Evaluation and Interventional Management of Pain After Vertebral Augmentation Procedures

Abstract

IntroductionA small subset of patients who underwent successful vertebral compression fracture (VCF) augmentation procedures may develop subsequent pain requiring spinal injections. In a retrospective analysis, we determined whether the pain was related to the original fracture site or to another area within the lumbar or thoracic spine. The pain occurred either at the same/adjacent level and/or non-adjacent level as the VCF. Interventional treatments primarily targeted the facet joints, specifically in the form of facet joint blocks and/or radiofrequency ablation to the medial branches. The pattern of facet injections relative to the original fracture level was studied. Additionally, the elapsed time between the vertebral augmentation and the subsequent interventional blocks was also evaluated.MethodsA total of 56 patients sustained VCFs. 12 of these patients underwent interventional procedures after vertebral augmentation procedures. The level(s) of same/adjacent level and non-adjacent level pain were determined via physical examination and/or imaging studies. These levels were subsequently treated with interventional procedures primarily focused on the facet joints. The time period of the injections varied from two weeks status post-vertebral augmentation to as late as 304 weeks (5.8 years) status post-vertebral augmentation.ResultsWe performed 25 vertebral augmentation procedures on these 12 patients. 15 lumbar, eight lower thoracic, and two mid-thoracic VCFs were augmented. 9/14 cases of blocks included those performed at non-adjacent levels, whereas 5/14 cases of blocks were performed only at the same and/or adjacent levels as the VCF. For the events in which thoracic VCFs were augmented, 6/7 (or 86%) had developed non-adjacent level pain in areas of the lumbar spine. The time from vertebral augmentation procedure to subsequent pain procedure ranged from two weeks to five plus years. The average time elapsed was 83 weeks. Only one case required blocks performed within the first six weeks after vertebral augmentation. In this case, the blocks included those at non-adjacent levels. A total of 4/12 cases (33%) had a block within 12 weeks of the original vertebral augmentation procedure.Lumbar spine imaging showed that at least 9/12 patients had pre-existing significant lumbar pathology at the time of fracture treatment. This may have contributed to the later development of pain.ConclusionPain after a successful vertebral augmentation is typically non-acute (i.e., beyond six weeks). Mechanisms other than the primary VCF are usually responsible for non-adjacent level pain, which are present a majority of the time on reviewing the patients' diagnostic studies. These mechanisms usually take many weeks to develop and subsequently elicit pain that requires additional interventional pain procedures. In our study, the pain is usually related to the pre-existing degenerative spondylosis and stenosis rather than the fracture site. This study shows that the facet joints in closely related lumbar degenerative changes are ...

Use of Spinal Cord Stimulation in Elderly Patients with Multi-Factorial Chronic Lumbar and Non-Radicular Lower Extremity Pain

“…Dual or triple array epidural leads have been used to provide stronger axial coverage [ 19 , 20 ]. This may be important in patients with more diffuse lumbar pain associated with multiple vertebral compression fractures [ 11 - 13 ]. Another option is a combination of an epidural lead with a second lead positioned in the lumbar subcutaneous tissue for peripheral nerve field stimulation (PNFS) [ 21 , 22 ].…”

“…Some degree of persistent pain after vertebral augmentation and kyphoplasties is common especially when the fractures are in the lumbar spine [ 11 , 12 ]. Back pain persisting after the first three months post vertebroplasty is seen in 19% to 23% of cases [ 13 ]. Radicular pain is not usually associated with osteoporotic vertebral compression fractures, however, these elderly patients may also have chronic extremity pain from peripheral neuropathy or from other osteoporotic fractures in the hip or after joint replacement that can be helped with spinal cord stimulation targeting both the lumbar spine and lower extremities [ 11 , 13 ].…”

Progression of Vertebral Compression Fractures After Previous Vertebral Augmentation: Technical Reasons for Recurrent Fractures in a Previously Treated Vertebra

“…Persistent pain after a vertebral augmentation can be caused by different spinal problems, including another osteoporotic compression fracture at a new or adjacent level, surgical infection, concurrent lumbar stenosis, and rarely, a recurrent fracture at the previously treated level [ 11 , 15 ]. There are case reports of the development of an adjacent level fracture as early as the first month after kyphoplasty [ 3 , 6 ].…”

Vertebral Compression Fractures after Lumbar Instrumentation

“…As the population becomes older, it is common to see patients developing concurrent spinal problems such as lumbar spinal stenosis (LSS), degenerative spondylolisthesis (DSL), and osteoporotic vertebral compression fractures (VCF). These conditions often affect the same or adjacent regions of the thoracic and lumbar spine [ 1 - 3 ]. Large radiologic and anatomic studies have shown a biphasic distribution of VCF with 45% to 55% found in the mid-thoracic spine from T6 to T8, and 10% to 20% from T12 to L2 [ 4 ].…”

“…Magnetic resonance imaging (MRI) and computerized tomography (CT) scans are a key part of the diagnosis. Often patients are being studied for one problem, such as a traumatic VCF, and are found to have previously asymptomatic lumbar stenosis or spondylolisthesis; or the reverse, where a patient is being evaluated for radicular pain or neurogenic claudication, and is found to have a previous VCF [ 3 , 5 ] (Figure 1 ).…”