Jewish World Review May 9, 2003 / 7 Iyar, 5763

Filling in the cracks— in your back

By Judy Foreman

http://www.NewsAndOpinion.com | Dorothy Griffin, 84, was in agony. The broken vertebrae in her back were making it virtually impossible to get out of bed, despite painkilling medications.

For most of last year, all she could do was lie there, said her husband of 61 years, Cecil, 83, who suffered right along with her in their home in Westborough, Mass. "She was having such pain all the time,'' he said.

Dorothy Griffin had done nothing unusual to acquire her back pain: All she had was osteoporosis, the bone-thinning disease that affects 10 million Americans, most of them women.

Once osteoporosis weakens the bones, vertebral compression fractures -- cracks or breaks in the spine -- can happen with a movement as slight as a cough. If the vertebra then collapses in on itself, the result can be chronic pain, a hunched-over appearance and an increased risk of further fractures because of new stresses on adjacent vertebrae.

Until recently, the treatment for such fractures was simple -- bed rest and painkillers. And in many cases, this works -- the broken vertebrae heal in six to eight weeks, and the person can resume normal activities. But if a person is old and frail, lying in bed for weeks can result in profound muscle weakness that can make it impossible to ever get out of bed. Inactivity can also lead to blood clots, bed sores and other complications. And in some cases, the rest treatment just doesn't work.

But a pair of relatively unknown treatments -- vertebroplasty, which was introduced in the United States about a decade ago, and kyphoplasty, just now being introduced in a few medical centers -- may provide significant pain relief for many people with painful compression fractures, according to one review article.

So far, only small amounts of data on kyphoplasty have been published, but there have been more than 100 studies on vertebroplasty, said Dr. Mary (Lee) Jensen, director of interventional radiology at the University of Virginia Health Sciences Center in Charlottesville, Va.

Many of these studies are small or have methodological flaws, but the overall message seems fairly positive, even with possible complications. In one study of 37 people published in April in the journal Radiology, 44 percent had complete pain relief up to two years after vertebroplasty, and more than half had partial pain relief.

In a different study of 30 patients published in February in the Journal of Vascular and Interventional Radiology, the majority of patients treated also reported significant pain relief that persisted throughout the 15 to 18 months of follow-up.

The doctors who have performed the procedures are enthusiastic about the results they've seen.

"Vertebroplasty is one of those procedures that really works,'' said Dr. William Palmer, director of musculoskeletal radiology at Massachusetts General Hospital in Boston. It certainly helped Dorothy Griffin, who had vertebroplasty last year at Massachusetts General and said, "I am up all the time now. ... I can walk around.''

In vertebroplasty, the patient is sedated and the doctor watches closely under X-ray guidance as he guides a needle into the big, chunky part of the vertebra (called the vertebral body) through a piece of bone called the pedicle. When the X-rays show the needle is in exactly the right spot, the doctor slowly injects a bone cement called polymethylmethacrylate. In 10 to 20 minutes, the cement hardens, providing stabilization for the bone -- and immediate pain relief since the tiny fractured ends of bone no longer rub against each other.

In kyphoplasty, the doctor inserts a needle and an inflatable balloon into the broken vertebra. The balloon is inflated with fluid to create a hole into which bone cement is then injected. The point is to restore some of the height of a collapsed vertebra and to allow doctors to use more viscous cement, which in theory is less likely to leak out into surrounding tissues than the runnier version used in vertebroplasty, said Dr. Stephen Parazin, an orthopedic spine surgeon at New England Baptist Hospital.

The bone cement techniques can be "phenomenal aids'' for back pain, said Dr. Wade Wong, an interventional radiologist at the University of California in San Diego's Thornton Hospital. "I saw a person on Tuesday in incredible back pain. He came in through the emergency room and could not turn over.'' An hour after a vertebroplasty, the patient was up and walking. "It makes very dramatic changes in people's lives,'' Wong said.

So far, thousands of Americans have had vertebroplasty, which costs roughly $1,000 to $2,000 per procedure, and roughly 400 have had kyphoplasty, which can run as high as $4,000 to $7,000. The number of procedures is growing "by leaps and bounds,'' said Dr. Reza Jahan, an interventional radiologist at the University of California at Los Angeles.

Insurance coverage for vertebroplasty and kyphoplasty varies from state to state.

The key to success in both procedures is picking patients carefully. This means making sure -- with MRI scans and other tests -- that the problem really is a broken vertebra. If it's a herniated disc, pinched nerve, arthritic changes or spinal stenosis (a narrowing of the spinal canal, the space inside the backbone), the procedures won't help.

For kyphoplasty, the best candidates are patients with relatively recent fractures and those whose fractures have led to significant deformity of the vertebra.

By contrast, people whose fractures have not caused the vertebra to collapse significantly probably should just get vertebroplasty, which is also being studied for people whose vertebrae are damaged by spinal tumors or cancer that has spread from other areas.

On the downside, both procedures are technically demanding and have some risks. The bone cement must be injected exactly right or it will leak out, a complication that occurs in roughly one- to two-thirds of cases, according to a review article in Spine.

"The vast majority of leaks cause no problem whatsoever,'' said Jensen of Virginia. But if cement gets into a vein, it can travel to the lungs and cause respiratory and cardiac problems. And if it leaks into the spinal canal, it can compress the spinal cord and cause paralysis or loss of sensation. Even when these accidents happen, however, long-term problems result less than 2 percent of the time.

Given that the new procedures are relatively lucrative, it's no surprise that there's a nasty turf war brewing over who should do them -- surgeons or interventional radiologists. This is "clearly an economically charged question,'' said Dr. Thomas Einhorn, chairman of orthopedic surgery at the Boston University School of Medicine. He said he believes that kyphoplasty is intrinsically safer than vertebroplasty because, by creating a space inside the bone with a balloon and using thicker cement, it's easier to avoid cement leakage.

But others, among them Jensen of Virginia, argue that vertebroplasty is better for most patients. Jensen worries that the high pressure created by the balloon procedure can "rupture the vertebral body or blow out the endplate.'' She said she objects to what she sees as hyping of kyphoplasty, given that there's much less research on it.

As more medical centers begin to offer vertebroplasty and kyphoplasty, researchers say they believe the procedures will be increasingly used in patients with very recent fractures -- only a few weeks old, rather than the six to eight weeks most doctors wait now. It's still worth trying the bed rest initially, doctors say. But if it's clear after a month or so that the fracture is not healing, or if the patient has become dangerously weak from lying in bed, it makes sense to do one of the new procedures.

In fact, vertebroplasty may help even with extremely old, unhealed fractures, said Wong of San Diego. One patient, he said, had had two vertebrae broken decades ago when a tank rolled over him and had never properly healed.

"This guy had been having chronic back pain since World War II,'' Wong said. Vertebroplasty immediately "took away his pain.''

Judy Foreman is a lecturer at Harvard Medical School. Comment by clicking here.