I Have a 72-Year-Old Female With a Symptomatic T12 Vertebral Compression Fracture That has Failed a Course of Bracing. How Do I Decide Whether She Should Undergo a Kyphoplasty or a Vertebroplasty?
Osteoporotic vertebral compression fractures (OVCF) affect up to 25% of postmenopausal women. The frequency reported in the United States is 700,000 per year, which is more than double the annual incidence of hip fractures. A single OVCF increases the risk of a subsequent OCVF by five times. Although most OVCF recover without incident in 6 to 12 weeks, up to 30% of patients who seek care do not have adequate pain relief.1
Chronic pain from OVCF leads to increased morbidity from prolonged use of medications and bed rest, poor appetite and nutrition, decreased pulmonary function, and overall poor quality of life. There is also some suggestion that mortality may be increased. The prolonged course of conservative management—bed rest, medication, and bracing—has led to the development of percutaneous cement injection into the fractured vertebrae.
Kyphoplasty (KP) involves inflating a balloon in the vertebral body prior to injection of cement (Figure 29-1). Vertebroplasty (VP) involves cement placement, without a balloon, into the fractured vertebral body. Once your patient has failed a 6-week course of conservative treatment, she may want to consider KP or VP. The superiority of one procedure over the other has not been determined in high-quality level I studies.
Figure 29-1. Schematic of the inflatable balloon used in kyphoplasty prior to cement injection. The balloon allows for vertebral height restoration and low-pressure cement injection.
Taylor et al2 performed a literature review and meta-analysis on VP and KP. They analyzed two nonrandomized controlled studies and 57 case series on VP. For KP, they examined 4 nonrandomized comparative studies and 13 case series. In the comparative studies (VP or KP versus medical care), pain relief was significantly better after both VP and KP. Pain relief was similar in the one study comparing VP and KP, albeit with a short 4.5-month follow-up.3 Similar results were seen when functional outcomes were measured: VP and KP performed better than medical care. Follow-up times and outcomes measurements were not standardized, so no direct comparisons could be made. Height restoration and kyphosis correction were not significantly different between VP and KP. The authors examined procedural safety and found significant differences in complications between the two procedures. The pooled data showed that the rate of cement leakage (40%, of which 3% were symptomatic) and pulmonary embolism in the VP group were significantly higher. No differences in rates of subsequent fractures were noted.
Hulme and colleagues reported similar outcomes for pain relief and function. From their pooled data, they found both KP and VP changed alignment by an average of 6.6 degreees. They also showed 34% of KP and 39% of VP procedures showed no height restoration or change in kyphosis. Cement leakage and complications were higher in the VP group than the KP group.4
In the end, there is only class III evidence that VP and KP are effective and have positive outcomes. There are no published, randomized controlled trials comparing the efficacy and safety of KP and VP. Based on expert opinion only, if the patient is able to undergo KP, then this may be a better alternative for correction of sagittal height and pain relief. On the other hand, if the patient cannot tolerate a general anesthesia, VP may be preferred. There are no firm recommendations beyond opinion and comfort level of the treating physician.
1. Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine: current options and considerations for treatment. Spine. 2006;6(5):479-487.
2. Taylor RS, Taylor RJ, Fritzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a comparative systematic review of efficacy and safety. Spine. 2006;31(23):2747-2755.
3. Fourney DR, Schomer DF, Nader R, et al. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg. 2003;98(1 Suppl):21-30.
4. Hulme PA, Krebs J, Ferguson SJ, Berlemann U. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies. Spine. 2006;31(17):1983-2001.