Overview
Balloon kyphoplasty and vertebroplasty are minimally invasive options for treating painful vertebral compression fractures. These procedures can be performed on an outpatient basis; they can provide successful pain relief, along with a return to activities of daily living immediately after the procedures; and they can stabilize vertebral fractures. In addition, balloon kyphoplasty can reduce spinal deformity by restoring vertebral body height.
The incidence of procedure-related complications such as cement leakage is low, especially in balloon kyphoplasty, whereas pain relief has been reported in more than 90% of patients. The medical cost of kyphoplasty is higher than that of vertebroplasty. Most patients (88%) who require vertebroplasty or kyphoplasty may also have facet joint pain adjacent to the corresponding affected vertebrae. Supplementary facet joint injections or medial branch blocks could, therefore, improve the level of pain relief in such cases. If the duration of nerve blocks is temporary, radiofrequency thermocoagulation of the corresponding medial branches will be required for long-term pain relief.
Treatment Objectives
The treatment objectives of kyphoplasty or vertebroplasty are pain relief and early return to function. In cases of kyphoplasty, restoration of the anatomy could be achieved by reducing and stabilizing the fracture, restoring vertebral height, and diminishing the spinal deformity.
Indications
Kyphoplasty or vertebroplasty is performed in patients who have recent vertebral fractures as a result of osteoporosis, angioma, myeloma, metastasis, and so on and who have pain refractory to conservative treatment, which includes bed rest, physical therapy, and medications. The best results are obtained when the vertebral collapse has occurred recently; that is, within 3 months of the patient’s seeking medical attention.
Contraindications
Contraindications to kyphoplasty and vertebroplasty may be absolute or relative. Absolute contraindications are as follows:
- ▪
Coagulation disorders
- ▪
Local infection in the proposed site of access (osteomyelitis or spondylodiskitis)
- ▪
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)
- ▪
Less than one third of the original vertebral body height remains.
- ▪
Pedicles or articular facets are damaged.
- ▪
Tumor invasion into the spinal canal makes any potential leakage of even a small amount of cement into the already compromised canal especially hazardous.
Complications
Overall incidence of complications with the aforementioned procedures ranges from 0% to 9.8%. The most common complication is cement extravasation, which may be avoided with the following precautions :
- ▪
Adequate imaging with high-quality digital fluoroscopy, adequate cement opacification with sterile barium, and injection of cement that is not too liquefied can all prevent leakage.
- ▪
Filling the void with thick, toothpastelike cement under low injection pressure in kyphoplasty 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.
- ▪
Pneumothorax and rib fracture during thoracic kyphoplasty
- ▪
Pulmonary embolism
- ▪
Bleeding or spinal epidural hematoma
- ▪
Radiculopathy
- ▪
Paraplegia
- ▪
Infection
- ▪
Cerebrospinal fluid leakage
- ▪
Transient acute respiratory distress syndrome
Preoperative Preparation
The physician should obtain a description of the symptoms from the patient, which may include complaints of motion limitation and varying degrees of local pain with or without radiation around the trunk and farther anteriorly. Physical examination at the level of the recent fracture 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. 71-1 )
Figure 71-1
Computed tomography scan with three-dimensional images of a vertebral body fracture from the right ( A ) and left ( B ).
(Modified from Kim DH, Kim KH, Kim YC: Minimally invasive percutaneous spinal techniques. Philadelphia, 2011, Saunders Elsevier.)
- ▪
Magnetic resonance imaging (MRI) to detect signal change caused by bone edema at the level of a recent fracture ( Fig. 71-2, A )
Figure 71-2
A, T1-weighted sagittal magnetic resonance imaging shows a complete vertebral body collapse (vertebra plana) at T12 and L2. A few fracture fragments at T12 compress the spinal cord anteriorly. B, Bone scan image 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, a loss of high signal intensity is seen on the T1-weighted image, with high uptake on the bone scan image, indicating an acute pathologic process. Kyphoplasty or vertebroplasty at the T12 and L2 levels is contraindicated, whereas at L3, either procedure is indicated.
(Modified from Kim DH, Kim KH, Kim YC: Minimally invasive percutaneous spinal techniques. Philadelphia, 2011, Saunders Elsevier.)
- ▪
Bone scan to determine the most recent fracture in patients with multiple fractures (see Fig. 71-2, B )
Radiologic Anatomy for Kyphoplasty and Vertebroplasty
Radiologic landmarks for kyphoplasty or vertebroplasty should be identified as follows ( Fig. 71-3 ):
- ▪
Pedicles, to define the starting point of the bone access needle on each side
- ▪
Spinous process, to gauge vertebral body rotation
- ▪
End plates, to enable planning of a posterior–anterior trajectory
- ▪
Posterior cortical margin, to avoid the anterior margin of the spinal canal
Equipment for Vertebroplasty and Kyphoplasty
Various devices have been introduced for vertebroplasty and kyphoplasty. All photos in this chapter were obtained from the kits supplied by Kyphon (Sunnyvale, CA; Fig. 71-4 ).
Procedure
Inserting Tools into the Fractured Vertebral Body
Three approaches have been introduced to access the vertebral body using a bone access needle: transpedicular, extrapedicular, or unipedicular-posterolateral ( Fig. 71-5 ). The selection of approach depends on fracture configuration and the patient’s anatomy ( Table 71-1 ).
| Approaches | Indications |
|---|---|
| Transpedicular | Most osteoporotic and osteolytic compression fractures |
| Extrapedicular | Cancer invasion of the pedicle |
| Pedicle screw fixation in place | |
| Compression fractures in upper and mid thoracic vertebrae | |
| Unipedicular posterolateral | Special cases in which a transpedicular or extrapedicular approach cannot be performed |
Related posts:
Craniovertebral Junction Instabilities and Surgical Fixation Techniques
Surgical Approaches to the Craniovertebral Junction in Rheumatoid Arthritis
Anterior and Posterior Cervicothoracic Junction Stabilization Techniques
Percutaneous and Endoscopic Diskectomy
Sacral Screw Fixation and Plating Techniques
Surgical Management of Gunshot Wounds to the Spine
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
