When an external force is applied to the spine, such as that from a fall or carrying of a sudden heavyweight, the forces may exceed the ability of the bone within the vertebral body to support the load. This may cause the front part of the vertebral body to crush forming a wedge shape. This is known as a compression fracture. If the entire vertebral body breaks, this is considered a burst fracture.
Spinal fractures can be traumatic in normal bone, or repetitive stress-related in athletes, or pathological secondary to osteoporosis (senile, post-menopausal, Calcium deficiency, or steroid/drug/immobility induced), spinal tumors (Myeloma, Metastasis, etc), spinal infection, etc.
Kyphoplasty is definitely not indicated in all types of spinal fractures.
During balloon kyphoplasty, a thin tube (called a cannula) is inserted into the fractured bone. Attached to the tube is a small balloon that moves the pieces of broken bone and creates a space when it’s inflated. The surgeon then fills this space with orthopedic bone cement.
Kyphoplasty treats spinal compression fractures by stabilizing the fracture and reducing back pain. It has the additional benefit of restoring vertebral height. This reduces the kyphosis that many people with spinal fractures have.
Other benefits of the procedure include Improvement in mobility, Reduction in the number of days the patient stays in bed, a low complication rate, and improvement in quality of life.
Its success rate ranges from 80% to 95% from the existing reports.
Kyphoplasty is 4-5 years old in India. It can be performed by Spine Surgeons, Interventional Radiologists, Orthopedic Surgeons, and Neurosurgeons familiar with spine surgery and spinal anatomy. All aspects of the Kyphoplasty technique can be performed by anyone who is trained in doing so.
Conventionally, these compression fractures were treated by Bed rest with postural reduction, Braces, Percutaneous Vertebroplasty, and open surgical stabilization. With non-surgical treatment, most patients heal, but there are risks, such as persistence of pain, spinal deformity, and the potential for spinal canal compromise. In addition, bed rest can cause many additional complications, including worsening bone mineral density, de-conditioning, bedsores, and it can even increase your risk of pneumonia and urinary tract infections.
Open surgical stabilization of spinal compression fractures needs general anesthesia and this increases the risk.
In most cases, balloon kyphoplasty takes about a half-hour per level, and most patients are released from the hospital within a day of their surgery. Kyphoplasty can be performed most often using local anesthesia. Patients will be able to walk and return to their normal activities shortly after surgery.
Although balloon kyphoplasty has a low complication rate, it isn’t a risk-free procedure. As with any surgery, complications can occur. Below are the serious—but rare—risks associated with kyphoplasty: Heart attack, Cardiac arrest, Stroke, Cement leakage (this can cause a pulmonary embolism when the cement spreads to the lungs; the cement can also leak into the muscle and tissue around the spinal cord) and even lead to spinal cord injury. This procedure can also be associated with a lack of pain relief, osteomyelitis, and fracture of the vertebra or pedicle.
Spinal compression fractures can compromise the spinal canal. This means they may cause or be at risk for causing spinal cord injury (numbness, weakness, or bowel/bladder dysfunction). Such fractures with neurological involvement often require open surgical decompression and are not a candidate for minimally invasive kyphoplasty alone.
Patients with acute or chronic compression or burst fractures of the spine with intact neurological function below the level of the fracture are perfect indications for balloon kyphoplasty. The fractures secondary to osteoporosis (primary or secondary), primary or secondary spinal tumors are the indications for kyphoplasty. Most ideal candidates have mostly activity-related axial pain corresponding to the level of a recent compression fracture. This pain lessens or disappears completely with recumbency and/or sitting still.
A complete neurological examination and evaluation of recent radiographic studies are mandatory. The MR image will demonstrate an increased T2 signal due to bone edema at the level of a recent fracture. Bone scans have also been used to target the most recent break(s) in patients with multiple fractures.
It is contraindicated in spinal infection or local superficial skin infection, prolonged bleeding time, and cardio-pulmonary abnormalities precluding its use. It is relatively contraindicated in vertebrae with the deficient posterior wall for the fear of cement extravasation into the spinal canal. Generally, its use in more than three vertebrae is not recommended in one operative setting.
Future treatment of compression fractures will likely consist of injecting materials such as hydroxyapatite, hormones, osteogenic growth factors, allograft or autograft, and other agents that induce bone regeneration. Biodegradable bone mineral substitutes that resorb as the bone remodeling proceeds are currently in evaluation, as are osteoconductive materials such as coral exoskeleton. Newer systems for vertebral augmentation will combine minimally invasive surgical access with bioactive, injectable material to restore vertebral body height and sagittal alignment, provide structural stability by sustaining physiological loads, and allow for the incorporation of graft material into native vertebral bone.
a) Lieberman, et al. conducted a prospective trial of Kyphoplasty for osteoporotic vertebral fractures, in which 30 patients underwent 70 levels of Kyphoplasty for painful osteoporotic vertebral fractures. The SF-36 scores showed significant change in the measures for bodily pain and physical function post-procedure. In 70% of patients, restoration of a mean of 47% of lost VB height occurred. There was an 8.6% rate of asymptomatic cement leakage.
b) Ledlie and Renfro reviewed a large retrospective series of 96 patients who had undergone Kyphoplasty at 133 levels, mainly for osteoporotic vertebral fractures. The mean patient age was 76 years, and 70% were female. The mean pre-procedure pain score was 8.6/10, the score was 2.7/10 in the early post-procedure period, and it was 1.4/10 at the 1-year follow-up mark. Activity levels improved dramatically in most patients. With Kyphoplasty, vertebral body height is often restored, and in this cohort, the mean anterior vertebral body height changed from 65% of normal before the procedure to 90% of normal at 1 month after cement injection.
The kyphoplasty kit is available in a disposable pump with pressure gauges and the cost varies from 1.2 to 1.5 Lakhs.
It is marketed in all the major cities of India as affordability is a concern in rural India for an expensive gadget such as of Kyphoplasty.
Kyphoplasty overcomes the complications of vertebroplasty such as the cement leak outside the vertebra including the extravasation into the spinal canal compromising the neural elements. In addition, it reduces the kyphotic spinal deformity, thus restoring the near-normal sagittal spinal balance.
The procedure may seem pretty expensive at this point in time as there are very limited companies in the market with the approved kits. However, in the time to come, the prices are bound to reduce drastically, and also we may have the development of similar kits by Indian manufacturers at cost-price. I see a bright future for this technological advance in India.
The global incidence of osteoporotic spinal compression fractures is currently estimated at 700,000/year and is expected to increase fourfold over the next 50 years. India too will have a significant proportionate increase in these fractures and hence Kyphoplasty may have an enhanced role in the future medical care of patients with osteoporosis.
HOD & Consultant – Spine Surgery, Spine Care
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