Dr. Tigran Khachatryan, MD, PhD.

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Balloon Kyphoplasty

Patient Education: Vertebroplasty and Kyphoplasty

What Are Vertebroplasty and Kyphoplasty?

Vertebroplasty and Kyphoplasty are minimally invasive treatment techniques used for vertebral body compression fractures. These procedures involve injecting bone cement into a fractured vertebra to stabilize the spine and alleviate pain.

  • Vertebroplasty involves the direct percutaneous injection of bone cement, most commonly polymethyl methacrylate (PMMA), into the fractured vertebral body. Its primary goals are pain alleviation and preventing further loss of vertebral body height.
  • Kyphoplasty is a modification of vertebroplasty where an inflatable balloon is first inserted into the vertebral body. This balloon is inflated to compress the cancellous bone, create a cavity, and gently elevate the fractured vertebra in an attempt to restore it to the correct position. After the balloon is deflated and removed, the created cavity is filled with bone cement. Additional goals of kyphoplasty include restoring vertebral body height and reducing kyphosis (a hunched back).

Both procedures aim to stabilize your spine and reduce your pain.

What is a Spinal Fracture? (Etiology)

A spinal fracture, also known as a vertebral compression fracture (VCF), occurs when the thick portion of bone at the front of a vertebra fractures and collapses. These fractures most often happen in your thoracic (mid-back) or lumbar (lower back) spine.

The leading cause of spinal fractures is osteoporosis, a disease that makes bones brittle and prone to breaking easily. Osteoporosis often progresses without obvious symptoms, meaning a person might not know they have it until a fracture occurs. Spinal fractures can also result from:

  • Trauma
  • Weakening of the bone structure due to conditions like neoplasia, which includes osteolytic metastases, spinal myeloma lesions, or vascular neoplasms. Remarkably, these fractures can occur during normal daily activities, such as bending over, reaching for an object, carrying groceries, twisting, coughing, sneezing, lifting, or even rolling over in bed.

Symptoms of Spinal Fractures

Spinal fractures can cause a range of pain, from sudden and severe to mild and persistent. Acute pain typically lasts around 4–6 weeks, felt along the axis of the spine and correlating with the fracture level. Activities often aggravate the pain, while lying down or sitting may alleviate it.

It’s important to note that spinal fracture symptoms can easily be mistaken for general back pain or a “normal” part of aging, leading to many cases going undiagnosed and untreated. Some individuals may even have a spinal fracture without experiencing any symptoms at all.

Multiple spinal fractures can lead to more severe consequences:

  • Your spine may shorten and angle forward, resulting in a stooped posture or hunched back (kyphosis).
  • This can make it difficult to walk, reach for things, or perform activities of daily living.
  • Chronic back pain, height loss, diminished appetite, and difficulty sleeping can be associated with kyphosis.
  • There's an increased risk of serious, or even fatal, pulmonary (lung) complications.
  • Psychosocial effects may include depression, anxiety, lowered self-esteem, isolation, and sadness.

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Diagnosis of Spinal Fractures

If a spinal fracture is suspected, your doctor will perform a complete physical exam. Diagnosis is typically confirmed with imaging studies:

  • X-rays
  • Magnetic Resonance Imaging (MRI), especially T2-weighted or STIR sequences, which can show increased signal intensity associated with edema in recent fractures.
  • A bone scan can also help identify more recent fractures.
  • Computed Tomography (CT) scans may be used for precise assessment of the posterior cortical wall integrity and pedicle sizes.

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Treatment Options and Indications

Traditional (Conservative) Treatment

Before minimally invasive procedures became common, spinal fractures were often treated with methods such as:

  • Bedrest
  • Bracing
  • Pain management, often with narcotics
  • Physical therapy for core muscle strengthening
  • For osteoporosis, calcium supplements, vitamin D, hormone replacement, and bisphosphonates While appropriate in some cases, these traditional treatments may not address the spinal deformity caused by the fracture and do not help restore lost vertebral height or reduce kyphotic deformity. Bed rest, in particular, can be counterproductive for patients with osteoporosis in the long run.

Indications for Vertebroplasty and Kyphoplasty

These minimally invasive procedures are generally recommended for:

  • Osteoporotic vertebral body compression fractures that cause persistent symptoms despite nonsurgical interventions.
  • Pathological fractures due to osteolytic metastases, spinal myeloma lesions, or vascular neoplasms.
  • Patients experiencing pain that correlates well with the level of a recent compression fracture.
  • Fractures located in the lumbar and thoracic spine.

Kyphoplasty has been shown to be superior to medical therapy alone in improving both pain and patient function. Both procedures effectively reduce back pain and stabilize the spine. Kyphoplasty, in particular, aims to restore vertebral body height and correct spinal alignment, which can lead to improved quality of life, mobility, and ability to perform daily activities.

Absolute contraindications for these procedures include local infection, untreated hematogenous infection, uncorrected coagulopathy, spinal canal compromise, radiculopathy, posterior vertebral body cortical fractures, and severe (>75%) vertebral body collapse.

How the Procedures Work

Vertebroplasty and kyphoplasty are typically performed in a specialized spine clinic, although a hospital stay may sometimes be necessary. You will lie face down on the procedure table, and the procedure will be guided by X-ray (fluoroscopy) or CT scans for precise needle placement and monitoring of cement injection.

The procedure usually takes less than one hour per fracture level treated. Your doctor will determine whether local or general anesthesia is most appropriate for you, or if sedation will be used to make you relaxed and sleepy.

For Kyphoplasty:

  • Small Incision: A spine specialist creates a small pathway into the fractured bone using a hollow instrument. The incision site is approximately 1 cm in length.
  • Balloon Placement: A small orthopedic balloon is guided through this instrument into the vertebra.
  • Balloon Inflation: The balloon is carefully inflated to gently elevate the collapsed vertebra, attempting to return it to its normal position and create a cavity within the bone.
  • Balloon Removal & Cement Filling: Once the desired position is achieved, the balloon is deflated and removed, leaving a cavity. This cavity is then filled with a special bone cement to support the surrounding bone and prevent further collapse.
  • Internal Cast: The cement hardens, forming an internal cast that holds the vertebra in place. This process is generally performed on both sides of the vertebral body.

For Vertebroplasty:

  • Cement Injection: Bone cement (most commonly PMMA) is directly injected into the fractured vertebral body through a needle.
  • Stabilization: The cement then hardens within about 20 minutes, stabilizing the vertebra.

During cement injection, it is crucial to use live fluoroscopy and halt the injection once the cement reaches the posterior third of the vertebral body to minimize risks. Ensuring proper mixing and polymerization of the PMMA bone cement before injection is vital to prevent complications like cement embolisms.

 

Presurgical Preparation

Careful preparation is key to a successful procedure:

  • Your provider will give you detailed instructions regarding fluids, meals, and medications before the procedure. You will need to avoid eating or drinking for several hours beforehand.
  • If you take blood thinners, you may need to stop them for a few days before the procedure, with approval from your medical doctor.
  • You might need to obtain medical clearance from your primary care physician or cardiologist.
  • Preoperative routine checks of inflammatory parameters (C-reactive protein and white blood cell count) and an MRI should be performed. If inflammatory markers are elevated and an infection is suspected, an enhanced MRI should be done.
  • If you have any type of acute infection, the procedure should be delayed until the infection improves and inflammatory parameters decrease. A one- to two-week period of conservative management is suggested to exclude infection in patients with an acute compression fracture and elevated inflammatory parameters.
  • For immunocompromised patients with comorbidities, conservative treatment might lead to better outcomes than cement augmentation. In high-risk patients, some suggest adding tobramycin to the cement or using perioperative intravenous prophylactic antibiotics.
  • You must arrange in advance for an accompanying family member or friend, over the age of 18, to stay with you during the procedure and drive you home afterwards.
  • Wear comfortable clothing and leave your jewelry at home on the day of the procedure.

Postoperative Care

After your vertebroplasty or kyphoplasty, you can expect the following during your recovery:

  • Immediate Recovery: You will likely be transferred to the recovery room for about an hour, where a nurse will monitor your condition and assess your pain.
  • Hospital Stay: Most patients go home the same day, but some may require an overnight hospital stay.
  • Pain Management: The area where the needle was inserted in your back might be sore for a few days up to two weeks. You may not need as much pain medicine as before the procedure, as pain relief is often significant within the first 24 hours. Take any prescribed pain medicines exactly as directed, and ask your doctor about over-the-counter options if needed. Do not take multiple pain medicines simultaneously without your doctor's guidance.
  • Incision Care: You will have a dressing over the incision. Your doctor will provide specific instructions for its care. Generally, the dressing should stay on for 2 days, after which you may remove it, shower, and cover the area with a dry dressing. Avoid using ointments or creams on the incision and do not submerge it in water (e.g., baths or swimming) for at least one week.
  • Ice Application: To relieve soreness at the needle insertion site, apply ice or a cold pack for 10 to 20 minutes at a time, every 1 to 2 hours for the first 3 days (while awake), or until swelling subsides. Always place a thin cloth between the ice and your skin.
  • Activity: Take it easy for the first 24 hours and rest when you feel tired, as sufficient sleep aids recovery. Gradually increase your activity over the next few weeks as your pain lessens. Mobility is often quickly improved after treatment. You should avoid heavy lifting for at least six weeks.
  • Diet: You can typically resume your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
  • Medications: Your doctor will instruct you on when to restart your regular medications, including any blood thinners.
  • Follow-up Care: You will need to schedule a follow-up visit, usually two to four weeks post-procedure, to assess for any complications and discuss any limitations on physical activity. If you have osteoporosis, it's important to follow up with your primary care provider or a Bone Health Program for ongoing medication treatment.

It’s vital to make and attend all follow-up appointments and to contact your doctor if you experience any concerning symptoms.

Surgical Complications

While vertebroplasty and kyphoplasty are generally considered safe procedures with low complication rates, some risks can occur. Complications can be categorized by severity:

Mild Complications:

  • Temporary increase in pain or fever: Attributed to an inflammatory response from the heat generated by the cement polymerization. This can usually be managed with analgesics and antipyretics.
  • Transient arterial hypotension: An infrequent complication that usually responds well to supportive measures and is self-limiting.
  • Rib fractures, radiculopathy, or pneumothorax: May occur, especially in patients with advanced osteoporosis, due to pressure during needle insertion. Radiculopathy is generally treatable with conservative approaches.

Moderate Complications:

  • Infections: Discitis, osteomyelitis, and epidural infections can occur, as is a risk with any percutaneous procedure. Infections occurring shortly after the procedure may indicate a pre-existing infection or a procedure-induced one.
  • Cement extravasation (leakage) into foraminal, epidural, or dural spaces: This is a common occurrence, though most cases remain asymptomatic or have negligible symptoms. However, it can potentially lead to neurological compromise, such as spinal cord or nerve root damage, paraplegia, or radiculopathy, depending on the volume of leakage.

Severe Complications:

  • Cement Leakage into the Venous System and Pulmonary Embolism: This is one of the most prevalent complications. Cement can leak into the perivertebral venous plexus, reaching the azygos vein or vena cava, then the right cardiac chamber, and ultimately the pulmonary arterial system, potentially causing a fatal pulmonary embolism. Factors include insufficient cement polymerization, incorrect needle positioning, or overfilling the vertebral body.
  • Cardiac Perforation: If cement advances into the right ventricle and is too long or rigid to pass, it may lodge in the heart and lead to cardiac perforation, an extremely rare but potentially fatal complication.
  • Cerebral Embolism: Instances have been reported, often attributed to fat emboli resulting from heightened intramedullary pressure during cementation.
  • Additional fractures in neighboring spinal bones: These procedures might increase the risk of fractures in adjacent spinal bones. However, some research suggests this may be more related to underlying osteoporosis than the procedure itself.
  • Bleeding or Infection: Any needle-guided procedure carries a small risk of bleeding or infection at the site.
  • Nerve Damage or Paralysis: Can occur if leaked cement presses on the spinal cord or nerves.
  • Spinal Fluid Leak: A rare potential complication.

The frequency of complications is notably higher in cases of neoplastic vertebral collapse compared to osteoporotic collapse. Factors such as cortical destruction, epidural soft-tissue masses, highly vascular lesions, and significant vertebral collapse contribute to an elevated likelihood of complications. Cement leakage rates are generally higher with vertebroplasty (40–41%) than with kyphoplasty (8–9%), with symptomatic leaks being more common in vertebroplasty.

 

Reducing the Risk and Effects of Complications

To minimize the risk of complications, healthcare providers adhere to strict protocols:

  • Precise Technique: The procedure technique aims for access through the transpedicular route in the lumbar spine and the costovertebral junction in the thoracic spine, avoiding cortical breaches when possible.
  • Cement Optimization: Cement opacification should be optimized by following manufacturer recommendations, not exceeding recommended powder and liquid polymer proportions, and ensuring optimal cement viscosity before injection.
  • Procedure Termination: If cement leakage occurs, termination of the procedure is recommended.
  • Preoperative Screening: Mandatory preoperative checks of inflammatory parameters and MRI are crucial.
  • Post-Procedure Vigilance: Persistent severe pain, new severe pain of a different character, signs of spinal canal stenosis, or sudden onset of respiratory symptoms should prompt emergency diagnostics to rule out complications and initiate treatment if necessary.
  • Follow-up: Outpatient clinic follow-up typically occurs two to four weeks post-procedure to assess for signs of complications.

Clinicians must have a clear understanding of the patient’s condition, follow proper protocols during the procedure, and often utilize a combination of fluoroscopy and CT for precise needle positioning and injection assessment.

Summary

Vertebroplasty and Kyphoplasty are effective, minimally invasive treatments for vertebral compression fractures, most often caused by osteoporosis or cancer. These fractures can lead to severe back pain, spinal deformity, and reduced quality of life.

Diagnosis typically involves physical examination, X-rays, and MRI. Prior to the procedure, comprehensive presurgical preparation includes medication adjustments, medical clearance, and screening for infection.

During the procedure, bone cement is injected into the fractured vertebra to stabilize it and reduce pain. Kyphoplasty additionally uses a balloon to create a cavity and attempt to restore vertebral height.

Postoperative care focuses on managing soreness with ice and pain medication, gradual return to activity, incision care, and important follow-up appointments.

While generally safe, surgical complications can occur, including cement leakage (potentially leading to pulmonary embolism or nerve damage), infection, and new fractures. However, careful technique, thorough preoperative screening, and vigilant post-procedure monitoring are crucial in minimizing these risks.

Both procedures have shown to significantly reduce pain and improve patient function, offering a valuable treatment option for those suffering from debilitating vertebral compression fractures.

Disclaimer: This information is for educational purposes only and does not replace the advice of a medical doctor. Always consult with your physician for diagnosis and treatment of any medical condition.