Vertebral Body Stenting: Establishing the Value of a Novel Percutaneous Cement Augmenting Technique for the Treatment of Vertebral Body Compression Fractures: Commentary on an article by Clément M.L. Werner, MD, et al.: “Vertebral Body Stenting Versus Kyphoplasty for the Treatment of Osteoporotic Vertebral Compression Fractures. A Randomized Trial”
 

The demographic shift in numerous societies around the globe has led spine surgeons to focus on the diagnosis and treatment of osteoporotic vertebral body compression fractures, which are associated with debilitating pain, functional decline, and impaired mobility. Previous studies have demonstrated greater morbidity and significantly higher overall mortality rates of patients who have sustained vertebral compression fractures in comparison with age-matched controls1. Secondary negative effects of vertebral compression fracture include an altered kyphotic sagittal alignment, chronic back pain, and decreased pulmonary capacity.

Conservative measures including pain management, temporary bed rest, narcotics, and/or extension bracing represent a first line of treatment. Patients for whom conservative treatment fails or cases with progressive/advanced collapse of the vertebral body and instability of the spine may need reconstructive surgical procedures with posterior stabilization and, possibly, anterior column reconstruction. However, the risks of surgery, including perioperative complications, must be expected to increase significantly with increasing patient age, particularly when more invasive surgical strategies including instrumentation are chosen2-5.

Conversely, early mobilization has been associated with reduced morbidity and improved survival following other types of skeletal fractures in elderly patients. In order to reduce the morbidity rate associated with vertebral compression fractures, the main focus of the treatment strategy should be on pain reduction and mobilization at the earliest possible stage.

Recently, minimally invasive percutaneous techniques with vertebral body bone cement augmentation have gained popularity. Cement application may be achieved with prior balloon dilation (kyphoplasty) or without it (vertebroplasty). Both techniques combine the advantages of immediate fracture stabilization, pain reduction, early mobilization, and possibly partial correction of the sagittal imbalance.

Most noteworthy are the data in a recently published survival analysis highlighting significantly improved survival rates of patients who had been treated surgically with cement augmentation for vertebral compression fractures in comparison with those who had received conservative treatment; these improved rates were found regardless of age, sex, the number of vertebral fractures, or comorbidities6. The authors concluded that rather aggressive management should be considered for patients who have refractory and intractable back pain if they otherwise would require hospitalization to control these symptoms of vertebral compression fracture.

It is crucial to assess patient safety as well as appropriate mid-term and long-term results in the evaluation of any surgical technique. For a subset of elderly patients, however, the major clinical relevance falls within the immediate posttraumatic period following a vertebral compression fracture, during which early mobilization and, if surgery is required, minimal perioperative trauma are paramount for the patient’s survival. Despite well-justified demands for long-term follow-up data from an evidence-based-medicine point of view, from the patient’s perspective the short-term results are as decisive as the five to ten-year follow-up data in a cohort of eighty-year-olds. Therefore, a mere comparison of mid-term and long-term results may be misleading in the discussion of adequate treatment options for vertebral compression fracture.