Kyphoplasty considerations and alternatives

Timing of Kyphoplasty surgery
As a general rule, the earlier Kyphoplasty is performed, the better are the chances of achieving significant correction of spinal alignment. Therefore, the earlier compression fractures are diagnosed, and the closer the follow-up is, the more effective Kyphoplasty intervention would be once it is indicated. The determination to proceed with Kyphoplasty intervention is determined by the individual patient and surgeon on a case by case basis.

Factors influencing early intervention with kyphoplasty (within the first two weeks of the fracture) include:

Severe pain that is poorly controlled with pain medication
Severe functional limitations such as inability to stand or walk
Fractures with greater loss of height and angular deformity
Fractures with progressive collapse
Fractures located at the thoraco-lumbar junction (the area of the spine between the lumbar spine and the rib cage)
Multiple fractures (including a new fractrure in a patient who has old healed compression fractures)

Once a compression fracture is healed, there are no real benefits to performing a Kyphoplasty, even if the patient still has back pain. Residual back pain in patients with healed compression fractures is typically muscular and results from the (now permanent) spinal deformity caused by the fracture. The determination of whether or not a fracture is healed is done by a Magnetic Resonance Imaging (MRI) study, or a Nuclear Bone Scan.

Most compression fractures demonstrate advanced healing within three months after the onset of pain. Patients with compression fractures that are not healed by more than six weeks after injury have a 90% chance at good pain relief with a kyphoplasty. However, the ability to correct their spinal deformity is negatively affected by the duration of time between their fracture and the Kyphoplasty procedure.

Kyphoplasty risks
The risk of significant complications from Kyphoplasty is overall very low, although—as with all types of spine surgery—it is not zero. The risk of significant bleeding, infection, nerve injury, spinal fluid leak, paralysis, and pulmonary embolus is significantly less than 1% for each, and estimated at significantly less than 2 % for all combined. Adverse reactions to the bone cement resulting in hypotension and possibly death are extremely rare, and may be related to performing Kyphoplasty at multiple levels of the spine.

The risk of additional compression fractures at other vertebral levels after kyphoplasty has been reported between 10 to 15%. Most studies demonstrate that these additional fractures are not the result of the Kyphoplasty itself, but rather the result of the weak bone of the patient that caused him or her to have the initial fracture in the first place. From a theoretical standpoint, Kyphoplasty may actually reduce the chance of additional compression fractures if good restoration of spinal alignment is achieved during the procedure. However, this benefit has not yet been proven in long term clinical studies.

Alternatives to Kyphoplasty
The main alternative surgical treatment option is Vertebroplasty. Like Kyphoplasty, this procedure is also minimally invasive and involves the injection of cement into the fractured vertebra. Vertebroplasty is considered a safe, minimally invasive procedure resulting in good pain relief for patients with compression fractures from osteoporosis.

Unlike Kyphoplasty, however, Vertebroplasty does not use balloons and does not allow for significant restoration of height to improve spinal alignment. In Vertebroplasty the cement is more liquid and is injected under relatively high pressure, compared with more viscous cement injected under low pressure in Kyphoplasty. The lower viscosity has been shown to result in more cement leakage problems in Vertebroplasty, although complications are rare.

Alternative non-operative treatment options for patients with painful compression fractures include rest, modifying activities, pain control by medication, bracing, and physical therapy. These measures are aimed at making the patient comfortable and functional while allowing time for the fracture to heal. Although the fracture will heal in most cases within 6 to 12 weeks, non-operative treatment has its own risks, which include:

Reduced physical activity resulting in increased bone loss, possibly leading to further increased risk of additional fractures
Complications and side effects from pain medications
Progressive collapse of the fracture and increased deformity while the fracture in healing