Vertebroplasty And Kyphoplasty

Vertebroplasty treats pain by treating the underlying condition. Thus, it involves injecting bond cement to create a permanent "cast" for vertebral structures damaged by osteoporotic compression fractures (its main use in the United States) (49), hemangiomas, or neoplasms (its main use in Europe) (50). This procedure can lead to rapid pain relief.

Kyphoplasty expands vertebroplasty by first inflating a "balloon" in the vertebra to restore its height before injecting the cement. Some clinicians use kyphoplasty only to treat relatively fresh fractures (those that have had less than 2 weeks to heal) (J. M. Mathis, personal communication, June 2002).

Clinical experience indicates the promising nature of the expanded procedure. In 2001, Garfin et al. (51) reported that preliminary results of a multicenter trial involving 376 procedures to treat 603 fractures in 340 patients showed a 90% improvement in symptoms and function. That same year, Lieberman et al. (52) published the results of 70 kyphoplasty procedures in 30 patients and noted that 47% of lost height was restored in 70% of the vertebral bodies treated. The investigators found that all outcome measures improved, and the only complications during the procedure were rib fractures in two patients and pulmonary edema and myo-cardial infarction in another.

There is controversy about obtaining a venograph before vertebro-plasty; some clinicians insist that this test improves safety (55), but others point out that the venography contrast agent can increase a patient's risk of a potentially fatal allergic reaction and can impede cement injection if the agent stagnates on injection (54,55).

The contraindications for vertebroplasty include complete loss of vertebral height, the presence of osteoblastic metastasis, and acute fracture. The contraindications for kyphoplasty include bleeding disorders, fractured pedicles, the presence of solid tumors or osteomyelitis, and known allergy to the contrast agent used in the balloon.

No controlled study of vertebroplasty with or without kyphoplasty exists, yet it is agreed that vertebroplasty can cause serious neurological complications. Thus, many clinicians recommend reserving these procedures for carefully selected subjects of clinical trials (56-58). Initial follow-up studies, however, indicate that vertebroplasty may lead to long-term pain reduction and halt an otherwise likely progression to deformity. It is possible, on the other hand, that vertebroplasty may increase a patient's risk of another vertebral fracture near the site of an original vertebroplasty repair (59).

The development and use of resorbable cements and kyphoplasty balloons will reduce the risk of these procedures and encourage their application in the United States to severe fractures (60,61) and spinal malignancies (62).

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