Kyphoplasty in osteoporotic vertebral compression fractures--guidelines and technical considerations

Abstract

Osteoporotic vertebral compression fractures are a menace to the elderly generation causing diminished quality of life due to pain and deformity. At first, conservative treatment still is the method of choice. In case of resulting deformity, sintering and persistent pain vertebral cement augmentation techniques today are widely used. Open correction of resulting deformity by different types of osteotomies addresses sagittal balance, but has comparably high morbidity. Besides conventional vertebral cement augmentation techniques balloon kyphoplasty has become a popular tool to address painful thoracic and lumbar compression fractures. It showed improved pain reduction and lower complication rates compared to standard vertebroplasty. Interestingly the results of two placebo-controlled vertebroplasty studies question the value of cement augmentation, if compared to a sham operation. Even though there exists now favourable data for kyphoplasty from one randomised controlled trial, the absence of a sham group leaves the placebo effect unaddressed. Technically kyphoplasty can be performed with a transpedicular or extrapedicular access. Polymethyl methacrylate (PMMA)-cement should be favoured, since calcium phosphate cement showed inferior biomechanical properties and less effect on pain reduction especially in less stable burst fractures. Common complications of kyphoplasty are cement leakage and adjacent segment fractures. Rare complications are toxic PMMA-monomer reactions, cement embolisation, and infection.

Figure 1

Transpedicular approach for balloon kyphoplasty. After entry in the craniolateral pedicle (red cross) in the p-a-projection (a), the medial cortex of the pedicle is first breached when the vertebral body is entered in the lateral projection (blue cross) (b). After preparation of the working channel a balloon can be placed in the vertebral body.

Figure 2

Unilateral extrapedicular costotransversary approach for balloon kyphoplasty. Following the cranioposterior part of the respective rib into the costotransversary space (c) allows extrapedicular access to the vertebral body in the thoracic spine. Due to the far lateral approach a single balloon is placed in the middle of the vertebral body (a, b).