Chapter 18 Kyphoplasty
Balloon kyphoplasty is a minimally invasive option for treating vertebral compression fractures. It can be performed as an outpatient procedure and can provide immediate pain relief. The patient can return to activities of daily living just after the procedure, which stabilizes vertebral fractures and reduces spinal deformity by restoring vertebral body anatomy and height.
The incidence of cement leakage and other procedure-related complications is low, and pain relief has been reported in more than 90% of patients. The procedure time requires 20 to 40 minutes per level, and the medical cost is higher than that of vertebroplasty. Supplementary facet joint injections or medial branch blocks may improve the level of pain relief in some cases.
Treatment objectives of kyphoplasty
The treatment objectives are to provide an early return to function, to relieve pain, and to restore the anatomy by reducing and stabilizing the fracture, restoring vertebral height, and diminishing the spinal deformity.
Indications
Kyphoplasty is performed in patients with recent vertebral fractures due to osteoporosis, angiomas, myelomas, metastasis, and so on, who present with pain refractory to conservative treatment including bed rest and drug treatment. The best results are obtained when the vertebral collapse has occurred recently—that is 3 months or less before the patient’s presentation [1,2].
Contraindications
Contraindications to kyphoplasty may be absolute or relative [1–3]. Absolute contraindications are as follows:
Unstable fractures or neoplasms with involvement of the posterior vertebral wall (i.e., complex fractures with or without retropulsed fragments) and accompanying spinal canal compromise
Relative contraindications to the procedure are as follows:
Complications
There is an overall incidence rate of complications with this procedure ranges from 0 to 9.8% [4–9]. The most common is cement extravasation, which may be avoided with the following precautions [10]:
Filling the void with thick, toothpaste-like cement using a low-pressure injection yields less cement leakage than filling the interstices of a fractured vertebra with thin, less viscous cement via a high-pressure injection, as is done in vertebroplasty.
Adequate imaging with high-quality digital fluoroscopy, adequate cement opacification with sterile barium, and injection of cement which is not too liquefied can avoid leakage.Other, extremely rare complications of kyphoplasty are as follows:
Preoperative preparation
The physician should obtain a description of the presenting symptoms from the patient, which may include complaints of limitation of motion, and varying degrees of local pain with or without radiation around the trunk and further anteriorly.
The physical examination at the level of the recent fracture(s) reveals corresponding tenderness upon deep palpation and pain provoked by percussion.
The imaging diagnosis would include the following:
Computed tomography (CT) scan with or without three-dimensional imaging to assess details of the bony architecture in cases of suspicion of a posterior cortical fracture (Fig. 18-1)
Magnetic resonance imaging (MRI) to detect signal change caused by bone edema at the level of a recent fracture (Fig. 18-2)
Figure 18–1 Computed tomography scan with three-dimensional images of a vertebral body fracture from the right (A) and left (B).
Figure 18–2 Left, A T1-weighted sagittal magnetic resonance image shows a complete vertebral body collapse (vertebra plana) at T12 and L2. A few fracture fragments of T12 compress the spinal cord anteriorly. Right, A bone scan shows no radiotracer uptake at the T12 and L2 levels, indicating chronic, rather than acute, fractures at these levels. At the L3 lower vertebral body, there is a loss of high signal intensity on the T1-weighted image and a high uptake on the bone scan image, indicating an acute pathologic process. Kyphoplasty at the T12 and L2 levels are contraindicated, whereas a kyphoplasty at L3 is indicated.
Radiologic anatomy for kyphoplasty
Radiologic landmarks for kyphoplasty should be identified as follows (Fig. 18-3)
Figure 18–3 Fluoroscopic views of the lumbar spine. (A) On a true anteroposterior (AP) view, the pedicles (black circles) should be located equidistant from both lateral margins of the corresponding vertebral bodies, and the spinous process should also be located at the midline of the width of the vertebral body. (B) On an oblique view, the pedicle (dotted circle) should be visualized at its widest and most circular aspects. (C) On a true lateral view, the two pedicles should be superimposed. For assessment of the location of the needle tip and its correct trajectory, frequent check of the true AP and lateral views is essential.
Methods of kyphoplasty
The two methods of kyphoplasty currently performed, along with available products for them, are as follows:
Bone graft kyphoplasty: OptiMesh Deployable Grafting System (Spineology, Inc., St. Paul, MN) (Fig. 18-4)
Figure 18–4 The OptiMesh system. (A) The OptiMesh graft containment device in its unfilled (left) and filled (right) states. (B) Allograft bone material prepared for the bone filling tube. (C) An expandable reamer. (D) Preoperative (left) and postoperative (right) computed tomography scans of three-level OptiMesh implantations for treatment of three vertebral fractures. (E) The surgeon fills the cavity with allograft bone through the bone filling tube. Pressure is exerted firmly with a mallet.
(Courtesy of Spineology, Inc., St. Paul, MN.)
Instrumentation
Operating Room Setup
Figure 18-5 depicts the operating room setup for balloon kyphoplasty, consisting of the following:
Figure 18–5 The operating room to be used for kyphoplasty contains a radiolucent operating table and a high quality C-arm (fluoroscope), both of which are mandatory for maximal procedural safety. An anesthesia machine, monitoring devices, and equipment for cardiopulmonary resuscitation are also necessary for the patient’s safety.
Kyphoplasty Kit
Figure 18-6 illustrates the components of the balloon kyphoplasty system manufactured by Medtronic, Sunnyvale, CA, use of which is described in the procedure section of this chapter:
KYPHON® Inflation Syringe, which consists of a long tube to keep the clinician out of the radiation beam, an easy to read digital pressure gauge and volume scale, and provide safe, precise control of balloon inflation (Fig. 18-9)Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
