COLORADO SPRINGS — Focal point tenderness on palpation over the fractured vertebral level is no longer a requirement for performing vertebroplasty, Dr. Benjamin A. Aronovitz said at the annual scientific conference of the Colorado Academy of Family Physicians.
“It used to be thought that pushing on the level of the fracture would tell you if vertebroplasty would help. Now we know that even if the pain is not at the level of the fracture, these procedures help,” explained Dr. Aronovitz, president of the Colorado Radiological Society and a neuroradiologist who practices in Denver.
This about-face in the conventional wisdom was the result of a recent influential study by radiologists at the Mayo Clinic, Rochester, Minn. They reviewed the records of 534 consecutive patients who underwent vertebroplasty. Baseline focal point tenderness over subsequently treated fractures was present in 70% of the patients. Another 22% had focal point tenderness over the treated fractures plus subjective off-midline pain or tenderness upon palpation over nontreated vertebrae. And 8% of patients had no focal point tenderness at the level of the treated fractures, but had tenderness upon palpation elsewhere, either over nontreated vertebrae or subjective off-midline pain.
Patients with no baseline focal point tenderness over their treated fractures had significantly lower pain scores at rest at 1 month follow-up than the other two groups (Am. J. Neuroradiol. 2008;29:1622-6).
Dr. Aronovitz stressed that despite this development, the broad indication for vertebroplasty and kyphoplasty remains unchanged: pain relief in patients with painful acute or subacute vertebral compression fractures.
“If a fracture is not causing pain there's no reason to do these procedures. Medication and bed rest would work,” he said.
A STIR (Short Tau Inversion Recovery) sequence MRI is the best indicator of the presence of a treatable vertebral compression fracture. Almost all patients will undergo this imaging procedure prior to vertebroplasty or kyphoplasty. Edema is often readily apparent on the MRI as long as 6-8 months after the fracture occurred—and that late edema is a strong indicator that the fracture is subacute and the patient will experience significant pain relief in response to the procedure.
“In our experience, 95% of treated patients get great pain relief. The best part of this procedure is these patients usually come in with terrible pain, and it's significantly reduced 2 hours post procedure,” according to Dr. Aronovitz.
Referring physicians can write an order for vertebroplasty or kyphoplasty. Having done nearly 400 of them, Dr. Aronovitz is convinced the two procedures yield similar results. The bulk of the radiologic literature—as well as his personal experience—suggest that both procedures achieve roughly a 4-mm improvement in height per treated vertebra.
'Even if the pain is not at the level of the fracture, these procedures help.' DR. ARONOVITZ