Abstract. Background Data: Vertebral augmentation procedures are widely used today in treating acute and subacute osteoporotic vertebral compression ...
Clinical Article
Online ISSN : 2314-8969 Print ISSN: 2314-8950 www.esa.org.eg
CHRONIC PAINFUL OSTEOPOROTIC V E R T E B R A L CO M PR E S S I O N F R AC T U R E S O F T H O R A CO L U M B A R S P I N E : P E R C U TA N E O U S V E R T E B R O PL A S T Y V E R S U S CO N S E R VAT I V E M A N AG E M E NT A M O N G EGY P T I A N PAT I E NTS
Egy Spine J 14:4-14, 2015
Chronic Painful Osteoporotic Vertebral Compression Fractures of Thoracolumbar Spine: Percutaneous Vertebroplasty versus Conservative Management among Egyptian Patients
Khaled M Hassan, MD, Mohammad El-Sharkawi, MD.
Orthopedic & Trauma Surgery department, Assiut University Medical School, Assiut 71511, Egypt.
Received at: January 12th, 2015 Accepted at: March 15th, 2015
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Abstract
Background Data: Vertebral augmentation procedures are widely used today in treating acute and subacute osteoporotic vertebral compression fractures (OVCFs). However, percutaneous vertebroplasty for patients with chronic painful OVCFs has been less well studied. Study Design: A prospective cohort study. Purpose: to compare the efficacy and safety of percutaneous vertebroplasty with conservative treatment for management of chronic painful OVCFs in the thoracolumbar spine among Egyptian patients. Patients and Methods: Ninety-eight patients presented with acute OVCFs during the period from October 2009 to December 2013. They were treated conservatively and followed for at least 3 months. Thereafter, 38 patients were excluded from this study as significant pain improvement was noticed in 32 patients and 6 didn't fulfill the inclusion criteria of this study. The remaining 60 patients (38 females and 22 males, mean age: 65.42±8.63) with chronic painful OVCFs were included in this prospective cohort study. Twenty-eight patients were treated with percutaneous vertebroplasty (Vertebroplasty group). Thirty two patients refused surgical treatment and constituted the control group (Conservative group). All patients were evaluated with X-rays and CT scan, where Cobb angle and the anteroposterior height comparison (APHC) were measured. Overall pain and quality of life were assessed with the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) respectively. Results: All patients were followed for at least 12 months. Statistical analysis of the demographic data of the two groups could not reveal any significant differences. At
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latest follow up, there was significant improvement in Cobb angle and APHC in Vertebroplasty group when compared with Conservative group (P=0.001). Three patients in the Conservative group (9.37%) went into nonunion, while all patients in the Vertebroplasty group showed radiological evidence of good stability at latest follow up. A significant improvement of VAS Scores (P=0.001) and ODI (P=0.001) was observed in the Vertebroplasty group when compared to the Conservative group at the latest follow up. Conclusion: Percutaneous vertebroplasty is safe and effective in treatment of chronic painful osteoporotic vertebral compression fractures with significantly better radiological and clinical outcomes when compared with conservative management. (2015ESJ086) Keywords: Chronic painful osteoporotic vertebral compression fracture, vertebroplasty, conservative treatment, nonunion.
Introduction Osteoporotic vertebral compression fractures (OVCFs) are commonly seen complication of primary or secondary osteoporosis. Although pain is usually the most pronounced initial problem, OVCFs can also lead to spinal deformity that may be associated with impaired mobility and physical function,25 decreased pulmonary function,12 and gastrointestinal problems.21 These conditions may have a significant impact on quality of life26 and may even contribute to a reduced life expectancy.16 Today, vertebral augmentation procedures (vertebroplasty and kyphoplasty) are commonly used in the treatment of OVCFs.29,19,11 Augmentation of the vertebral body using polymethylmethacrylate (PMMA), vertebroplasty, has gained wide clinical acceptance as an effective treatment option for patients with intractable pain related to OVCFs especially in acute and subacute fractures. However, percutaneous vertebroplasty for patients with chronic painful OVCFs has been less well studied.4 Thus, the aim of this study was to compare the efficacy and safety of percutaneous vertebroplasty with conservative treatment for managing chronic painful OVCFs in the thoracolumbar spine among Egyptian patients.
Patients and Methods
Out of 98 patients presenting during the period from October 2009 to December 2013 with acute OVCFs at the Emergency Unit of Assiut University Hospital, who were treated conservatively and prospectively followed for at least 3 months, 32 patients showed significant pain improvement and functional recovery. The remaining 66 who were still complaining of severe back pain were then recruited for this prospective cohort study.
Egy Spine J - Volume 14 - April 2015
The inclusion criteria for this study were as follow: Chronic painful OVCFs matched with radiological finding (at least 3 months duration from the fracture), the age at least 50 years old, the fracture level from T5 down to L5, the presence of osteoporosis as defined by decreased bone mineral density (T-score -2.5 or lower), which was measured with Dual-Energy X-ray Absorptiometry (DXA) according to the world Health Organization (WHO)18 the Visual Analogue Scale (VAS) at least 5, and absence of neurological deficits. We excluded all patients with: Acute and subacute OVCFs (less than 3 months duration of the fracture), the age less than 50 years old, the level of the fracture beyond T5 and L5, pathological fractures (due to metastases, myeloma, infection and etc), DXA T-score more than -2.5, VAS less than 5, and presence of neurological deficits. Six patients didn't fulfill the inclusion criteria of this study and were excluded. Of the remaining 60 patients, 28 consented to undergo percutaneous vertebroplasty (Vertebroplasty group) while the remaining 32 refused this surgical treatment and constituted the control group (Conservative group). There were 38 females and 22 males with a mean age of 65.42±8.63 years. At presentation, all patients received back brace, analgesics, anti-osteoporosis therapy. Plain X-rays (anteroposterior and lateral views) were done for all patients. CT scan was done for all patients of Vertebroplasty group and 23 in Conservative group. The fractured vertebral body (VB) was assessed by the Cobb angle, and anteroposterior height comparison (APHC). The Cobb angle was assessed in a lateral radiograph. A line was drawn along the superior end plate of the vertebra above the affected level and a second line was drawn along the inferior end plate of vertebra below. The angle between
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these two lines (or lines drawn perpendicular to them) was measured as the Cobb angle.3 APHC was expressed as the percentage of VB height at the anterior region compared with that at the posterior region.24 Bony healing and stability of the fractures were determined by stability in flexion-extension lateral radiographs, presence of bridging callus and unchanged Cobb angle and APHC. Overall pain and quality of life were assessed with the Visual Analogue Scale (VAS) 28 and Oswestry Disability Index (ODI)9 respectively. Table 1 summarizes the demographic data of both groups. Statistical Analysis: The follow up results of either group were analyzed using Wilcoxon Signed Ranks test. Both groups were compared using Mann-Whitney test. The accepted level of statistical significance was P
