Vertebroplasty and Kyphoplasty




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)

Relative contraindications to the procedure are as follows:


  • 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.

Other rare complications are as follows:


  • 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




Figure 71-3


Fluoroscopic images of the lumbar spine. A, On a true anteroposterior (AP) image, the pedicles ( dotted circles ) should be equidistant from both lateral margins of the corresponding vertebral bodies, and the spinous process should be located at the midline of the width of the vertebral body. B, On an oblique image, 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 checks of the AP and lateral views are essential.




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 ).




Figure 71-4


The instruments used for kyphoplasty.

(Modified from Kim DH, Kim KH, Kim YC: Minimally invasive percutaneous spinal techniques. Philadelphia, 2011, Elsevier.)




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 ).




Figure 71-5


Imaginary approach lines of various techniques for vertebroplasty and kyphoplasty. White arrow denotes transpedicular approach. Blue and red arrows denote extrapedicular and unipedicular posterolateral approaches, respectively. Arrow tips represent the final target points of each approach from where bone cement is injected. A yellow oval represents potential area of cavity made by the inflation of the balloon during kyphoplasty.


Table 71-1

Approach Methods for Percutaneous Vertebroplasty




















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

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Jul 11, 2019 | Posted by in NEUROSURGERY | Comments Off on Vertebroplasty and Kyphoplasty
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