Kyphoplasty & Vertebroplasty

Osteoporosis

• Quantitative loss of bone mass
• Mineralisation & fracture healing normal
• WHO definition is T score <-2.5
• Senile or Post-menopausal
  • Senile: age-related reduction in bone mass
  • Post-menopausal: due to loss of oestrogen
    • Worst in first 5 years
    • Total bone mass loss of 3% per year

Vertebral Compression Fractures

• Increased incidence in proportion to age
• For each SD below 2.5, risk of vertebral fracture increases by 2x
• 5-year mortality after VCF higher than after hip fracture
• Each thoracic VCF causes 9% decrease in lung FVC
• Wedge – thoracic spine
• Biconcave – lumbar spine
• Mild, moderate, or severe (>40% height reduction)

Differential Diagnosis

• Metastatic disease
  • More likely with fracture above T5
• Lymphoma/leukaemia
• Infection
• Haemangioma
• Myeloma

Management

• Non-operative – supportive treatment is mainstay
• Medical therapy for pain relief and future fracture prevention

Surgical

• Failed non-operative Rx (6 weeks) – consider biopsy to rule out tumour
• Open surgery
  • For neurologic compromise & instability (rare)
• Kyphoplasty & Vertebroplasty
  • Contraindications
    • Posterior cortex disruption – cement extrusion (VP > KP)
    • Retropulsed bone fragments
    • Neurologic Injury
    • Instability
    • Healed, sclerotic vertebra that is painful
  • Indications
    • Intractable pain
    • Failure of non-operative management
    • Fracture < 3 months old

Kyphoplasty

• Aim: Pain relief and correction of deformity
• Technique
  • Transpedicular – any level where pedicles are >4mm size
  • Extrapedicular – in upper T-spine – uses rib & pedicle as a complex
  • Posterolateral – For L2-4, which have small pedicles
• Procedure
  • Balloon is inflated within vertebra to check it works
  • Balloon deflated
  • Cement passed into balloon
• Complications
  • Transient fever
  • Cement extrusion – rarely of clinical significance if it occurs
  • Epidural haematoma
  • Cord injury

Vertebroplasty

• For Pain relief – no kyphosis correction
• Same approaches but transpedicular preferred
  • Posterolateral has higher rate of cement leakage
• Procedure
  • Cement injected at low viscosity under low pressure
  • Fills fracture lines – spider-like
  • Once reaches posterior cortex, injection is stopped
• Complications as for KP

Outcomes

• Equivalent outcomes at 6 months in terms of pain relief
• Kyphoplasty does improve radiographic appearance
• Not proven to correlate to better clinical outcome
• No long-term data