Vertebroplasty and kyphoplasty.
ABSTRACT Vertebral compression fractures occur more frequently than hip and ankle fractures combined. These fragility fractures frequently result in both acute and chronic pain, but more importantly are a source of increased morbidity and possibly mortality. Percutaneous veretebral augmentation offers a minimally invasive approach for the treatment of vertebral compression fractures. The history, technique, and results of vertebroplasty and kyphoplasty are reviewed. Both methods allow for the introduction of bone cement into the fracture site with clinical results indicating substantial pain relief in approximately 90% of patients.
- SourceAvailable from: ossano.se[show abstract] [hide abstract]
ABSTRACT: To review the pathophysiology of osteoporosis and describe vertebroplasty and kyphoplasty, which are minimally invasive procedures to treat the pain associated with vertebral compression fractures (VCFs). Extensive literature review of osteoporosis, vertebroplasty, and kyphoplasty supplemented by case study and clinical experience in the minimally invasive interventional neuroradiology interventions. Osteoporosis is a progressive debilitating process that destroys the cancellous bone, weakening the overall integrity and stability of the bone. The loss of bone mass places the individual at increased risk for vertebral body, hip, and wrist fractures. In the past, there was no treatment option to repair vertebral body deformity or instability after osteoporotic VCFs. Management solely relied on the use of nonsteroidal anti-inflammatory drugs, narcotics, muscle relaxants, and/or orthotic bracing to provide pain relief. VCFs alter the stability of the vertebral body and column, and the lack of stabilization can lead to chronic pain syndrome, immobility, pulmonary compromise, progression of spinal deformity, increase in the risk for additional VCFs, and increase in the risk for comorbidities and mortality related to immobility. Vertebroplasty and kyphoplasty are minimally invasive procedures aimed at pain control, stabilization of the vertebral body, and with kyphoplasty, the ability to provide some correction of deformity with partial restoration of vertebral body height. Providing pain control and stabilization of the vertebral column improves mobility, thus decreasing the potential risks associated with immobility.Journal of the American Academy of Nurse Practitioners 08/2005; 17(7):268-76. · 0.71 Impact Factor
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ABSTRACT: Osteoporotic compression fractures cause great morbidity to the aging population. Various percutaneous methods have been developed to aid in treatment, including vertebral kyphoplasty. Biomechanical studies and recent published data relate concerns about adjacent fracture. This study investigated the incidence of recurrent fracture after the kyphoplasty procedure. Retrospective review of kyphoplasty procedures preformed by a single surgeon. A total of 109 procedures in 94 patients were reviewed. Patient medical records were reviewed as well as the radiology database at two major regional hospitals. Patient records were reviewed for fracture recurrence. Confounding factors of age at procedure, sex, and chronic steroid use were also considered and found to have no statistically significant difference between those with fracture recurrence and those without fracture recurrence (p=.1979, p=.2058, p=.4684, respectively). Eleven kyphoplasty procedures resulted in a recurrent fracture after kyphoplasty within the first 90 days (34+/-19). After the first 90 days, five recurrent fractures occurred (459+/-101). The number of vertebral levels treated was found to be related to incidence of recurrent fracture with a p value of .0005 via chi-square testing. Patients who sustained a recurrent fracture tended to have a higher number of vertebral levels treated. There was no statistically significant difference between the survival time of kyphoplasty procedures that resulted in recurrent adjacent versus distant vertebral body fracture (survival time 112+/-145 vs. 237+/-268, p value .2362). The incidence of recurrent fracture after kyphoplasty is substantial at 10% within the first 90 days. It is difficult to determine if this fracture rate is the result of surgical intervention or the natural history of the patient's osteoporosis.The Spine Journal 01/2006; 6(5):488-93. · 3.36 Impact Factor
- American Journal of Neuroradiology 03/2001; 22(2):373-81. · 3.17 Impact Factor
Vertebroplasty and Kyphoplasty
William Lavelle, MDa,*, Allen Carl, MDa,
Elizabeth Demers Lavelle, MDb,
Mohammed A. Khaleel, MSa
aDepartment of Orthopaedic Surgery, 1367 Washington Avenue, Albany Medical Center,
Albany, NY 12206, USA
bDepartment of Anesthesiology, Albany Medical Center, 43 New Scotland Avenue, Albany,
NY 12208, USA
The problem of osteoporosis
The aging population has brought new challenges to the medical commu-
nity including osteoporosis, which is considered one of the most debilitating
estimates that more than 55% of Americans over the age of 50 suffer from ei-
ther osteopenia or osteoporosis. Women bear the largest burden, making up
standing height. The three sites that are typical of fragility fractures are the
vertebra, hip, and wrist. Figs. 1–3 demonstrate a vertebral body fracture.
With an annual incidence of 700,000, vertebral compression fractures occur
more frequently than hip and ankle fractures combined . Patients who
have vertebral compression fractures often suffer such pain that it interferes
with their daily living. Vertebral compression fractures account for 150,000
hospital admissions, 161,000 physician office visits, and more than 5 million
tures in the United States topped $13.8 billion, or $38 million daily [5,6].
Vertebral compression fractures frequently result in both acute and
chronic pain, as well as leading to progressive vertebral collapse [5,7]. One
thoracic vertebral compression fracture can cause enough overall sagittal
kyphosis to cause a 9% loss of forced vital capacity [8–10]. Patients
A version of this article originally appeared in the 91:2 issue of Medical Clinics of North
* Corresponding author.
E-mail address: email@example.com (W. Lavelle).
1932-2275/07/$ - see front matter ? 2007 Elsevier Inc. All rights reserved.
25 (2007) 913–928
sustaining osteoporotic compression fractures also face increased risks for
multiple comorbidities such as weight loss due to early satiety and poor psy-
chologic well being [11–14]. Although these fractures are rarely a direct
cause of death, they do frequently produce significant morbidities that
Fig. 1. A radiograph of a vertebral fracture is shown, demonstrating an osteoporotic compres-
Fig. 2. Bone scan showing an acute vertebral fracture.
LAVELLE et al
may eventually affect the mortality of the patient [12–19]. The 5-year
survival of a patient who sustains a vertebral compression fracture is lower
than that of a similar patient sustaining a hip fracture . More commonly,
elderly patients who were independent before their injury find themselves
dependent on their adult children .
In the past, attempts at open surgical treatment of these injuries have
been fraught with disaster. Poor bone quality would often lead to implant
failure. Perioperative morbidity was often high because elderly patients
bear other medical comorbidities. This has lead to patients being treated
conservatively with oral, narcotic analgesia and an orthosis. Because this
treatment offers little for those truly debilitated by their injury, physicians
have become interested in new methods for pain relief and functional resto-
ration to a degree that patients may return to their activities of daily living.
Use of cement in orthopaedics
Chemist Otto Ro ¨ hm developed a new substance in the early twentieth
century with novel structural properties and good biocompatibility. In the
1960s, Sir John Charnley began using Polymethyl methacrylate (PMMA)
as bone cement on numerous patients for the fixation of both the femur
and acetabulum for total hip replacement. Borrowing this idea from dentists
of his era, bone cement acts as a grout, filling in the voids between the metal
prosthesis and bone [21,22].
In the spine, PMMA was first used to treat a painful and aggressive var-
iant of a vertebral haemangioma [21–26]. Bone cement was later used to
Fig. 3. Model showing a vertebral body fracture.
VERTEBROPLASTY AND KYPHOPLASTY
treat painful vertebral lesions caused by metastatic disease to the spine
[27–29]. Multiple explanations have been offered for the pain relief associ-
ated with introduction of PMMA into an osteoporotic compression fracture
site. Thermal necrosis and chemotoxicity of the intraosseous pain receptors
have been offered as explanations in addition to the obvious improvement in
mechanical stability offered by the bone cement . It has been proposed
that the cement monomer itself may be neurotoxic [31–33] and possibly
act on the interossious nerve endings in the vertebral body. To create less
viscous cement with a longer working time for use in percutaneous vertebral
augmentation, more monomer is typically added to the powder than is rec-
ommended by the manufacturer [4,34,35]. The polymerization reaction of
PMMA cement is exothermic. During the polymerization, temperatures
can reach up to 122?C [36,37]; however, cadaveric study of osteoporotic
vertebrae found that temperatures generated during vertebroplasty may
not be sufficient to result in widespread thermal necrosis of osteoblasts
[38–40] or nerve endings . Whatever its mechanism, injection of bone
cement into painful vertebral compression fractures is a successful technique
with well-published clinical efficacy.
Indications for percutaneous vertebral augmentation
As with any surgical procedure, the typical patient who is offered percu-
taneous vertebral augmentation is one who has already failed several weeks
of conservative therapy consisting of oral nonsteroidal medications and
mild opiate analgesia. Usually, patients have been offered a supportive
orthosis as well. The prime issue is mobility. Osteoporotic patients are at
risk of significant medical morbidity the longer they remain immobile.
However, controversy exists as to what the exact number of weeks or
months of conservative therapy is appropriate before offering percutaneous
vertebral augmentation. Some physicians offer an early percutaneous verte-
bral augmentation to patients who have a documented inability to mobilize
after their injury. Typically patients who are mobile but still have pain are
given 4 to 6 weeks to improve .
There are particular fracture patterns that are less likely to improve with
conservative treatment, such as fractures of the thoracolumbar junction
(T11–L2), osteoporotic burst fractures, wedge anterior compression frac-
tures with greater than 30?of sagittal angulation, and patients with continu-
ing radiographic collapse upon subsequent follow-up radiographs .
Despite the feeling that percutaneous vertebral augmentation is effective,
the technique does have limitations and relative contraindications. Patients
who have cortical disruption that would preclude cement containment
should not undergo a percutaneous vertebral augmentation. Patients who
have preexisting radicular complaints are often disappointed and report
a poor result. This is perhaps because patients are undereducated about
the difference between the subaxial back pain that would be attributable
LAVELLE et al
to the compression fracture site and the more peripherial radicular pain that
they are experiencing . In the face of vertebra plana or complete verebral
collapse, any technique of percutaneous vertebral augmentation is difficult
. Obtaining preoperative imaging such as sagittal CT or MRI images
to assess trajectory and cortical integrity is often helpful [27,42,43]. Bone
scan may also be useful in determining fracture acuity because these
patients often have had previous fractures that may be obvious in a plain
radiograph but inconsequential in the patient’s current clinical state of
History of vertebroplasty
Galibert and Deramond  reported the first percutaneous vertebral
augmentation, or vertebroplasty. This landmark procedure was performed
in Amiens, France in 1984. These French physicians injected PMMA into
a C2 vertebra that had been destroyed by an aggressive hemangioma. The
authors reported that the procedure relieved the patient’s long-standing
pain. PMMA was then introduced by way of a similar percutaneous tech-
nique aided by fluoroscopic guidance into the vertebral bodies of veterbra
that had sustained fractures caused by osteoporosis .
After the initial investigations in Europe, vertebroplasty was introduced
in the United States by interventional neuroradiologists at the University of
Virginia . Veterbroplasty has gained increasing popularity with patients
reporting rapid pain relief . The technique used to perform vertebro-
plasty has been modified with time to include larger bore needles and addi-
tional barium in the cement to decrease the risk of extravasation.
Technique of vertebroplasty
Before attempting a procedure on the spine, it behooves the practitioner
to have acceptable fluoroscopic imaging. It is the standard in the surgical
community to confirm the spinal level for the procedure with the patient
and the room staff. The procedure and level is again verified on the preop-
erative imaging and finally on the image intensifier before needle/cannula
placement. Proper imaging is essential to performing the procedure with
safety and precision. Proper cannula placement is observed on the fluoro-
scope before injection of the cement (Fig. 4). Fluoroscopic imaging also
provides real-time images of the injection of the cement and the potential
extravasation into surrounding tissues, which represents the most likely
complication of the procedure [4,23,28,34,47].
As is done in many surgical procedures, prophylactic antibiotics are
administered to the patient approximately 30 minutes before the actual pro-
cedure; however, the efficacy of this practice in preventing infection has
never been affirmed by controlled study . Some surgeons mix antibiotics
such as tobramycin into the cement that will be injected into the vertebral
VERTEBROPLASTY AND KYPHOPLASTY