Vertebroplasty and Kyphoplasty: Reasons for Concern?

https://doi.org/10.1016/j.ocl.2009.05.004Get rights and content

Two different minimally invasive percutaneous vertebral augmentation methods for cement application into the vertebral body for the management of symptomatic compression fractures without neurologic impairment have been developed, namely, vertebroplasty and kyphoplasty. In vertebroplasty, polymethylmethacrylate cement is injected percutaneously into a collapsed vertebral body. Kyphoplasty involves placing an inflatable bone tamp percutaneously into a vertebral body. The inflation of the bone tamp with fluid allows restoration of vertebral height and correction of the kyphosis. After deflation, the cavity that has been produced is filled by injection of polymethylmethacrylate. This article provides an overview of the state of the art in vertebroplasty and kyphoplasty, discussing the indications, techniques, results, and pitfalls.

Section snippets

Indications

The field of vertebroplasty and kyphoplasty is continuously evolving, and the authors recommend following the guidelines put forth by national and international societies.20

The main indications for vertebroplasty and kyphoplasty are (1) intractable, intense pain adjacent to the level of the fracture9, 10 in patients who have osteoporotic fractures diagnosed by radiographs, CT, or MRI. Conservative management for at least 3 to 4 weeks21 should have failed in these patients for the surgical

Vertebroplasty

To achieve a low complication rate, the most important factor influencing the outcome of the vertebroplasty is the visualization of needle placement and cement application.26 Vertebroplasty may be performed using single-plane fluoroscopy, but the authors prefer to use CT scanning, which decreases the procedure time27 and facilitates accurate visualization of needle placement and distribution of the cement. Monitoring cement distribution under direct fluoroscopic control is another crucial

Pitfalls

The procedures have a low rate of clinically relevant complications, but some can potentially be devastating, and should be discussed thoroughly with the patient and their family before the procedure. Cement extravasation is one of the possible complications of vertebroplasty. The reported incidence is up to 40% in patients who have osteoporotic fractures. Paravertebral soft tissue, intervertebral disc, needle tract, epidural and paravertebral veins, the spinal canal, and the neural foramen can

Vertebroplasty versus kyphoplasty: What does the available evidence suggest?

Despite the good clinical outcomes reported with both vertebroplasty and kyphoplasty, and the fact that percutaneous vertebroplasty has been performed for more than 30 years, there is a lack of well-conducted randomized control trials on the subject. The evidence to support these techniques in the management of patients who have symptomatic osteoporotic vertebral compression fractures refractory to conventional medical therapy is, at best, based at Level III.51, 52 Three systematic reviews

Costs

Kyphoplasty is 10 to 20 times more expensive than vertebroplasty performed with conscious sedation on an outpatient basis.27, 30, 54 Additional costs of a kyphoplasty include the device itself, the cost of the anesthesia, duration of the procedure, and inpatient hospitalization.55

Causes for concern

Minimally invasive percutaneous vertebral augmentation methods for cement application into the vertebral body are potentially useful tools for the management of symptomatic compression fractures without neurologic impairment. However, they are not indicated for every type of fracture. External immobilization (ie, bracing or casting) remains the most important nonoperative management for vertebral fracture, and most patients will heal in a brace with nonoperative management.

A critical evaluation

References (56)

  • D.T. Gold

    The clinical impact of vertebral fractures: quality of life in women with osteoporosis

    Bone

    (1996)
  • F.M. Phillips

    Minimally invasive treatments of osteoporotic vertebral compression fractures

    Spine

    (2003)
  • C.A. Dickman et al.

    Transpedicular screw-rod fixation of the lumbar spine: operative technique and outcome in 104 cases

    J Neurosurg

    (1992)
  • S.I. Esses et al.

    Complications associated with the technique of pedicle screw fixation. A selected survey of ABS members

    Spine

    (1993)
  • P. Galibert et al.

    Neurochirurgie

    (1987)
  • S.R. Garfin et al.

    New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures

    Spine

    (2001)
  • T.H. Diamond et al.

    Clinical outcomes after acute osteoporotic vertebral fractures: a 2-year non-randomised trial comparing percutaneous vertebroplasty with conservative therapy

    Med J Aust

    (2006)
  • R.T. Hoffmann et al.

    Radiologe

    (2003)
  • R.T. Hoffmann et al.

    Radiologe

    (2003)
  • D.R. Fourney et al.

    Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients

    J Neurosurg

    (2003)
  • I.H. Lieberman et al.

    Initial outcome and efficacy of “kyphoplasty” in the treatment of painful osteoporotic vertebral compression fractures

    Spine

    (2001)
  • I.H. Lieberman et al.

    Vertebroplasty and kyphoplasty: filler materials

    Spine J

    (2005)
  • J.V. Coumans et al.

    Kyphoplasty for vertebral compression fractures: 1-year clinical outcomes from a prospective study

    J Neurosurg

    (2003)
  • J.T. Ledlie et al.

    Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic pain, and activity levels

    J Neurosurg

    (2003)
  • K. Siemionow et al.

    Vertebral augmentation in osteoporosis and bone metastasis

    Curr Opin Support Palliat Care

    (2007)
  • F.M. Phillips et al.

    Early radiographic and clinical results of balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

    Spine

    (2003)
  • F.M. Phillips et al.

    An in vivo comparison of the potential for extravertebral cement leak after vertebroplasty and kyphoplasty

    Spine

    (2002)
  • W.T. Ploeg et al.

    Percutaneous vertebroplasty as a treatment for osteoporotic vertebral compression fractures: a systematic review

    Eur Spine J

    (2006)
  • Cited by (49)

    • History of Spinal Instrumentation: The Modern Era

      2016, Benzel's Spine Surgery: Techniques, Complication Avoidance and Management: Volume 1-2, Fourth Edition
    • Vertebral Augmentation for Osteoporotic Compression Fractures

      2016, Journal of Clinical Densitometry
      Citation Excerpt :

      For KP, the needle is introduced if the infusion needle is the same as used for VP. Balloon tamps are introduced through the needle and inflated to make a cavity (ies) in the vertebral body (9,14). PMMA can then be introduced into the cavity under lower pressure to fill the cavity (15).

    • Tissue engineering strategies applied in the regeneration of the human intervertebral disk

      2013, Biotechnology Advances
      Citation Excerpt :

      Spinal fusion secondary to fractures, deformity or instability such as spondylolisthesis has been shown to be very effective (Swan et al., 2006). However, due to the complexity of the spine articulations, its benefits in the control of pain related to IDD are inconclusive (Denaro et al., 2009). Spinal fusion compromises spine flexibility and usually leads to pseudoarthrosis, due to the increased strain in adjacent segments which accelerates IDD in the adjacent vertebrae (Don and Carragee, 2008).

    View all citing articles on Scopus
    View full text