Treatment of subacute osteoporotic vertebral compression fractures with percutaneous vertebroplasty – A case report

Introduction. Percutaneous vertebroplasty (PVP), as a mini-invasive approach in the treatment of patients with osteoporotic vertebral compression fractures (OVCFs), provides stabilization of the spine and relives pain. The most commonly it is applied in the 3–6 weeks before bending of the spine. Complete cessation of pain is easier to achieve if you treat “less mature” fractures. The aim of the report is to show that PVP is effective and safe for old fractures too. Case report. A 77-old patient suffered from a stable compression fracture of 3th lumbar (L3) vertebral body after minor trauma. This fracture was clinically and radiologically diagnosed. The conservative treatment that included lumbo-sacral orthosis (LSO), analgesic drugs and physical therapy, was primarily applied due to permanent pain and type of fracture. After a period of two months, pain persisted, but it was localized in a thoracic spinal segment with radiologically diagnosed fractured bodies of 8th (Th8) and 10th (Th10), thoracic vertebra without neurological deficit. Thoraco-lumbo-sacral orthosis (TLSO) was prescribed and after six months the indication for vertebroplasty of the Th8 and Th10 vertebral body was given. The pain relief had been achieved and the patient was discharged from the Clinic for Orthopedics on the postoperative day 2, and was symptom free during the follow-up period. Conclusion. In patients with stable OVCFs, PVP is an effective therapy for reducing pain and improving mobility of 6 months old fractures.


Introduction.
Percutaneous vertebroplasty (PVP), as a mini-invasive approach in the treatment of patients with osteoporotic vertebral compression fractures (OVCFs), provides stabilization of the spine and relives pain.The most commonly it is applied in the 3-6 weeks before bending of the spine.Complete cessation of pain is easier to achieve if you treat "less mature" fractures.The aim of the report is to show that PVP is effective and safe for old fractures too.Case report.A 77-old patient suffered from a stable compression fracture of 3th lumbar (L3) vertebral body after minor trauma.This fracture was clinically and radiologically diagnosed.The conservative treatment that included lumbo-sacral orthosis (LSO), analgesic drugs and physical therapy, was primarily applied due to permanent pain and type of fracture.After a period of two months, pain persisted, but it was localized in a thoracic spinal segment with radiologically diagnosed fractured bodies of 8th (Th8) and 10th (Th10), thoracic vertebra without neurological deficit.Thoraco-lumbo-sacral orthosis (TLSO) was prescribed and after six months the indication for vertebroplasty of the Th8 and Th10 vertebral body was given.The pain relief had been achieved and the patient was discharged from the Clinic for Orthopedics on the postoperative day 2, and was symptom free during the follow-up period.Conclusion.In patients with stable OVCFs, PVP is an effective therapy for reducing pain and improving mobility of 6 months old fractures.

Introduction
Painful vertebral compression fractures (VCFs) may be the consequences of different pathological factors such as osteoporosis, myeloma or vertebral metastases.The very common cause of these fractures is trauma, even the minor one, especially when associated with osteoporosis 1 .The most of these fractures are asymptomatic, but even in this cases and especially in symptomatic ones, quality of life may be notably changed due to height loss, kyphosis, back pain, and lost selfconfidence regarding physical activities 2 .The conservative treatment including analgesic medications, rest and physical therapy is often ineffective on long-term basis, because of the persistent pain, decreased mobility and neurological complications 3,4 .
Operative management of VCFs has gained popularity as it produces rapid, significant and sustained improvements in back pain, function and quality of life.Surgical intervention is indicated for those patients with intractable back pain in whom conservative therapy failed, or where there is evidence of impending or existing neurologic deficit, or where the spinal deformity is extremely severe 5 .
Percutaneous vertebroplasty (PVP) is one of the favored methods of treating painful VCFs.It encompasses augmentation of the vertebral body by injection of polymethylmethacrylate.Short-term results indicated that 75% to 100% of patients can have good to moderate pain relief after vertebroplasty.PVP is most effective in compression fractures less than 6 months old 5 .
The pain relief is the primary goal of this treatment, beside the vertebral stabilization, better mobility and functional improvement 4 .Indications for the PVP are persistent and intensive back pain at the level of osteoporotic fractured vertebra when the Visual Analogue Scale (VAS) is 5 or higher 4,6 ; fracture not older than a year, with the best analgesic results with lesions not older than six months, increased risk for kiphosis 2, 7 , vertebral fracture with less than 30% height loss 8 .Contraindications include coagulation disorders, allergies to bone cement or contrast, systemic or local infection 7 , osteomyelitis and spondylodiscitis, tumor extension into epidural space 2 , unstable or older fractures 7 , asymptomatic fractures and fracture with spinal cord compression and resulting neurological signs 4,6 .
The aim of this paper was to show that PVP can successfully be used for six months old osteoporotic VCFs.

Case report
A 77-old patient was admitted with a chief complaint of the back pain, primarily localized in lumbosacral (LS) region after minor injury.The fracture of the body of third lumbar (L3) vertebra was clinically and radiologically diagnosed and estimated as stable, with no indication for surgical treatment.The lumbo-sacral orthosis (LSO), analgesic drugs and physical therapy were prescribed as conservative treatment for spine stability and pain reduction.
After a period of 2 months, the patient, denying any kind of trauma, was examined again due to back pain in the thoracic region.Pain in the LS spinal segment persisted, in spite of prescribed therapy and wearing of LSO.Vertebral injuries of thoracic vertebra 8 (Th8) and thoracic vertebra 10 (Th10) were radiologically diagnosed, with no neurological deficit on physical examination (Figure 1).Thoraco-lumbo-sacral orthosis (TLSO) was prescribed.After 6 months, the patient still felt pain in the injured region, predominantly in thoracic region, with the Visual Analogue Scale (VAS) score of 8. Nervous structures were intact and the strength of lower extremity muscle was preserved -score was 5. Earlier fracture of L3 was healed, but because of persisted pain, the indication for PVP of the Th8 and Th10 vertebral body was given.The patient was admitted to the Clinic for Orthopedics at the Clinical Center Kragujevac.After the usual and appropriate preoperative preparation and administration of 2% lidocaine (10 mL) as local anesthetic, standard PVP 2 of injured vertebral bodies of Th8 and Th10 was performed (Figures 2 and 3).Pathohistological findings showed fragments of cortical, partly grossly calcified bone, with elements of active bone marrow, with slight domination of granulocytes (eosinophils), with no elements of myeloproliferative or metastatic disease (Figure 4).The patient's early postoperative course was uneventful; he achieved full vertical posture a day after the surgical treatment and was able to walk without assistance.He was discharged from the Clinic for Orthopedics on the second postoperative day without clinical symptoms, with recommendation to use TLSO brace.The patient was reviewed in clinic 5 days after the procedure, when he came without help, with no complaints and without prescribed TLSO brace.He was followed-up in two weeks intervals and was symptom free.Complete physical rehabilitation program was conducted and patient returned to his daily life activities.

Discussion
The first PVP was performed in 1984 by French radiologists Galibert and Deramond for treatment of a painful hemangioma in the cervical spine of a young female patient.PVP is a technique in which a medical grade cement is injected through a needle into a painful vertebral body.This stabilizes the fracture, allowing most patients to discontinue or significantly decrease analgesics and resume normal activities.The success rate for this procedure in treating osteoporotic VCFs is 73%-90%.Significant complications of the procedure are less than 1% 5 .
The presented patient underwent PVP in order to reduce the back pain caused by the vertebral fractures occurred after the minor trauma.
The symptoms associated with vertebral osteoporotic vertebral compression fractures (OVCFs) changes in quality of life.In the group of patients with clinical symptoms due to an OVCFs (one-third of all patients with a OVCFs), pain is the most striking feature of the fracture.In 80%-85% of the acute symptomatic patients, pain will disappear with conservative treatment within 6-8 weeks after initiation of the treatment 9 .
In managing the presented patient, the surgeons opted for PVP, considering that conservative therapy was not effective in the pain relief in thoracic and lumbar spine.The pain reduction in our patient was complete after the conducted PVP.The results of most of the studies showed much better pain relief after PVP than after conservative treatment 4,10 .The significant reduction of pain score from the first postoperative day is also the great advantage of PVP 11 .The adverse effects of analgesic drugs and long period in bed during the conservative medical management may contribute to worsening of the symptoms and the further demineralization of the bones 12,13 .Several studies also reported improving kyphosis to a certain degree after PVP 11,14 .It is also shown that minimally invasive procedures, such as this one, are cost-effective in comparison to nonsurgical treatment for osteoporotic and tumor related vertebral fractures 15 .
Also, obtaining bone biopsies during PVP does not lead to increased morbidity and can verify the pathologic process underlying the VCFs 16 .
According to Röllinghoff et al. 6 PVP should not be conducted in patients younger than 48 years.Also, patients over the 85 are not candidates for PVP, considering the low bone mineral density 16 .The presented patient in our case was 77 years old, so the age was not the contraindication for PVP.The fractured vertebrae of our patient were not with posterior dislocation, which would also be the contraindication for this surgical procedure 6,12 .The presented PVP was conducted with satisfactory results six months after the reported trauma.In several conducted studies it was shown that better results were obtained when the procedure was done in the first months after the trauma 4 , but the pain relief and normal life quality after PVP were also described in patients with one year old fracture of the spine 14 .In managing this patient, surgeons opted for unilateral transpedicular approach, which advantages over the bilateral approach are in the reducing the time required to perform the treatment, radiation exposure, risks of the side effects and the costs 15 .The one of the described common complications of PVP is the fracture of the non-treated vertebrae next to the treated one 16,17 .This may be the consequence of the greater stiffness of the vertebra filled with bone cement and altered biomechanics and the load transfer of the spine 11 .According to the others, these new fractures are not the side effect of the PVP, but the result of the further deterioration of the osteoporotic spine and reduction of bone mineral density 3,10,16 .In presented case, no complications were encountered.
Several clinical studies and meta-analysis concluded that the PVP is very successful surgical method in reducing the pain in OVCFs, the complications of this technique are rare and that is more successful in pain relief and functional recovery than non-surgical therapy 12,17 .PVP is effective in patients with chronic painful osteoporotic VCFs.Pain relief after PVP was immediate, sustained for one year and may be an important factor for reducing persistent pain.PVP for patients with chronic painful osteoporotic VCFs has not been extensively studied 18 .The majority of papers describe populations that are a case mix of "acute" (fracture age < 8 weeks) and "long-standing" (fracture > 8 weeks) OVCs.Subacute (> 2 month old) and chronic (> 6 month old) OVCFs are fractures which do not respond to at least 8 weeks of conservative treatment using analgesics, a short period of bed rest and a corset.Treatment of long-standing fractures remains controversial.Despite these preliminary reports, outcomes in patients with older fractures treated by PVP remain undefined.The most of the older fractures respond to PVP, although there may be fewer complete responses.However, treating patients earlier is still preferable because they are more likely to have complete eradication of pain and may retain more mobility 19 .

Conclusion
In patient with compression fracture of vertebral body, when the pain relief cannot be achieved by application the conservative therapy, PVP, performed under local anesthesia, is the treatment of choice for spine stabilization and fast and lasting pain reduction even for OVCF six months old.

Fig. 4 -
Fig. 4 -Fragments of cortical bone with elements of active bone marrow, with domination of granulocytes hematoxylin-eosin (HE x 400).