Osteoporotic vertebral fractures (OVFs) occur more frequently than ankle, wrist or hip fractures. OVFs constitute major health problem to patients, resulting in worse quality of life compared to normal people [1,2,3,4].

Because of the poor quality of osteoporotic bone, classical open surgery with metal implants often fails, contributing to persistent back pain, neurological symptoms and functional limitations [5]. Vertebroplasty (VP) and balloon kyphoplasty (KP) are less invasive procedures to treat OVFs. Recently, two randomized controlled trials have indicated that both VP and KP can produce immediate pain relief compared to conservative treatments [6,7].

There are many literatures that compared the effectiveness and complications of the two procedures [8,9,10,11,12]. Comparison studies demonstrated similar results in terms of pain and functional status improved by VP or KP [13,14]. Kim et al. [15] reported that KP had a significant advantage over VP in terms of kyphosis correction, vertebral height restoration, and cement leakage prevention. However, few reports compared the quality of life after the two procedures. Therefore, the objective of this study was to compare the quality of life in postmenopausal women with OVFs who received VP or KP.

Five hundred twenty-eight postmenopausal women from 17 study sites in nationwide hospitals with age of 50 years or older who underwent VP or KP for OVFs were enrolled in this study. Enrollment was taken between April 2008 and January 2009. Total number of the VP group was 283 and that of the KP group was 245.

Average ages of the VP group and the KP group were 72.58 (±7.95) years and 73.94 (±6.92) years, respectively. The difference of age between the two groups was not statistically significant (p=0.134). Average bone mineral density of the VP group was 0.47 (±0.22) mg/cm², which was significantly (p=0.001) lower than that (0.56±0.16 mg/cm2) of the KP group. Chronic disease properties of patients in the two groups are summarized in Table 1.

Both procedures were performed most commonly at the lumbar spine level. The thoracic spine was the second most frequently performed level (Table 2).

In the VP group, average value of each EQ-5D dimension was 1.95 in mobility, 1.86 in self care, 2.02 in usual activities, 2.19 in pain, 1.69 in anxiety or depression. In the KP group, average value of each EQ-5D dimension was 1.83 in mobility, 1.78 in self care, 1.98 in usual activities, 2.03 in pain, 1.55 in anxiety or depression. The quality of life in the VP group was significantly worse than that of the KP group in mobility (p=0.016), pain (p=0.001), and anxiety or depression (p=0.008). Average EQ-5D index in the VP group was 0.353 (±0.472), which was significantly (p<0.001) lower than that (0.485±0.357) of the KP group. In the VP group, average VAS was 57.49, which was not significantly (p=0.580) different from that (56.40) of the KP group (Table 3).

OVFs are the most frequently observed pathology and the leading cause of morbidity and mortality in geriatric patients [13]. Progressive loss of posture as a result of OVFs is one of the major problems associated with its enormous impact on the quality of life. A vertebral deformity leads to relapse of pain, cosmetic problems, decreased activity, change in mood, and reduced pulmonary function, which subsequently results in a decrease in thoracic volume and an increased risk of further fractures of the adjacent vertebra [14].

Initial therapies for OVFs are sustained bracing, prolonged bed rest, and medical treatment with nonsteroidal anti-inflammatory drugs, narcotic medication and antiresorptive therapy. However, some patients fail to benefit from these treatment modalities, resulting in persistent disease-related morbidity. The pain and incapacity resulting from OVFs demand the development of new treatment modalities as effective therapy.

The following two related techniques were developed to regain vertebral body height and function as well as to decrease pain and incapacity: 1) percutaneous VP, in which cement is inserted into the vertebral body to reinforce the fractured bone; and 2) KP, a modification of VP in which a balloon is inserted and inflated in a compressed vertebral body to reestablish the height of the compressed bone [17]. Clinical studies have reported that similar results in terms of pain and functional status improvement are achieved from both VP and KP [13,14]. However, it is currently unclear whether VP or KP can provide better clinical outcome. Few studies have compared the quality of life between the two procedures. In our study, we compared the outcomes between VP and KP in treating painful OVFs with regard to the quality of life using EQ-5D and VAS. The difference of VAS between VP and KP group was not statistically significant (p=0.580). However, in the aspect of EQ-5D, there were statistical differences between the two groups on mobility, pain and anxiety or depression. Our results indicated that KP resulted in significantly better quality of life compared to VP.

Klazen et al. [6] reported that VP resulted in greater pain relief than conservative treatment. Differences in mean VAS scores between baseline and 1 month were -5.2 and -2.7 after VP and conservative treatment, respectively. Differences in mean VAS scores between baseline and 1 year were -5.7 (-6.22 to -4.98) and -3.7 (-4.35 to -3.05) after VP and conservative treatment, respectively [6]. In our study, in each dimension of EQ-5D, pain was the most impaired dimension of quality of life. However, the quality of life after VP or KP was not compared to that at the preoperative status. Therefore, we assumed that the pain was significantly decreased after VP or KP. However, many patients suffered from persistent back pain.

Some studies have reported that KP has a significant advantage over VP in terms of kyphosis correction and vertebral height restoration [15,18,19]. Suzuki et al. [20] reported that initial severe deformation of OVF was the worst prognostic factor for severe lasting pain and disability, resulting in the deterioration of daily living activities and quality of life. In our study, EQ-5D index was significantly higher in the KP group than that in the VP group. More restoration of vertebral height and kyphosis correction may have resulted in better quality of life in the aspect of mobility, pain, and anxiety or depression.

The main limitation of our study is that we compared quality of life between the VP group and the KP group without measuring quality of life before at preoperative status. As a result, we could not calculate the improvement of quality of life after the procedures compared to the preoperative status. In addition, misclassification of the medical condition might be possible, which might have resulted in an underestimation of their effect on the quality of life. Furthermore, clinical outcome was based on VAS and EQ-5D dimensions in this study. There are other measures for quality of life, such as 36-Item Short Form Health Survey (SF-36), which should have been taken into account to make this study more valuable.

Health related quality of life in osteoporotic vertebral fracture patients who received balloon KP was significantly better than that of patients who underwent VP in the aspect of mobility, pain, and anxiety or depression. In addition, pain was the most impaired dimension after both procedures. Therefore, balloon KP should be considered as a better choice than VP to achieve a better quality of life in patients with OVFs.