vertabrae fractures treatment

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Foresight into fissures

CELIA STOREY

ARKANSAS DEMOCRAT-GAZETTE

Ila Marshall has driven more than two hours to talk about vertebroplasty.

" It's wonderful, wonderful, " the 67-year-old Nashville resident cries, as

strangers glance her way in the radiology waiting room at St.

Infirmary Medical Center.

" Used to, " she says, " I couldn't even stand to sit in that car. " Forget about

driving for hours.

She has osteoporosis. For months last year, it packed her days into a hard

wad of misery that wouldn't go away with pills, therapy or a back brace. One

of her spinal bones had cracked while she was working in a nursing home, and

a few months later, two others broke at a laundry.

Today, she grins. " I'm so thankful my back doesn't hurt. Oh! I am so grateful

for vertebroplasty. "

Percutaneous vertebroplasty is a new outpatient treatment for painful

compression fractures of the spine. Such fractures are typically caused by

osteoporosis, but may also occur with cancer or hemangioma, an abnormal

growth of blood vessels.

Marshall had vertebroplasty in December at St. . Interventional

radiologist Dr. Steve Dunnagan tapped a biopsy needle into her broken bones

and injected an orthopedic cement through it to fill her fractures. The

cement, polymethylmethacrylate (PMMA), stopped her broken bones from moving

and compacting, relieving her deep pain within a few hours.

In effect, he put a cast inside the bone.

A brief in the April 26, 2000, Journal of the American Medical Association

explains that vertebroplasty " consists of injecting sterile liquid bone

cement with the consistency of toothpaste into fractured vertebral bodies of

the spine. " The cement hardens inside the bone within about an hour, and

" fills tiny holes and crevasses, strengthening collapsed vertebrae and

relieving pressure and pain. "

Radiologists -- who are old hands at hammering big biopsy needles into the

bones of the spine and who use the same X-ray equipment to do angiograms --

originated and continue to refine the method, which does not yet have the

approval of the Food and Drug Administration.

" It's technical, " Dunnagan explains. The FDA does approve the cement for use

in bones (the same formula is used for gluing pieces of skull back in

craniotomy). The FDA also approves the use of biopsy needles. But it has not

yet approved the cement for delivery through the needles, and so

vertebroplasty is considered investigational.

No large randomized trials have compared it to nonoperative therapy. But

results have been consistently good with few complications, so Medicare

covers it.

Hospitals typically insist that a surgeon familiar with the method be on call

" just in case " something goes wrong, says Dr. E. , whose group

Radiology Consultants began offering vertebroplasty in the Baptist Health

system in late 2000.

PERSONAL CATASTROPHE

According to the National Osteoporosis Foundation, the 28 million Americans

who have the bone-dissolving disease suffer 700,000 vertebral fractures every

year.

" Medicine really didn't have anything to offer these patients before this, "

Dunnagan says. " A lot of these people go to bed, and they're old ladies.

They're in bed, on heavy narcotics. ... And then they're depressed. And now

other things start to happen like pneumonia and urinary tract infections.

" It starts a vicious cycle of rapid aging. The pain is so bad that it really

messes their lives up. "

His partner at Radiology Associates, Dr. C. Deaton, did the first

vertebroplasty in Arkansas in 1999 on a tumor patient at St. . He and

Dunnagan are part of a teaching group that meets several times a year in

Memphis at the Medical Education and Research Institute, where doctors can

train on cadavers.

The two radiologists learned about the method in 1997 while attending a

lecture given by its American pioneer, Dr. E. Jensen of the University

of Virginia. She learned from Dr. Herve Deramond, a French radiologist, who

developed vertebroplasty in 1984 to help a patient with a neck bone wrecked

by a hemangioma.

The results Jensen described were " incredible, " Dunnagan says, and he didn't

believe in them at first. Jensen was able to eliminate or reduce pain for 90

percent of her patients, with no serious complications and without harming

those who weren't helped.

An article in the February issue of the American Journal of Neuroradiology

says that " although the reports that do exist must be considered anecdotal,

they are uniformly positive about the ability of [vertebroplasty] to produce

pain relief for [vertebral compression fractures] with low complication

rates. "

But low rates don't mean no complications. The neurology journal reports that

" clinical complications reported after [vertebroplasty] include transitory

fever, transient worsening of pain, radiculopathy [spinal nerve disease], rib

fractures, cement pulmonary embolism, infection, and spinal cord

compression. "

Complications in cases of osteoporotic fractures are " few (usually 1 percent

to 2 percent) ... and transient, " the article says, but in tumor cases, where

cancer has eaten into a disc, the risk is higher.

" We haven't had any complications, knock on wood, so far, " says.

He took the cadaver course in Memphis and calls such hands-on training

" crucial. " Safety depends upon judgment, control and " very good X-ray

equipment, " he says, because if the practitioner can't see where the cement

is going as he injects it, he could put in too much, potentially harming the

spinal cord and causing paralysis.

The preferred equipment, he says, allows biplane fluoroscopy.

Fluoroscopy is a " real-time X-ray, " he explains. " You press on a button and

you get an X-ray image. " With biplane fluoroscopy " you can see in from two

angles. You press on a button, you get two directions. You can see it now

from the top and now the side. That's very important. "

BOUNCE-BACK BREAKS

After having performed about 200 vertebroplasties, Dunnagan says, " the two

things I worry about are infection and new fractures. "

Antibiotics mixed into the cement or given before and after the procedure

prevent infection.

But in " about 15 to 20 percent of cases, " he said, patients will crack

another vertebra after they get back on their feet. He calls these

" bounce-back " breaks.

" It's osteoporosis that's causing these fractures, " he said. " What we're

causing is ambulation.

" Patients get up. That can cause a new fracture " because their muscles are

weak and their bones soft. But if they stay down on bed rest, their bones

dissolve faster.

He sends patients home with orders to begin aggressive treatment for

osteoporosis with their family doctors. Any bounce-back fractures, he says,

can also be treated with vertebroplasty to stop the pain.

" This is a pain-relief procedure, " he stresses. It doesn't cure osteoporosis.

This article was published on Monday, March 12, 2001