Submitted by: JERROLD R WILDENAUER, DC, FACO, West St. Paul, MN

A 63-year old male presented to our clinic complaining of intense lumbosacral and sacroiliac pain. There was also a complaint of diffuse pain over the left iliac crest spreading toward the greater trochanter. The patient was severely antalgic, demonstrated early signs and symptoms of shock and began vomiting when escorted to the examination room. Earlier that day he was standing on a stepladder which collapsed beneath him, causing him to fall about 4 feet directly upon his buttocks. The pain was so intense that he was unable to stand. He managed to crawl to his car and drive to our clinic where he was assisted to the examination room.

There was a significant reduction in the dorsal lumbar range of motion with a severe left lateral antalgia. Achilles and patellar reflexes were intact and there are no obvious sensory changes. Soto-Hall was positive and referred pain to the thoracolumbar junction. Percussion generated significant pain over the T-12, L-1 and L-2 segments. There was considerable muscle guarding.

Radiographic examination included an APLS and LLS view. The lateral view (Figure 1) demonstrated significant osteoporosis of the lumbar spine with moderate aortic calcification. A compression fracture is noted at the L-1 level. An incidental finding of a hemangioma is visualized at T-12. The APLS (Figure 2) reveals the L-1 compression fracture (see Arrow). Also apparent are the vertical striations of the T-12 vertebral body, which represents a common radiographic finding in hemangioma.

The compression fracture is the most frequent type of injury involving the vertebral body. It is caused by an acute forward flexion of the spine and the damage is usually limited to the upper portion of the vertebral body. (1) With more extensive compression there is usually some loss in vertebral height posterior as well as inferior. The T-12 / L-1 level is one of the most common levels in which compression fractures occur. (2) The patient was initially given a standard lumbar brace and instructed in the use of the Tens unit and ice to control pain. Over the next seven days he was treated at home using high voltage interrupted galvanic current and acupuncture to control the pain. By this time the patient was ambulatory and was fitted for a chair back brace. During his office visits, we continued the high-voltage galvanic current and used conservative chiromanis distraction. The patient responded remarkably well to conservative care and within four weeks was relatively asymptomatic. If the patient had been a younger individual, his management may have included casting for 6 weeks to minimize deformity of the vertebral body. Since there were no positive neurological findings, there was no need for a referral in this case.

This case is actually several years old. If the identical case walked through my door today I would handle it differently. Once I established there was in fact a compression fracture I would determine if there was a significant loss of vertebral height. If not, I would refer this patient to a facility that provided the Vertebroplasty Procedure. This procedure is designed to provide pain relief within 24 to 48 hours. It is a therapeutic technique that involves filling a vertebral body with acrylic cement and does not require you to be sedated. This procedure is performed using fluoroscopic guidance. An intravenous antibiotic will be given prior to the procedure. Following the local anesthetic injection, a needle is inserted into the vertebral body. Bone cement is then injected into the vertebral body. The clinical success rate for this procedure at a St. Paul Radiological Facility translates to 82 percent with significant relief after 24 hours for the thoracic spine and 88 percent in the lumbar spine.

If there is significant loss of bone height I will then refer the patient to the same facility that for a Kyphoplasty Procedure. This procedure is also designed to provide pain relief but it also restores vertebral height and minimizes the deformity. It is a therapeutic technique that involves inserting balloons into the fractured bone, and then the balloons are inflated to restore the bone to its original shape. The acrylic cement is injected into the bone after the balloons are removed. This procedure is performed using fluoroscopic guidance and does require you to be sedated and given an intravenous antibiotic. Preparation for this procedure includes having nothing to eat or for 8 hours prior to the procedure. Medications may be given with sips of water. If the patient is taking Coumadin it needs to be stopped 72 hours prior to the procedure. Generally, the patients are admitted to the hospital overnight following the procedure for observation.

The acrylic cement is harder than bone and the patients that have had the procedure are amazed at how quickly their pain disappears.

It is most commonly used to treat the pain associated with osteoporotic compression fractures. It is often used on patients to elderly or frail to tolerate open spinal surgery. It is sometimes used where there is vertebral damage due to a malignant tumor.

Patients feel significant relief almost immediately. Within 1 to 2 weeks, two-thirds of patients are able to lower their doses of pain medication substantially or totally eliminate it.

Vertebroplasty is generally a very safe and effective procedure, however, a small amount of orthopedic cement can leak out of the vertebral body which usually does not create a problem unless it moves into the spinal canal which can be potentially dangerous. Other potential complications include neurological symptoms, including numbness or tingling and paralysis (which is extremely rare). There is the potential for infection, increased back pain, and bleeding. There have been rare case reports of a pulmonary embolism of the lungs and even death associated with these procedures.

1. The procedure cannot serve as a preventive treatment to prevent future fractures.

2. It is not used for arthritic back pain or herniated disc.

3. It is generally not recommended for younger individuals because of the limited experience of the cement in the vertebral body for longer periods of time.