Vertebroplasty and Kyphoplasty: Reasons for Concern?
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
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