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Regarding the Surgical Management of Vertebral Compression Fractures

  • Andrés Rocha-Romero
    Correspondence
    Requests for reprints should be addressed to Andrés Rocha Romero, MD, Centro Nacional de Rehabilitación, Hospital de Trauma, Alborada, San Jose, Costa Rica.
    Affiliations
    Department of Anesthesia and Pain Management, Centro Nacional de Rehabilitacion, Hospital de Trauma, San José, Costa Rica
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      To the Editor:
      I read the recent overview of diagnosis and management of vertebral compression fractures with great interest by Alsoof et al.

      Alsoof D, Anderson G, McDonald CL, et al. Diagnosis and management of vertebral compression fracture [e-pub ahead of print]. Am J Med. doi: 10.1016/j.amjmed.2022.02.035, May 1, 2022.

      As they mentioned, determining when to refer a patient for surgical treatment remains a challenge when confirming a reduction in the height of the individual vertebral by 20% or 4 mm. According to guidelines,
      • Tsoumakidou G
      • Too CW
      • Koch G
      • et al.
      CIRSE guidelines on percutaneous vertebral augmentation.
      specific indications must include pain refractory to medical management for 3 weeks or achievement of adequate pain relief with intolerable side effects.
      It is always essential to evaluate adverse events; an interesting metanalysis by Guo et al
      • Guo JB
      • Zhu Y
      • Chen BL
      • et al.
      Surgical versus non-surgical treatment for vertebral compression fracture with osteopenia: a systematic review and meta-analysis.
      found no significant difference between surgical and conservative treatments. Nonsurgical management is not free of complications, and follow-up must be offered, emphasizing associated neurological symptoms.
      The most feared complication in vertebral augmentation is cement leakage, especially to the epidural and foraminal space, and massive pulmonary embolization in the postoperative period. However, a usually forgotten complication is the augmented risk of new vertebral fractures reported up to 30% at 1 year.
      • Rocha Romero A
      • Hernández-Porras BC
      • Plancarte-Sanchez R
      • et al.
      Risk of new fractures in vertebroplasty for multiple myeloma. a retrospective study.
      This demands a close follow-up, emphasizing low thoracic and lumbar levels.
      Medial branch nerve intervention is a safer option to treat pain. In a prospective randomized controlled trial,
      • Wang B
      • Guo H
      • Yuan L
      • et al.
      A prospective randomized controlled study comparing the pain relief in patients with osteoporotic vertebral compression fractures with the use of vertebroplasty or facet blocking.
      the difference in pain relief between these 2 techniques was insignificant in the long term. The disadvantage is that it does not provide stability to the fracture, but the fracture heals, and pain remains in the posterior column of Denis. Another option that must be mentioned in cases of cancer-related bone pain is a single 8-Gy radiotherapy dose. It must be offered as early as possible for palliative, analgesic, or decompressive purposes and to prevent severe bone events, even for those with poor survival prognosis.
      • Gottumukkala S
      • Srivastava U
      • Brocklehurst S
      • et al.
      Fundamentals of radiation oncology for treatment of vertebral metastases.
      Finally, a recent metanalysis

      Mattie R, Brar N, Tram JT, et al. Vertebral augmentation of cancer-related spinal compression fractures: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2021;46(24):1729–37. doi: 10.1097/BRS.0000000000004093

      demonstrated an overall positive and statistically significant effect of vertebral augmentation, especially when compared with nonsurgical management. So, this procedure must always be considered in the multimodal management of pain in this scenario.

      References

      1. Alsoof D, Anderson G, McDonald CL, et al. Diagnosis and management of vertebral compression fracture [e-pub ahead of print]. Am J Med. doi: 10.1016/j.amjmed.2022.02.035, May 1, 2022.

        • Tsoumakidou G
        • Too CW
        • Koch G
        • et al.
        CIRSE guidelines on percutaneous vertebral augmentation.
        Cardiovasc Intervent Radiol. 2017; 40: 331-342https://doi.org/10.1007/s00270-017-1574-8
        • Guo JB
        • Zhu Y
        • Chen BL
        • et al.
        Surgical versus non-surgical treatment for vertebral compression fracture with osteopenia: a systematic review and meta-analysis.
        PLoS One. 2015; 10e0127145https://doi.org/10.1371/journal.pone.0127145
        • Rocha Romero A
        • Hernández-Porras BC
        • Plancarte-Sanchez R
        • et al.
        Risk of new fractures in vertebroplasty for multiple myeloma. a retrospective study.
        Pain Med. 2020; 21: 3018-3023https://doi.org/10.1093/pm/pnaa018
        • Wang B
        • Guo H
        • Yuan L
        • et al.
        A prospective randomized controlled study comparing the pain relief in patients with osteoporotic vertebral compression fractures with the use of vertebroplasty or facet blocking.
        Eur Spine J. 2016; 25: 3486-3494https://doi.org/10.1007/s00586-016-4425-4
        • Gottumukkala S
        • Srivastava U
        • Brocklehurst S
        • et al.
        Fundamentals of radiation oncology for treatment of vertebral metastases.
        Radiographics. 2021; 41: 2136-2156https://doi.org/10.1148/rg.2021210052
      2. Mattie R, Brar N, Tram JT, et al. Vertebral augmentation of cancer-related spinal compression fractures: a systematic review and meta-analysis. Spine (Phila Pa 1976). 2021;46(24):1729–37. doi: 10.1097/BRS.0000000000004093