Kyphoplasty and Vertebroplasty

(This is the section that explains the detail of the operation or procedure above and should be read in conjunction with the section Your Back Operation).

The treatment of vertebral compression fractures historically revolved around bed rest, analgesic medication and the use of a brace (corset) for extended periods. Spinal compression fractures can take up to 6–18 months to heal and in some cases might never heal. In some patients the pain becomes tolerable after 1–2 months despite the fact that the fracture has not healed. Where the use of steroids is the cause of the spinal fractures, the patient often presents with multiple vertebral fractures, severe collapse and extensive complications without treatment. A painful fracture that has not healed can qualify for operative treatment if the MRI scan reveals that the fracture has not healed. This means that some fractures can still be surgically treated after a year.

Kyphoplasty and Vertebroplasty are minimally invasive procedures to mainly, but not exclusively, treat osteoporotic and metastatic vertebral compression fractures of the spine and sacrum. These procedures are performed to stabilise the bodies of the collapsed (fractured) vertebrae and restore the height of the vertebrae.

These procedures are also used to treat haemangioma (benign vascular tumours of the spine), to reinforce soft bone with bone cement before insertion of pedicle screws and rods (see the section Lumbar Fusion) and in reduction and splinting of traumatic fractures. Treatment with Kyphoplasty and Vertebroplasty should be performed according to strict treatment protocols. Kyphoplasty is a technically demanding procedure and requires that specialists attend a formal training course. Fractures in the soft, osteoporotic vertebrae of the older patient are fixed with bone cement (PMMA) which acts as glue and increases the inherent strength of the vertebrae. Fractures in the normal, hard vertebrae of younger patients are splinted with calcium phosphate, as opposed to using PMMA. Calcium phosphate undergoes remodeling and gets absorbed in time. These procedures should only be done by trained specialists in hospitals with proper equipment.

 

   
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Images used with permission from Medtronic

In a Kyphoplasty procedure, a balloon is inserted into the vertebral body through the needle and the vertebra is lifted up under the pressure that the balloon generates when it is filled with fluid. Thereafter, the balloon is removed and the void carefully filled with bone cement. All of this is performed under constant fluoroscopic guidance.

 

There are a few significant differences between Kyphoplasty and Vertebroplasty.

In both these procedures PMMA is injected into the vertebrae. With Kyphoplasty the shape and height of the collapsed vertebrae can be restored to varying degrees. This is achieved by increasing the height of the fractured vertebrae by inserting a cannula through the skin of the back into the vertebral body. A balloon that can generate high pressures is inserted through the cannula and inflated to achieve this. By increasing the height of the fractured vertebrae and restoring the alignment of the spine, the stress in the adjacent vertebral segments is reduced. This is thought to diminish the incidence of adjacent vertebral fractures. In Vertebroplasty the fracture is partially restored and therefore the height of the vertebral body by positioning the patient on bolsters in a specific manner in theatre prior to the PMMA being injected. This is less efficient in restoring height than is the case in Kyphoplasty.

The incidence of cement leakage in Kyphoplasty is lower than in Vertebroplasty, since a cavity is created within the vertebral body by means of an inflatable balloon, before the cement is injected into the cavity. In Vertebroplasty, the cement is injected under pressure into the vertebra and the flow of cement may be difficult to control and this may lead to leakage.

The difference in the pressure generated during cement injection is especially important in the treatment of metastatic fractures where the outer layer of the vertebra is softer. Kyphoplasty is therefore a safer procedure in these patients. In both procedures significant improvement in pain can be achieved within hours of the procedure.
 
There is a significant difference in the cost between the two procedures.

The success of both procedures not only depends on surgical finesse and experience, but on proper follow-up. In osteoporotic patients the vertebrae adjacent to the treated vertebra, are also osteoporotic. Therefore, pain experienced after a previous Kyphoplasty or Vertebroplasty is an indication of another vertebral fracture, unless proven otherwise.

It is important to perform a specific sequence MRI scan before a Kyphoplasty or Vertebroplasty procedure is carried out, since it is impossible to distinguish between an old, healed fracture and a new fracture on X-rays or a CT scan. The MRI scan is also useful in diagnosing adjacent or distant damaged vertebrae with impending fractures. It is therefore necessary to have an up to date MRI scan prior to commencing treatment with Kyphoplasty or Vertebroplasty.

It is important to have a proper first consultation with a specialist where a full medical history, physical examination and appropriate scans are performed. It is advisable that a family member accompany the patient on the first visit so that all parties are educated with regards to the pathology, treatment and potential complications. After a Kyphoplasty or Vertebroplasty procedure was performed, it is crucial that the patient is followed-up within weeks of the procedure in order to exclude any complications and to diagnose any new fractures.

The patient and the family must know that if and when the patient experiences new acute pain after surgery from the first week onwards, it is vital that the patient is seen by a specialist immediately. The specialist will determine whether there is progressive collapse of the vertebrae that necessitates another operation.

Treating new fractures promptly reduces the pain associated with the fracture and prevents multi-level disease. Multi-level osteoporotic vertebral fractures leads to progressive kyphosis (increased angle or forward bend of the spine) which can lead to other morbidities such as decreased lung function, congestive heart failure, bowel problems, depression, satiety, flatulence and other complications.

There is a small risk of bone cement leakage involved with Kyphoplasty and Vertebroplasty procedures. Bone cement leaking out of the vertebral body can irritate or damage the spinal cord or nerves. This can cause pain, abnormal sensation, or very rarely, paralysis. In severe cases of cement leakage, an operation may be needed to stop the irritation of the nerves and spinal cord. There is also a small risk of the cement travelling via blood channels in the bone and blood vessels to the patient’s lungs.

Ward care

Log-rolling (where the patient’s hips and shoulders are kept in alignment) is allowed immediately following the procedure. The patient may sit or walk as soon as they feel up to it, but must be assisted by a member of the nursing staff or a physiotherapist. If the patient is too frail, mobilisation can commence the next morning. The use of a brace is normally not required, except in young patients where fractures were treated with calcium phosphate. Improvement of symptoms is usually immediate with full recovery in the first month depending on factors such as the number of fractured vertebrae as well as the time elapsed since the fracture occurred.  

Discharge

Patients are normally discharged the day after the procedure if there are no complications or co-morbidities necessitating a longer stay. You may be given analgesic medication, a back exercise routine and a follow-up date. You are advised to contact your specialist prior to your follow-up date if you experience any undue discomfort after your discharge. 

Rehabilitation

Rehabilitation consists of a strict back routine. You are not allowed to bend or twist your back during your rehabilitation period. Use the log-rolling technique when turning over in bed. You are allowed to sit, stand, kneel, walk and drive a vehicle. If you experience acute pain, contact your specialist immediately.

Follow-up

During the follow-up appointment your specialist will discuss ongoing osteoporotic treatment, investigate the cause of any persisting pain or new symptoms and discuss the treatment of co-morbidities. 

It is important to realise that you will have to protect your back for the rest of your life and apply good back habits (see the section Caring for your Spine).

 
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This website is a patient resource compiled from information from leading spinal surgeons practicing in South Africa and complements the My Spine – Lumbar and My Spine – Cervical information booklets that you can obtain directly from your spinal specialist. You will find information about spinal conditions and treatment on this website.

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