Post-vertebral augmentation back pain: evaluation and management

Abstract

Background and purpose: Vertebral augmentation is an established treatment for painful osteoporotic vertebral fractures of the spine. Nevertheless, patients may continue to have significant back pain afterward. The purpose of this study was to assess the source of persistent or recurrent back pain following vertebral augmentation.

Materials and methods: Our institutional review board approved this study. We evaluated 124 consecutive patients who underwent vertebral augmentation for painful osteoporotic vertebral fractures. All patients were evaluated after 3 weeks, 3 months, and 1 year following their procedure. Patients with any type of back pain after their procedure were examined under fluoroscopy.

Results: Thirty-four of 124 (27%) patients were men, and 90/124 (73%) were women. Persistent or recurrent back pain, not due to a new fracture or a failed procedure, was present in 29/124 (23%) patients. The source of pain was most often attributed to the sacroiliac and/or lumbar facet joints (25/29 or 86%). Seventeen of 29 (59%) patients experienced immediate relief after facet joint injection of a mixture of steroid and local anesthetic agents. The remaining 12 (41%) had relief after additional injections. Ten (34%) patients ultimately required radio-frequency neurolysis for long-term relief.

Conclusions: Back pain after vertebral augmentation may not be due to a failed procedure but rather to an old or a new pain generator, such as an irritated sacroiliac or lumbar facet joint. This is of importance not only for further pain management of these patients but also for designing trials to compare the efficacy of vertebral augmentation to other treatments.

Fig 1.

CT-guided unilateral facet joint injection. The patient is a 97-year-old woman (patient 19 in Table 1) with recurrent back pain after T10 and T11 vertebral augmentation. Her initial back pain symptoms were localized to the right upper lumbar facet joints under fluoroscopic evaluation. She was pain-free after undergoing right L1-L2 and L2-L3 facet joint injections 2 weeks after vertebral augmentation. She returned 11 months after her vertebral augmentation procedure for new low-back-pain symptoms that localized to her SIJs and responded to bilateral SIJ injections.

Fig 2.

CT-guided bilateral SIJ injection. This 74-year-old woman (patient 28 in Table 1) had recurrent low back pain after T12 vertebral augmentation. On evaluation, including a pain diagram and fluoroscopic examination, her pain localized to her SIJs. Her T12 level revealed no evidence of palpable tenderness, and there was no new vertebral compression fracture. She became pain-free after 2 sessions of bilateral SIJ injection 6 weeks and 7.5 months after T12 vertebral augmentation.