Multi-Specialty Case Reviews: Kyphoplasty

Pain relief after a vertebral compression fracture: Kyphoplasty case review

Kyphoplasty for spine fractures
When a painful fracture from osteoporosis occurs in the spine, kyphoplasty is a treatment option designed to help reduce or eliminate the pain, restore height of the vertebral body and reduce spinal deformity. Vertebral compression fractures from osteoporosis are quite common, occurring in approximately twenty percent of women over the age of seventy years old. Men may also be affected, although spine fractures from osteoporosis are not as common in men. Not all osteoporosis-related spine fractures are painful or need to be treated, but when they do produce pain it is important to consider treatment options such as kyphoplasty quickly (before the fractured bone heals on its own).

There are two commonly used procedures for spine fractures from osteoporosis: kyphoplasty and vertebroplasty. Both procedures have been shown to decrease or eliminate the pain associated with vertebral compression fractures.

Vertebroplasty is a procedure where low viscosity cement is injected into the vertebral body under high pressure, stabilizing the fracture and reducing or eliminating pain.
Kyphoplasty first inserts a balloon into the bone, then injects high viscosity cement under low pressure to stabilize the fracture as well as restore vertebral height, thereby reducing or eliminating pain.

Risks of both procedures include cement extrusion into the vertebral canal leading to spinal cord or nerve root compression, venous embolism, pulmonary embolism, and risks of anesthesia. The risk of cement extrusion into the vertebral canal is theoretically less with kyphoplasty than with vertebroplasty, although a large randomized controlled study comparing kyphoplasty to vertebroplasty has yet to be published confirming this.

This article presents the case of a medically complicated patient who successfully underwent kyphoplasty for a sub-acute vertebral compression fracture solely under local anesthesia with complete resolution of symptoms and return to baseline function.

It is important to note that not all patients with spine fractures from osteoporosis are candidates for kyphoplasty, and kyphoplasty should not be used to correct an established deformity of the spine, such as a healed vertebral compression fracture. Kyphoplasty is not indicated for traumatic compression fractures in normal (i.e. non-osteoporotic) bone.

Osteoporosis caused the patient's mid back pain
Mr. WW is a sixty-four year old man who had suffered debilitating mid back pain after sustaining a fall from standing height. At the time of the fall, he underwent an inpatient cardiac examination for evaluation of his fall. After four days in the hospital, he was sent home with narcotic medication to treat his mid back pain. He had little to no long term pain relief from these or other over-the-counter medications and continued to be limited with regard to his activities and quality of life.

He sought consultation with a spinal surgeon several months later. Aspects that led to the patient's diagnosis of a vertebral compression fracture as the cause of the patient's pain include:

Mr. WW's pain was only present in the mid back area.
There was no evidence of neurological involvement. Neurological involvement could be manifested as numbness, weakness, or pain in his arms or legs, or as dysfunction of his normal bladder and bowel function.
Mr. WW's radiographs (images produced by an x-ray and MRI scan) revealed multiple thoracic compression fractures (Figure 1). A Magnetic Resonance Imaging (MRI) study of his spine was obtained to help distinguish the more recent vertebral compression fracture at the T11 level from the older, healed vertebral compression fractures at the other thoracic levels (Figure 2).

Along with the patient's primary care doctor, the spine surgeon formulated a plan to evaluate Mr. WW for osteoporosis with a DEXA bone density scan and treat accordingly with medication. When an osteoporotic fracture occurs, it is important to treat the osteoporosis—the underlying cause of the fracture—with medication and other means in order to reduce the likelihood of additional fractures. For Mr. WW, in addition to treating the osteoporosis, he discussed the risks and benefits of kyphoplasty with the surgeon and decided to proceed with surgery to address the mid back pain caused by the T11 spine fracture.