Vertebroplasty, Kyphoplasty and Cementoplasty in Osteoporotic Fractures

Vertebroplasty and cementoplasty consist in the percutaneous injection of a bone cement, usually polymethylmetacrylate, into a fractured or weakened bone.In the case of vertebroplasty, a needle is introduced percutaneouly into the vertebral body through the neural arch and vertebral pedicle in a patient in a prone position under fluoroscopic or scannographic guidance.Goals of vertebroplasty in osteoporotic fractures are to decrease the pain related to the fracture and to help the patient to resume walking and normal activities.The efficiency of vertebroplasty in osteoporotic vertebral fractures was once challenged by the publication in 2009 of two randomized multicentric trials, which both found no statistical difference on vertebral pain between vertebroplasty and a shame intervention. However, more recent randomized studies comparing vertebroplasty to conservative treatment found a significant difference in vertebral pain in favor of vertebrolasty.Vertebroplasty is indicated in osteoporotic fractures only in the case of recent and painful fractures with presence of bone marrow edema at spine MRI or in the case of unhealed vertebral fractures with the persistence of an intravertebral cleft filled with vacuum or water.According to the FDA and Nice recommendations, the use of vertebroplasty in osteoporotic vertebral fractures should be restricted to painful fractures resisting to conservative treatment. However, vertebral height loss and vertebral kyphosis may increase during this step of conservative treatment and have adverse effects on patient general status. In addition, the risk of complications of prolonged bed rest due to vertebral pain in elderly patients should also be taken into account. Therefore, vertebroplasty may be indicated earlier in elderly patients or when some criteria suggest an increased risk of additional vertebral fractures and increased kyphosis.Sacroplasty, which consists in the percutaneous injection of polymethylmetacrylate in the sacral wings, may be indicated in patients with intractable pain due to insufficiency fractures of the sacrum.Overall, indications of cementoplasty should be restricted to bone areas submitted to compressive forces. Conversely, cementoplasty should not be used in bone areas where shearing forces are exerted.