Dear Doctor Column, November 21, 2005

Minimally Invasive Procedures for Vertebral Compression Fractures

Question:

I have osteoporosis and lately I've been suffering from terrible low-back back pain. My doctor says fractures in my vertebra are responsible for the pain and also are causing my spine to curve. Bed rest and Tylenol haven't helped, and she recommends a procedure that involves injecting cement into the vertebrae. What can you tell me about this?

Answer:

Kyphoplasty and vertebroplasty, the procedures your doctor is referring to, are minimally invasive techniques that can reduce or eliminate pain caused by vertebral compression fractures — breaks in the bones of the spine — and sometimes correct spinal deformity, a complication of the fractures.

Fractures are the most common and devastating complication of osteoporosis, a condition that decreases bone mineral density, weakening bones and making them vulnerable to breaks. A fall or other injury also can cause vertebral compression fractures, as can some infections and cancers. Once a first fracture occurs, the risk of additional breaks in surrounding vertebrae increases significantly.

Most vertebral compression fractures caused by injury heal within a month or two when treated with activity modification and pain medication. Osteoporotic fractures also usually respond to rest and medication, but some cause chronic pain and disability.

When breaks occur, the bone tissue of injured vertebrae collapses and loses height, and multiple fractures can cause the spine to curve forward, a condition called kyphosis. Fractures and kyphosis compress nerves and strain supporting muscles and ligaments of the back. Each successive fracture can cause you to hunch forward a little more, and kyphosis can eventually interfere with bending, eating, walking, and breathing. Kyphoplasty, which some physicians feel is an enhancement of vertebroplasty, may restore vertebral height and both procedures improve physical functions impaired by pain and deformity.

Kyphoplasty and vertebroplasty provide pain relief and involve injecting a stabilizing acrylic bone cement into the compressed portion of the vertebrae. Kyphoplasty adds an additional step; a balloon is inserted into involved vertebrae before bone cement is injected. The surgeon inflates the balloon, raising the collapsed vertebra and creating a cavity for the cement, which forms an internal cast that supports the bone.

Although both vertebroplasty and kyphoplasty relieve pain, the newer procedure may restore some height to compressed vertebrae, allowing a straighter stance and relieving impaired breathing and other difficulties caused by kyphosis. Ongoing head-to-head trials comparing kyphoplasty with vertebroplasty will help doctors learn more about choosing the best treatment for individual patients.

Vertebral compression fractures are uncommon in people younger than 50, but as we age, risk increases rapidly. Fractures occur in about 6% of women in their 50s while 75% of women who reach their 90s experience breaks. The 2004 US Surgeon General's Report on Bone Health and Osteoporosis estimates 30% to 50% of women and 20% to 30% of men will develop a vertebral fracture in their lifetime and half of these people will sustain more than one break.

Both kyphoplasty and vertebroplasty are well tolerated by the older adults most often affected by fractures, and Medicare usually covers the procedures. Although cement leakage is a potential complication of both vertebroplasty and kyphoplasty, leaks appear to happen less often with the newer procedure. Kyphoplasty is significantly more expensive and takes longer — about 1 hour for each compressed vertebra treated versus 30 minutes per vertebra with vertebroplasty.

Kyphoplasty is not suitable for all patients with vertebral compression fractures. The procedure works best in people who have fractures as a result of osteoporosis or some kind of injury, such as a fall. Kyphoplasty is also most effective when performed 6 months to a year after the initial break. Your physician will use MRI (magnetic resonance imaging) and CT (computed tomography) scans to determine if your breaks are amenable to repair with kyphoplasty or vertebroplasty. After the procedure, your doctor should continue treating your osteoporosis, the underlying cause of the fractures, with medical therapies such as calcium supplements and bisphosphonates (Fosamax and Actonel) that increase bone mass and reduce risk of future fractures.

For more information on kyphoplasty, osteoporosis, and vertebral compression fractures visit the National Institutes of Health online.