PERCUTANEOUS VERTEBRAL AUGMENTATION ( PVA )
More than 700,000 vertebral compression fractures ( VCFs ) occur in the United States each year, the vast majority associated with osteoporosis. A third of these fractures are acutely painful. And, given the expected increased longevity and aging of the population, the occurrence of VCFs is likely to rise.

Until recently, conventional treatment of painful vertebral compressions has been supportive, rehabilitative and rarely surgical.

"Generally, even without specific intervention, vertebral fractures mend themselves and become less painful over two to three months," said Dr. Fergus McKiernan, Marshfield Clinic Rheumatologist on staff at Saint Joseph's Hospital. "Occasionally, however, fracture pain can be incapacitating. Severely painful vertebral fractures can initiate a cascade of impaired mobility, physical deconditioning, accelerated bone loss and further frailty."

Long-term consequences can include chronic back pain, reduced lung capacity, abdominal discomfort, social withdrawal, altered body image and future fraction and depression.

Fortunately, however, percutaneous vertebral augmentation ( PVA ), developed in the last few years, has proved to be a hopeful option for managing the pain of VCFs in osteoporotic patients.

According to Dr. Tom Faciszewski, Marshfield Clinic orthopedic spine surgeon also on staff at Saint Joseph's Hospital, PVA refers primarily to vertebroplasty, the percutaneous fixation of the fractured vertebrae with polymethylmethacrylate ( PMMA ), a bone cement. The minimally invasive surgical procedure is intended to reduce the pain of fractured osteoporotic vertebra and return patients to their normal level of function - quickly.

"We've done more than 100 of these procedures since we started here about 2 1/2 years ago, and in 98 percent of patients, results of have been dramatic," Dr. Faciszewski said. "In many cases, the fracture pain has often been relieved in a matter of hours."

Vertebroplasty consists of the percutaneous placement of a large bore needle into the fractured vertebra through which bone cement is directly injected into the vertebral body to reinforce the bone. The cement solidifies in about 10 minutes actually becoming harder than the native bone. Usually one, and no more than three, fractured vertebrae are treated during a single procedure, which is done using x-ray guidance. The procedure lasts from one to three hours, and patients generally remain in the hospital overnight. Medicare and most insurance companies cover it.

Since PVA can only relieve vertebral fracture pain, careful patient selection for either process is critical. In addition, PVA use in treating vertebral fractures is relatively new, and the long-term variables are still being studied.

Drs. McKiernan and Faciszewski, like other researchers, are presently accumulating a clinical database from which they hope to better define the risks and benefits of augmentation, improve candidate selection criteria, refine technical aspects and describe long-term outcomes.

A somewhat unexpected result of their preliminary research, which they published in a November, 2001 issue of "Journal of Bone and Mineral Research," concerns the mobility of a significant portion of painful fractures.

"What we observed was that many vertebral fractures actually move, and can return to their original configuration with careful patient positioning alone," said Dr. McKiernan. "This mobility of the fracture is a significant source of pain for patients and if the mobility of the fractured bone is alleviated (by PVA) the pain is dramatically improved."

According to the two physicians, this simple observation provides the opportunity for physicians to :

• Permanently cement the vertebra in a more natural configuration.
• Alleviate the stooped posture that can result from vertebral fractures.
• Perform vertebroplasty on more severely fractured vertebrae
• Eliminate the need for surgical devices such as balloon tamps (kyphoplasty) in many cases.

"Percutaneous vertebral augmentation is an exciting new intervention, but there are still questions that not only need to be answered, but asked," Dr. Faciszewski said. "But for carefully selected patients, it does alleviate fracture pain and improves the quality of life."