The Use of Vertebral Augmentation and
External Beam Radiation Therapy in the
Multimodal Management of Malignant
Vertebral Compression Fractures
Authors: Hirsch Ariel E. 
Published: March 2021

Background: Vertebral augmentation (VA) techniques such as vertebroplasty and kyphoplasty are
increasingly performed minimally invasive procedures for osteoporotic or malignant compression
fractures (MCFs) and involve injection of polymethylmethacrylate (PMMA) cement directly into a
compressed vertebral body.
Objective: This article will evaluate the efficacy of VA in relieving fracture-related pain. We also
intend to identify procedural and clinical variables that could potentially influence outcomes in this
population. 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 and
MCFs who underwent one or more vertebral augmentation procedures at our institution between
2003 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 Visual
Analog 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 paper
and electronic medical records. Our data collection methodology has been previously reported and
includes variables such as procedure dates, gender, age, type of malignancy, fracture etiology, history
of cancer treatment, type of procedure performed, vertebral level treated, the number of levels treated
per procedure, complications, and follow-up information on pain response. The updated dataset
incorporates new variables including information on pain medications and standardized questionnaires
such 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 either
vertebroplasty 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 report
worsening of their fracture-related pain post-procedure. There was no difference in pain outcomes
with regard to sequencing of EBRT and VA.
Limitations: One of the limitations of our analysis is that it did not evaluate the effect of pain
improvement or resolution before and after EBRT alone and on activities of daily living in the majority
of patients. However, one of the main goals of this analysis is to address previous limitations. We
attempt to standardize outcome measures by using the Visual Analog Scale (VAS) for pain and the
Roland Morris Disability Questionnaire (RMDQ).
Conclusion: A multimodality approach for the management of MCFs includes VA procedures. The
majority of patients with MCFs have excellent palliation with this approach. In patients who receive
both 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