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Do Vertebral Augmentation Procedures for Spine Fractures Actually Work?

 

What we know

There are 750,000 spine (vertebral) fractures, also called compression fractures or fragility fractures, each year in the United States. They are highly prevalent in patients with osteoporosis. One-third of patients with spine fractures have chronic or severe back pain, causing an inability to manage daily life activities. The traditional treatment for spine fractures is also called nonsurgical management. Doctors may prescribe pain medication, bed rest, and use of a back brace to help stabilize the fracture.

A more aggressive management is surgical and called vertebral augmentation. Vertebroplasty and kyphoplasty are the most common surgical procedures. In vertebroplasty, a bone cement is injected directly into the fractured area of the spine bone to form an internal “cast.” In kyphoplasty, a balloon is inserted into the fractured area and inflated to create a cavity and bring back the height of the bone.  Then bone cement is injected.

There has been a lack of consensus about the best approach to managing painful spine fractures. Both types of vertebral augmentation relieve pain, but it is not clear that they are superior to more conservative nonsurgical management.

New findings question long-term effectiveness of spine fracture management

The American Society for Bone and Mineral Research published a report looking to answer questions about the effectiveness of the two surgical procedures compared to nonsurgical management. They reviewed five randomized trials and concluded that the surgical procedures provided no notable benefit over nonsurgical management in relieving pain or improving the physical function. Additionally, at least one prospective trial has shown that vertebroplasty is associated with an increased risk of vertebral fractures at vertebral bodies adjacent to the ones where the procedure was performed (Blasco, et al. Journal of Bone and Mineral Research, Vol. 27, No. 5, May 2012, pp 1159–1166.)  The studies completed at this time cannot confirm either the effectiveness or the risk of these procedures.

In addition to the surgical procedures, the researchers were not able to determine if the use of a brace can improve physical function, disability or quality of life.

The authors stressed that we need more research and better data to improve outcomes in managing osteoporosis-related spine fractures. They recommended larger sample sizes in future trials, use of a placebo group in further trials of balloon kyphoplasty, and more research on nonsurgical interventions in general. 

Aggressive spine fracture management is not for everyone

Another panel of physicians including pain specialists, surgeons and radiologists published a study in November 2018 in The Spine Journal to try to clear up when vertebral augmentation procedures should be used. The panel recommended these procedures in cases where an MRI or CT scan tests positive for a fracture, and where symptoms such as pain, limited activity or loss of height got worse more than a week after the injury. If pain and activity level are stable or improve, or if an MRI comes back negative for bone edema, nonsurgical management is likely the better option.   

The panel’s study was different from some previous recommendations in that it found that many spinal fractures should be treated early with vertebral augmentation, rather than only after six weeks of no improvement. Authors said that in these cases, particularly where symptoms worsen, getting patients back on their feet as quickly as possible might be better than having them inactive and in pain.

What can you do if you have a spine fracture?

Any fracture, including those in the spine, can take 6-8 weeks to fully heal, and there is pain during the healing process, especially in the beginning. Since there is no cast to help stabilize the bone, rest and pain medicines can help. Calcium and vitamin D are also important for fracture healing.

You may benefit from a surgical procedure or bracing if:

  1. An MRI or CT scan tests positive for an acute (very recent) fracture, and
  2. Pain, limited activity or loss of height get worse more than a week after the injury.

Most importantly: Get treatment. When the fracture has healed, exercise may improve your ability to get around, but the most important step to take is to get on a medicine to strengthen your bones. One in five women with a vertebral fracture will suffer another fracture within a year, according to the International Osteoporosis Foundation. Having had a vertebral fracture also doubles your risk of having another fracture of any kind. Medication to treat osteoporosis can reduce the risk of additional fractures by 40 percent to 70 percent.


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