At the 2009 European Congress of Radiology, held in Vienna, Austria, between 6–10 March, Dr Gregg H. Zoarski, Director of Diagnostic and Interventional Neuroradiology at Maryland University in Baltimore, reviewed available data on vertebroplasty and kyphoplasty.
Both vertebroplasty and kyphoplasty are radiological procedures used in the treatment of pain caused by vertebral compression fracture. For some time now, a raging debate has surrounded the issue of who decides which procedure a particular patient should undergo.
In his talk, Zoarski highlighted that the forces that drove decision-making were the physician’s education and experience, and their perception of success and risks. Other factors that affected decision-making included findings from scientific literature, professional consensus, the cost of devices and reimbursement, and patients’ preference.
Both techniques use cement, typically polymethylmethylacrylate, to stabilise the compromised vertebra. While in vertebroplasty there is only a simple cement injection, in kyphoplasty there is a balloon pre-dilatation which is followed by cement injection. In fact, kyphoplasty is sometimes referred to as “balloon-assisted vertebroplasty”.
Zoarski said that the phrase “vertebroplasty vs. kyphoplasty” evokes images of competitive procedures and battling groups of entrenched physicians. Perhaps viewed more properly however, the two procedures should be viewed as choices along a spectrum of solutions to help patients. Both offer potential benefit with an acceptable safety profile when used by properly trained physicians in appropriately selected patients.
He said patients with focal pain and tenderness corresponding to the level of fracture by X-ray or oedema by MRI tended to show the best results from either procedure. Those who had fractures which were less than two months old, or those who had a recent worsening of fracture were particularly suited.
The doctor from Maryland also stressed that the division over the two techniques may stem from their origins. “Vertebroplasty was developed largely through the efforts of academic physicians at teaching centres with little incentive for fee for service compensation. Whereas balloon-assisted vertebroplasty was developed and marketed from the outset as a commercial venture”, he said.
Percutaneous vertebroplasty was introduced by Dr Herve Deramond et al in France in 1984;the idea of attempting to restore lost vertebral body height and reduce associated kyphotic deformity while stabilising a vertebral compression came up in the early 1990s in the USA, by an orthopaedic surgeon, Dr Mark Reiley.
However Zoarski clarifies that, “Height restoration by balloon-assisted vertebroplasty is minimal in most cases, and at best, inconsistently achieved.”
On the limitations front, both techniques have not been tested in a comparison trial against conservative therapy. Zoarski finds that “the goal should now be to refine the indications for each procedure so that patients are appropriately selected to maximise benefits to patients.”