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used to treat osteoporotic vertebral compression fractures (OVCF), but the risk of vertebral... (Meta-Analysis)
Meta-Analysis Review
Risk factors of vertebral re-fracture after PVP or PKP for osteoporotic vertebral compression fractures, especially in Eastern Asia: a systematic review and meta-analysis.
OBJECTIVE
Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used to treat osteoporotic vertebral compression fractures (OVCF), but the risk of vertebral re-fracture after PVP/PKP remains controversial. This study aims to investigate the incidence and risk factors of vertebral re-fracture after PVP/PKP.
METHODS
Relevant literatures published up to November 2021 were collected from PubMed, Embase and Web of Science. A meta-analysis was performed to extract data associated with risk factors of SVCF following the PRISMA guidelines. Also, pooled odds ratio (OR) or weighted mean difference (WMD) with 95% confidence interval (CI) was calculated.
RESULTS
A total of 23 studies, encompassing 9372 patients with OVCF, met the inclusion criteria. 1255 patients (13.39%) suffered re-fracture after PVP/PKP surgery. A total of 22 studies were from Eastern Asia and only 1 study was from Europe. Female sex (OR = 1.34, 95%CI 1.09-1.64, P = 0.006), older age (WMD = 2.04, 95%CI 0.84-3.24, P = 0.001), lower bone mineral density (BMD, WMD = - 0.38, 95%CI - 0.49-0.26, P < 0.001) and bone cement leakages (OR = 2.05, 95% CI 1.40-3.00, P < 0.001) increased the risk of SVCF. The results of subgroup analysis showed the occurrence of re-fracture was significantly associated with gender (P = 0.002), age (P = 0.001) and BMD (P < 0.001) in Eastern Asia. Compared with the unfractured group, anterior-to-posterior vertebral body height ratio (AP ratio, WMD = 0.06, 95%CI 0.00-0.12, P = 0.037) and visual analog scale score (VAS, WMD = 0.62, 95%CI 0.09-1.15, P = 0.022) were higher in the refracture group, and kyphotic angle correction ratio (Cobb ratio, WMD = - 0.72, 95%CI - 1.26-0.18, P = 0.008) was smaller in Eastern Asia. In addition, anti-osteoporosis treatment (OR = 0.40, 95% CI 0.27-0.60, P < 0.001) could be a protective factor.
CONCLUSION
The main factors associated with re-fracture after PVP/PKP are sex, age, bone mineral density, AP ratio, Cobb ratio, VAS score, bone cement leakage and anti-osteoporosis treatment, especially in Eastern Asia.
Topics: Bone Cements; Female; Fractures, Compression; Humans; Kyphoplasty; Osteoporotic Fractures; Reoperation; Risk Factors; Spinal Fractures; Treatment Outcome; Vertebroplasty
PubMed: 35279177
DOI: 10.1186/s13018-022-03038-z -
RMD Open Jun 2021Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however... (Review)
Review
Appropriate care of patients with a recent painful osteoporotic vertebral fracture (VF) requires immobilisation, analgesics and spinal orthoses. Some VFs are however responsible for disabling pain and prolonged bed rest. In this context, vertebroplasty techniques have been proposed with a large benefit in case series and open-label randomised studies, but lack efficacy in three among four double-blind randomised studies. The objectives of the treatment of a recent painful VF are to relieve pain and to preserve mechanical conditions. With this in mind, we report an experts' opinion paper on the indications for vertebroplasty and research agenda for clinical studies.
Topics: Bone Cements; Fractures, Compression; Humans; Quality of Life; Randomized Controlled Trials as Topic; Spinal Fractures; Vertebroplasty
PubMed: 34193518
DOI: 10.1136/rmdopen-2021-001655 -
AJNR. American Journal of Neuroradiology Oct 2018
Topics: Humans; Kyphoplasty; Osteoporotic Fractures; Spinal Fractures; Spine; Vertebroplasty
PubMed: 30213814
DOI: 10.3174/ajnr.A5781 -
World Neurosurgery Aug 2023Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide... (Review)
Review
Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide patients with pain relief, prevent further height loss of the vertebral body, and help correct kyphosis. Many clinical studies have investigated the characteristics of bone cement. Bone cement is a biomaterial injected into the vertebral body that must have good biocompatibility and biosafety. The optimization of the characteristics of bone cement has become of great interest. Bone cement can be mainly divided into 3 types: polymethyl methacrylate, calcium phosphate cement, and calcium sulfate cement. Each type of cement has its own advantages and disadvantages. In the past 10 years, the performance of bone cement has been greatly improved via different methods. The aim of our review is to provide an overview of the current progress in the types of modified bone cement and summarize the key clinical findings.
Topics: Humans; Bone Cements; Fractures, Compression; Spinal Fractures; Spine; Vertebroplasty; Osteoporotic Fractures; Kyphoplasty; Treatment Outcome; Retrospective Studies
PubMed: 37087028
DOI: 10.1016/j.wneu.2023.04.048 -
Medicina (Kaunas, Lithuania) Aug 2023Percutaneous vertebroplasty is a minimally invasive treatment technique for vertebral body compression fractures. The complications associated with this technique can be... (Review)
Review
Percutaneous vertebroplasty is a minimally invasive treatment technique for vertebral body compression fractures. The complications associated with this technique can be categorized into mild, moderate, and severe. Among these, the most prevalent complication is cement leakage, which may insert into the epidural, intradiscal, foraminal, and paravertebral regions, and even the venous system. The occurrence of a postprocedural infection carries a notable risk which is inherent to any percutaneous procedure. While the majority of these complications manifest without symptoms, they can potentially lead to severe outcomes. This review aims to consolidate the various complications linked to vertebroplasty, drawing from the experiences of a single medical center.
Topics: Humans; Bone Cements; Fractures, Compression; Hospitals; Vertebroplasty
PubMed: 37763655
DOI: 10.3390/medicina59091536 -
AJNR. American Journal of Neuroradiology May 2018Osteoporotic vertebral compression fractures frequently result in significant morbidity and health care resource use. For patients with severe and disabling pain,... (Review)
Review
Osteoporotic vertebral compression fractures frequently result in significant morbidity and health care resource use. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered. Although vertebroplasty was introduced >30 years ago, there are conflicting opinions regarding the role of these procedures in the treatment of osteoporotic vertebral compression fractures. This review article updates clinicians on the published prospective randomized controlled data, including the most recent positive trials that followed initial negative trials in 2009. Analysis of multiple national claim datasets has also provided further insight into the utility of these procedures. Finally, we considered the recent recommendations of national organizations and medical societies that advise on the use of vertebral augmentation procedures for osteoporotic vertebral compression fractures.
Topics: Fractures, Compression; Humans; Kyphoplasty; Osteoporotic Fractures; Spinal Fractures; Treatment Outcome; Vertebroplasty
PubMed: 29170272
DOI: 10.3174/ajnr.A5458 -
Annals of Palliative Medicine Feb 2022Pain is a common source of suffering for seriously ill patients. Typical first-line treatments consist of lifestyle modifications and medication therapy, including...
Pain is a common source of suffering for seriously ill patients. Typical first-line treatments consist of lifestyle modifications and medication therapy, including opioids. However, medical treatments often fail or are associated with limiting systemic toxicities, and more targeted interventional approaches are necessary. Herein, we present options for minimally invasive techniques for the alleviation of pain in palliative patients from a head-to-toe approach, with a focus on emerging therapies and advanced techniques. Head and neck: image-guided interventions targeted to sympathetic ganglia of the head and neck, such as sphenopalatine ganglion (SPG) and stellate ganglion, have been shown to be effective for some forms of sympathetically-maintained and visceral pain. Interventions targeting branches of cranial nerves and upper cervical nerves, such as the glossopharyngeal nerve (GPN), are options in treating somatic head and face pain. Abdominal and pelvic: sympathetic blocks, including celiac plexus, inferior hypogastric, and ganglion impar can relieve visceral abdominal and pelvic pain. Spine and somatic pain: fascial plane blocks of the chest and abdominal wall and myofascial trigger point injections can be used for somatic pain indications. Cementoplasties, such as kyphoplasty and vertebroplasty, are used for pain related to bony metastases and compression fractures. Tumor ablative techniques can also be used for lytic lesions of the bone. Spinal cord stimulation (SCS), intrathecal drug delivery systems (IDDS), and cordotomy have also been used successfully in patients requiring advanced options, such as those with significant spinal, ischemic, or visceral pain.
Topics: Humans; Nerve Block; Pain; Pain Management; Palliative Care; Vertebroplasty
PubMed: 34412500
DOI: 10.21037/apm-20-2386 -
Medicine Aug 2016Although the majority of available evidence suggests that vertebroplasty and kyphoplasty can relieve pain associated with vertebral compression fractures (VCFs) and... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Although the majority of available evidence suggests that vertebroplasty and kyphoplasty can relieve pain associated with vertebral compression fractures (VCFs) and improve function, some studies have suggested results are similar to those of placebo. The purpose of this meta-analysis was to compare the outcomes of vertebroplasty and kyphoplasty with conservative treatment in patients with osteoporotic VCFs.
METHODS
Medline, Cochrane, and Embase databases were searched until January 31, 2015 using the keywords: vertebroplasty, kyphoplasty, compression fracture, osteoporotic, and osteoporosis. Inclusion criteria were randomized controlled trials (RCTs) in which patients with osteoporosis, and VCFs were treated with vertebroplasty/kyphoplasty or conservative management. Outcome measures were pain, function, and quality of life. Standardized differences in means were calculated as a measure of effect size.
MAIN RESULTS
Ten RCTs were included. The total number of patients in the treatment and control groups was 626 and 628, respectively, the mean patient age ranged from 64 to 80 years, and the majority was female. Vertebroplasty/kyphoplasty was associated with greater pain relief (pooled standardized difference in means = 0.82, 95% confidence interval [CI]: 0.374-1.266, P < 0.001) and a significant improvement in daily function (pooled standardized difference in means = 1.273, 95% CI: 1.028-1.518, P < 0.001) as compared with conservative treatment. The pooled estimate indicated vertebroplasty/kyphoplasty was associated with higher quality of life (pooled standardized difference in means = 1.545, 95% CI: 1.293-1.798, P < 0.001). Subgroup analysis of 8 vertebroplasty studies and 2 kyphoplasty studies that reported pain data, however, indicated that vertebroplasty provided greater pain relief than conservative treatment but kyphoplasty did not.
CONCLUSION
Vertebroplasty may provide better pain relief than balloon kyphoplasty in patients with osteoporotic VCFs, both may improve function, and their effect on quality of life is less clear.
Topics: Conservative Treatment; Fractures, Compression; Humans; Kyphoplasty; Osteoporotic Fractures; Pain Management; Quality of Life; Randomized Controlled Trials as Topic; Spinal Fractures; Vertebroplasty; Visual Analog Scale
PubMed: 27495096
DOI: 10.1097/MD.0000000000004491