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November 2012 Dear Colleague: Due mainly to osteoporosis, Americans experience 700,000 vertebral body compression fractures (VCFs) annually. That’s more than the number of hip and wrist fractures combined. Approximately 150,000 of these patients are hospitalized for medical management of pain—with an average stay of eight days at a collective cost of $1.6 billion a year. Add nursing home care into the mix and the estimated direct cost for osteoporotic and associated fractures soars to $17 billion annually (or $47 million a day.) Having recently returned from the annual meeting of the Society for Minimally Invasive Spine Surgery in Miami, where I presented an abstract on minimally invasive spine surgery performed at Michigan Neurosurgical Institute, I thought it might be helpful to pass along some information about VCFs. Our practice has special expertise in minimally invasive procedures for treating VCFs—kyphoplasty and vertebroplasty—both of which are usually done on an outpatient basis. Compression fractures tend to occur at the thoracic curve and thoracolumbar junction. Failure to diagnose and treat can result in a downward spiral as one VCF leads to another, and then to kyphotic angulation or over-curvature of the spine. This can leave patients in chronic pain, with decreased lung function, height loss, impaired gait or poor balance, and a greater risk of age-adjusted mortality. Fortunately, this progressive decline in health-related quality of life can often be delayed or prevented with three forms of intervention: Nonsurgical, Pharmacological, and Surgical. Prevention and Treatment Nonsurgical intervention may include bed rest, analgesics, physical therapy, and bracing. While this may relieve pain, it doesn’t restore the anatomy or provide long-term functional improvement, and the inactivity can exacerbate bone loss. Pharmacological intervention may also involve pain medication (usually short-term), as well as calcium supplements, vitamin D, bisphosphonate drugs and certain hormones, such as calcitonin, to increase bone growth and density and prevent vertebral fractures. Surgical intervention is either via an open approach or a minimally invasive approach. The open approach is considered when there is radiographic spinal instability, canal stenosis, or neurologic impairment. The minimally invasive approach is the prevalent surgical treatment option for most compression fracture patients. Patient Selection VCFs call for complete neurological and radiological evaluation. At MNI, our screening criteria for recommending a minimally invasive surgical approach include the following: • • • •

The patient is 60 years of age or older He or she experiences pain in response to percussion at the level of the vertebra in question The injury or compression fracture is > 4-6 weeks old or < 1 year old Positive MRI or bone scan imaging supports the above clinical/historical findings and may support this treatment option in patients who fall outside of the above parameters (i.e. age <60 years old, etc.)

The medical literature tells us that patients 60 and older who have experienced VCF pain for less than a year typically do very well with vertebroplasty or kyphoplasty. While the U.S. health system has tended to focus on treating the pain caused by VCFs, vertebroplasty and kyphoplasty now enable us to weigh such factors as quality of life, height restoration, and increasing patient mobility when choosing the best course of treatment. Vertebroplasty or Kyphoplasty? Vertebroplasty is designed to reduce pain. Kyphoplasty is designed to reduce pain, correct deformity, and stabilize the spine. For vertebral augmentation, both procedures use injections of PMMA bone cement (i.e., polymethyl methacrylate or Plexiglas.) You can find plain-language explanations—and video animations—of these and many other neurosurgical procedures on our website. Please feel free to use them in talks with your patients. 1, 2

Unfortunately, two studies of vertebroplasty published in 2009 cast doubt on its efficacy, temporarily discouraging the use of both procedures. Those studies were promptly criticized as flawed (too little PMMA used; fewer than 100 patients studied; enrollment bias, etc.) and at odds with 15 years of accumulated medical literature, as well as the experience of hundreds of thousands of patients. 3, 4, 5, 6

have published evidence that treating VCFs with vertebroplasty and kyphoplasty is Several leading medical journals 7 relatively safe and effective. In particular, the largest study of kyphoplasty (the Fracture REduction Evaluation or FREE study), found that the procedure can relieve pain, restore height, and improve mobility and quality of life. Today, tens of thousands of vertebroplasties and kyphoplasties are performed each year. Moreover, the consensus is that the procedures are “safe, efficacious, and durable” when performed in a standard manner for appropriate patients. So say the American Society of Interventional and Therapeutic Neuroradiology, Society of Interventional Radiology, American Association of Neurological Surgeons/Congress of Neurological Surgeons, and American Society of Spine Radiology. You can find this and related information online at the federal Agency for Healthcare Research and Quality ( Please feel free to contact me at any time. I look forward to serving as a resource for you and your patients. Sincerely,

Avery M. Jackson III, M.D., F.A.C.S., F.A.A.N.S. Michigan Neurosurgical Institute, P.C. Diplomate of the American Board of Neurological Surgery


Kallmes, D., et al., N Engl J Med 2009; 361:569-579 Buchbinder, R., et al., N Engl J Med 2009; 361:557-568 3 Alverez , L., et al. Spine 2006 May 1;31(10) 1113-8 4 Diamond, TH, et al. Med J Aust. 2006 Feb 6; 184(3):113-7 5 Ledlie J, et al. Spine 2006; 31: 2213-2220 6 Klazen, C., et al., Lancet 2010; 376: 1085-1092 7 Wardlaw, D., Lancet 2009; 373: 1016–24 2

Background: Vertebral Compression Fractures  
Background: Vertebral Compression Fractures