In recent months, much has been discussed about the advances and advantages of kyphoplasty to repair vertebral compression fractures (VCFs). However, vertebroplasty, which researchers developed in the early 1990s as a minimally invasive method to fix VCFs by injecting cement into the fracture to strengthen the bone, has been unfairly described by some healthcare professionals as, well, almost archaic.
"Vertebroplasty has over a 95 percent success rate and less than 1 percent complication rate," emphasized Dr. Mark Shaw, a Nashville neuroradiologist at Radiology Alliance who practices primarily at St. Thomas Hospital and who handles more vertebroplasty and kyphoplasty procedures than any other physician in Tennessee. "Yes, there is a very small chance of extravasation of cement into the venous system, and if not recognized may result in pulmonary emboli. This, however, can also happen with kyphoplasty."
Vertebroplasty is performed under X-ray guidance to repair painful compression fractures. A needle is advanced into the broken vertebral body and a mixture of bone cement is then injected into the fracture. The bone cement initially has a consistency of toothpaste when injected, but within minutes, the cement hardens in place, reducing the patient's pain by immobilizing the fracture.
"Many patients with compression fractures find the pain extremely debilitating," said Dr. Gerald Niedzwiecki of Tampa, Fla., widely recognized as one of the nation's leading interventional radiologists who specializes in minimally invasive, targeted treatments performed using imaging guidance. "In fact, many independent elderly patients with osteoporosis who developed compression fractures no longer are able to perform their usual activities of daily living due to extreme pain. After a vertebroplasty, the pain resolves almost immediately and the patients can return to their normal independent lifestyle."
Both vertebroplasty and kyphoplasty are useful in osteoporotic and pathologic compression fractures of the spine, Shaw pointed out, adding that vertebroplasty is less invasive, with no balloons (tamps), no drills, and much smaller needles (trochars). Because the needles are smaller, it's easier to perform vertebroplasty in patients with fractures of the upper thoracic spine, where the pedicles are very narrow and harder to see, he said, comparing vertebroplasty's 11-13 gauge needles to kyphoplasty's 8-10 gauge needles.
Vertebroplasty can be performed with less anesthesia than kyphoplasty because it's less invasive, and it's easier to get the needles in place. Therefore, the procedure can usually be done with just intravenous sedation and local anesthesia. Also, vertebroplasty is quicker, often requiring just one needle stick and there is quite a bit less radiation exposure to the physician. With vertebroplasty, the operator can stand back a foot or so from the X-ray tube, whereas with kyphoplasty, the way the system is set up, you have to be very close to the X-ray beam, Shaw explained.
Shaw offers the kyphoplasty procedure to patients whom he believes are viable candidates. "However, the amount of height restoration of a compression fracture is, again in my experience and reported nationally, 5-mm," he explained. "The cost differential of kyphoplsty — kits start at $3,500 — to vertebroplasty — $500 — is very hard to justify for 5-mm of height restored. Both vertebroplasty and kyphoplasty are effective and safe procedures, which is why I offer both. Patient selection is the key here."
Shaw said he opts to perform kyphoplasty in patients who have fracture involving the posterior cortex or with retropulsion of fracture fragment. "In these patients, you know the posterior wall is not intact, and I prefer to use balloons to slowly and controllably make a 'cavity' in the vertebral body to deposit the bone cement. If there's a new fracture, just a few weeks old, and there is a moderate amount of vertebral body height loss and/or kyphosis, I generally prefer kyphoplasty. The amount of retropulsion, however, can be a contraindication for doing either procedure."
Shaw often prefers kyphoplasty in very elderly patients who have marked osteoporosis. "In these patients, there is such little bone density in the vertebral body that they are very vascular, which means you have to be especially careful when injecting the cement to avoid intravascular injection/extravasation," he said. "In these patients, the thicker the cement, the better."
The Advanced Imaging and Interventional Institute, which Niedzwiecki founded and presides over, is one of few facilities in the nation offering Enhanced Vertebroplasty for Metastatic Spine Tumors® (see box), a procedure used in patients suffering from VCFs or pain related to metastatic or primary tumors involving the bone.
"A specialized probe is placed into the bone containing the tumor, and the tumor is vaporized, making a void in the bone to accept the bone cement and strength in the bone," explained Niedzwiecki, whom patients refer to as "Dr. Jerry." "This provides excellent pain relief for patients suffering from pain related to the tumor involvement in the bone. The void formed in the bone allows for the safe injection of the bone cement without the worry of cement being squeezed into undesired areas."
Last fall, Niedzwiecki was the first physician in Florida to perform the enhanced vertebroplasty procedure. "The patient had excellent pain relief following the procedure," he reported.
Debating which method is preferable — vertebroplasty or kyphoplasty — depends on who you talk to. "You seriously need to take each patient, each one of their fractures separately, and decide what is the best way to treat this particular fracture," said Shaw. "So many people try to make medicine a 'cookie-cutter' industry.
"I have a really hard time justifying the added expense of kyphoplasty when I can perform vertebroplasty for a fraction of the cost, get the same good result, at the same level of safety. Archaic? I don't think so."
