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Kyphoplasty and Vertebroplasty: Minimally Invasive Percutaneous Treatment for Osteoporotic Compression Fractures
Last updated Tuesday, December 02, 2008
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SummaryOverview Edited By: Michael J. Lee, M.D.
Compression fractures in the spine can occur in the in patients with osteoporosis, which is commonly seen in the elderly. These fractures occur with little trauma to metabolically weakened bone. This is in contrast with a traumatic compression fracture which can occur in high energy traumas like a motor vehicle accident.
Osteoporotic compression fractures area source of disability and morbidity in the elderly population. Often these can be challenging to treat as elderly patients often have other medical conditions.
Historically, osteoporotic compression fractures have been treated with rest, medication, and bracing. If these non surgical treatments were not successful, open surgeries have been performed to stabilize the spine. These surgeries can be extensive and can be complicated by patients’ advanced age, medical co-morbidities, and weakened bone and are not ideal in the elderly patient.
Recently, minimally invasive procedures have been developed to treat osteoporotic compression fractures. There are two minimally invasive treatments that have been used: vertebroplasty and kyphoplasty. In these procedures, bone cement is inserted into the fractured vertebra which allows for stabilization, and relief of pain.
Characteristics of osteoporotic compression fractures in the spine Patients with osteoporotic compression fractures generally have back pain. After several fractures, a kyphotic or hunched over deformity can be present. Usually the pain will decrease after weeks to months, however it is not uncommon for the pain to persist beyond this time period.Osteoporotic compression fractures occur because of metabolically weakened bone (from osteoporosis). The bone is weakend to the point, that very little force can cause to vertebra to collapse or become crushed.Types Osteoporotic compression fractures occur because of metabolically weakened bone (from osteoporosis). The bone is weakend to the point, that very little force can cause to vertebra to collapse or become crushed.
Compression fractures can also be caused by weakened bone from other non-osteoporotic diseases. Cancer, which spreads to the bone can also weakened the vertebra so that it fractures with little force.
Finally, trauma can cause compression fractures. Usually in these cases, the bone strength and density is normal, but the high energy nature of the trauma (such as a fall from a high height, or a motor vehicle accident) creates the fracture
Similar conditions Back pain can occur from other causes as well. In general compression fractures occur from disease (osteoporosis, cancer) or trauma. There are numerous other causes of back pain. These include degenerative arthritis, infection, disc herniation, and many more. The compression fractures, however can be easily differentiated from these other causes of back pain with a thorough history, physical exam, x-rays, and occasionally advanced imaging, such as a CT scan or an MRI.Incidence and risk factors Vertebral compression fractures can affect up to 20% in patients older than 70 years, and up to 16 % of women after menopause. An estimated 700,000 compression fractures occur annually in the United States.
Diagnosis The diagnosis of osteoporotic compression fractures is usually suspected by a simple history and physical exam. This diagnosis can be confirmed with x-rays of the spine. A CT scan can be used to further evaluate the fracture, and an MRI scan be used to determine if the fracture was a recent event, or if it is an old healed fracture.
Medications In general, oral medications do not make the fracture heal more quickly. Medications help in the treatment of compression fractures in that they can lessen the pain, while the fracture heals. While exercise is beneficial in a number of conditions and for overall health, they do not assist in the healing of osteoporotic compression fractures.
Exercises While exercise is beneficial in a number of conditions and for overall health, they do not assist in the healing of osteoporotic compression fractures.
Possible benefits of kyphoplasty and vertebroplasty Under anesthesia, the fractured vertebra is approached posteriorly (from the backside). Using x-ray in the operating room, a trochar, or a thin tube, is inserted into the fractured bone in the spine through the pedicle.
For vertebroplasty, bone cement is then injected into the fracture.
For kyphoplasty, a balloon is inserted through the trochar and inflated once inside the bone. This balloon inflation restores the natural form of the vertebra. After inflation of the balloon, the bone resembles its pre-fracture shape. After the balloon inflation has been performed, it is removed. Bone cement is then inserted to fill the void that the bone cement created.
The main difference between kyphoplasty and vertebroplasty is the restoration of normal bone shape with kyphoplasty. In vertebroplasty, the bone cement stabilizes the fracture, but does not attempt to reconstitute the normal bone shape. In kyphoplasty, the inflation of the balloon before inserting the cement is intended to restore the bone shape to what it was like before the fracture.
The cement injected into the bone with both vertebroplasty and kyphoplasty, acts to stabilize the fracture. This fracture stabilization usually resolves the pain the patient feels.
Types of surgery recommended Historically, surgery for osteoporotic compression fractures were extensive. These surgeries included a large incision and exposure, and usually a multilevel fusion for stabilization. In general, such extensive surgeries were poorly tolerated by the elderly population. In addition, the weak osteoporotic bone was not ideal for using instrumentation (screws, rods, hooks) which are often used to provide stabilization in fusion.
Recently, the development of minimally invasive techniques allowed patients with osteoporotic compression fractures to avoid such large extensive surgeries. In general, kyphoplasty and vertebroplasty are performed through two small stab incisions, and the patient usually returns home the day of surgery or the day after surgery.
Who should consider kyphoplasty and vertebroplasty? A large majority of osteoporotic compression fractures can be treated without surgery. Treated conservatively, most of these fractures can heal uneventfully. Occasionally, these fractures can require much longer to heal, and some of them do not heal at all. These are the patients who would benefit from a minimally invasive procedure, such as kyphoplasty or vertebroplasty.
What happens without surgery? In many of these fractures, the bone will heal and the pain will resolve. However, there are patients in whom the bone does not heal in a timely fashion. If left untreated, this can develop into chronic pain. In addition, if numerous compression fractures occur, a kyphotic (hunch back) posture may develop. This hunched over posture is thought to predispose patients to developing additional fractures.Surgical options Historically, surgery for osteoporotic compression fractures were extensive. These surgeries included a large incision and exposure, and usually a multilevel fusion for stabilization. In general, such extensive surgeries were poorly tolerated by the elderly population. In addition, the weak osteoporotic bone was not ideal for using instrumentation (screws, rods, hooks) which are often used to provide stabilization in fusion.
Recently, the development of minimally invasive techniques allowed patients with osteoporotic compression fractures to avoid such large extensive surgeries. In general, kyphoplasty and vertebroplasty are performed through two small stab incisions, and the patient usually returns home the day of surgery or the day
Effectiveness In the hands of an experienced physician, kyphopalsty and vertebroplasty are extremely effective in relieving pain from osteoporotic fractures. If done correctly, the relief of symptoms from that fracture should last for decades.
Because of the patient’s osteoporosis, the patient is certainly at risk for developing additional fractures elsewhere in the spine, and new symptoms of pain may occur, but in a well performed kyphoplasty or vertebroplasty, pain generally does not re occur at the treated level.
Urgency n osteoporotic compression fractures, there is little urgency for surgical treatment. In fact, many of these fractures are treated without surgery.
Kyphoplasty or Vertebroplasty should be done in patients who have persistent pain, despite a trial of non operative treatment.
Risks The most serious complication of the kyphoplasty or vertebroplasty procedure is from cement leak. At times, because the vertebra is fractured, when cement is injected into the vertebra, cement can leak outside the bone. In the overwhelmingly large majority, these cement leaks do not have a clinical consequence. However, cement can leak into the blood stream and result in an embolism (vessel blockage). Cement can also leak towards the spine and its nerve roots and can potentially damage the spine resulting in neurological injury. Although such cases are extremely rare, they have been reported in the scientific literature and the patient should be aware of these reported complications.
According to recent studies, cement leak appears to be more common in the vertebroplasty procedure than it is in the kyphoplasty procedure. However the larger majority of these leaks did not have any clinical consequence.
There are also risks of bleeding and infection, although these are also very rare.
In addition, if general anesthesia is used for the procedure, the patient carries the risk of general anesthesia in addition to the risk of the surgery.
Managing risk In the rare event of a complication, measures can be taken to counter them. If cement leakage around the nerves occur, these can be managed in different ways. If there is mild nerve root irritation, steroid injection has been used to treat these patients. If there is evidence suggestive of injury to the spinal cord itself, emergent surgery has been done to remove the cement from around the cord to minimize risks of paralysis.Preparation No specific preparation for the procedure is required for kyphoplasty and vertebroplasty. If the patient is taking anticoagulation medication (such as Coumadin), I usually ask the patients to discontinue it one week before the procedure to minimize risks of bleeding.
Generally, blood transfusion is not necessary, so donation of blood units is not needed, as is common in other surgical procedures.
Prior to the surgery, the patient should have a thorough understanding of the risks, benefits, and potential complications of surgical vs. nonsurgical treatment. In addition, the patient should have an excellent understanding of the goals of surgery. Depending on the condition, the goals of surgery range from preventing further neurological damage to relieving pain and symptoms.
Timing As long as the patient’s spine is stable and the patient can tolerate the symptoms, this procedure can be delayed for months.
Costs The surgeon's office should provide a reasonable estimate of:
• the surgeon's fee;
• the hospital fee;
• the degree to which these should be covered by the patient's insurance.
Surgical team A surgeon, radiologist, anesthesia specialist or physiatrist who has
been specifically trained in these techniques may perform these
procedures. It should be performed at a medical center where these
procedures are done routinely.Finding an experienced surgeon
Facilities Surgery is usually performed in a major medical center that performs these procedures on a regular basis. These centers have surgical teams and facilities specially designed for this type of surgery. In addition, neurological monitoring should be used, depending on the patients’ condition and this should be avail. They also have nurses and therapists who are accustomed to assisting patients in their recovery.Technical details After the anesthesia is administered and the patient is given prophylactic antibiotic, a horizontal incision (3 cm to 4 cm) is made on the front of the neck. This incision is made in line with the way the skin runs, so it can heal along skin lines with minimal scarring.
Dissection through superficial muscle layers, around the midline esophagus and airway structures, and onto the cervical spine is then performed. Retractors are placed. An intra-operative X-ray is performed to confirm the appropriate level of surgery.
The intervertebral disc is then completely removed. Foraminotomies are can also be performed. A foraminotomy is the direct decompression of the space through which the nerve root travels. Disc material or bone spurs can impinge in this area, and place pressure on the nerve root.
After discectomy (removal of the disc) and foraminotomy (decompression of the nerve root), partial or complete removal of the vertebral body can be done. The decision to remove the vertebra (corpectomy) is dependent upon the nature of the condition. This may or may not be necessary.
After adequate decompression of the spinal cord and or nerve roots, a bone graft is then impacted into place where the disc was removed, between the two vertebrae.
A small titanium plate is then placed on top of the bone graft and into the bone above and below Screws are placed into the bone above and below to hold the plate in place. This plate gives additional stability to the structure.
The surgical wound is then washed out, and the layers are closed with suture. The skin is closed with an absorbable suture, and there is no need for suture or staple removal. A drain is placed for 24 hours and is removed the next day.
The patient is placed in a soft neck collar postoperatively, typically for a few weeks.
Anesthetic General anesthesia or local anestheisa have been used to perform these procedures.
Length of kyphoplasty and vertebroplasty Osteoporotic compression fractures can occur at one particular location in the spine, or at multiple levels. The length of the procedure depends on the number of levels. In general, the procedure takes less than 30 minutes per level.Pain and pain management Usually the patients experience immediate relief of their pain. After the procedure, the patient is given a prescription of strong pain medicine (hydrocodone or Tylenol with codeine) for the pain from the surgery.Effectiveness of medications
Important side effects Pain medications can cause drowsiness, slowness of breathing,
difficulties in emptying the bladder and bowel, nausea, vomiting and
allergic reactions. Patients who have taken substantial narcotic
medications in the recent past may find that usual doses of pain
medication are less effective. For some patients, balancing the benefit
and the side effects of pain medication is challenging. Patients should
notify their surgeon if they have had previous difficulties with pain
medication or pain control.Hospital stay After surgery, the patient usually spends an hour or two in the recovery room. The patient may be discharged home the day of the procedure, or occasionally may require an overnight stay for observation.
Hospital discharge The patient will have few limitations at the time of discharge. The patient is not required to wear a brace, nor are there any specific limitations in activity. These patients may have been de-conditioned from the pain of these fractures for months prior to the surgery, and a gradual return to activity is advised. If the de-conditioning has been severe, then physical therapy may be useful in the rehabilitation of the patient.Convalescent assistance If the patient has been de-conditioned prior to the surgery, they may require physical therapy for rehabilitation. It is important to remember that these fractures tend to occur in the elderly who may lower activity levels before the occurrence of the fracture. The return to activity after kyphoplasty or vertebroplasty should be gradual, and physical therapy may be required.Physical therapy The use of physical therapy is variable from patient to patient and can be used for overall rehabilitation if the patient is deconditioned.
Can rehabilitation be done at home? Depending on the physical therapist’s prescribed program, some stretching and strengthening exercises likely can be performed independently at home.Summary of kyphoplasty and vertebroplasty for osteoporotic compression fractures in the spine Osteoporotic compression fractures in the spine are a cause of disability and morbidity in the elderly population.
The majority of these fractures can be treated without any kind of procedure or surgery.
When non operative treatment fails to relieve the pain, kyphoplasty and vertebroplasty are minimally invasive options to treat these fractures.
Kyphoplasty and Vertebroplasty are effective in improving the pain from osteoporotic compression fractures.
Surgery for Osteoporotic Compression Fractures in the Spine at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 to make an appointment. Our clinical center is located in Seattle Washington, USA
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