Percutaneous vertebroplasty in patients with intractable pain from osteoporotic or metastatic fractures: A prospective study using quality-of-life assessment.
OBJECTIVE
Percutaneous vertebroplasty (PVP) is a minimally invasive outpatient procedure whereby vertebral compression fractures are stabilized by the injection of bone cement, or polymethyl methacrylate (PMMA). Rapid partial or complete pain relief can usually be achieved through this procedure. We prospectively evaluate the efficacy of PVP in the relief of pain and improvement in quality of life of patients with intractable pain from osteoporotic and metastatic fractures.


METHODS
Patients with intractable pain from vertebral metastases (many resistant to palliative radiation therapy) and patients with intractable painful osteoporotic fractures were treated with parapedicular or transpedicular injection of PMMA. Plane X-rays, computed tomography (CT) scan, and magnetic resonance imaging (MRI) scan were performed on all patients. With a reflex hammer, percussion pain was correlated to the imaging abnormalities. The preplanning CT scan was used to calculate the exact entry point and angle of the bone-biopsy needle. All patients were assessed before and after the procedure for quality of life and amount of pain. The following measures were used: 1) the Edmonton Symptom Assessment System (ESAS), for global pain, nausea, tiredness, depression, anxiety, drowsiness, appetite, sense of well-being, and shortness of breath; 2) a site-specific pain score (SSPS); 3) the amount of analgesic intake in morphine equivalents in the last 24 hours; and 4) the Townsend Functional Assessment Scale (TFAS), ascertaining mobility. A postprocedural CT scan was performed the same day on all patients. Follow-up assessment consisted of a phone call at Days 1, 2, and 4 and Weeks 1, 2, 4, 8, and 12. Patients with recurrent back pain or complications were followed in the bone metastases clinic.


RESULTS
Thirty patients (19 women, 11 men) were evaluated. Their median age was 68 years (range 31 to 87 years). Thirty procedures (n = 30) at 45 vertebral levels were performed; 13 were for pathologic fractures, and 17 were for osteoporotic fractures. SSPS showed a decrease of 2 or more levels in 88.5% of patients at 12-week follow-up. The mean SSPS with movement was 8.7 preprocedure and 1.8 postprocedure (P < 0.0001). Also, there was significant improvement in all 9 ESAS domains (P < 0.0004). The ingestion of analgesics in morphine equivalents showed a trend toward reduction post-PVP (P < 0.0599). When the patients with pathologic fractures were separated out, the reduction in ingestion of analgesics was significant (P < 0.0008). The TFAS demonstrated significant improvement in patient mobility and function. Extravertebral extravasation of cement was noted in 55.6% of the levels. We used a general linear mixed-model repeated-measures analysis of variance to analyze the data.


CONCLUSIONS
PVP in osteoporotic and metastatic fractures significantly improved many patients' global quality-of-life scores and function by markedly decreasing their back pain and reducing their intake of pain medications. The procedure is safe, with no serious complications noted in our study.
Cheung
Gordon
G
Bone Metastases Clinic, Toronto Sunnybrook Regional Cancer Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, ON. drgordon.cheung@gmail.com
Chow
Edward
E
Holden
Lori
L
Vidmar
Marjan
M
Danjoux
Cyril
C
Yee
Albert J M
AJ
Connolly
Ruth
R
Finkelstein
Joel
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D001843:Bone Cements / Q000627:therapeutic use*; D003627:Data Interpretation, Statistical; D005260:Female; D005500:Follow-Up Studies; D005598:Fractures, Spontaneous / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D010024:Osteoporosis / Q000150:complications*; D010147:Pain Measurement; D010148:Intractable Pain / Q000209:etiology* / Q000628:therapy; D019904:Polymethyl Methacrylate / Q000008:administration & dosage*; D011446:Prospective Studies; D011788:Quality of Life; D012449:Safety; D016103:Spinal Fractures / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D013123:Spinal Fusion; D013125:Spinal Neoplasms / Q000150:complications* / Q000556:secondary; D013131:Spine / Q000473:pathology; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D001843:Bone Cements; D019904:Polymethyl Methacrylate