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:

Coagulation disorders

Local infection in the proposed site of access (osteomyelitis or spondylodiscitis)

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

Vertebra plana (complete vertebral body collapse)

Relative contraindications to the procedure are as follows:

Less than one third of the original vertebral body height remaining

Damaged pedicles or articular facets

Tumor invasion into the spinal canal, making any potential leakage of even a small amount of cement into the already compromised canal especially hazardous

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:

Pneumothorax and rib fracture after thoracic kyphoplasty

Pulmonary embolism

Bleeding or spinal epidural hematoma

Radiculopathy

Paraplegia

Infection

Cerebrospinal fluid leakage

Transient adult respiratory distress syndrome

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:

Plain spine anteroposterior (AP) and lateral films

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)

Bone scan to determine the most recent fracture(s) in patients with multiple fractures [11]

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)

Pedicles, to define the starting point of bone access needle on each side

Spinous process, to gauge vertebral body rotation

End plates, to enable planning of a posterior-to-anterior trajectory

Posterior cortical margin, to avoid the anterior margin of the spinal canal

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:

Balloon kyphoplasty (Kyphon, Inc., Sunnyvale, CA)

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.)

Balloon kyphoplasty is described in detail in this chapter.

Instrumentation

Operating Room Setup

Figure 18-5 depicts the operating room setup for balloon kyphoplasty, consisting of the following:

Radiolucent operating table

A high quality C-arm (fluoroscope)

An anesthesia machine

Monitoring devices

Equipment for cardiopulmonary resuscitation

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® Bone Access Needle, 11-gauge

KYPHON® Osteo Introducer® System (Fig. 18-7)

KYPHON® Precision Drill

Guide Pins

KYPHON® Bone filler device (Fig. 18-8)

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)

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