Original Research
Vascular and Interventional Radiology
November 23, 2012

Added Value of Percutaneous Vertebroplasty: Effects on Respiratory Function

Abstract

OBJECTIVE. The objective of our study was to investigate the effects of percutaneous vertebroplasty on respiratory function in patients with compression fractures caused by osteoporosis.
SUBJECTS AND METHODS. Ninety-eight patients (87 women, 11 men; mean age, 74 years; age range, 60–90 years) with compression fractures of 75 thoracic (Th7–Th12) and 89 lumbar (L1–L5) vertebrae were enrolled in this study. Percentage vital capacity (VC%), percentage forced vital capacity (FVC%), and percentage forced expiratory volume in 1 second (%FEV1) were measured using a spirometer before, 1 day after, and 1 month after percutaneous vertebroplasty. The Wilcoxon signed rank test was used to evaluate whether any significant differences in VC%, FVC%, or %FEV1 values existed between before, 1 day after, and 1 month after percutaneous vertebroplasty.
RESULTS. The VC% and FVC% values had improved significantly by 1 month after percutaneous vertebroplasty compared with before percutaneous vertebroplasty (p < 0.01). No significant difference was noted between values before and 1 day after percutaneous vertebroplasty. Likewise, no significant difference was identified in %FEV1 before percutaneous vertebroplasty and either 1 day or 1 month after percutaneous vertebroplasty. The mean degree of improvement in VC% values after percutaneous vertebroplasty for patients with one vertebra treated, which we refer to as the “single-vertebroplasty” group, and for patients with two or more vertebrae treated, or “multiple-vertebroplasty” group, was 1.1% ± 7% (SD) and 6.3% ± 8%, respectively, representing a significant difference between groups (p = 0.01). The mean VC% values before and 1 month after percutaneous vertebroplasty differed significantly (p = 0.02) in the thoracic group and overlapping group.
CONCLUSION. Percutaneous vertebroplasty improves restrictive ventilatory impairment, but this improvement requires approximately 1 month to occur. Greater improvement in restrictive ventilatory dysfunction was observed in patients who underwent multiple vertebroplasty procedures than those who underwent a single procedure and in patients who underwent treatment of thoracic vertebrae than those who underwent treatment of other vertebrae.
Percutaneous vertebroplasty was first reported in the literature in 1987 [1]. Since then, percutaneous vertebroplasty has been performed to alleviate pain caused by various types of vertebral compression fracture [24]. Its dramatic pain-relieving effects mean that percutaneous vertebroplasty has also frequently been performed to treat compression fractures caused by osteoporosis [5, 6]. In August 2009, however, investigators reported that no significant difference exists between percutaneous vertebroplasty and placebo treatment in terms of pain-relieving effect for compression fractures caused by osteoporosis, casting doubt on the reality of this effect [7, 8]. A compression fracture not only causes pain but also deforms the vertebral body, thereby reducing quality of life and respiratory function [9, 10]. Most previous reports of the value of percutaneous vertebroplasty have focused on its pain-relieving effects, which are now being called into question, as described. We believe, however, that the utility of percutaneous vertebroplasty lies not only in its potential pain-relieving effects, but also in the fact that it can be expected to improve alignment of the thorax, with a corresponding favorable effect on respiratory function. In a previous study, we tested respiratory function before and after percutaneous vertebroplasty and reported the possibility that percutaneous vertebroplasty may improve restrictive respiratory dysfunction [11].
For the current study, we performed respiratory function tests before, 1 day after, and 1 month after percutaneous vertebroplasty to obtain more detailed data than our previous study. The objective of this study was to investigate the effects of percutaneous vertebroplasty on respiratory function in patients with compression fractures caused by osteoporosis.

Subjects and Methods

Patients

Subjects comprised 109 consecutive patients in whom percutaneous vertebroplasty was performed on 200 vertebral bodies with compression fractures caused by osteoporosis between January 2006 and August 2009. Osteoporosis was diagnosed from patient history and MRI findings. If a tumor was suspected from MRI findings, biopsy was performed. Eleven of the 109 patients were excluded: four because they were not examined 1 month after percutaneous vertebroplasty, meaning that investigation of respiratory function after 1 month was not possible; five because they experienced recurrent fracture within 1 month of treatment; one who suffered from bronchiectasis; and one with left pleural effusion. The final number of subjects analyzed was 98 patients (164 vertebral body fractures). These 98 patients (87 women, 11 men; mean age, 74 years; age range, 60–90 years) had one or more vertebral compression fractures that had been caused by osteoporosis. Percutaneous vertebroplasty was performed to treat 75 thoracic vertebral bodies (Th7–Th12) and 89 lumbar vertebral bodies (L1–L5).

Percutaneous Vertebroplasty Procedure

Informed consent was obtained from all patients before the procedure. All procedures were performed by either an author who had 12 years of experience in percutaneous vertebroplasty at the time of the study or a fellowship trainee under the supervision of that author. Percutaneous vertebroplasty was performed using combined CT and fluoroscopic guidance (Axiom Artis Dta and Aomatom Sensation 16, Siemens Healthcare). Thirty minutes before the procedure, 10 mg of morphine hydrochloride, 0.5 mg of atropine sulfate, and 25 mg of hydroxyzine hydrochloride were administered intramuscularly. Local anesthesia was achieved with 10 mL of 1% lidocaine administered from the skin to the periosteum of the pedicle using a 22-gauge needle (Cathelin, Terumo Europe) under fluoroscopic guidance.
After the orientation of the puncture needle was confirmed on CT and the puncture needle was aligned with the Cathelin needle, a 13-gauge bone biopsy needle (Osteo-Site Bone Biopsy Needle Murphy M2, Cook) was advanced into the pedicle of the vertebral arch. A unilateral transpedicular approach was chosen in all cases. CT was repeated and after the orientation of the biopsy needle was confirmed, the visualization modality was changed to lateral fluoroscopy and the bone biopsy needle was advanced to the anterior third of the vertebral body close to the midline.
Intraosseous venography was performed with 1–5 mL of iopamidol (Iopamiron 300, Bayer Schering Pharma Japan) or 5–20 mL of carbon dioxide to confirm that the needle was not positioned within a direct venous anastomosis to the central or epidural veins. Subsequently, 20 g of methylmethacrylate powder (Osteobond copolymer bone cement, Zimmer) was mixed with 5 g of barium sulfate powder that had been sterilized with dry heat to increase its opacity. Ten milliliters of liquid methylmethacrylate monomer was added to the powder, and the mixture was blended to a toothpastelike consistency, producing polymethylmethacrylate (PMMA). The PMMA was injected using 1-mL syringes with lateral fluoroscopic guidance. PMMA injection was terminated when adequate filling of the vertebral body had been achieved or if leakage occurred. The needle was then removed and all patients were observed in the supine position for 2 hours.

Pulmonary Function Testing

Vital capacity (VC), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) were measured using a spirometer (System 9, Minato Ika) with an online computer, and then respiratory function was assessed using percentage VC (VC%), percentage FVC (FVC%), and percentage FEV1 (%FEV1). Spirometry was performed at least three times for VC, FVC, and FEV1 using the best results that fulfilled the criteria of the American Thoracic Society [12]. All respiratory function tests were performed before, 1 day after, and 1 month after percutaneous vertebroplasty.

Statistical Analysis

Severity of back pain was assessed by all patients using a visual analog scale (VAS) of 0–10 points, with a score of 0 representing no pain and 10 indicating the worst pain imaginable, before percutaneous vertebroplasty, 1 day after, and 1 month after percutaneous vertebroplasty. The Wilcoxon signed rank test was used to evaluate whether any significant differences existed between VC%, FVC%, or FEV1% values obtained before percutaneous vertebroplasty and those obtained 1 day after percutaneous vertebroplasty and 1 month after percutaneous vertebroplasty.
Further analysis was carried out for patients with a VC% of less than 100%. First, subjects were divided into the following two groups with respect to the number of vertebral bodies treated: single-vertebroplasty group and multiple-vertebroplasty group. The single-vertebroplasty group consisted of patients who underwent treatment of one vertebra, whereas the multiple-vertebroplasty group comprised patients who underwent treatment of two or more vertebrae. A Mann-Whitney U test was used to compare the degree of improvement between groups, which was calculated as follows: [(FVC% before percutaneous vertebroplasty) – (FVC% 1 month after percutaneous vertebroplasty)].
Patients were then categorized into four groups according to the level of the vertebral body or bodies treated: a thoracic group, a thoracolumbar group, a lumbar group, and an overlapping group. Patients in the thoracic group underwent treatment of vertebral bodies including T5–T10 and no lumbar vertebral bodies, those in the thoracolumbar group underwent treatment of T11–L1 only, those in the lumbar group underwent treatment of L2–L5 only, and those in the overlapping group had vertebrae involved in more than one group. The Wilcoxon signed rank test was used to evaluate whether any significant differences existed between the thoracic, thoracolumbar, lumbar, and overlapping groups before percutaneous vertebroplasty and 1 month after percutaneous vertebroplasty.
Patients were also divided into two groups with respect to improvement in VAS score (preprocedural VAS score – VAS score 1 month after percutaneous vertebroplasty). The statistically significant difference between the group with VAS improvement, defined as improvement of 2 points or more, and the group with no VAS improvement, defined as improvement of less than 1.9 points, was evaluated by the Wilcoxon signed rank test.

Results

The mean (± SD) VAS score was 7.8 ± 1.6 before percutaneous vertebroplasty, 3.3 ± 2.3 at 1 day after percutaneous vertebroplasty, and 2.6 ± 2.3 at 1 month after percutaneous vertebroplasty. Table 1 shows the VC%, FVC%, and FEV1% values before percutaneous vertebroplasty, 1 day after percutaneous vertebroplasty, and 1 month after percutaneous vertebroplasty. The VC% and FVC% values had improved significantly by 1 month after percutaneous vertebroplasty compared with before percutaneous vertebroplasty (p < 0.1). No significant difference was noted between values before percutaneous vertebroplasty and 1 day after percutaneous vertebroplasty. Likewise, no significant difference was identified in FEV1% before percutaneous vertebroplasty and either 1 day after or 1 month after percutaneous vertebroplasty.
The subgroup analysis described in the next subsections was performed of the patients with a VC% value of less than 100%. The number of the patients with a VC% of less than 100% was 62.

Single-Vertebroplasty Group Versus Multiple-Vertebroplasty Group

Regarding the number of treated vertebral bodies per patient, 31 patients underwent treatment of one vertebra were categorized in the single-vertebroplasty group and 31 patients underwent treatment of two or more vertebrae were categorized in the multiple-vertebroplasty group. The mean degree of improvement in VC% after percutaneous vertebroplasty for the single and multiple groups was 1.1% ± 7% and 6.3% ± 8%, respectively, representing a significant difference between groups (p = 0.01).

Spinal Treatment Level

Nine patients were categorized to the thoracic group; 27 patients, to the thoracolumbar group; 16 patients, to the lumbar group; and 10 patients, to the overlapping group. The mean VC% values before percutaneous vertebroplasty and 1 month after percutaneous vertebroplasty are shown in Table 2. The thoracic group and the overlapping group showed a significant difference in VC% values (both, p = 0.02).

Improvement in Visual Analog Scale Scores

Fifty-eight patients were categorized in the group with an improvement in VAS score and four patients in the group with no improvement in VAS score. The mean VC% values before percutaneous vertebroplasty and 1 month after percutaneous vertebroplasty are shown in Table 3. Only the VAS improvement group showed a significant difference (p < 0.01).
TABLE 1: Changes in Percentage Vital Capacity (VC%), Percentage Forced Vital Capacity (FVC%), and Percentage Forced Expiratory Volume in 1 Second (%FEV1) in All Patients
TABLE 2: Relationship Between Treatment Level and Change of Percentage Vital Capacity (VC%) in Patients With VC% of Less Than 100
TABLE 3: Relationship Between Improvement in Visual Analog Scale (VAS) Score and Change in Percentage Vital Capacity (%VC) for Patients With %VC Less Than 100

Discussion

The development of compression fractures is known to result in respiratory dysfunction due to thoracic deformation caused by the fractures [2, 13, 14]. In addition to this deformation of the thorax, acute and subacute compression fractures may also easily be conjectured to restrict thoracic movement due to pain, thereby impairing respiratory function. When we performed percutaneous vertebroplasty of such patients and regularly measured respiratory function, we found that VC% and FVC% had improved after 1 month. Because both VC% and FVC%, but particularly VC%, are indicators of restrictive ventilatory dysfunction, we deduced that restrictive ventilatory dysfunction had improved after 1 month as a result of percutaneous vertebroplasty. The first potential reason for this improvement is that percutaneous vertebroplasty relieved pain, improving restrictions on thorax movement. Assessment of pain using a VAS, however, showed that pain had improved by 1 day after percutaneous vertebroplasty. This finding indicates that different timing was involved in pain relief and relief of respiratory dysfunction. This difference may have been because pain relief alone is insufficient to improve thoracic movement and pain relief and improvement in quality of life over time resulted in increased exercise, which acted as training for thoracic movement and improved restrictive ventilatory dysfunction. The improvement in respiratory function, especially in VC% values, was correlated with the seven items excluding bodily pain in the Short Form-36 Health Survey, which is one indicator used to quantify quality of life [15].
Yang et al. [16] reported that kyphoplasty improved respiratory function, with significantly better FVC and maximum voluntary ventilation (MVV) values 3 days after surgery compared with the values before surgery, and that additional significant improvements in MVV were seen 1 month after surgery compared with 3 days after surgery. The fact that MVV required time to improve in that study is consistent with our results.
Percutaneous vertebroplasty also may restore vertebral body height at the level of the compression fracture [17, 18] and may sometimes improve local kyphosis [19]. Such improvements in local kyphosis also increase thoracic capacity and probably also improve restrictive ventilatory dysfunction.
We performed a subanalysis of patients with a VC% value of less than 100%. Because there was no scope of further improvement for percutaneous vertebroplasty to improve restrictive ventilatory dysfunction in patients with a VC% value of 100% or greater, such patients were excluded as subjects of the subanalysis. A comparison of the single- and multiple-vertebroplasty groups showed significant improvements after 1 month in the multiple-vertebroplasty group. This difference in improvement by treatment group may have been because small improvements at each individual vertebral level reinforced each other, resulting in greater improvement in vertebral alignment, which improved movement of the thorax.
An analysis by the level of the treated vertebral body or bodies that divided patients into thoracic, thoracolumbar, lumbar, and overlapping groups showed that VC% improved significantly in the thoracic and overlapping groups. The overlapping group included patients who underwent percutaneous vertebroplasty for thoracic vertebrae. Therefore, this improvement in VC% may have been because compression fractures in thoracic vertebrae are directly involved in deformation of the thorax and improvement of vertebrae at the thoracic level thus increased thoracic capacity.
Several limitations must be considered for this study. An optimal study design for testing the effect of percutaneous vertebroplasty on respiratory dysfunction would set up a control group such as a sham-treated group, conservative treatment group, or age-matched population receiving respiratory rehabilitation for the same period and comprise a randomized controlled study comparing percutaneous vertebroplasty and control groups. The greatest limitation of the current study is the absence of such a control group. In addition, the 1-month follow-up period was short. Long-term tests of respiratory function might be able to show whether percutaneous vertebroplasty reduces the incidence of respiratory disorders, particularly complications such as pneumonia.
In conclusion, percutaneous vertebroplasty improves restrictive ventilatory impairment, but this improvement requires approximately 1 month to occur. Greater improvement in restrictive ventilatory dysfunction was observed in patients who underwent vertebroplasty of multiple vertebrae and those who underwent treatment of thoracic vertebrae.

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: W51 - W54
PubMed: 22194515

History

Submitted: February 21, 2011
Accepted: May 5, 2011

Keywords

  1. compression fractures
  2. osteoporosis
  3. percutaneous vertebroplasty
  4. respiratory function

Authors

Affiliations

Noboru Tanigawa
Department of Radiology, Kansai Medical University, Hirakata Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
Shuji Kariya
Department of Radiology, Kansai Medical University, Hirakata Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
Atsushi Komemushi
Department of Radiology, Kansai Medical University, Takii Hospital, Moriguchi, Osaka, Japan.
Miyuki Nakatani
Department of Radiology, Kansai Medical University, Hirakata Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
Rie Yagi
Department of Radiology, Kansai Medical University, Hirakata Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.
Satoshi Sawada
Department of Radiology, Kansai Medical University, Hirakata Hospital, 2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan.

Notes

Address correspondence to N. Tanigawa ([email protected]).

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