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Kyphoplasty and Vertebroplasty in painful osteoporotic vertebral

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Kyphoplasty and Vertebroplasty in painful osteoporotic vertebral Powered By Docstoc
					Kyphoplasty and Vertebroplasty in
       vertebral fractures
    Kyphoplasty and Vertebroplasty
•   Epidemiology of osteoporotic fractures
•   Natural history
•   Morbidity and mortality
•   Conservative treatment
•   Vertebroplasty/Kyphoplasty
•   How its done
•   Selection of patients and imaging
    Kyphoplasty and Vertebroplasty
•   Results
•   Vertebroplasty v Kyphoplasty
•   Acute v Chronic fractures
•   Controversies
•   Other indications
•   Future developments
                              Epidemiology
                              Radiographic
• 25 % in post
  menopausal females
• 40% in women > 80yrs
• Age group 65 yrs+ are
  fastest growing
  segment of the
  population
• Less common in men
•   Melton et al. Epidemiology of vertebral
    fractures in women. Am J Epidemiol 1989;
    129:1000-11.
            Consequences of vertebral
                   fractures
• Sentinel sign of failing
  health
• 35-40% increase in
  cancer deaths
• 23-34% increase in
  mortality rates
• 5yr survival 61% cf. 76%
•   Cooper C et al. Population based study of
    survival after osteoporotic fractures. Am J
    Epidemiol 1993:137;1001-5.
                           Clinical incidence
• Majority are
  asymptomatic
• Loss of height and
  stooped posture
• 23-33% are painful
• Over ⅔rds become
  manageable or
  asymptomatic in 6-12
  weeks
•   Cooper C et al. The epidemiology of vertebral
    fractures. Bone 1993-14.611-5
             Predictors of fracture

•   Age
•   Sex
•   Osteoporosis
•   Inactivity
•   Smoking
•   20-30% are multiple
•   Previous fracture
                         Predictors of fracture
Predictors of fracture
  19.2% of females with a
  confirmed incidental
  fracture had a second
  fracture within one year.

    24% of females with two or
    more fractures developed a
    further fracture within a
    year.
Lindsay et al. JAMA 2001; 285: 320-3.
                    Evaluation
• Severe back pain
• Often no history of
  trauma
• Pain is worse upright
• Thoracic kyphosis
• Pain reproduced by
  pressure over spinous
  process
• Very rare neurological
  deficit
• Exclude other causes
                      Evaluation
Think twice!

• Fractures above T6
• Less than 55 yrs without
  history of trauma
• Patients with known
  malignancy
          Radiographic evaluation
             of age of fracture
• Plain films
• MRI
 Low signal T1
 High signal T2
 High signal STIR
Best indicator of age is the
   history.
                                   Bone Scan
• Not as commonly used
  as MRI
• Been show to have a
  93% predictive value in
  vertebroplasty!
• May be abnormal when
  MRI is normal
•   Maynard et al. Value of bone scan imaging
    in predicting pain relief in vertebroplasty.
    AJNR 2000;21:1807-12.
                   Treatment
•   Pain relief
•   Exercise
•   Diet
•   Osteoporosis
•   Brace?
       Vertebroplasty / Kyphoplasty
               What is it?
Vertebroplasty       Kyphoplasty
           How does it work?
• Structural support – but no good correlation
  with amount of cement injected
• Thermal properties
• Decompression
• Placebo
                How is it done?

• Usually performed under
  general anaesthetic
• Can be performed under
  local
• Day case procedure
• Minimal invasive
How is it done?
How is it done?
                 How is it done?
Vertebroplasty           Kyphoplasty
How is it done?
             Indications for
       vertebroplasty/kyphoplasty
• Only needed in a small
  subset of patients
• High signal on STIR.
• Pain on percussion
• Increased activity on
  bone scan
• T5 and below-
  kyphoplasty
• Timing?
            Contraindications
• Infection
• Uncorrectable
  coagulopathy
• Anaesthetic Risk
• Neurology
• Middle column
  compromise is NOT.
              Complications
• Very few cliniccal relevant complications.
• Cement extravasation 70%+
• Pulmonary embolus 70%+
                                         Results
Vertebroplasty                                   Kyphoplasty
• Significant better pain and                    • FREE trial.
  functional improvement                         • 300 patients randomised.
  than conservative
  treatment at 3 months.                         • Assessed at one year
• No difference at twelve                        • SF 36 PCS 0-100.
  months.                                        • Kyphoplasty 26 33.4
• Vertebroplasty patients had                    • Conservative 25.5 27.4
  significantly more pain than
  the conservative group.                                        p<0.0001
•   Hulme PA et al. Vertebroplasty and           Wardlaw D et al Lancet 2009;21:1016-24
    kyphoplasty: a systematic review of 69
    clinical studies. Spine 2006:31;1983-2001.
                      Controversies
                       No Benefit
• A Randomized Trial of Vertebroplasty for
  painful Osteoporotic Vertebral Fractures
• Buckbinder R et al. NEJM 2009;361:557-568.

• A Randomized Trial of Vertebroplasty for
  Osteoporotic Spinal Fractures
• Kalmes DF et al. NEJM 2009;361: 569-579.
• No improvement against sham procedure at 1 week,
  or at 1,3 or 6 months.
               Controversies
                No Benefit
• Previous studies – lack of blinding, lack of true
  sham control. Couldn’t exclude a placebo
  effect.
• NEJM studies- randomised, blinded and a
  sham procedure. Buckbinder needle against
  lamina. Kalmes – local anaesthetic around the
  facet joint.
                 Problems
              Fracture acuity
  Buckbinder: bone marrow oedema indicates
  an acute fracture but a detectable fracture
  line sufficed for inclusion.
  Kalmes only used MRI or Bone scan in which
  fracture age was uncertain.
• Both groups had to have a fracture less than a
  year old- most groups would use 6 weeks as
  an acute fracture definition.
                 Problems
                Enrollment
• Kalmes: 1812 patients initially screened,only
  131 entered into study. Most common reason
  – patient refusal.
• Buckbinder: Needed 4.5 years in 4 high
  volume centres to accrue 78 patients- 141
  declined randomisation.
• Pain severity of groups who refused not
  reported.
                 Problems
               Control Group
• Is injection of local anaesthetic around the
  facet joint a sham procedure?
                         Vertos II Study
• Prospective randomised trial vertebroplasty v
  conservative treatment. 202 patients.
• Results Vertebroplasty had better pain relief at
  one year.
• All fractures less than six weeks old.
•   Klazen C et al Lancet 2010:376;1085-1092.
                    Timing
• The best evidence is that the best results are
  achieved within 6 weeks of onset!
• Rarely achievable in the UK
• 50% + get better within 6 weeks
  conservatively treated.
• Philosophical when to treat.
• Most fractures treated in UK > 3 months old.
                         Timing
                     Older fractures
• No randomised control trials for efficacy of
  treatment of old fractures.
• There are trials suggesting similar success
  rates to acute fractures of 80% success in
  fractures a year or older.
• Brown et al. Treatment of Chronic symptomatic vertebral compression
  fractures with percutaneous vertebroplasty . AJN 2004;182:319-312.
                 My protocol
• Fractures less than 6
  weeks old who need to
  be hospitilised.
• Failure of conservative
  treatment after 3
  months
• Vertebroplasty for all
  except where middle
  column is involved –
  Kyphoplasty,
• Bone scan +ve
     Vertebroplasty v Kyphoplasty
Vertebroplasty     Kyphoplasty
• Cheaper          • Expensive
• Quicker          • Takes longer
                   • Restoration of vertebral
                     height?
                   • Less adjacent fractures
                   • Less cement leakage
                   • Quality of life
             Vertebroplasty v Kyphoplasty
                A review of 168 studies.

Vertebroplasty               Kyphoplasty
• Mean change in VAS 5.68    • Mean change in VAS 4.60
                               p<0.001
• New fracture 17.9%         • New fracture 14.1%
                               p<0.01
• Cement leak 19.7%          • Cement leak 7.0%
                               p<0.001

                             •   Comparison of vertebroplasty and
                                 kyphoplasty in vertebral compression
                                 fractures: a meta-analysis of the
                                 literature. Spine J 2008;8:488-97.
            Other Uses
• Tumours
• Trauma
• Myeloma
                 Other uses
• Sacroplasty
• Sacral insufficiency
  fractures
• Best performed under
  CT guidance.
               Developments
• Calcium phosphate in
  young patients with
  traumatic fractures
• Prophylaxis
• Adding chemotherapy
  agents or radioactive
  isotopes to the cement
  in tumour
                Conclusions
• Vertebroplasty/Kyphoplasty is useful in the
  treatment of vertebral osteoporotic fractures
  although some controversy still exists.
• Low morbidity
• Should be considered in painful fractures over
  6 weeks old.

				
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