Abstract
Background
Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity.
Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.
Keywords:
Kyphoplasty; vertebroplasty; osteoporosis; spinal fractures
Abstract
Background
Osteoporosis and pathological osteoporotic fractures are common findings in the elderly population. The age-standardised annual incidence of vertebral compression fractures (VCF) is 10.7/1000 in women and 5.7/1000 in men, increasing markedly with age1. At the age of 75 to 79 the annual incidence was 29.3/1000 in women and 13.6/1000 in men. Due to the continued aging of our population, VCF represent a major cause of disability and are a burden to the national healthcare budgets2. Non-surgical management with pain control and physical therapy-assisted mobilisation has for a long time been the only treatment option in VCF. Unfortunatelty a great number of patients remain functionally impaired after VCF, and some of them are severely handicapped due to chronic back pain3. The functional and physical consequences of VCF lead to anxiety, depression, and have devastating impact on interpersonal relationships and social roles4. It is therefore no surprise that untreated VCF contribute significantly to shorter life-expectancy both in women (mortality ratio 1.66, p < 0.01) and even greater in men (mortality ratio 2.38, p $lt; 0.0001) within one year after onset of symptoms5.
Indications for cement augmentation
while medical therapy of osteoporosis improves dramatically, the restoration of quality of life is still a major issue in VCF treatment. Osteoporotic kyphotic compression fractures often lead to a anterior shift of the sagittal plumb line and increased load of the anterior vertebral column, which may cause further compression fractures6. This cascade of sequential compression fractures is eventually causing the typical hump of the elderly, with significant thoracic kyphosis and low pelvic incidence, forcing the patient to bend hips and knees to maintain sagittal balance7.
Galibert et al8 presented the first cases of successful vertebral augmentation by intravertebral injection (vertebroplasty) of polymethyl methacrylate (PMMA) in patients with vertebral haemagiomas. Later, vertebroplasty was successfully introduced for the management of osteoporotic compres