The Use of Vertebral Augmentation and External Beam Radiation Therapy in the Multimodal Management of Malignant Vertebral Compression Fractures

Background: Vertebral augmentation (VA) techniques such as vertebroplasty and kyphoplasty areincreasingly performed minimally invasive procedures for osteoporotic or malignant compressionfractures (MCFs) and involve injection of polymethylmethacrylate (PMMA) cement directly into acompressed vertebral body.Objective: This article will evaluate the efficacy of VA in relieving fracture-related pain. We alsointend to identify procedural and clinical variables that could potentially influence outcomes in thispopulation. In the subset of patients with cancer who received both external beam radiation therapy(EBRT) and VA, we will assess the impact of the treatment sequence on pain outcomes.Study Design: We performed a retrospective analysis of 201 cases of patients with cancer andMCFs who underwent one or more vertebral augmentation procedures at our institution between2003 and 2009. The majority of cancers represented were multiple myeloma, metastatic lung cancer,and metastatic breast cancer. The primary outcome measure was pain relief, as measured by the VisualAnalog Scale and a 4-point pain scale.Setting: We present an institutional experience at an academic medical center of 201 cases of MCFs.Methods: We compiled an institutional database of vertebroplasty and kyphoplasty cases using paperand electronic medical records. Our data collection methodology has been previously reported andincludes variables such as procedure dates, gender, age, type of malignancy, fracture etiology, historyof cancer treatment, type of procedure performed, vertebral level treated, the number of levels treatedper procedure, complications, and follow-up information on pain response. The updated datasetincorporates new variables including information on pain medications and standardized questionnairessuch as the Visual Analog Scale (VAS) for pain and the Roland Morris Disability Questionnaire (RMDQ).Results: In the 201 cases of MCFs, a total of 316 vertebral levels were treated with eithervertebroplasty or kyphoplasty. Follow-up data on pain relief was available for 190 out of 201 cases(95%). Among this subgroup, 168 cases (88%) with MCFs responded. Thirty-nine percent (39%)of the time patients experienced complete pain resolution. In only 4% of cases did patients reportworsening of their fracture-related pain post-procedure. There was no difference in pain outcomeswith regard to sequencing of EBRT and VA.Limitations: One of the limitations of our analysis is that it did not evaluate the effect of painimprovement or resolution before and after EBRT alone and on activities of daily living in the majorityof patients. However, one of the main goals of this analysis is to address previous limitations. Weattempt to standardize outcome measures by using the Visual Analog Scale (VAS) for pain and theRoland Morris Disability Questionnaire (RMDQ).Conclusion: A multimodality approach for the management of MCFs includes VA procedures. Themajority of patients with MCFs have excellent palliation with this approach. In patients who receiveboth EBRT and VA, the sequence in which they are given does not affect pain improvement outcomes.Key words: malignant compression fractures, palliation, vertebroplasty, radiation therapy