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SUMMARY:Osteoporotic vertebral compression fractures frequently result in significant morbidity and health care resource use. For patients with severe and disabling pain, vertebral augmentation (vertebroplasty and kyphoplasty) is often considered. Although vertebroplasty was introduced Ͼ30 years ago, there are conflicting opinions regarding the role of these procedures in the treatment of osteoporotic vertebral compression fractures. This review article updates clinicians on the published prospective randomized controlled data, including the most recent positive trials that followed initial negative trials in 2009. Analysis of multiple national claim datasets has also provided further insight into the utility of these procedures. Finally, we considered the recent recommendations of national organizations and medical societies that advise on the use of vertebral augmentation procedures for osteoporotic vertebral compression fractures. ABBREVIATIONS:NRS ϭ numeric rating scale; PMMA ϭ polymethylmethacrylate; QUALEFFO ϭ Quality of Life Questionnaire of the European Foundation for

V ertebral fractures are the most common complication of osteoporosis and account for almost half of osteoporotic fractures annually (1,2). Osteoporotic vertebral compression fractures (OVCFs) occur when the vertebral body collapses axially and are associated with a statistically significant increase in morbidity and mortality (3,4). Most patients improve with nonsurgical management (NSM) involving bed rest, analgesia, and thoracolumbar bracing while fracture healing occurs. NSM carries inherent risks relating to the adverse side effects of impaired mobility, deconditioning, pressure ulcers, and gastrointestinal effects of both nonsteroidal and opioid analgesia (5).Vertebroplasty (VP) is a minimally invasive surgical technique first developed in the treatment of vertebral hemangiomas (6). VP aims to stabilize OVCFs with the introduction of bone cement into the fracture. Balloon kyphoplasty (BKP) aims to restore vertebral body height by means of inflation of a balloon within the fracture, creating a cavity for cement injection. These two procedures are types of vertebral augmentation (VA). For the purposes of this analysis, VA was defined as vertebroplasty and/or balloon kyphoplasty and did not include radiofrequencytargeted vertebral augmentation. A number of small nonrandomized controlled studies throughout the 1990s and

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Spinal metastases are the most commonly encountered tumour of the spine, occurring in up to 40% of patients with cancer. Each year, approximately 5% of cancer patients will develop spinal metastases. This number is expected to increase as the life expectancy of cancer patients increases. Patients with spinal metastases experience severe and frequently debilitating pain, which often decreases their remaining quality of life. With a median survival of less than 1 year, the goals of treatment in spinal metastases are reducing pain, improving or maintaining level of function and providing mechanical stability. Currently, conventional treatment strategies involve a combination of analgesics, bisphosphonates, radiotherapy and/or relatively extensive surgery. Despite these measures, pain management in patients with spinal metastases is often suboptimal. In the last two decades, minimally invasive percutaneous interventional radiology techniques such as vertebral augmentation and radiofrequency ablation (RFA) have shown progressive success in reducing pain and improving function in many patients with symptomatic spinal metastases. Both vertebral augmentation and RFA are increasingly being recognised as excellent alternative to medical and surgical management in carefully selected patients with spinal metastases, namely those with severe refractory pain limiting daily activities and stable pathological vertebral compression fractures. In addition, for more complicated lesions such as spinal metastasis with soft tissue extension, combined treatments such as vertebral augmentation in conjunction with RFA may be helpful. While combined RFA and vertebral augmentation have theoretical benefits, comparative trials have not been performed to establish superiority of combined therapy. We believe that a multidisciplinary approach as well as careful pre-procedure evaluation and imaging will be necessary for effective and safe management of spinal metastases. RFA and vertebral augmentation should be considered during early stages of the disease so as to maintain the remaining quality of life in this patient population group.

Level 4, Technical Report.

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